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Thapa BB, Rahman M, Were L, Wamai R, Galárraga O. Do targeted intergovernmental fiscal transfers improve health outcomes? Evidence from Kenyan decentralization using the difference-in-differences technique. Health Res Policy Syst 2024; 22:172. [PMID: 39707406 DOI: 10.1186/s12961-024-01272-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2024] [Accepted: 12/10/2024] [Indexed: 12/23/2024] Open
Abstract
BACKGROUND As envisioned by the 2010 Constitution, Kenya implemented a devolved system of government in March 2013, setting up 47 counties and a corresponding number of local governments. These counties differed in their levels of development. While counties such as Nairobi and Kiambu led in social and economic indicators, others such as Turkana, Mandera and Wajir were at the bottom of the list. Keeping the between-country disparities and the need to remedy those disparities in mind, the national government used formula-based criteria to determine counties' eligibility for the receipt of financial resources. On the basis of these criteria, counties were classified into marginalized and nonmarginalized counties. The marginalized counties were the 14 (of the 47) most socially and economically disadvantaged counties. These counties receive additional financial resources, which we call targeted intergovernmental fiscal transfers (i.e. fiscal transfers from the national government to county governments). METHODS We used the difference-in-differences (DID) technique and fixed effects models to estimate the effects of these targeted intergovernmental fiscal transfers on human immunodeficiency virus (HIV) incidence and diarrhoea incidence. RESULTS The results revealed that the counties receiving those transfers experienced a statistically significant decline in the incidence of diarrhoea but had no impact on the incidence of HIV. Our study fills a major gap in causal evidence linking intergovernmental fiscal transfers to health outcomes, especially in the context of low-middle-income countries in a newly decentralized setting. CONCLUSIONS Our results imply that targeted intergovernmental fiscal transfers may be effective at improving some subnational health outcomes, and therefore in reducing within-country health inequalities.
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Affiliation(s)
- Bishnu Bahadur Thapa
- Department of Health Services, Policy and Practice, School of Public Health, Brown University, Providence, United States of America.
| | - Momotazur Rahman
- Department of Health Services, Policy and Practice, School of Public Health, Brown University, Providence, United States of America
| | - Lawrence Were
- Department of Health Sciences, School of Public Health, Boston University, Boston, United States of America
| | - Richard Wamai
- College of Social Sciences and Humanities, Northeastern University, Boston, United States of America
| | - Omar Galárraga
- Department of Health Services, Policy and Practice, School of Public Health, Brown University, Providence, United States of America
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Ndambo MK, Ndambo TB, Manda-Taylor L. Exploring healthcare workers' perceptions of child health research at Kamuzu Central Hospital, Malawi: an interpretative phenomenological analysis. HUMAN RESOURCES FOR HEALTH 2024; 22:57. [PMID: 39164721 PMCID: PMC11334372 DOI: 10.1186/s12960-024-00938-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Accepted: 07/22/2024] [Indexed: 08/22/2024]
Abstract
BACKGROUND Children's health is a global public health priority and a determinant of development and sustainability. Its effective delivery and further improvements require constant and dedicated research on children, especially by child healthcare workers (HCWs). Studies have shown a high involvement of child HCWs from developed countries in child health research, with an under-representation from the global south in authorship and leadership in international collaborations. To our knowledge, there is very little literature on challenges faced by child HCWs in Malawi in conducting child health research. We sought to explore the lived experiences of child HCWs at Kamuzu Central Hospital (KCH) in Malawi by examining their perceptions of child health research and assessing the availability of child health research opportunities. METHODS From July 2023 to August 2023, we conducted five key informant interviews with purposively sampled policymakers and 20 in-depth interviews with child HCWs at KCH. The interviews were conducted in English, audio-recorded, and transcribed verbatim. We utilised interpretative phenomenological analysis by reviewing initial transcripts for familiarity, generating codes manually, and refining them into broader themes through comparisons and iterative processes. RESULTS The analysis revealed three main themes on perceptions of child HCWs at KCH in child health research. These are (i) perceived motivation and challenges for engaging in child health research, (ii) perceptions of resource availability and research opportunities at KCH, and (iii) perceptions of gaps in research training and participation among child HCWs. CONCLUSIONS Our study has uncovered critical factors influencing the low participation of child HCWs in child health research at KCH. Lack of collaboration, limited financial opportunities, and non-research-based training were the key barriers to participation in child health research among child HCWs at KCH. We advocate for the inclusion of child HCWs at all stages of collaborative health research, transparency on funding opportunities for child health research, and inclusion of research in the training of HCWs. These initiatives can strengthen the participation of child HCWs in child health research and ultimately enhance child health outcomes in Malawi.
