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Nabyonga-Orem J, Christmal C, Addai KF, Mwinga K, Aidam K, Nachinab G, Namuli S, Asamani JA. The state and significant drivers of health systems efficiency in Africa: A systematic review and meta-analysis. J Glob Health 2023; 13:04131. [PMID: 37934959 PMCID: PMC10630696 DOI: 10.7189/jogh.13.04131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2023] Open
Abstract
Background Low-and-middle-income countries, especially in Africa, lack the capacity to adequately invest in health systems to attain universal health coverage (UHC). As such, countries must improve efficiency and provide more services within the available resources. This systematic review synthesised evidence on the efficiency of health systems in the African region and its drivers. Methods We conducted a systematic literature review guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 statement. Related studies were grouped and meta-analysed, while others were descriptively analysed. We employed a qualitative content synthesis for synthesising the drivers of efficiency. Results Overall, 39 studies met a predetermined inclusion criterion and were included from a possible 4 609 records retrieved through a rigorous search and selection process. Using a random effects restricted maximum likelihood method, the pooled efficiency score for the Africa region was estimated to be 0.77, implying that on the flip side, health system inefficiency across countries in the African region was approximately 23%. Across 22 studies that used data envelopment analysis to examine efficiency at the level of health facilities and sub-national entities, the efficiency level was 0.67. Facility-level studies tended to estimate low levels of efficiency compared to health system-level studies. Across the 39 studies, 21 significant drivers of inefficiency were reported, including population density of the catchment area, governance, health facility ownership, health facility staff density, national economic status, type of health facility, education index, hospital size and bed occupancy rate. Conclusion With approximately 23% of the inefficiency of health systems in Africa, improving efficiency alone will yield an average of 34% improvement in resource availability, assuming all countries are performing similarly to the frontier countries. However, with the low level of health expenditure per capita in Africa, the efficiency gains alone will be insufficient to meet the minimum funding requirement for UHC. Registration PROSPERO: CRD42022318122.
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Affiliation(s)
- Juliet Nabyonga-Orem
- World Health Organization (WHO) Africa Regional Office, Office of the Regional Director, Brazzaville, Congo
- Centre for Health Professions Education, Faculty of Health Sciences, North-West University, Potchefstroom, South Africa
| | - Christmals Christmal
- Centre for Health Professions Education, Faculty of Health Sciences, North-West University, Potchefstroom, South Africa
| | - Kingsley F Addai
- World Health Organization (WHO) Ghana Country Office, Universal Health Coverage Life Course Cluster, Accra, Ghana
| | - Kasonde Mwinga
- World Health Organization (WHO) Africa Regional Office, Universal Health Coverage Life Course Cluster, Brazzaville Congo
| | | | | | - Sylivia Namuli
- World Health Organization (WHO) Africa Regional Office, Universal Health Coverage Life Course Cluster, Brazzaville Congo
| | - James A Asamani
- Centre for Health Professions Education, Faculty of Health Sciences, North-West University, Potchefstroom, South Africa
- World Health Organization (WHO) Africa Regional Office, Universal Health Coverage Life Course Cluster, Brazzaville Congo
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Oskowitz SP, Rwiyereka AK, Rurangwa T, Shepard DS, Rwamasirabo E, Isaacson KB, van der Poel S, Racowsky C. Infertility services integrated within the maternal health department of a public hospital in a low-income country, Rwanda. F S Rep 2023; 4:130-142. [PMID: 37398610 PMCID: PMC10310971 DOI: 10.1016/j.xfre.2023.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 04/05/2023] [Accepted: 04/05/2023] [Indexed: 07/04/2023] Open
Abstract
Objective To describe the initiation, integration, and costs of reduced-cost infertility services within the maternal health department of a public hospital in a low-income country. Design Retrospective review of the clinical and laboratory components of patients undergoing in vitro fertilization (IVF) treatment in Rwanda from 2018 to 2020. Setting Academic tertiary referral hospital in Rwanda. Patients Patients seeking infertility services beyond the primary gynecological options. Interventions The national government furnished facilities and personnel, and the Rwanda Infertility Initiative, an international nongovernmental organization, provided training, equipment, and materials. The incidence of retrieval, fertilization, embryo cleavage, transfer, and conception (observed until ultrasound verification of intrauterine pregnancy with fetal heartbeat) were analyzed. Cost calculations used the government-issued tariff specifying insurers' payments and patients' copayments with projected delivery rates using early literature. Main Outcome Measures Assessment of functional clinical and laboratory infertility services and costs. Results A total of 207 IVF cycles were initiated, 60 of which led to transfer of ≥1 high-grade embryo and 5 to ongoing pregnancies. The projected average cost per cycle was 1,521 USD. Using optimistic and conservative assumptions, the estimated costs per delivery for women <35 years were 4,540 and 5,156 USD, respectively. Conclusions Reduced-cost infertility services were initiated and integrated within a maternal health department of a public hospital in a low-income country. This integration required commitment, collaboration, leadership, and a universal health financing system. Low-income countries, such as Rwanda, might consider infertility treatment and IVF for younger patients as part of an equitable and affordable health care benefit.
