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Waithaka D, Cashin C, Barasa E. Is Performance-Based Financing A Pathway to Strategic Purchasing in Sub-Saharan Africa? A Synthesis of the Evidence. Health Syst Reform 2022; 8:e2068231. [PMID: 35666240 PMCID: PMC7613548 DOI: 10.1080/23288604.2022.2068231] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 04/10/2022] [Accepted: 04/15/2022] [Indexed: 11/09/2022] Open
Abstract
Many countries in sub-Saharan Africa have implemented performance-based financing (PBF) to improve health system performance. Much of the debate and analysis relating to PBF has focused on whether PBF "works"-that is, whether it leads to improvements in indicators tied to incentive-based payments. Because PBF schemes embody key elements of strategic health purchasing, this study examines the question of whether and how PBF programs in sub-Saharan Africa influence strategic purchasing more broadly within country health financing arrangements. We searched PubMed, Scopus, EconLit, Cochrane Database of Systematic Reviews, Google Scholar, Google, and the World Health Organization and World Bank's repositories for studies that focused on the implementation experience or effects of PBF in sub-Saharan African and published in English from 2000 to 2020. We identified 44 papers and used framework analysis to analyze the data and generate key findings. The evidence we reviewed shows that PBF has the potential to raise awareness about strategic purchasing, improve governance and institutional arrangements, and strengthen strategic purchasing functions. However, these effects are minimal in practice because PBF has been introduced as narrow, often pilot, projects that run parallel to and have little integration with the mainstream health financing system. We concluded that PBF has not systematically transformed health purchasing in countries in sub-Saharan Africa but that the experience with PBF can provide valuable lessons for how system-wide strategic purchasing can be implemented most effectively in that region-either in countries that currently have PBF schemes and aim to integrate them into broader purchasing systems, or in countries that are not currently implementing PBF. We also concluded that for countries to pursue more holistic approaches to strategic health purchasing and achieve better health outcomes, they need to implement health financing reforms within or aligned with existing financing systems.
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Affiliation(s)
- Dennis Waithaka
- Health Economics Research Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Cheryl Cashin
- Results for Development Institute, Washington, D.C, USA
| | - Edwine Barasa
- Health Economics Research Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
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Rua T, Brandão D, Nicolau V, Escoval A. The Utilisation of Payment Models Across the HIV Continuum of Care: Systematic Review of Evidence. AIDS Behav 2021; 25:4193-4208. [PMID: 34184134 PMCID: PMC8602234 DOI: 10.1007/s10461-021-03329-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/29/2021] [Indexed: 10/31/2022]
Abstract
The increasing chronicity and multimorbidities associated with people living with HIV have posed important challenges to health systems across the world. In this context, payment models hold the potential to improve care across a spectrum of clinical conditions. This study aims to systematically review the evidence of HIV performance-based payments models. Literature searches were conducted in March 2020 using multiple databases and manual searches of relevant papers. Papers were limited to any study design that considers the real-world utilisation of performance-based payment models applied to the HIV domain. A total of 23 full-text papers were included. Due to the heterogeneity of study designs, the multiple types of interventions and its implementation across distinct areas of HIV care, direct comparisons between studies were deemed unsuitable. Most evidence focused on healthcare users (83%), seeking to directly affect patients' behaviour based on principles of behavioural economics. Despite the variability between interventions, the implementation of performance-based payment models led to either a neutral or positive impact throughout the HIV care continuum. Moreover, this improvement was likely to be cost-effective or, at least, did not compromise the healthcare system's financial sustainability. However, more research is needed to assess the durability of incentives and its appropriate relative magnitude.
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Affiliation(s)
- Tiago Rua
- King's Health Economics, King's College London, London, UK.
| | - Daniela Brandão
- Escola Nacional de Saúde Pública, Nova University, Lisbon, Portugal
| | - Vanessa Nicolau
- Escola Nacional de Saúde Pública, Nova University, Lisbon, Portugal
| | - Ana Escoval
- Escola Nacional de Saúde Pública, Nova University, Lisbon, Portugal
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Uzoaru F, Nwaozuru U, Ong JJ, Obi F, Obiezu-Umeh C, Tucker JD, Shato T, Mason SL, Carter V, Manu S, BeLue R, Ezechi O, Iwelunmor J. Costs of implementing community-based intervention for HIV testing in sub-Saharan Africa: a systematic review. Implement Sci Commun 2021; 2:73. [PMID: 34225820 PMCID: PMC8259076 DOI: 10.1186/s43058-021-00177-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 06/22/2021] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Community-based interventions (CBIs) are interventions aimed at improving the well-being of people in a community. CBIs for HIV testing seek to increase the availability of testing services to populations that have been identified as at high risk by reaching them in homes, schools, or community centers. However, evidence for a detailed cost analysis of these community-based interventions in sub-Saharan Africa (SSA) is limited. We conducted a systematic review of the cost analysis of HIV testing interventions in SSA. METHODS Keyword search was conducted on SCOPUS, CINAHL, MEDLINE, PsycINFO, Web of Science, and Global Health databases. Three categories of key terms used were cost (implementation cost OR cost-effectiveness OR cost analysis OR cost-benefit OR marginal cost), intervention (HIV testing), and region (sub-Saharan Africa OR sub-Saharan Africa OR SSA). CBI studies were included if they primarily focused on HIV testing, was implemented in SSA, and used micro-costing or ingredients approach. RESULTS We identified 1533 citations. After screening, ten studies were included in the review: five from East Africa and five from Southern Africa. Two studies conducted cost-effectiveness analysis, and one study was a cost-utility analysis. The remainder seven studies were cost analyses. Four intervention types were identified: HIV self-testing (HIVST), home-based, mobile, and Provider Initiated Testing and Counseling. Commonly costed resources included personnel (n = 9), materials and equipment (n = 6), and training (n = 5). Cost outcomes reported included total intervention cost (n = 9), cost per HIV test (n = 9), cost per diagnosis (n = 5), and cost per linkage to care (n = 3). Overall, interventions were implemented at a higher cost than controls, with the largest cost difference with HIVST compared to facility-based testing. CONCLUSION To better inform policy, there is an urgent need to evaluate the costs associated with implementing CBIs in SSA. It is important for cost reports to be detailed, uniform, and informed by economic evaluation guidelines. This approach minimizes biases that may lead decision-makers to underestimate the resources required to scale up, sustain, or reproduce successful interventions in other settings. In an evolving field of implementation research, this review contributes to current resources on implementation cost studies.