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Affiliation(s)
- Myness Kasanda Ndambo
- School of Global and Public Health, Kamuzu University of Health Sciences, Blantyre, Malawi.
- Training and Research Unit of Excellence (TRUE), Kufa Road, Mandala, P. O. Box 30538, Blantyre, 3, Malawi.
| | - Tuntufye Brighton Ndambo
- Department of Civic Education, Ministry of Local Government, Unity and Culture, Lilongwe, Malawi
| | - Lucinda Manda-Taylor
- School of Global and Public Health, Kamuzu University of Health Sciences, Blantyre, Malawi
- Training and Research Unit of Excellence (TRUE), Kufa Road, Mandala, P. O. Box 30538, Blantyre, 3, Malawi
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Brikci N. Innovative domestic financing mechanisms for health in Africa: An evidence review. J Health Serv Res Policy 2024; 29:132-140. [PMID: 37328259 PMCID: PMC10910821 DOI: 10.1177/13558196231181081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Abstract
OBJECTIVES This article synthesizes the evidence on what have been called innovative domestic financing mechanisms for health (i.e. any domestic revenue-raising mechanism allowing governments to diversify away from traditional approaches such as general taxation, value-added tax, user fees or any type of health insurance) aimed at increasing fiscal space for health in African countries. The article seeks to answer the following questions: What types of domestic innovative financial mechanisms have been used to finance health care across Africa? How much additional revenue have these innovative financing mechanisms raised? Has the revenue raised through these mechanisms been, or was it meant to be, earmarked for health? What is known about the policy process associated with their design and implementation? METHODS A systematic review of the published and grey literature was conducted. The review focused on identifying articles providing quantitative information about the additional financial resources generated through innovative domestic financing mechanisms for health care in Africa, and/or qualitative information about the policy process associated with the design or effective implementation of these financing mechanisms. RESULTS The search led to an initial list of 4035 articles. Ultimately, 15 studies were selected for narrative analysis. A wide range of study methods were identified, from literature reviews to qualitative and quantitative analysis and case studies. The financing mechanisms implemented or planned for were varied, the most common being taxes on mobile phones, alcohol and money transfers. Few articles documented the revenue that could be raised through these mechanisms. For those that did, the revenue projected to be raised was relatively low, ranging from 0.01% of GDP for alcohol tax alone to 0.49% of GDP if multiple levies were applied. In any case, virtually none of the mechanisms have apparently been implemented. The articles revealed that, prior to implementation, the political acceptability, the readiness of institutions to adapt to the proposed reform and the potential distortionary impact these reforms may have on the targeted industry all require careful consideration. From a design perspective, the fundamental question of earmarking proved complex both politically and administratively, with very few mechanisms actually earmarked, thus questioning whether they could effectively fill part of the health-financing gap. Finally, ensuring that these mechanisms supported the underlying equity objectives of universal health coverage was recognized as important. CONCLUSIONS Additional research is needed to understand better the potential of innovative domestic revenue generating mechanisms to fill the financing gap for health in Africa and diversify away from more traditional financing approaches. Whilst their revenue potential in absolute terms seems limited, they could represent an avenue for broader tax reforms in support of health. This will require sustained dialogue between Ministries of Health and Ministries of Finance.