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Affiliation(s)
- Selwyn P. Oskowitz
- Department of Obstetrics, Gynecology and Reproductive Biology, Harvard Medical School, Boston, Massachusetts
- Rwanda Infertility Initiative (RII), Los Angeles, California
| | - Angélique K. Rwiyereka
- Rwanda Infertility Initiative (RII), Los Angeles, California
- Schneider Institutes for Health Policy and Research, Institute for Global Health and Development, Heller School of Social Policy, Brandeis University, Waltham, Massachusetts
| | - Théogène Rurangwa
- Rwanda Infertility Initiative (RII), Los Angeles, California
- Department of Obstetrics and Gynecology, Rwanda Military Hospital, Kigali, Rwanda
| | - Donald S. Shepard
- Rwanda Infertility Initiative (RII), Los Angeles, California
- Schneider Institutes for Health Policy and Research, Institute for Global Health and Development, Heller School of Social Policy, Brandeis University, Waltham, Massachusetts
| | - Emile Rwamasirabo
- Rwanda Infertility Initiative (RII), Los Angeles, California
- Rwanda Accreditation Agency for Quality Healthcare (RAAQH), Kigali, Rwanda
| | - Keith B. Isaacson
- Department of Obstetrics, Gynecology and Reproductive Biology, Harvard Medical School, Boston, Massachusetts
- Rwanda Infertility Initiative (RII), Los Angeles, California
| | | | - Catherine Racowsky
- Department of Obstetrics, Gynecology and Reproductive Biology, Harvard Medical School, Boston, Massachusetts
- Rwanda Infertility Initiative (RII), Los Angeles, California
- Department of Obstetrics, Gynecology and Reproductive Medicine, Hospital Foch, Suresnes, France
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Uwamariya J, Nshunguyabahizi M, Nshimyumuremyi JN, Mukesharurema G, Ndayishimiye E, Kamali I, Ndahimana JD, Hedt-Gauthier B, Cubaka VK, Barnhart DA. Rediscovering life after being diagnosed with HIV: A qualitative analysis of lived experiences of youth living with HIV in rural Rwanda. FRONTIERS IN REPRODUCTIVE HEALTH 2022; 4:993916. [DOI: 10.3389/frph.2022.993916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Accepted: 10/06/2022] [Indexed: 11/06/2022] Open
Abstract
IntroductionIn sub-Saharan Africa, youth living with HIV, especially those who have lost one or both parents, face economic, socially and psychological challenges that hinder adherence to ART, ultimately leading to poor health outcomes. Partners In Health/Inshuti Mu Buzima implemented an Adolescent Support Group (ASG) to support HIV-positive youth aged 15–25 years. During the evaluation of the ASG program, we sought to better understand youths' lived experiences to improve our delivery of HIV care.MethodsWe conducted qualitative in-depth, semi-structured individual interviews with youth enrolled in the ASG program. All interviews were conducted in-person or by telephone. Thematic analysis applying the framework approach with parallel inductive coding in Kinyarwanda and English was used.ResultsWe interviewed 35 youth who ranged in age from 16 to 29 years. The main themes related to the lived experiences of youth were (a) Experiences living with HIV, including disclosure, stigma, interactions with the health care system, and medication adherence; (b) external challenges, defined as challenges that were not related to the implementation of the ASG program; and (c) personal vision. Almost all youth reported acquiring HIV from their mothers and disclosure of HIV status occurred around the age of 10. Disclosure was often unintentional and followed by internalized and enacted stigma. Many reported poor past medication adherence which improved following enhanced counselling. External challenges were overwhelmingly economic in nature, and orphanhood was a root cause of other challenges such as difficulty accessing education, lack of transport to health facility, and lack of insurance fees. Despite these challenges, youth have an optimistic view of the future with dreams of health, economic attainment, marriage, and children.ConclusionHealthcare providers should empower caregivers to support HIV disclosure. Supporting youth as they face many economic challenges could help address socio-economic barriers to good health and promote holistic well-being.