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Affiliation(s)
- Florida Uzoaru
- College of Public Health and Social Justice, Saint Louis University, St Louis, MO, USA.
| | - Ucheoma Nwaozuru
- College of Public Health and Social Justice, Saint Louis University, St Louis, MO, USA
| | - Jason J Ong
- Department of Clinical Research and Development, London School of Hygiene and Tropical Medicine, United Kingdom Central Clinical School, Monash University, Melbourne, Australia
| | - Felix Obi
- Health Policy Research Group, University of Nigeria, Nsukka, Nigeria
| | - Chisom Obiezu-Umeh
- College of Public Health and Social Justice, Saint Louis University, St Louis, MO, USA
| | - Joseph D Tucker
- Division of Infectious Diseases, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - Thembekile Shato
- College of Public Health and Social Justice, Saint Louis University, St Louis, MO, USA
| | - Stacey L Mason
- College of Public Health and Social Justice, Saint Louis University, St Louis, MO, USA
| | - Victoria Carter
- College of Public Health and Social Justice, Saint Louis University, St Louis, MO, USA
| | - Sunita Manu
- College of Public Health and Social Justice, Saint Louis University, St Louis, MO, USA
| | - Rhonda BeLue
- College of Public Health and Social Justice, Saint Louis University, St Louis, MO, USA
| | - Oliver Ezechi
- Clinical Sciences Department, Nigerian Institute of Medical Research, Lagos, Nigeria
| | - Juliet Iwelunmor
- College of Public Health and Social Justice, Saint Louis University, St Louis, MO, USA
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Behrends CN, Kapadia SN, Schackman BR, Frimpong JA. Addressing Barriers to On-site HIV and HCV Testing Services in Methadone Maintenance Treatment Programs in the United States: Findings From a National Multisite Qualitative Study. JOURNAL OF PUBLIC HEALTH MANAGEMENT AND PRACTICE 2021; 27:393-402. [PMID: 33346582 PMCID: PMC8137509 DOI: 10.1097/phh.0000000000001262] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
CONTEXT Few substance use disorder (SUD) treatment programs provide on-site human immunodeficiency virus (HIV) and/or hepatitis C virus (HCV) testing, despite evidence that these tests are cost-effective. OBJECTIVE To understand how methadone maintenance treatment (MMT) programs that offer on-site HIV/HCV testing have integrated testing services, and the challenges related to offering on-site HIV/HCV testing. DESIGN We used the 2014 National Drug Abuse Treatment System Survey to identify outpatient SUD treatment programs that reported offering on-site HIV/HCV testing to 75% or more of their clients. We stratified the sample to identify programs based on combinations of funding source, type of drug treatment offered, and Medicaid-managed care arrangements. We conducted semi-structured qualitative interviews with leadership and staff in 2017-2018 using a directed content analysis approach to identify dominant themes. SETTING Seven MMT programs located in 6 states in the United States. PARTICIPANTS Fifteen leadership and staff from 7 MMT programs with on-site HIV/HCV testing. MAIN OUTCOME MEASURE Themes related to integration of on-site HIV/HCV testing. RESULTS Methadone maintenance treatment programs identified 3 domains related to the integration of HIV/HCV testing on-site at MMT programs: (1) payment and billing, (2) internal and external stakeholders, and (3) medical and SUD treatment coordination. Programs identified the absence of state policies that facilitate medical billing and inconsistent grant funding as major barriers. Testing availability was limited by the frequency at which external organizations could provide services on-site, the reliability of those external relationships, and MMT staffing. Poor electronic health record systems and privacy policies that prevent medical information sharing between medical and SUD treatment providers also limited effective care coordination. CONCLUSION Effective and sustainable integration of on-site HIV/HCV testing by MMT programs in the United States will require more consistent funding, improved billing options, technical assistance, electronic health record system enhancement and coordination, and policy changes related to privacy.
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Affiliation(s)
- Czarina N Behrends
- Departments of Population Health Sciences (Drs Behrends, Schackman, and Kapadia) and Medicine (Dr Kapadia), Weill Cornell Medical College, New York, New York; and Carey Business School, John Hopkins University, Baltimore, Maryland (Dr Frimpong)
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Paul E, Bodson O, Ridde V. What theories underpin performance-based financing? A scoping review. J Health Organ Manag 2021; ahead-of-print. [PMID: 33463972 DOI: 10.1108/jhom-04-2020-0161] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE The study aims to explore the theoretical bases justifying the use of performance-based financing (PBF) in the health sector in low- and middle-income countries (LMICs). DESIGN/METHODOLOGY/APPROACH The authors conducted a scoping review of the literature on PBF so as to identify the theories utilized to underpin it and analyzed its theoretical justifications. FINDINGS Sixty-four studies met the inclusion criteria. Economic theories were predominant, with the principal-agent theory being the most commonly-used theory, explicitly referred to by two-thirds of included studies. Psychological theories were also common, with a wide array of motivation theories. Other disciplines in the form of management or organizational science, political and social science and systems approaches also contributed. However, some of the theories referred to contradicted each other. Many of the studies included only casually alluded to one or more theories, and very few used these theories to justify or support PBF. No theory emerged as a dominant, consistent and credible justification of PBF, perhaps except for the principal-agent theory, which was often inappropriately applied in the included studies, and when it included additional assumptions reflecting the contexts of the health sector in LMICs, might actually warn against adopting PBF. PRACTICAL IMPLICATIONS Overall, this review has not been able to identify a comprehensive, credible, consistent, theoretical justification for using PBF rather than alternative approaches to health system reforms and healthcare providers' motivation in LMICs. ORIGINALITY/VALUE The theoretical justifications of PBF in the health sector in LMICs are under-documented. This review is the first of this kind and should encourage further debate and theoretical exploration of the justifications of PBF.
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Affiliation(s)
- Elisabeth Paul
- School of Public Health, Universite Libre de Bruxelles, Brussels, Belgium
| | | | - Valéry Ridde
- CEPED, Institute for Research on Sustainable Development (IRD), IRD-Université de Paris, Paris, France
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Resubun TF, Darmawansyah, Amiruddin R, Palluturi S, Syafar M. Qualitative analysis of financing HIV and AIDS program in Health Office of Jayawijaya District, Papua Province. GACETA SANITARIA 2021; 35 Suppl 1:S64-S66. [PMID: 33832630 DOI: 10.1016/j.gaceta.2020.12.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 12/04/2020] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The purpose of this study is to see the financing of HIV and AIDS prevention programs in Jayawijaya District, Papua Province. METHOD This study used a qualitative research design with a case study approach. RESULTS The results of this study indicate that the source of HIV and AIDS prevention programs in the Jayawijaya Health Office comes from the Government (Special Autonomy Fund) and the State Budget (BOK Funds at Puskesmas) and assistance from international NGOs with a very large amount every year. CONCLUSIONS This study concludes that HIV and AIDS from the APBN and APBN data should be reviewed to improve with the decreasing number of donor agencies assisting in the Jayawijaya District. So that the HIV and AIDS program in Jayawijaya Regency, Papua Province, is reliable, balanced with a comprehensive coping program strategy.