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Affiliation(s)
- Nouria Brikci
- Research Fellow in health economics, Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
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Nabanoba C, Zakumumpa H. Experiences of membership in munno mubulwadde (your friend indeed) - a novel community-based health insurance scheme in Luwero district in rural central Uganda. BMC Health Serv Res 2024; 24:89. [PMID: 38233909 PMCID: PMC10792776 DOI: 10.1186/s12913-023-10517-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 12/21/2023] [Indexed: 01/19/2024] Open
Abstract
BACKGROUND Community-Based Health Insurance (CBHI) schemes are recognized as an important health financing pathway to achieving universal health coverage (UHC). Although previous studies have documented CBHIs in low-income countries, the majority of these have been provider-based. Non-provider based schemes have received comparatively less empirical attention. We sought to describe a novel non-provider based CBHI munno mubulwadde (your friend indeed) comprising informal sector members in rural central Uganda to understand the structure of the scheme, the experiences of scheme members in terms of the perceived benefits and barriers to retention in the scheme. METHODS We report qualitative findings from a larger mixed-methods study. We conducted in-depth interviews with insured members (n = 18) and scheme administrators (n = 12). Four focus groups were conducted with insured members (38 participants). Data were inductively analyzed by thematic approach. RESULTS Munno mubulwadde is a union of ten CBHI schemes coordinated by one administrative structure. Members were predominantly low-income rural informal sector households who pay annual premiums ranging from $17 and $50 annually and received medical care at 13 scheme-contracted private health facilities in Luwero District in Central Uganda. Insured members reported that scheme membership protected them from catastrophic health expenditure during episodes of sickness among household members, and especially so among households with children under-five who were reported to fall sick frequently, the scheme enabled members to receive perceived better quality health care at private providers in the study district relative to the nearest public facilities. The identified barriers to retention in the scheme include inconvenient dates for premium payment that are misaligned with harvest periods for cash crops (e.g. maize corn) on which members depended for their agrarian livelihoods, long distances to insurance-contracted private providers, falling prices of cash crops which diminished real incomes and affordability of insurance premiums in successive years after initial enrolment. CONCLUSION Munno mubulwadde was perceived by as a valuable financial cushion during episodes of illness by rural informal sector households. Policy interventions for promoting price stability of cash crops in central Uganda could enhance retention of members in this non-provider CBHI which is worthy of further research as an additional funding pathway for realizing UHC in Uganda and other low-income settings.
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Affiliation(s)
- Christine Nabanoba
- Department of Social Work and Social Administration, Makerere University, Kampala, Uganda
| | - Henry Zakumumpa
- School of Public Health, Makerere University, Kampala, Uganda.
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Ogbuabor D, Olwande C, Semini I, Onwujekwe O, Olaifa Y, Ukanwa C. Stakeholders’ Perspectives on the Financial Sustainability of the HIV Response in Nigeria: A Qualitative Study. GLOBAL HEALTH: SCIENCE AND PRACTICE 2023; 11:GHSP-D-22-00430. [PMID: 37116920 PMCID: PMC10141423 DOI: 10.9745/ghsp-d-22-00430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 03/01/2023] [Indexed: 03/31/2023]
Abstract
BACKGROUND Countries in sub-Saharan Africa, including Nigeria, continue to depend on donor funding to achieve their national HIV response goals. The Government of Nigeria has made limited progress in translating political commitment to reduce donor dependency into increased domestic investment to ensure the sustainable impact of the HIV response. We explored the context-specific factors affecting the financial sustainability of the HIV response in Nigeria. METHODS Between November 2021 and March 2022, we conducted document reviews (n=13) and semistructured interviews with purposively selected national and subnational stakeholders (n=35). Data were analyzed thematically using the framework of health financing functions comprising revenue generation, pooling, and purchasing. RESULTS Stakeholders reported that there is a low level of government funding for the HIV response, which has been compounded by the weak engagement of Ministry of Finance officials and the unpredictable and untimely release of budgeted funds. Opportunities for domestic funding include philanthropy and an HIV Trust Fund led by the private sector. Integration of HIV treatment services into social health insurance schemes has been slow. Commodity purchasing has been inefficient due to ineffective coordination. Government stakeholders have been reluctant to support one-stop-shop facilities that target key and priority populations. CONCLUSION Opportunities exist in the government and private sectors for improving domestic health financing to support transitioning from donor support and ensuring the financial sustainability of the HIV response in Nigeria. To ensure that domestic financing for the HIV response is stable and predictable, the amount of domestic funding needs to increase and a framework that incorporates donor transition milestones must be developed, implemented, and monitored.