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Binyaruka P, Anselmi L. Understanding efficiency and the effect of pay-for-performance across health facilities in Tanzania. BMJ Glob Health 2020; 5:e002326. [PMID: 32474421 PMCID: PMC7264634 DOI: 10.1136/bmjgh-2020-002326] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 04/15/2020] [Accepted: 04/19/2020] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Ensuring efficient use and allocation of limited resources is crucial to achieving the UHC goal. Performance-based financing that provides financial incentives for health providers reaching predefined targets would be expected to enhance technical efficiency across facilities by promoting an output-oriented payment system. However, there is no study which has systematically assessed efficiency scores across facilities before and after the introduction of pay-for-performance (P4P). This paper seeks to fill this knowledge gap. METHODS We used data of P4P evaluation related to healthcare inputs (staff, equipment, medicines) and outputs (outpatient consultations and institutional deliveries) from 75 health facilities implementing P4P in Pwani region, and 75 from comparison districts in Tanzania. We measured technical efficiency using Data Envelopment Analysis and obtained efficiency scores across facilities before and after P4P scheme. We analysed which factors influence technical efficiency by regressing the efficiency scores over a number of contextual factors. We also tested the impact of P4P on efficiency through a difference-in-differences regression analysis. RESULTS The overall technical efficiency scores ranged between 0.40 and 0.65 for hospitals and health centres, and around 0.20 for dispensaries. Only 21% of hospitals and health centres were efficient when outpatient consultations and deliveries were considered as output, and <3% out of all facilities were efficient when outpatient consultations only were considered as outputs. Higher efficiency scores were significantly associated with the level of care (hospital and health centre) and wealthier catchment populations. Despite no evidence of P4P effect on efficiency on average, P4P might have improved efficiency marginally among public facilities. CONCLUSION Most facilities were not operating at their full capacity indicating potential for improving resource usage. A better understanding of the production process at the facility level and of how different healthcare financing reforms affects efficiency is needed. Effective reforms should improve inputs, outputs but also efficiency.
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Affiliation(s)
- Peter Binyaruka
- Health System, Impact Evaluation and Policy, Ifakara Health Institute, Dar es Salaam, Tanzania
| | - Laura Anselmi
- Health Organisation, Policy and Economics, Centre for Primary Care and Health Services Research, University of Manchester, Manchester, UK
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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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Assessing frontline HIV service provider efficiency using data envelopment analysis: a case study of Philippine social hygiene clinics (SHCs). BMC Health Serv Res 2019; 19:415. [PMID: 31234853 PMCID: PMC6591825 DOI: 10.1186/s12913-019-4163-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Accepted: 05/15/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Globally, local and frontline HIV service delivery units have been deployed to halt the HIV epidemic. However, with the limited resources, there is a need to understand how these units can deliver their optimum outputs/outcomes efficiently given the inputs. This study aims to determine the efficiency of the social hygiene clinics (SHC) in the Philippines as well as to determine the association of the meta-predictor to the efficiencies. METHODS In determining efficiency, we used the variables from two data sources namely the 2012 Philippine HIV Costing study and 2011 Integrated HIV Behavioral and Serologic Surveillance, as inputs and outputs, respectively. Various data management protocols and initial assumptions in data matching, imputation and variable selection, were used to create the final dataset with 9 SHCs. We used data envelopment analysis (DEA) to analyse the efficiency, while variations in efficiencies were analysed using Tobit regression with area-specific meta-predictors. RESULTS There were potentially inefficient use of limited resources among sampled SHC in both aggregate and key populations. Tobit regression results indicated that income was positively associated with efficiency, while HIV prevalence was negatively associated with the efficiency variations among the SHCs. CONCLUSIONS We were able to determine the inefficiently performing SHCs in the Philippines. Though currently inefficient, these SHCs may adjust their inputs and outputs to become efficient in the future. While there were indications of income and HIV prevalence to be associated with the efficiency variations, the results of this case study may only be limited in generalisability, thus further studies are warranted.