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Affiliation(s)
| | - Darmawansyah
- Department of Health Policy and Administration, Faculty of Public Health, Hasanuddin University
| | - Ridwan Amiruddin
- Department of Epidemiology, Faculty of Public Health, Hasanuddin University
| | - Sukri Palluturi
- Department of Health Policy and Administration, Faculty of Public Health, Hasanuddin University
| | - Muhammad Syafar
- Department of Health Promotion and Behavioral Science, Faculty of Public Health, Hasanuddin University
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A realist review to assess for whom, under what conditions and how pay for performance programmes work in low- and middle-income countries. Soc Sci Med 2020; 270:113624. [PMID: 33373774 DOI: 10.1016/j.socscimed.2020.113624] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 11/08/2020] [Accepted: 12/14/2020] [Indexed: 12/12/2022]
Abstract
Pay for performance (P4P) programmes are popular health system-focused interventions aiming to improve health outcomes in low-and middle-income countries (LMICs). This realist review aims to understand how, why and under what circumstance P4P works in LMICs.We systematically searched peer-reviewed and grey literature databases, and examined the mechanisms underpinning P4P effects on: utilisation of services, patient satisfaction, provider productivity and broader health system, and contextual factors moderating these. This evidence was then used to construct a causal loop diagram.We included 112 records (19 grey literature; 93 peer-reviewed articles) assessing P4P schemes in 36 countries. Although we found mixed evidence of P4P's effects on identified outcomes, common pathways to improved outcomes include: community outreach; adherence to clinical guidelines, patient-provider interactions, patient trust, facility improvements, access to drugs and equipment, facility autonomy, and lower user fees. Contextual factors shaping the system response to P4P include: degree of facility autonomy, efficiency of banking, role of user charges in financing public services; staffing levels; staff training and motivation, quality of facility infrastructure and community social norms. Programme design features supporting or impeding health system effects of P4P included: scope of incentivised indicators, fairness and reach of incentives, timely payments and a supportive, robust verification system that does not overburden staff. Facility bonuses are a key element of P4P, but rely on provider autonomy for maximum effect. If health system inputs are vastly underperforming pre-P4P, they are unlikely to improve only due to P4P. This is the first realist review describing how and why P4P initiatives work (or fail) in different LMIC contexts by exploring the underlying mechanisms and contextual and programme design moderators. Future studies should systematically examine health system pathways to outcomes for P4P and other health system strengthening initiatives, and offer more understanding of how programme design shapes mechanisms and effects.
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Mbuagbaw L, Hajizadeh A, Wang A, Mertz D, Lawson DO, Smieja M, Benoit AC, Alvarez E, Puchalski Ritchie L, Rachlis B, Logie C, Husbands W, Margolese S, Zani B, Thabane L. Overview of systematic reviews on strategies to improve treatment initiation, adherence to antiretroviral therapy and retention in care for people living with HIV: part 1. BMJ Open 2020; 10:e034793. [PMID: 32967868 PMCID: PMC7513605 DOI: 10.1136/bmjopen-2019-034793] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2019] [Revised: 07/01/2020] [Accepted: 08/07/2020] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVES We sought to map the evidence and identify interventions that increase initiation of antiretroviral therapy, adherence to antiretroviral therapy and retention in care for people living with HIV at high risk for poor engagement in care. METHODS We conducted an overview of systematic reviews and sought for evidence on vulnerable populations (men who have sex with men (MSM), African, Caribbean and Black (ACB) people, sex workers (SWs), people who inject drugs (PWID) and indigenous people). We searched PubMed, Excerpta Medica dataBASE, Cumulative Index to Nursing and Allied Health Literature, PsycINFO, Web of Science and the Cochrane Library in November 2018. We screened, extracted data and assessed methodological quality in duplicate and present a narrative synthesis. RESULTS We identified 2420 records of which only 98 systematic reviews were eligible. Overall, 65/98 (66.3%) were at low risk of bias. Systematic reviews focused on ACB (66/98; 67.3%), MSM (32/98; 32.7%), PWID (6/98; 6.1%), SWs and prisoners (both 4/98; 4.1%). Interventions were: mixed (37/98; 37.8%), digital (22/98; 22.4%), behavioural or educational (9/98; 9.2%), peer or community based (8/98; 8.2%), health system (7/98; 7.1%), medication modification (6/98; 6.1%), economic (4/98; 4.1%), pharmacy based (3/98; 3.1%) or task-shifting (2/98; 2.0%). Most of the reviews concluded that the interventions effective (69/98; 70.4%), 17.3% (17/98) were neutral or were indeterminate 12.2% (12/98). Knowledge gaps were the types of participants included in primary studies (vulnerable populations not included), poor research quality of primary studies and poorly tailored interventions (not designed for vulnerable populations). Digital, mixed and peer/community-based interventions were reported to be effective across the continuum of care. CONCLUSIONS Interventions along the care cascade are mostly focused on adherence and do not sufficiently address all vulnerable populations.
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Affiliation(s)
- Lawrence Mbuagbaw
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Biostatistics Unit, Father Sean O'Sullivan Research Centre, St Joseph's Healthcare, Hamilton, Ontario, Canada
- Centre for the Develoment of Best Practices in Health, Yaounde Central Hospital, Yaounde, Cameroon
| | - Anisa Hajizadeh
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Annie Wang
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Dominik Mertz
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Daeria O Lawson
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Division of Rheumatology, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Marek Smieja
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Anita C Benoit
- Women's College Research Institute, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Elizabeth Alvarez
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Centre for Health Economics and Policy Analysis (CHEPA), McMaster University, Hamilton, Ontario, Canada
| | - Lisa Puchalski Ritchie
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Emergency Medicine, University Health Network, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
| | - Beth Rachlis
- Division of Clinical Public Health, Dalla Lana School of Toronto, University of Toronto, Toronto, Ontario, Canada
| | - Carmen Logie
- Women's College Research Institute, Toronto, Ontario, Canada
- Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, Ontario, Canada
| | | | - Shari Margolese
- Canadian HIV Trials Network Community Advisory Committee, Vancouver, British Columbia, Canada
| | - Babalwa Zani
- Knowledge Translation Unit, University of Cape Town Lung Institute, Rondebosch, Western Cape, South Africa
| | - Lehana Thabane
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Biostatistics Unit, Father Sean O'Sullivan Research Centre, St Joseph's Healthcare, Hamilton, Ontario, Canada
- Pediatrics and Anesthesia, McMaster University, Hamilton, Ontario, Canada
- Centre for Evaluation of Medicine, St Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada
- Population Health Research Institute, Hamilton Health Sciences, Hamilton, Ontario, Canada
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Olakunde BO, Adeyinka DA, Olawepo JO, Pharr JR, Ozigbu CE, Wakdok S, Oladele T, Ezeanolue EE. Towards the elimination of mother-to-child transmission of HIV in Nigeria: a health system perspective of the achievements and challenges. Int Health 2019; 11:240-249. [PMID: 31028402 DOI: 10.1093/inthealth/ihz018] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Revised: 02/28/2019] [Accepted: 03/09/2019] [Indexed: 11/14/2022] Open
Abstract
Despite its scaled-up response for prevention of mother-to-child transmission of HIV (PMTCT), Nigeria still contributes the greatest number of infants infected with HIV worldwide. Drawing on our knowledge, and review of policy documents and research papers, we explored the achievements and challenges in the elimination of mother-to-child transmission of HIV in Nigeria using the WHO's health systems framework. We found that Nigeria has increased the number of PMTCT sites, decentralized and integrated PMTCT care for expanded service delivery, adopted task-shifting to address the shortage of skilled healthcare providers, explored alternative sources of domestic funding to bridge the funding gap and harmonized the health management information system to improve data quality. Some of the challenges we identified included: difficulty in identifying HIV-infected pregnant women because of low uptake of antenatal care; interrupted supplies of medical commodities; knowledge gaps among healthcare workers; and lack of a national unique identifying system to enhance data quality. While there have been some achievements in the PMTCT program, gaps still exist in the different blocks of the health system. Elimination of mother-to-child transmission of HIV in Nigeria will require the implementation of feasible, culturally acceptable and sustainable interventions to address the health system-related challenges.