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Affiliation(s)
- Daniel Ogbuabor
- Department of Health Administration and Management, Faculty of Health Sciences and Technology, University of Nigeria, Enugu Campus, Enugu, Nigeria
| | | | - Iris Semini
- Equitable Financing Practice, Joint United Nations Programme on HIV/AIDS, Geneva, Switzerland
| | - Obinna Onwujekwe
- Department of Health Administration and Management, Faculty of Health Sciences and Technology, University of Nigeria, Enugu Campus, Enugu, Nigeria
| | | | - Chioma Ukanwa
- National AIDS, Sexually Transmitted Infections, and Hepatitis Control Programme, Federal Ministry of Health, Abuja, Nigeria
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Zi H, He SH, Leng XY, Xu XF, Huang Q, Weng H, Zhu C, Li LY, Gu JM, Li XH, Ming DJ, Li XD, Yuan S, Wang XH, He DL, Zeng XT. Global, regional, and national burden of kidney, bladder, and prostate cancers and their attributable risk factors, 1990-2019. Mil Med Res 2021; 8:60. [PMID: 34819142 PMCID: PMC8611255 DOI: 10.1186/s40779-021-00354-z] [Citation(s) in RCA: 65] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 11/01/2021] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND The burden of kidney, bladder, and prostate cancers has changed in recent decades. This study aims to investigate the global and regional burden of, and attributable risk factors for genitourinary cancers during the past 30 years. METHODS We extracted data of kidney, bladder, and prostate cancers from the Global Burden of Disease 2019 database, including incidence, mortality, disability-adjusted life-years (DALYs), and attributable risk factors from 1990 to 2019. Estimated annual percentage changes (EAPC) were calculated to assess the changes in age-standardized incidence rate, age-standardized mortality rate (ASMR), and age-standardized DALYs rate (ASDR). The associations between cancers burden and socio-demographic index (SDI) were also analyzed. RESULTS Compared with 1990, the global incident cases in 2019 were higher by 154.78%, 123.34%, and 169.11% for kidney, bladder, and prostate cancers, respectively. During the 30-year study period, there was a downward trend in ASMR and ASDR for bladder cancer (EAPC = - 0.68 and - 0.83, respectively) and prostate cancer (EAPC = - 0.75 and - 0.71, respectively), but an upward trend for kidney cancer (EAPC = 0.35 and 0.12, respectively). Regions and countries with higher SDI had higher incidence, mortality, and DALYs for all three types of cancers. The burden of bladder and prostate cancers was mainly distributed among older men, whereas the burden of kidney cancer increased among middle-aged men. Smoking related mortality and DALYs decreased, but high body mass index (BMI) and high fasting plasma glucose (FPG) related mortality and DALYs increased among kidney, bladder, and prostate cancers during the study period. CONCLUSIONS Kidney, bladder, and prostate cancers remain major global public health challenges, but with distinct trend for different disease entity across different regions and socioeconomic status. More proactive intervention strategies, at both the administrative and academic levels, based on the dynamic changes, are needed.
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Affiliation(s)
- Hao Zi
- Department of Urology, Zhongnan Hospital of Wuhan University, Wuhan, 430071 China
- Center for Evidence-Based and Translational Medicine, Zhongnan Hospital of Wuhan University, Wuhan, 430071 China
| | - Shao-Hua He
- Department of Urology, Zhongnan Hospital of Wuhan University, Wuhan, 430071 China
- Center for Evidence-Based and Translational Medicine, Zhongnan Hospital of Wuhan University, Wuhan, 430071 China
- Precision Medicine Centre, The Second People’s Hospital of Huaihua, Huaihua, 418000 China
| | - Xie-Yuan Leng
- Center for Evidence-Based and Translational Medicine, Zhongnan Hospital of Wuhan University, Wuhan, 430071 China
- The First School of Clinical Medicine, Anhui Medical University, Hefei, 230000 China
| | - Xiao-Feng Xu
- Department of Urology, Xianyang Central Hospital, Xianyang, 712000 China
- Department of Urology, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, 710061 China
| | - Qiao Huang
- Center for Evidence-Based and Translational Medicine, Zhongnan Hospital of Wuhan University, Wuhan, 430071 China
| | - Hong Weng
- Department of Urology, Zhongnan Hospital of Wuhan University, Wuhan, 430071 China
- Center for Evidence-Based and Translational Medicine, Zhongnan Hospital of Wuhan University, Wuhan, 430071 China