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Karatzas N, Peter T, Dave S, Fogarty C, Belinsky N, Pant Pai N. Are policy initiatives aligned to meet UNAIDS 90-90-90 targets impacting HIV testing and linkages to care? Evidence from a systematic review. PLoS One 2019; 14:e0216936. [PMID: 31166957 PMCID: PMC6550376 DOI: 10.1371/journal.pone.0216936] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Accepted: 05/01/2019] [Indexed: 11/18/2022] Open
Abstract
Background The Joint United Nations Programme on HIV/AIDS (UNAIDS) Fast-Track initiative seeks to eliminate AIDS as a health threat by 2030, with its focus on UNAIDS 90-90-90 targets. Effective policies and programs, if scaled nationally, have the potential to generate a greater impact on HIV control, yet a synthesis of successful HIV policies/programs aligned to the targets is currently unavailable. To fill this gap, we conducted a systematic review to evaluate successful HIV policies and programs to direct future interventions. Methods For the period 2007–2018, we searched 8 databases and classified eligible studies by country income level, UNAIDS targets, intervention type, and reported outcomes. Study outcomes were classified as per UNAIDS targets; proportionally: 90% target 1, 81% target 2, and 73% target 3. Results We retrieved 5201 citations and a final set of eight studies on policies. Break up by income: three (38%) from high income, one (12%) from middle income and four (50%) from low income. Break up by outcomes reported: 36% (4/11) focused on HIV testing, 46% (5/11) on antiretroviral therapy initiation, and 18% (2/11) on viral suppression. Across studies, UNAIDS targets were met in high-income countries, where policies and guidelines were adhered to, whereas in low and middle-income countries, non-adherence led to failure to reach the targets. Targets were also met when country infrastructure supported a targeted program and stakeholders were actively engaged. Conclusions From the studies identified, we deduced a clear, positive correlation between implementation of policies and programs that resulted in an increase in patient awareness and an increase in partner notification with services that encouraged them, and together these resulted in increasing testing rates, and deployment of linkage/retention programs that improved retention in care. An analysis of these studies also suggests that policies, combined with the scale-up incentives, are needed to change the status quo. Incentives to improve the targets must exist; performance incentives at the health care worker level and country level incentives that could transform the nature of care. Given the complexity in reporting of targets, a one size fits all model is not a feasible option. However, the policies created a strong framework to shape future interventions.
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Affiliation(s)
- Nicolaos Karatzas
- Division of Clinical Epidemiology, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Trevor Peter
- Clinton Health Access Initiative, Gaborone, Botswana
| | - Sailly Dave
- Division of Clinical Epidemiology, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Clare Fogarty
- Division of Clinical Epidemiology, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Nandi Belinsky
- Division of Clinical Epidemiology, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Nitika Pant Pai
- Division of Clinical Epidemiology, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada.,Department of Medicine, McGill University, Montreal, Quebec, Canada
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Rajkotia Y, Zang O, Nguimkeu P, Gergen J, Djurovic I, Vaz P, Mbofana F, Jobarteh K. The effect of a performance-based financing program on HIV and maternal/child health services in Mozambique-an impact evaluation. Health Policy Plan 2017; 32:1386-1396. [PMID: 29069378 PMCID: PMC5886140 DOI: 10.1093/heapol/czx106] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/08/2017] [Indexed: 11/30/2022] Open
Abstract
Performance-based financing (PBF) is a mechanism by which health providers are paid on the basis of outputs or results delivered. A PBF program was implemented on the provision of HIV, prevention of mother-to child HIV transmission (PMTCT), and maternal/child health (MCH) services in two provinces of Mozambique. A retrospective case-control study design was used in which PBF provinces were matched with control provinces to evaluate the impact of PBF on 18 indicators. Due to regional heterogeneity, we evaluated the intervention sites (North and South) separately. Beginning January 2011, 11 quarters (33 months or 2.75 years) of data from 134 facilities after matching (84 in the North and 50 in the South) were used. Our econometric framework employed a multi-period, multi-group difference-in-differences model on data that was matched using propensity scoring. The regression design employed a generalized linear mixed model with both fixed and random effects, fitted using the seemingly unrelated regression technique. PBF resulted in positive impacts on MCH, PMTCT and paediatric HIV program outcomes. The majority of the 18 indicators responded to PBF (77% in the North and 66% in the South), with at least half of the indicators demonstrating a statistically significant increase in average output of more than 50% relative to baseline. Excluding pregnant women, the majority of adult HIV treatment indicators did not respond to PBF. On average, it took 18 months (six quarters) of implementation for PBF to take effect, and impact was generally sustained thereafter. Indicators were not sensitive to price, but were inversely correlated to the level of effort associated with marginal output. No negative impacts on incentivized indicators nor spill-over effects on non-incentivized indicators were observed. The PBF program in Mozambique has produced large, sustained increases in the provision of PMTCT, paediatric HIV and MCH services. Our results demonstrate that PBF is an effective strategy for driving down the HIV epidemic and advancing MCH care service delivery as compared with input financing alone.