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Affiliation(s)
- Babayemi O Olakunde
- Department of Occupational and Environmental Health, School of Public Health, University of Nevada, Las Vegas, 4505 S Maryland Pkwy, Las Vegas, NV, USA.,National Agency for the Control of AIDS, Plot 823, Ralph Shodeinde Street, Central Business District, Abuja, Nigeria
| | - Daniel A Adeyinka
- Department of Community Health and Epidemiology, University of Saskatchewan, 104 Clinic Place, Saskatoon, SK, Canada.,National AIDS & STIs Control Programme, Federal Ministry of Health, Plot 75, Ralph Sodeinde Street, Central Area, Abuja, Nigeria
| | - John O Olawepo
- Department of Occupational and Environmental Health, School of Public Health, University of Nevada, Las Vegas, 4505 S Maryland Pkwy, Las Vegas, NV, USA
| | - Jennifer R Pharr
- Department of Occupational and Environmental Health, School of Public Health, University of Nevada, Las Vegas, 4505 S Maryland Pkwy, Las Vegas, NV, USA
| | - Chamberline E Ozigbu
- National AIDS & STIs Control Programme, Federal Ministry of Health, Plot 75, Ralph Sodeinde Street, Central Area, Abuja, Nigeria.,Department of Health Services Policy and Management, Arnold School of Public Health, University of South Carolina, 915 Greene Street, Columbia, SC, USA
| | - Sabastine Wakdok
- National Agency for the Control of AIDS, Plot 823, Ralph Shodeinde Street, Central Business District, Abuja, Nigeria
| | - Tolu Oladele
- National Agency for the Control of AIDS, Plot 823, Ralph Shodeinde Street, Central Business District, Abuja, Nigeria
| | - Echezona E Ezeanolue
- Department of Pediatrics and Child Health, College of Medicine, University of Nigeria, 1, Old UNTH Road, Nsukka, Enugu, Nigeria.,HealthySunrise Foundation, 308 South Jones Blvd, Las Vegas, NV, USA
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Salas-Ortiz A, La Hera-Fuentes G, Nance N, Sosa-Rubí SG, Bautista-Arredondo S. The relationship between management practices and the efficiency and quality of voluntary medical male circumcision services in four African countries. PLoS One 2019; 14:e0222180. [PMID: 31581192 PMCID: PMC6776351 DOI: 10.1371/journal.pone.0222180] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Accepted: 08/23/2019] [Indexed: 01/01/2023] Open
Abstract
Introduction Given constrained funding for Human Immunodeficiency Virus (HIV) programs across Sub-Saharan Africa, delivering services efficiently is paramount. Voluntary medical male circumcision (VMMC) is a key intervention that can substantially reduce heterosexual transmission—the primary mode of transmission across the continent. There is limited research, however, on what factors may contribute to the efficient and high-quality execution of such programs. Methods We analyzed a multi-country, multi-stage random sample of 108 health facilities providing VMMC services in sub-Saharan Africa in 2012 and 2013. The survey collected information on inputs, outputs, process quality and management practices from facilities providing VMMC services. We analyzed the relationship between management practices, quality (measured through provider vignettes) and efficiency (estimated through data envelopment analysis) using Generalized Linear Models and Mixed-effects Models. Applying multivariate regression models, we assessed the relationship between management indices and efficiency and quality of VMMC services. Results Across countries, both efficiency and quality varied widely. After adjusting for type of facility, country and scale, performance-base funding was negatively correlated with efficiency -0.156 (p < 0.05). In our analysis, we did not find any significant relationships between quality and management practices. Conclusions No significant relationship was found between process quality and management practices across 108 VMMC facilities. This study is the first to analyze the potential relationships between management and service quality and efficiency among a sample of VMMC health facilities in sub-Saharan Africa and can potentially inform policy-relevant hypotheses to later test through prospective experimental studies.
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Affiliation(s)
- Andrea Salas-Ortiz
- Division of Health Economics and Health Systems Innovations, National Institute of Public Health (INSP), Cuernavaca, Mexico
- University of York, York, United Kingdom
| | - Gina La Hera-Fuentes
- Division of Health Economics and Health Systems Innovations, National Institute of Public Health (INSP), Cuernavaca, Mexico
- University of Newcastle, Newcastle, Australia
| | - Nerissa Nance
- Division of Health Economics and Health Systems Innovations, National Institute of Public Health (INSP), Cuernavaca, Mexico
| | - Sandra G. Sosa-Rubí
- Division of Health Economics and Health Systems Innovations, National Institute of Public Health (INSP), Cuernavaca, Mexico
| | - Sergio Bautista-Arredondo
- Division of Health Economics and Health Systems Innovations, National Institute of Public Health (INSP), Cuernavaca, Mexico
- School of Public Health, University of California, Berkeley, California, United States of America
- * E-mail:
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Suthar AB, Khalifa A, Joos O, Manders EJ, Abdul-Quader A, Amoyaw F, Aoua C, Aynalem G, Barradas D, Bello G, Bonilla L, Cheyip M, Dalhatu IT, De Klerk M, Dee J, Hedje J, Jahun I, Jantaramanee S, Kamocha S, Lerebours L, Lobognon LR, Lote N, Lubala L, Magazani A, Mdodo R, Mgomella GS, Monique LA, Mudenda M, Mushi J, Mutenda N, Nicoue A, Ngalamulume RG, Ndjakani Y, Nguyen TA, Nzelu CE, Ofosu AA, Pinini Z, Ramírez E, Sebastian V, Simanovong B, Son HT, Son VH, Swaminathan M, Sivile S, Teeraratkul A, Temu P, West C, Xaymounvong D, Yamba A, Yoka D, Zhu H, Ransom RL, Nichols E, Murrill CS, Rosen D, Hladik W. National health information systems for achieving the Sustainable Development Goals. BMJ Open 2019; 9:e027689. [PMID: 31101699 PMCID: PMC6530305 DOI: 10.1136/bmjopen-2018-027689] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Revised: 03/20/2019] [Accepted: 04/17/2019] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES Achieving the Sustainable Development Goals will require data-driven public health action. There are limited publications on national health information systems that continuously generate health data. Given the need to develop these systems, we summarised their current status in low-income and middle-income countries. SETTING The survey team jointly developed a questionnaire covering policy, planning, legislation and organisation of case reporting, patient monitoring and civil registration and vital statistics (CRVS) systems. From January until May 2017, we administered the questionnaire to key informants in 51 Centers for Disease Control country offices. Countries were aggregated for descriptive analyses in Microsoft Excel. RESULTS Key informants in 15 countries responded to the questionnaire. Several key informants did not answer all questions, leading to different denominators across questions. The Ministry of Health coordinated case reporting, patient monitoring and CRVS systems in 93% (14/15), 93% (13/14) and 53% (8/15) of responding countries, respectively. Domestic financing supported case reporting, patient monitoring and CRVS systems in 86% (12/14), 75% (9/12) and 92% (11/12) of responding countries, respectively. The most common uses for system-generated data were to guide programme response in 100% (15/15) of countries for case reporting, to calculate service coverage in 92% (12/13) of countries for patient monitoring and to estimate the national burden of disease in 83% (10/12) of countries for CRVS. Systems with an electronic component were being used for case reporting, patient monitoring, birth registration and death registration in 87% (13/15), 92% (11/12), 77% (10/13) and 64% (7/11) of responding countries, respectively. CONCLUSIONS Most responding countries have a solid foundation for policy, planning, legislation and organisation of health information systems. Further evaluation is needed to assess the quality of data generated from systems. Periodic evaluations may be useful in monitoring progress in strengthening and harmonising these systems over time.