| | - Cong Zhu
- Department of Urology, Zhongnan Hospital of Wuhan University, Wuhan, 430071 China
- Center for Evidence-Based and Translational Medicine, Zhongnan Hospital of Wuhan University, Wuhan, 430071 China
| | - Lu-Yao Li
- Center for Evidence-Based and Translational Medicine, Zhongnan Hospital of Wuhan University, Wuhan, 430071 China
- Institutes of Evidence-Based Medicine and Knowledge Translation, Henan University, Kaifeng, 475000 China
| | - Jia-Min Gu
- Department of Urology, Zhongnan Hospital of Wuhan University, Wuhan, 430071 China
- Center for Evidence-Based and Translational Medicine, Zhongnan Hospital of Wuhan University, Wuhan, 430071 China
| | - Xu-Hui Li
- Center for Evidence-Based and Translational Medicine, Zhongnan Hospital of Wuhan University, Wuhan, 430071 China
| | - Dao-Jing Ming
- Center for Evidence-Based and Translational Medicine, Zhongnan Hospital of Wuhan University, Wuhan, 430071 China
- Institutes of Evidence-Based Medicine and Knowledge Translation, Henan University, Kaifeng, 475000 China
| | - Xiao-Dong Li
- Institutes of Evidence-Based Medicine and Knowledge Translation, Henan University, Kaifeng, 475000 China
- Department of Urology, Huaihe Hospital of Henan University, Kaifeng, 475000 China
| | - Shuai Yuan
- Center for Evidence-Based and Translational Medicine, Zhongnan Hospital of Wuhan University, Wuhan, 430071 China
| | - Xing-Huan Wang
- Department of Urology, Zhongnan Hospital of Wuhan University, Wuhan, 430071 China
- Center for Evidence-Based and Translational Medicine, Zhongnan Hospital of Wuhan University, Wuhan, 430071 China
- Institute of Urology, Wuhan University, Wuhan, 430071 China
| | - Da-Lin He
- Department of Urology, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, 710061 China
| | - Xian-Tao Zeng
- Department of Urology, Zhongnan Hospital of Wuhan University, Wuhan, 430071 China
- Center for Evidence-Based and Translational Medicine, Zhongnan Hospital of Wuhan University, Wuhan, 430071 China
- Institute of Urology, Wuhan University, Wuhan, 430071 China
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Ssengooba F, Ssennyonjo A, Musila T, Ekirapa-Kiracho E. Momentum for policy change: alternative explanations for the increased interest in results-based financing in Uganda. Glob Health Action 2021; 14:1948672. [PMID: 34330199 PMCID: PMC8330759 DOI: 10.1080/16549716.2021.1948672] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Background Results-based financing initiatives have been implemented in many countries as stand-alone projects but with little integration into national health systems. Results-based financing became more prominent in Uganda’s health policy agenda in 2014–2015 in the context of the policy imperative to finance universal health coverage. Objective To explore plausible explanations for the increased policy interest in the scale-up of results-based financing in Uganda. Methods In this qualitative study, information was collected through key informant interviews, consultative meetings (2014 and 2015) and document reviews about agenda-setting processes. The conceptual framework for the analysis was derived from the work of Sabatier, Kingdon and Stone. Results Four alternative policy arguments can explain the scale-up of results-based financing in Uganda. They are: 1) external funding opportunities tied to results-based financing create incentives for adopting policies and plans; 2) increased expertise by Ministry of Health officials in the implementation of results-based financing schemes helps frame capacity accumulation arguments; 3) the national ownership argument is supported by increased desire for alignment and fit between results-based financing structures and legitimate institutions that manage the health system; and 4) the health systems argument is backed by evidence of the levers and constraints needed for sustainable performance. Shortages in medicines and workforce are key examples. Overall, the external funding argument was the most compelling. Conclusion The different explanations illustrate the strengths and the vulnerability of the results-based financing policy agenda in Uganda. In the short term, donor aid has been the main factor shifting the policy agenda in favour of results-based financing. The high cost of results-based financing is likely to slow implementation. If results-based financing is to find a good fit within the Ugandan health system, and other similar settings, then policy and action are needed to improve system readiness.