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Affiliation(s)
- Yogesh Rajkotia
- ThinkWell, Av. Cahora Bassa, Nr 122 2, Andar (2 Floor) Bairro da Somerschield Maputo, Maputo, Mozambique
| | - Omer Zang
- ThinkWell, Av. Cahora Bassa, Nr 122 2, Andar (2 Floor) Bairro da Somerschield Maputo, Maputo, Mozambique
| | - Pierre Nguimkeu
- ThinkWell, Av. Cahora Bassa, Nr 122 2, Andar (2 Floor) Bairro da Somerschield Maputo, Maputo, Mozambique
| | - Jessica Gergen
- ThinkWell, Av. Cahora Bassa, Nr 122 2, Andar (2 Floor) Bairro da Somerschield Maputo, Maputo, Mozambique
| | - Iva Djurovic
- ThinkWell, Av. Cahora Bassa, Nr 122 2, Andar (2 Floor) Bairro da Somerschield Maputo, Maputo, Mozambique
| | - Paula Vaz
- Fundação Ariel Glaser Contra o SIDA Pediátrico, Maputo, Mozambique
| | - Franscisco Mbofana
- Direcção Nacional de Saude Publica, Ministerio da Saude, Maputo, Mozambique
| | - Kebba Jobarteh
- Centers for Disease Control and Prevention, Maputo, Mozambique
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Hickey MD, Odeny TA, Petersen M, Neilands TB, Padian N, Ford N, Matthay Z, Hoos D, Doherty M, Beryer C, Baral S, Geng EH. Specification of implementation interventions to address the cascade of HIV care and treatment in resource-limited settings: a systematic review. Implement Sci 2017; 12:102. [PMID: 28784155 PMCID: PMC5547499 DOI: 10.1186/s13012-017-0630-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Accepted: 07/17/2017] [Indexed: 01/23/2023] Open
Abstract
Background The global response to HIV has started over 18 million persons on life-saving antiretroviral therapy (ART)—the vast majority in low- and middle-income countries (LMIC)—yet substantial gaps remain: up to 40% of persons living with HIV (PLHIV) know their status, while another 30% of those who enter care are inadequately retained after starting treatment. Identifying strategies to enhance use of treatment is urgently needed, but the conceptualization and specification of implementation interventions is not always complete. We sought to assess the completeness of intervention reporting in research to advance uptake of treatment for HIV globally. Methods We carried out a systematic review to identify interventions targeting the adult HIV care cascade in LMIC dating from 1990 to 2017. We identified components of each intervention as “intervention types” to decompose interventions into common components. We grouped “intervention types” into a smaller number of more general “implementation approaches” to aid summarization. We assessed the reporting of six intervention characteristics adapted from the implementation science literature: the actor, action, action dose, action temporality, action target, and behavioral target in each study. Findings In 157 unique studies, we identified 34 intervention “types,” which were empirically grouped into six generally understandable “approaches.” Overall, 42% of interventions defined the actor, 64% reported the action, 41% specified the intervention “dose,” 43% reported action temporality, 61% defined the action target, and 69% reported a target behavior. Average completeness of reporting varied across approaches from a low of 50% to a high of 72%. Dimensions that involved conceptualization of the practices themselves (e.g., actor, dose, temporality) were in general less well specified than consequences (e.g., action target and behavioral target). Implications The conceptualization and Reporting of implementation interventions to advance treatment for HIV in LMIC is not always complete. Dissemination of standards for reporting intervention characteristics can potentially promote transparency, reproducibility, and scientific accumulation in the area of implementation science to address HIV in low- and middle-income countries. Electronic supplementary material The online version of this article (doi:10.1186/s13012-017-0630-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Matthew D Hickey
- Division of General Internal Medicine, San Francisco General Hospital, Department of Medicine, University of California, San Francisco (UCSF), San Francisco, CA, USA
| | | | - Maya Petersen
- Department of Biostatistics and Epidemiology, School of Public Health, University of California, Berkeley, CA, USA
| | - Torsten B Neilands
- Center for AIDS Prevention Studies, Department of Medicine, UCSF, San Francisco, CA, USA
| | - Nancy Padian
- Department of Biostatistics and Epidemiology, School of Public Health, University of California, Berkeley, CA, USA
| | - Nathan Ford
- Department of HIV/AIDS, World Health Organization, Geneva, Switzerland
| | | | - David Hoos
- Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Meg Doherty
- Department of HIV/AIDS, World Health Organization, Geneva, Switzerland
| | - Chris Beryer
- Center for Public Health and Human Rights, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Stefan Baral
- Center for Public Health and Human Rights, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Elvin H Geng
- Division of ID HIV and Global Medicine, San Francisco General Hospital, Department of Medicine, UCSF, Building 80, 6th Floor, 1001 Potrero Avenue, San Francisco, CA, 94110, USA.