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Affiliation(s)
- Amitabh Bipin Suthar
- Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Aleya Khalifa
- Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Olga Joos
- International Statistics Program, Centers for Disease Control and Prevention, Hyattsville, Maryland, USA
| | - Eric-Jan Manders
- Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Abu Abdul-Quader
- Center for Global Health, Centers for Disease Control and Prevention, Hanoi, Viet Nam
| | - Frank Amoyaw
- Center for Global Health, Centers for Disease Control and Prevention, Accra, Ghana
| | - Camara Aoua
- Ministere de la Sante et de l'Hygiene Publique, Abidjan, Lagunes, Côte d'Ivoire
| | - Getahun Aynalem
- Center for Global Health, Centers for Disease Control and Prevention, Pretoria, South Africa
| | - Danielle Barradas
- Center for Global Health, Centers for Disease Control and Prevention, Lusaka, Zambia
| | | | - Luis Bonilla
- Center for Global Health, Centers for Disease Control and Prevention, Santo Domingo, Dominican Republic
| | - Mireille Cheyip
- Center for Global Health, Centers for Disease Control and Prevention, Pretoria, South Africa
| | | | - Michael De Klerk
- Center for Global Health, Centers for Disease Control and Prevention, Windhoek, Namibia
| | - Jacob Dee
- Center for Global Health, Centers for Disease Control and Prevention, Kinshasa, Democratic Republic of the Congo
| | - Judith Hedje
- Center for Global Health, Centers for Disease Control and Prevention, Abidjan, Côte d'Ivoire
| | - Ibrahim Jahun
- Center for Global Health, Centers for Disease Control and Prevention, Abuja, Nigeria
| | | | - Stanley Kamocha
- Center for Global Health, Centers for Disease Control and Prevention, Lusaka, Zambia
| | - Leonel Lerebours
- Center for Global Health, Centers for Disease Control and Prevention, Santo Domingo, Dominican Republic
| | - Legre Roger Lobognon
- Center for Global Health, Centers for Disease Control and Prevention, Abidjan, Côte d'Ivoire
| | - Namarola Lote
- National Department of Health, Port Moresby, Papua New Guinea
| | - Léopold Lubala
- Ministère de la Santé Publique, Kinshasa, Democratic Republic of the Congo
| | - Alain Magazani
- Ministère de la Santé Publique, Kinshasa, Democratic Republic of the Congo
| | - Rennatus Mdodo
- Center for Global Health, Centers for Disease Control and Prevention, Dar es Salaam, United Republic of Tanzania
| | - George S Mgomella
- Center for Global Health, Centers for Disease Control and Prevention, Dar es Salaam, United Republic of Tanzania
| | | | - Mphatso Mudenda
- Center for Global Health, Centers for Disease Control and Prevention, Lusaka, Zambia
| | - Jeremiah Mushi
- Ministry of Health and Social Welfare, Dar es Salaam, United Republic of Tanzania
| | | | - Aime Nicoue
- Center for Global Health, Centers for Disease Control and Prevention, Abidjan, Côte d'Ivoire
| | - Rogers Galaxy Ngalamulume
- Center for Global Health, Centers for Disease Control and Prevention, Kinshasa, Democratic Republic of the Congo
| | - Yassa Ndjakani
- Center for Global Health, Centers for Disease Control and Prevention, Kinshasa, Democratic Republic of the Congo
| | - Tuan Anh Nguyen
- Center for Global Health, Centers for Disease Control and Prevention, Hanoi, Viet Nam
| | | | | | | | - Edwin Ramírez
- Servicio Nacional de Salud, Santo Domingo, Dominican Republic
| | - Victor Sebastian
- Center for Global Health, Centers for Disease Control and Prevention, Abuja, Nigeria
| | | | | | | | - Mahesh Swaminathan
- Center for Global Health, Centers for Disease Control and Prevention, Abuja, Nigeria
| | | | - Achara Teeraratkul
- Center for Global Health, Centers for Disease Control and Prevention, Bangkok, Thailand
| | - Poruan Temu
- Center for Global Health, Centers for Disease Control and Prevention, Port Moresby, Papua New Guinea
| | - Christine West
- Center for Global Health, Centers for Disease Control and Prevention, Lilongwe, Malawi
| | - Douangchanh Xaymounvong
- Center for Global Health, Centers for Disease Control and Prevention, Port Moresby, Papua New Guinea
| | - Abel Yamba
- Center for Global Health, Centers for Disease Control and Prevention, Port Moresby, Papua New Guinea
| | - Denis Yoka
- Ministere de la Sante Publique, Kinshasa, Democratic Republic of the Congo
| | - Hao Zhu
- Center for Global Health, Centers for Disease Control and Prevention, Beijing, China
| | - Ray L Ransom
- Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Erin Nichols
- International Statistics Program, Centers for Disease Control and Prevention, Hyattsville, Maryland, USA
| | - Christopher S Murrill
- Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Daniel Rosen
- Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Wolfgang Hladik
- Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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Renggli S, Mayumana I, Mboya D, Charles C, Mshana C, Kessy F, Glass TR, Pfeiffer C, Schulze A, Aerts A, Lengeler C. Towards improved health service quality in Tanzania: appropriateness of an electronic tool to assess quality of primary healthcare. BMC Health Serv Res 2019; 19:55. [PMID: 30670011 PMCID: PMC6341708 DOI: 10.1186/s12913-019-3908-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Accepted: 01/15/2019] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Progress in health service quality is vital to reach the target of Universal Health Coverage. However, in order to improve quality, it must be measured, and the assessment results must be actionable. We analyzed an electronic tool, which was developed to assess and monitor the quality of primary healthcare in Tanzania in the context of routine supportive supervision. The electronic assessment tool focused on areas in which improvements are most effective in order to suit its purpose of routinely steering improvement measures at local level. METHODS Due to the lack of standards regarding how to best measure quality of care, we used a range of different quantitative and qualitative methods to investigate the appropriateness of the quality assessment tool. The quantitative methods included descriptive statistics, linear regression models, and factor analysis; the qualitative methods in-depth interviews and observations. RESULTS Quantitative and qualitative results were overlapping and consistent. Robustness checks confirmed the tool's ability to assign scores to health facilities and revealed the usefulness of grouping indicators into different quality dimensions. Focusing the quality assessment on processes and structural adequacy of healthcare was an appropriate approach for the assessment's intended purpose, and a unique key feature of the electronic assessment tool. The findings underpinned the accuracy of the assessment tool to measure and monitor quality of primary healthcare for the purpose of routinely steering improvement measures at local level. This was true for different level and owner categories of primary healthcare facilities in Tanzania. CONCLUSION The electronic assessment tool demonstrated a feasible option for routine quality measures of primary healthcare in Tanzania. The findings, combined with the more operational results of companion papers, created a solid foundation for an approach that could lastingly improve services for patients attending primary healthcare. However, the results also revealed that the use of the electronic assessment tool outside its intended purpose, for example for performance-based payment schemes, accreditation and other systematic evaluations of healthcare quality, should be considered carefully because of the risk of bias, adverse effects and corruption.