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Duan Z, Wang L, Guo M, Ding C, Huang D, Yan H, Wilson A, Li S. Psychosocial characteristics and HIV-related sexual behaviors among cisgender, transgender, and gender non-conforming MSM in China. BMC Psychiatry 2021; 21:196. [PMID: 33865353 PMCID: PMC8053274 DOI: 10.1186/s12888-021-03189-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 03/30/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND While a growing number of studies focus on men who have sex with men (MSM), they typically ignore the heterogeneity of gender minorities within the MSM population. The recognition of new sub-groups among gender minorities (i.e., transgender and gender non-conforming), who also identify as MSM, play a considerable role in new HIV infections in China. Information on the psychosocial factors and HIV-related sexual behaviors require further consideration to understand the prevalence of HIV infection among MSM within these gender minority sub-groups. METHODS From September 2017 to January 2018, MSM without HIV were recruited in Wuhan, Nanchang, and Changsha cities in China. Participants were asked to fill out a structured self-administered questionnaire to assess depression, perceived social support, resilience, identity concealment, and HIV-related risky sexual behaviors. RESULTS A total of 715 MSM completed the structured questionnaire, the number of MSM identifying as gender minorities were 63 and accounted for 8.8% of the population. Compared to the cisgender MSM population, transgender MSM were more likely to have a one-night stand/occasional partner (AOR = 3.49, 95% CI =1.02-11.98), to have sex after drug use in the past 6 months (AOR = 2.57, 95%CI =1.05-6.29), and to have reported a significantly lower likelihood of identity concealment (mean difference = - 3.30, 95%CI = -5.86, - 0.74, P = 0.01). CONCLUSIONS The findings highlight the significance of providing targeted interventions for different gender minorities within the MSM population. Research is required to further understand the relationship between gender identity, mental health, and HIV-related sexual behaviors.
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Affiliation(s)
- Zhizhou Duan
- School of Health Sciences, Wuhan University, Wuhan, Hubei Province, China
| | - Liyin Wang
- School of Health Sciences, Wuhan University, Wuhan, Hubei Province, China
| | - Menglan Guo
- School of Health Sciences, Wuhan University, Wuhan, Hubei Province, China
| | - Changmian Ding
- The medical record department, The affiliated Dehong People's Hospital of Kunming Medical University, Kunming, Yunnan Province, China
| | - Danqin Huang
- School of Health Sciences, Wuhan University, Wuhan, Hubei Province, China
- Institute for Infectious Disease Control and prevention, Hubei provincial Center for Disease Control and Prevention, Wuhan, Hubei Province, China
| | - Hong Yan
- School of Health Sciences, Wuhan University, Wuhan, Hubei Province, China.
| | - Amanda Wilson
- Division of Psychology, Faculty of Health and Life Sciences, De Montfort University, Leicester, UK
| | - Shiyue Li
- School of Health Sciences, Wuhan University, Wuhan, Hubei Province, China
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Zakumumpa H, Paina L, Wilhelm J, Ssengooba F, Ssegujja E, Mukuru M, Bennett S. The impact of loss of PEPFAR support on HIV services at health facilities in low-burden districts in Uganda. BMC Health Serv Res 2021; 21:302. [PMID: 33794880 PMCID: PMC8017884 DOI: 10.1186/s12913-021-06316-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 03/25/2021] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Although donor transitions from HIV programs are more frequent, little research exists seeking to understand the perceptions of patients and providers on this process. Between 2015 and 2017, PEPFAR implemented the ´geographic prioritization´ (GP) policy in Uganda whereby it shifted support from 734 'low-volume' facilities and 10 districts with low HIV burden and intensified support in select facilities in high-burden districts. Our analysis intends to explore patient and provider perspectives on the impact of loss of PEPFAR support on HIV services in transitioned health facilities in Uganda. METHODS We report qualitative findings from a larger mixed-methods evaluation. Six facilities were purposefully selected as case studies seeking to ensure diversity in facility ownership, size, and geographic location. Five out of the six selected facilities had experienced transition. A total of 62 in-depth interviews were conducted in June 2017 (round 1) and November 2017 (round 2) with facility in-charges (n = 13), ART clinic managers (n = 12), representatives of PEPFAR implementing organizations (n = 14), district health managers (n = 23) and 12 patient focus group discussions (n = 72) to elicit perceived effects of transition on HIV service delivery. Data were analyzed using thematic analysis. RESULTS While core HIV services, such as testing and treatment, offered by case-study facilities prior to transition were sustained, patients and providers reported changes in the range of HIV services offered and a decline in the quality of HIV services offered post-transition. Specifically, in some facilities we found that specialized pediatric HIV services ceased, free HIV testing services stopped, nutrition support to HIV clients ended and the 'mentor mother' ART adherence support mechanism was discontinued. Patients at three ART-providing facilities reported that HIV service provision had become less patient-centred compared to the pre-transition period. Patients at some facilities perceived waiting times at clinics to have become longer, stock-outs of anti-retroviral medicines to have been more frequent and out-of-pocket expenditure to have increased post-transition. CONCLUSIONS Participants perceived transition to have had the effect of narrowing the scope and quality of HIV services offered by case-study facilities due to a reduction in HIV funding as well as the loss of the additional personnel previously hired by the PEPFAR implementing organizations for HIV programming. Replacing the HIV programming gap left by PEPFAR in transition districts with Uganda government services is critical to the attainment of 90-90-90 targets in Uganda.