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Suthar AB, Nagata JM, Nsanzimana S, Bärnighausen T, Negussie EK, Doherty MC. Performance-based financing for improving HIV/AIDS service delivery: a systematic review. BMC Health Serv Res 2017; 17:6. [PMID: 28052771 PMCID: PMC5210258 DOI: 10.1186/s12913-016-1962-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2016] [Accepted: 12/17/2016] [Indexed: 11/04/2022] Open
Abstract
Background Although domestic HIV/AIDS financing is increasing, international HIV/AIDS financing has plateaued. Providing incentives for the health system (i.e. performance-based financing [PBF]) may help countries achieve more with available resources. We systematically reviewed effects of PBF on HIV/AIDS service delivery to inform WHO guidelines. Methods PubMed, WHO Index Medicus, conference databases, and clinical trial registries were searched in April 2015 for randomised trials, comparative contemporaneous studies, or time-series studies. Studies evaluating PBF in people with HIV were included when they reported service quality, access, or cost. Meta-analyses were not possible due to limited data. This study is registered with PROSPERO, number CRD42015023207. Results Four studies, published from 2009 to 2015 and including 173,262 people, met the eligibility criteria. All studies were from Sub-Saharan Africa. PBF did not improve individual testing coverage (relative risk [RR], 1.00, 95% confidence interval [CI] 0.89 to 1.13), improved couples testing coverage (RR 1.11, 95% CI 1.02 to 1.20), and improved pregnant women testing coverage (RR 1.29, 95% CI 1.28-1.30). PBF improved coverage of antiretrovirals in pregnant women (RR 1.55, 95% CI 1.50 to 1.59), infants (RR 1.92, 95% CI 1.84 to 2.01), and adults (RR 1.74, 1.64 to 1.85). PBF reduced attrition (RR 0.84, 95% CI 0.74 to 0.96) and treatment failure (odds ratio 0.55, 95% CI 0.32 to 0.97). Potential harms were not reported. Conclusions Although the limited data suggests PBF positively affected HIV service access and quality, critical health system and governance knowledge gaps remain. More research is needed to inform national policymaking. Electronic supplementary material The online version of this article (doi:10.1186/s12913-016-1962-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Amitabh B Suthar
- Department of HIV/AIDS, World Health Organization, 20 Avenue Appia, CH-1211, Geneva 27, Switzerland.
| | - Jason M Nagata
- Department of Pediatrics, Stanford University School of Medicine, Stanford, USA
| | - Sabin Nsanzimana
- Rwanda Biomedical Center, Kigali, Rwanda.,Basel Institute for Clinical Epidemiology and Biostatistics, Swiss Tropical and Public Health Institute, Basel, Switzerland
| | - Till Bärnighausen
- Institute of Public Health, Faculty of Medicine, Heidelberg University, Heidelberg, Germany.,Harvard T.H. Chan School of Public Health, Boston, USA.,Africa Health Research Institute (AHRI), Somkhele and Durban, South Africa
| | - Eyerusalem K Negussie
- Department of HIV/AIDS, World Health Organization, 20 Avenue Appia, CH-1211, Geneva 27, Switzerland
| | - Meg C Doherty
- Department of HIV/AIDS, World Health Organization, 20 Avenue Appia, CH-1211, Geneva 27, Switzerland
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11
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Nahimana E, McBain R, Manzi A, Iyer H, Uwingabiye A, Gupta N, Muzungu G, Drobac P, Hirschhorn LR. Race to the Top: evaluation of a novel performance-based financing initiative to promote healthcare delivery in rural Rwanda. Glob Health Action 2016; 9:32943. [PMID: 27900933 PMCID: PMC5129093 DOI: 10.3402/gha.v9.32943] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Revised: 10/07/2016] [Accepted: 10/27/2016] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Performance-based financing (PBF) has demonstrated a range of successes and failures in improving health outcomes across low- and middle-income countries. Evidence indicates that the success of PBF depends, in large part, on the model selected, in relation to a variety of contextual factors. OBJECTIVE Partners In Health∣Inshuti Mu Buzima aimed to evaluate health outcomes associated with a novel capacity-building model of PBF at health centers throughout Kirehe district, Rwanda. DESIGN Thirteen health centers in Kirehe district, which provide healthcare to a population of over 300,000 people, agreed to participate in a PBF initiative scheme that integrated data feedback, quality improvement coaching, peer-to-peer learning, and district-level priority setting. Health centers' progress toward collectively agreed upon site-specific health targets was assessed every 6 months for 18 months. Incentives were awarded only when health centers met goals on all three priorities health centers had collectively agreed upon: 90% coverage of community-based health insurance, 70% contraceptive prevalence rate, and zero acute severe malnutrition cases. Improvement across all four time points and facilities was measured using mixed-effects linear regression. FINDINGS At 6-month follow-up, 4 of 13 health centers had met 1 target. At 12-month follow-up, 7 centers had met 1 target, and by 18-month follow-up, 6 centers had met 2 targets and 2 centers had met all 3. Average health center performance had improved significantly across the district for all three targets: mean insurance coverage increased from 68% at baseline to 93% (p<0.001); mean number of acute malnutrition cases in the previous 6 months declined from 24 to 5 per facility (p<0.001); and contraceptive prevalence increased from 42 to 59% (p<0.001). A number of innovative improvement initiatives were identified. CONCLUSION The combining of PBF, district engagement/support, and peer-to-peer learning resulted in significant improvements despite resource constraints and is now being considered as a model for scale-up in other districts of Rwanda.