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Affiliation(s)
- Sabine Renggli
- Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, P.O. Box, 4002 Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Iddy Mayumana
- Ifakara Health Institute, Dar es Salaam/Ifakara, United Republic of Tanzania
| | - Dominick Mboya
- Ifakara Health Institute, Dar es Salaam/Ifakara, United Republic of Tanzania
| | - Christopher Charles
- Ifakara Health Institute, Dar es Salaam/Ifakara, United Republic of Tanzania
| | - Christopher Mshana
- Ifakara Health Institute, Dar es Salaam/Ifakara, United Republic of Tanzania
| | - Flora Kessy
- Ifakara Health Institute, Dar es Salaam/Ifakara, United Republic of Tanzania
| | - Tracy R. Glass
- Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, P.O. Box, 4002 Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Constanze Pfeiffer
- Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, P.O. Box, 4002 Basel, Switzerland
- University of Basel, Basel, Switzerland
| | | | - Ann Aerts
- Novartis Foundation, Basel, Switzerland
| | - Christian Lengeler
- Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, P.O. Box, 4002 Basel, Switzerland
- University of Basel, Basel, Switzerland
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Munar W, Snilstveit B, Stevenson J, Biswas N, Eyers J, Butera G, Baffour T, Aranda LE. Evidence gap map of performance measurement and management in primary care delivery systems in low- and middle-income countries - Study protocol. Gates Open Res 2018; 2:27. [PMID: 29984360 PMCID: PMC6030397 DOI: 10.12688/gatesopenres.12826.2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/30/2018] [Indexed: 11/20/2022] Open
Abstract
Background . For the last two decades there has been growing interest in governmental and global health stakeholders about the role that performance measurement and management systems can play for the production of high-quality and safely delivered primary care services. Despite recognition and interest, the gaps in evidence in this field of research and practice in low- and middle-income countries remain poorly characterized. This study will develop an evidence gap map in the area of performance management in primary care delivery systems in low- and middle-income countries. Methods. The evidence gap map will follow the methodology developed by 3Ie, the International Initiative for Impact Evaluation, to systematically map evidence and research gaps. The process starts with the development of the scope by creating an evidence-informed framework that helps identify the interventions and outcomes of relevance as well as help define inclusion and exclusion criteria. A search strategy is then developed to guide the systematic search of the literature, covering the following databases: Medline (Ovid), Embase (Ovid), CAB Global Health (Ovid), CINAHL (Ebsco), Cochrane Library, Scopus (Elsevier), and Econlit (Ovid). Sources of grey literature are also searched. Studies that meet the inclusion criteria are systematically coded, extracting data on intervention, outcome, measures, context, geography, equity, and study design. Systematic reviews are also critically appraised using an existing standard checklist. Impact evaluations are not appraised but will be coded according to study design. The process of map-building ends with the creation of an evidence gap map graphic that displays the available evidence according to the intervention and outcome framework of interest. Discussion . Implications arising from the evidence map will be discussed in a separate paper that will summarize findings and make recommendations for the development of a prioritized research agenda.
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Affiliation(s)
- Wolfgang Munar
- Milken Institute School of Public Health, Department of Global Health, George Washington University, Washington, DC, 20052, USA
| | - Birte Snilstveit
- International Initiative for Impact Evaluation (3Ie), London International Development Centre, London, WC1H 0PD, UK
| | - Jennifer Stevenson
- International Initiative for Impact Evaluation (3Ie), London International Development Centre, London, WC1H 0PD, UK
| | - Nilakshi Biswas
- Milken Institute School of Public Health, Department of Global Health, George Washington University, Washington, DC, 20052, USA
| | - John Eyers
- International Initiative for Impact Evaluation (3Ie), London International Development Centre, London, WC1H 0PD, UK
| | - Gisela Butera
- Milken Institute School of Public Health, Department of Global Health, George Washington University, Washington, DC, 20052, USA
| | - Theresa Baffour
- Milken Institute School of Public Health, Department of Global Health, George Washington University, Washington, DC, 20052, USA
| | - Ligia E Aranda
- Milken Institute School of Public Health, Department of Global Health, George Washington University, Washington, DC, 20052, USA
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Munar W, Wahid SS, Mookherji S, Innocenti C, Curry L. Team- and individual-level motivation in complex primary care system change: A realist evaluation of the Salud Mesoamerica Initiative in El Salvador. Gates Open Res 2018. [DOI: 10.12688/gatesopenres.12878.1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background:We study the role of individual and team-level motivation in explaining large-scale primary care performance improvements in El Salvador, one of the top-performing countries in the Salud Mesoamerica Initiative.Methods:Case study with outlier sampling of high-performing, community health teams in El Salvador. Design includes scoping review of literature, document review, non-participant observation, and qualitative analysis of in-depth interviews following a realist case study protocol.Results:The interplay between program interventions and organizational, community and policy contexts trigger multi-level motivational mechanisms that operate in complex, dynamic fashion. Interventions like performance measurement and team-based, in-kind incentives foster motivation among individual members of high-performing teams, which may be moderated by working conditions, supervision practices, and by the stress exerted by the interventions themselves. Individuals report a strong sense of public service motivation and an overarching sense of commitment to the community they serve. At the interpersonal level, the linkage between performance measurement and in-kind incentives triggers a sense of collective efficacy and increases team motivation and improvement behaviors. The convening of learning forums and performance dialogue increases the stakes for high-performing teams, helps them make sense of performance data, and leads to performance information utilization for healthcare improvements. Closeness to communities creates strong emotional linkages among team members that further increases collective efficacy and social identity. Such changes in individuals, team, and organizational behaviors can contribute to improved delivery of primary care services and explain the gains in performance demonstrated by the program.Conclusions:This case suggests that primary care systems that rely on multi-disciplinary teams for the provision of care can benefit from performance measurement and management interventions that leverage individual and team-level motivation. Realist evaluation can help prioritize policy-relevant research and enhance the design and evaluation of large-scale performance reforms in primary care systems in low- and middle-income settings.