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Affiliation(s)
- Henry Zakumumpa
- School of Public Health, Makerere University, Kampala, Uganda.
| | - Ligia Paina
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, USA
| | - Jess Wilhelm
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, USA
| | | | - Eric Ssegujja
- School of Public Health, Makerere University, Kampala, Uganda
| | - Moses Mukuru
- School of Public Health, Makerere University, Kampala, Uganda
| | - Sara Bennett
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, USA
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Caton L, Yuan M, Louie D, Gallo C, Abram K, Palinkas L, Brown CH, McGovern M. The prospects for sustaining evidence-based responses to the US opioid epidemic: state leadership perspectives. SUBSTANCE ABUSE TREATMENT PREVENTION AND POLICY 2020; 15:84. [PMID: 33148283 PMCID: PMC7640430 DOI: 10.1186/s13011-020-00326-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 10/23/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND The US 21st Century Cures Act provided $7.5 billion in grant funding to states and territories for evidence-based responses to the opioid epidemic. Currently, little is known about optimal strategies for sustaining these programs beyond this start-up funding. METHODS Using an inductive, conventional content analysis, we conducted key informant interviews with former and current state leaders (n = 16) about barriers/facilitators to sustainment and strategies for sustaining time-limited grants. RESULTS Financing and reimbursement, service integration, and workforce capacity were the most cited barriers to sustainment. Status in state government structure, public support, and spending flexibility were noted as key facilitators. Effective levers to increase chances for sustainment included strong partnerships with other state agencies, workforce and credentialing changes, and marshalling advocacy through public awareness campaigns. CONCLUSIONS Understanding the strategies that leaders have successfully used to sustain programs in the past can inform how to continue future time-limited, grant-funded initiatives.
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Affiliation(s)
- Lauren Caton
- Center for Behavioral Health Services and Implementation Research, Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Mina Yuan
- Center for Behavioral Health Services and Implementation Research, Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Dexter Louie
- Center for Behavioral Health Services and Implementation Research, Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Carlos Gallo
- Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Karen Abram
- Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Lawrence Palinkas
- Department of Children, Youth and Families, Dworak-Peck School of Social Work, University of Southern California, Los Angeles, CA, USA
| | - C Hendricks Brown
- Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Mark McGovern
- Center for Behavioral Health Services and Implementation Research, Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, CA, USA. .,Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA, USA.