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Affiliation(s)
- Evrard Nahimana
- Partners In Health
- Inshuti Mu Buzima, Kigali, Rwanda.,Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA;
| | | | | | - Hari Iyer
- Department of Epidemiology, Harvard School of Public Health, Boston, MA, USA
| | | | - Neil Gupta
- Partners In Health
- Inshuti Mu Buzima, Kigali, Rwanda.,Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA.,Division of Global Health Equity, Brigham and Women's Hospital, Boston, MA, USA
| | | | - Peter Drobac
- Partners In Health
- Inshuti Mu Buzima, Kigali, Rwanda.,Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA.,Division of Global Health Equity, Brigham and Women's Hospital, Boston, MA, USA
| | - Lisa R Hirschhorn
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA.,Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
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12
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Di Giorgio L, Moses MW, Fullman N, Wollum A, Conner RO, Achan J, Achoki T, Bannon KA, Burstein R, Dansereau E, DeCenso B, Delwiche K, Duber HC, Gakidou E, Gasasira A, Haakenstad A, Hanlon M, Ikilezi G, Kisia C, Levine AJ, Maboshe M, Masiye F, Masters SH, Mphuka C, Njuguna P, Odeny TA, Okiro EA, Roberts DA, Murray CJL, Flaxman AD. The potential to expand antiretroviral therapy by improving health facility efficiency: evidence from Kenya, Uganda, and Zambia. BMC Med 2016; 14:108. [PMID: 27439621 PMCID: PMC4952151 DOI: 10.1186/s12916-016-0653-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Accepted: 07/06/2016] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Since 2000, international funding for HIV has supported scaling up antiretroviral therapy (ART) in sub-Saharan Africa. However, such funding has stagnated for years, threatening the sustainability and reach of ART programs amid efforts to achieve universal treatment. Improving health system efficiencies, particularly at the facility level, is an increasingly critical avenue for extending limited resources for ART; nevertheless, the potential impact of increased facility efficiency on ART capacity remains largely unknown. Through the present study, we sought to quantify facility-level technical efficiency across countries, assess potential determinants of efficiency, and predict the potential for additional ART expansion. METHODS Using nationally-representative facility datasets from Kenya, Uganda and Zambia, and measures adjusting for structural quality, we estimated facility-level technical efficiency using an ensemble approach that combined restricted versions of Data Envelopment Analysis and Stochastic Distance Function. We then conducted a series of bivariate and multivariate regression analyses to evaluate possible determinants of higher or lower technical efficiency. Finally, we predicted the potential for ART expansion across efficiency improvement scenarios, estimating how many additional ART visits could be accommodated if facilities with low efficiency thresholds reached those levels of efficiency. RESULTS In each country, national averages of efficiency fell below 50 % and facility-level efficiency markedly varied. Among facilities providing ART, average efficiency scores spanned from 50 % (95 % uncertainty interval (UI), 48-62 %) in Uganda to 59 % (95 % UI, 53-67 %) in Zambia. Of the facility determinants analyzed, few were consistently associated with higher or lower technical efficiency scores, suggesting that other factors may be more strongly related to facility-level efficiency. Based on observed facility resources and an efficiency improvement scenario where all facilities providing ART reached 80 % efficiency, we predicted a 33 % potential increase in ART visits in Kenya, 62 % in Uganda, and 33 % in Zambia. Given observed resources in facilities offering ART, we estimated that 459,000 new ART patients could be seen if facilities in these countries reached 80 % efficiency, equating to a 40 % increase in new patients. CONCLUSIONS Health facilities in Kenya, Uganda, and Zambia could notably expand ART services if the efficiency with which they operate increased. Improving how facility resources are used, and not simply increasing their quantity, has the potential to substantially elevate the impact of global health investments and reduce treatment gaps for people living with HIV.