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15
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Munar W, Wahid SS, Curry L. Characterizing performance improvement in primary care systems in Mesoamerica: A realist evaluation protocol. Gates Open Res 2018. [DOI: 10.12688/gatesopenres.12782.2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background. Evaluations of performance measurement and management interventions in public, primary care delivery systems of low- and middle-income countries are scarce. In such contexts, few studies to date have focused on characterizing how, why and under what contextual conditions do such complex, multifaceted arrangements lead to intended and unintended consequences for the healthcare workforce, the healthcare organizations involved, and the communities that are served. Methods. Case-study design with purposeful outlier sampling of high-performing primary care delivery systems in El Salvador and Honduras, as part of the Salud Mesoamerica Initiative. Case study design is suitable for characterizing individual, interpersonal and collective mechanisms of change in complex adaptive systems. The protocol design includes literature review, document review, non-participant observation, and qualitative analysis of in-depth interviews. Data analysis will use inductive and deductive approaches to identify causal patterns organized as ‘context-mechanism-outcome’ configurations. Findings will be triangulated with existing secondary data sources collected including country-specific performance measurement data, impact, and process evaluations conducted by the Salud Mesoamerica Initiative. Discussion. This realist evaluation protocol aims to characterize how, why and under what conditions do performance measurement and management arrangements contribute to the improvement of primary care system performance in two low-income countries.
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16
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Schuster RC, de Sousa O, Reme AK, Vopelak C, Pelletier DL, Johnson LM, Mbuya M, Pinault D, Young SL. Performance-Based Financing Empowers Health Workers Delivering Prevention of Vertical Transmission of HIV Services and Decreases Desire to Leave in Mozambique. Int J Health Policy Manag 2018; 7:630-644. [PMID: 29996583 PMCID: PMC6037490 DOI: 10.15171/ijhpm.2017.137] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Accepted: 11/20/2017] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Despite increased access to treatment and reduced incidence, vertical transmission of HIV continues to pose a risk to maternal and child health in sub-Saharan Africa. Performance-based financing (PBF) directed at healthcare providers has shown potential to improve quantity and quality of maternal and child health services. However, the ways in which these PBF initiatives lead to improved service delivery are still under investigation. METHODS Therefore, we implemented a longitudinal-controlled proof-of-concept PBF intervention at health facilities and with community-based associations focused on preventing vertical transmission of HIV (PVT) in rural Mozambique. We hypothesized that PBF would increase worker motivation and other aspects of the workplace environment in order to achieve service delivery goals. In this paper, we present two objectives from the PBF intervention with public health facilities (n=6): first, we describe the implementation of the PBF intervention and second, we assess the impact of the PBF on health worker motivation, key factors in the workplace environment, health worker satisfaction, and thoughts of leaving. Implementation (objective 1) was evaluated through quantitative service delivery data and multiple forms of qualitative data (eg, quarterly meetings, participant observation (n=120), exit interviews (n=11)). The impact of PBF on intermediary constructs (objective 2) was evaluated using these qualitative data and quantitative surveys of health workers (n=83) at intervention baseline, midline, and endline. RESULTS We found that implementation was challenged by administrative barriers, delayed disbursement of incentives, and poor timing of evaluation relative to incentive disbursement (objective 1). Although we did not find an impact on the motivation constructs measured, PBF increased collegial support and worker empowerment, and, in a time of transitioning implementing partners, decreased against desire to leave (objective 2). CONCLUSION Areas for future research include incentivizing meaningful quality- and process-based performance indicators and evaluating how PBF affects the pathway to service delivery, including interactions between motivation and workplace environment factors.
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Affiliation(s)
- Roseanne C. Schuster
- Program in International Nutrition, Division of Nutritional Sciences, Cornell University, Ithaca, NY, USA
- Center for Global Health, School of Human Evolution and Social Change, Arizona State University, Tempe, AZ, USA
| | | | - Anne-Kathe Reme
- Program in International Nutrition, Division of Nutritional Sciences, Cornell University, Ithaca, NY, USA
- CARE Mozambique, Maputo, Mozambique
| | - Carolyn Vopelak
- Mailman School of Public Health, Columbia University, New York, NY, USA
- International Medical Corps, Washington, DC, USA
| | - David L. Pelletier
- Program in International Nutrition, Division of Nutritional Sciences, Cornell University, Ithaca, NY, USA
| | - Lynn M. Johnson
- Cornell Statistical Consulting Unit, Cornell University, Ithaca, NY, USA
| | - Mduduzi Mbuya
- Program in International Nutrition, Division of Nutritional Sciences, Cornell University, Ithaca, NY, USA
- Global Alliance for Improved Nutrition (GAIN), Washington, DC, USA
| | | | - Sera L. Young
- Program in International Nutrition, Division of Nutritional Sciences, Cornell University, Ithaca, NY, USA
- Department of Population Medicine and Diagnostic Sciences, Cornell University, Ithaca, NY, USA
- Department of Anthropology, Northwestern University, Evanston, IL, USA
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17
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Borghi J, Singh NS, Brown G, Anselmi L, Kristensen S. Understanding for whom, why and in what circumstances payment for performance works in low and middle income countries: protocol for a realist review. BMJ Glob Health 2018; 3:e000695. [PMID: 29988988 PMCID: PMC6035508 DOI: 10.1136/bmjgh-2017-000695] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Revised: 05/03/2018] [Accepted: 05/17/2018] [Indexed: 12/22/2022] Open
Abstract
Background Many low and middle income countries (LMIC) are implementing payment for performance (P4P) schemes to strengthen health systems and make progress towards universal health coverage. A number of systematic reviews have considered P4P effectiveness but did not explore how P4P works in different settings to improve outcomes or shed light on pathways or mechanisms of programme effect. This research will undertake a realist review to investigate how, why and in what circumstances P4P leads to intended and unintended outcomes in LMIC. Methods Our search was guided by an initial programme theory of mechanisms and involved a systematic search of Medline, Embase, Popline, Business Source Premier, Emerald Insight and EconLit databases for studies on P4P and health in LMIC. Inclusion and exclusion criteria identify literature that is relevant to the initial programme theory and the research questions underpinning the review. Retained evidence will be used to test, revise or refine the programme theory and identify knowledge gaps. The evidence will be interrogated by examining the relationship between context, mechanisms and intended and unintended outcomes to establish what works for who, in which contexts and why. Discussion By synthesising current knowledge on how P4P affects health systems to produce outcomes in different contexts and to what extent the programme design affects this, we will inform more effective P4P programmes to strengthen health systems and achieve sustainable service delivery and health impacts.