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González-Alcaide G, Menchi-Elanzi M, Nacarapa E, Ramos-Rincón JM. HIV/AIDS research in Africa and the Middle East: participation and equity in North-South collaborations and relationships. Global Health 2020; 16:83. [PMID: 32943058 PMCID: PMC7499968 DOI: 10.1186/s12992-020-00609-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Accepted: 08/11/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND HIV/AIDS has attracted considerable research attention since the 1980s. In the current context of globalization and the predominance of cooperative work, it is crucial to analyze the participation of the countries and regions where the infection is most prevalent. This study assesses the participation of African countries in publications on the topic, as well as the degree of equity or influence existing in North-South relations. METHODS We identified all articles and reviews of HIV/AIDS indexed in the Web of Science Core Collection. We analyzed the scientific production, collaboration, and contributions from African and Middle Eastern countries to scientific activity in the region. The concept of leadership, measured through the participation as the first author of documents in collaboration was used to determine the equity in research produced through international collaboration. RESULTS A total of 68,808 documents published from 2010 to 2017 were analyzed. Researchers from North America and Europe participated in 82.14% of the global scientific production on HIV/AIDS, compared to just 21.61% from Africa and the Middle East. Furthermore, the publications that did come out of these regions was concentrated in a small number of countries, led by South Africa (41% of the documents). Other features associated with HIV/AIDS publications from Africa include the importance of international collaboration from the USA, the UK, and other European countries (75-93% of the documents) and the limited participation as first authors that is evident (30 to 36% of the documents). Finally, the publications to which African countries contributed had a notably different disciplinary orientation, with a predominance of research on public health, epidemiology, and drug therapy. CONCLUSIONS It is essential to foster more balance in research output, avoid the concentration of resources that reproduces the global North-South model on the African continent, and focus the research agenda on local priorities. To accomplish this, the global North should strengthen the transfer of research skills and seek equity in cooperative ties, favoring the empowerment of African countries. These efforts should be concentrated in countries with low scientific activity and high incidence and prevalence of the disease. It is also essential to foster intraregional collaborations between African countries.
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Affiliation(s)
| | - Marouane Menchi-Elanzi
- Department of Internal Medicine, General University Hospital of Alicante, Alicante, Spain
| | - Edy Nacarapa
- Infectious Disease Division, Carmelo Hospital of Chókwè - Daughters of Charity, Saint Vincent of Paul, Chókwè, Gaza Province, Mozambique
- Tinpswalo Association, Research Unit, Vincentian Association to Fight AIDS and TB, Chókwè, Gaza Province, Mozambique
| | - José-Manuel Ramos-Rincón
- Department of Internal Medicine, General University Hospital of Alicante, Alicante, Spain.
- Department of Clinical Medicine, Miguel Hernandez University of Elche, Alicante, Spain.
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Zakumumpa H. Reimagining the role of the nursing workforce in Uganda after more than a decade of ART scale-up. HUMAN RESOURCES FOR HEALTH 2020; 18:39. [PMID: 32471426 PMCID: PMC7257122 DOI: 10.1186/s12960-020-00479-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 05/11/2020] [Indexed: 05/25/2023]
Abstract
BACKGROUND The expanding roles and increasing importance of the nursing workforce in health services delivery in resource-limited settings is not adequately documented and sufficiently recognized in the current literature. Drawing upon the theme of 2020 as the International Year of the Nurse and the Midwife, we set out to describe how the role of nurses expanded tremendously in health facilities in Uganda during the era of anti-retroviral therapy (ART) scale-up that commenced in June 2004. METHODS We employed a mixed-methods sequential explanatory research design. Phase I entailed a cross-sectional health facility survey (n = 195) to assess the extent to which human resource management strategies (such as task shifting) were common. Phase II entailed a qualitative multiple case study of 16 (of the 195) health facilities for an in-depth understanding of the strategies adopted (e.g. nurse-centred HIV care). Descriptive analyses were performed in STATA (v 13) while qualitative data were analysed by thematic approach. RESULTS We found that nurses were the most represented cadre of health workers involved in the overall leadership of HIV clinics across Uganda. Most nurse-led HIV clinics were based in rural settings; however, this trend was fairly even across setting (rural/urban/peri-urban). While 181 (93%) health facilities allowed non-physician cadre to prescribe ART, a number of health facilities (n = 36) or 18% deliberately adopted nurse-led HIV care models. Nurses were empowered to be multi-skilled with a wide range of competencies across the HIV care continuum right from HIV testing to mainstream clinical HIV disease management. In several facilities, nursing cadre were the backbone of ART service delivery. A select number of facilities devised differentiated models of task shifting from physicians to nurses in which the latter handled patients who were stable on ART. CONCLUSION Overall, our study reveals a wide expansion in the scope-of-practice of nurses during ART scale-up in Uganda. Nurses were thrust in roles of HIV disease management that were traditionally the preserve of physicians. Our study underscores the importance of reforming regulatory frameworks governing nursing workforce scope of practice such as the need for developing a policy on task shifting which is currently lacking in Uganda.
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Affiliation(s)
- Henry Zakumumpa
- Makerere University, School of Public Health, P O Box 7072, Kampala, Uganda.
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