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Affiliation(s)
- Josephine Borghi
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Neha S Singh
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Garrett Brown
- School of Politics and International Studies, University of Leeds, Leeds, UK
| | - Laura Anselmi
- Manchester Centre for Health Economics, University of Manchester, Manchester, UK
| | - Soren Kristensen
- Faculty of Medicine, Institute of Global Health Innovation, Centre for Health Policy, Imperial College, London, UK
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18
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Munar W, Snilstveit B, Stevenson J, Biswas N, Eyers J, Butera G, Baffour T, Aranda LE. Evidence gap map of performance measurement and management in primary care delivery systems in low- and middle-income countries - Study protocol. Gates Open Res 2018; 2:27. [PMID: 29984360 PMCID: PMC6030397 DOI: 10.12688/gatesopenres.12826.1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/23/2018] [Indexed: 10/12/2023] Open
Abstract
Background. For the last two decades there has been growing interest in governmental and global health stakeholders about the role that performance measurement and management systems can play for the production of high-quality and safely delivered primary care services. Despite recognition and interest, the gaps in evidence in this field of research and practice in low- and middle-income countries remain poorly characterized. This study will develop an evidence gap map in the area of performance management in primary care delivery systems in low- and middle-income countries. Methods. The evidence gap map will follow the methodology developed by 3Ie, the International Initiative for Impact Evaluation, to systematically map evidence and research gaps. The process starts with the development of the scope by creating an evidence-informed framework that helps identify the interventions and outcomes of relevance as well as help define inclusion and exclusion criteria. A search strategy is then developed to guide the systematic search of the literature, covering the following databases: Medline (Ovid), Embase (Ovid), CAB Global Health (Ovid), CINAHL (Ebsco), Cochrane Library, Scopus (Elsevier), and Econlit (Ovid). Sources of grey literature are also searched. Studies that meet the inclusion criteria are systematically coded, extracting data on intervention, outcome, measures, context, geography, equity, and study design. Systematic reviews are also critically appraised using an existing standard checklist. Impact evaluations are not appraised but will be coded according to study design. The process of map-building ends with the creation of an evidence gap map graphic that displays the available evidence according to the intervention and outcome framework of interest. Discussion. Applications arising from the evidence map will be discussed in a separate paper that will summarize findings and make recommendations for the development of a prioritized research agenda.
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Affiliation(s)
- Wolfgang Munar
- Milken Institute School of Public Health, Department of Global Health, George Washington University, Washington, DC, 20052, USA
| | - Birte Snilstveit
- International Initiative for Impact Evaluation (3Ie), London International Development Centre, London, WC1H 0PD, UK
| | - Jennifer Stevenson
- International Initiative for Impact Evaluation (3Ie), London International Development Centre, London, WC1H 0PD, UK
| | - Nilakshi Biswas
- Milken Institute School of Public Health, Department of Global Health, George Washington University, Washington, DC, 20052, USA
| | - John Eyers
- International Initiative for Impact Evaluation (3Ie), London International Development Centre, London, WC1H 0PD, UK
| | - Gisela Butera
- Milken Institute School of Public Health, Department of Global Health, George Washington University, Washington, DC, 20052, USA
| | - Theresa Baffour
- Milken Institute School of Public Health, Department of Global Health, George Washington University, Washington, DC, 20052, USA
| | - Ligia E. Aranda
- Milken Institute School of Public Health, Department of Global Health, George Washington University, Washington, DC, 20052, USA
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Reed JC. Health systems flattening - the failed promises of decentralisation in Mozambique. Glob Public Health 2018; 13:1737-1752. [PMID: 29411676 DOI: 10.1080/17441692.2018.1436719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Over the past decade, health systems strengthening (HSS) has become a global health imperative. As an answer to the influence of large-scale initiatives and NGOs, HSS represents a backlash against disease-specific projects and funding. Depicted as a positive evolution, HSS advertises local autonomy, and a turn away from donor-driven agendas. Central to this shift was the hope that 'vertical' funding, especially for HIV/AIDS, could be better used to build up the 'crumbling core' of health infrastructure in sub-Saharan Africa. As part of the change in Mozambique, HIV specialty clinics known as 'day hospitals' were decentralised (closed down) nationwide. Done in the name of efficiency and increased treatment coverage, the full impacts of this remain uncharted. In this article, I critique the ethical adequacy of HSS as a reorganising principle, pointing out the pursuit not of robust health systems, but of easily monitored ones instead. Occurring alongside performance-based financing, HSS invites the removal of specialty services, exposing health systems to additional shaping by outside forces. Based on ethnography with HIV support groups, I suggest HSS was an inevitable policy choice, but partially coercive. Such changes are neither counter-hegemonic nor capable of ameliorating foreign distortions in the developing world.
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Affiliation(s)
- Joel Christian Reed
- a The Demographic and Health Surveys (DHS) Program at ICF , Rockville , Maryland , USA
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Determinants of time from HIV infection to linkage-to-care in rural KwaZulu-Natal, South Africa. AIDS 2017; 31:1017-1024. [PMID: 28252526 DOI: 10.1097/qad.0000000000001435] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
OBJECTIVE To estimate time from HIV infection to linkage-to-care and its determinants. Linkage-to-care is usually assessed using the date of HIV diagnosis as the starting point for exposure time. However, timing of diagnosis is likely endogenous to linkage, leading to bias in linkage estimation. DESIGN We used longitudinal HIV serosurvey data from a large population-based HIV incidence cohort in KwaZulu-Natal (2004-2013) to estimate time of HIV infection. We linked these data to patient records from a public-sector HIV treatment and care program to determine time from infection to linkage (defined using the date of the first CD4 cell count). METHODS We used Cox proportional hazards models to estimate time from infection to linkage and the effects of the following covariates on this time: sex, age, education, food security, socioeconomic status, area of residence, distance to clinics, knowledge of HIV status, and whether other household members have initiated antiretroviral therapy. RESULTS We estimated that it would take an average of 4.9 years for 50% of HIV seroconverters to be linked to care (95% confidence intervals: 4.2-5.7). Among all cohort members who were linked to care, the median CD4 cell count at linkage was 350 cells/μl (95% confidence interval: 330-380). Men and participants aged less than 30 years were found to have the slowest rates of linkage-to-care. Time to linkage became shorter over calendar time. CONCLUSION Average time from HIV infection to linkage-to-care is long and needs to be reduced to ensure that HIV treatment-as-prevention policies are effective. Targeted interventions for men and young individuals have the largest potential to improve linkage rates.
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Meessen B, Shroff ZC, Ir P, Bigdeli M. From Scheme to System (Part 1): Notes on Conceptual and Methodological Innovations in the Multicountry Research Program on Scaling Up Results-Based Financing in Health Systems. Health Syst Reform 2017; 3:129-136. [PMID: 31514678 DOI: 10.1080/23288604.2017.1303561] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
Abstract-This article presents conceptual and methodological developments made in analyzing the scale up of results-based financing (RBF) as part of a multicountry research program supported by the Alliance for Health Policy and Systems Research. Following a brief overview of the research process, the article proposes a new five-dimensional conceptualization of scale-up (population coverage, service coverage, health system integration, cross-sectoral diffusion, and knowledge expansion) to capture various facets of RBF scale-up. It also presents how Walt and Gilson's health policy triangle framework was modified to identify the enablers and barriers to scale-up in the country case studies included in this research program. The article then puts forth a four-phase model of scale-up, including phases of generation, adoption, institutionalization, and expansion, developed for the purpose of this research program. The article concludes by providing some lessons learned on the use of the methods and theoretical frameworks developed for this multicountry research program.
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Affiliation(s)
- Bruno Meessen
- Department of Public Health , Institute of Tropical Medicine , Antwerp , Belgium
| | | | - Por Ir
- National Institute of Public Health , Phnom Penh , Cambodia
| | - Maryam Bigdeli
- Health System Governance, Policy and Aid Effectiveness, World Health Organization , Geneva , Switzerland
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