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Affiliation(s)
- Laura Di Giorgio
- />Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave, Suite 600, Seattle, WA 98121 USA
| | - Mark W. Moses
- />Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave, Suite 600, Seattle, WA 98121 USA
| | - Nancy Fullman
- />Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave, Suite 600, Seattle, WA 98121 USA
| | - Alexandra Wollum
- />Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave, Suite 600, Seattle, WA 98121 USA
| | - Ruben O. Conner
- />Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave, Suite 600, Seattle, WA 98121 USA
| | - Jane Achan
- />Infectious Diseases Research Collaboration, Mulago Hospital Complex, Kampala, Uganda
| | - Tom Achoki
- />Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave, Suite 600, Seattle, WA 98121 USA
| | - Kelsey A. Bannon
- />Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave, Suite 600, Seattle, WA 98121 USA
| | - Roy Burstein
- />Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave, Suite 600, Seattle, WA 98121 USA
| | - Emily Dansereau
- />Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave, Suite 600, Seattle, WA 98121 USA
| | - Brendan DeCenso
- />Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave, Suite 600, Seattle, WA 98121 USA
| | - Kristen Delwiche
- />Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave, Suite 600, Seattle, WA 98121 USA
| | - Herbert C. Duber
- />Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave, Suite 600, Seattle, WA 98121 USA
| | - Emmanuela Gakidou
- />Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave, Suite 600, Seattle, WA 98121 USA
| | | | - Annie Haakenstad
- />Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave, Suite 600, Seattle, WA 98121 USA
| | - Michael Hanlon
- />Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave, Suite 600, Seattle, WA 98121 USA
| | - Gloria Ikilezi
- />Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave, Suite 600, Seattle, WA 98121 USA
- />Infectious Diseases Research Collaboration, Mulago Hospital Complex, Kampala, Uganda
| | | | - Aubrey J. Levine
- />Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave, Suite 600, Seattle, WA 98121 USA
| | - Mashekwa Maboshe
- />School of Humanities and Social Sciences, University of Zambia, Lusaka, Zambia
| | - Felix Masiye
- />Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave, Suite 600, Seattle, WA 98121 USA
- />School of Humanities and Social Sciences, University of Zambia, Lusaka, Zambia
| | - Samuel H. Masters
- />Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave, Suite 600, Seattle, WA 98121 USA
| | - Chrispin Mphuka
- />School of Humanities and Social Sciences, University of Zambia, Lusaka, Zambia
| | | | - Thomas A. Odeny
- />Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave, Suite 600, Seattle, WA 98121 USA
| | | | - D. Allen Roberts
- />Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave, Suite 600, Seattle, WA 98121 USA
| | - Christopher J. L. Murray
- />Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave, Suite 600, Seattle, WA 98121 USA
| | - Abraham D. Flaxman
- />Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave, Suite 600, Seattle, WA 98121 USA
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13
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Opening the ‘black box’ of performance-based financing in low- and lower middle-income countries: a review of the literature. Health Policy Plan 2016; 31:1297-309. [DOI: 10.1093/heapol/czw045] [Citation(s) in RCA: 87] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/21/2016] [Indexed: 11/14/2022] Open
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14
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Zeng W, Shepard DS, Avila-Figueroa C, Ahn H. Resource needs and gap analysis in achieving universal access to HIV/AIDS services: a data envelopment analysis of 45 countries. Health Policy Plan 2015; 31:624-33. [PMID: 26552409 DOI: 10.1093/heapol/czv109] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/06/2015] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND -To manage the human immunodeficiency virus and acquired immune deficiency syndrome (HIV/AIDS) epidemic, international donors have pledged unprecedented commitments for needed services. The Joint United Nations Programme on HIV/AIDS (UNAIDS) projected that low- and middle-income countries needed $25 billion to meet the 2010 HIV/AIDS goal of universal access to AIDS prevention and care, using the resource needs model (RNM). METHODS -Drawing from the results from its sister study, which used a data envelopment analysis (DEA) and a Tobit model to evaluate and adjust the technical efficiency of 61 countries in delivering HIV/AIDS services from 2002 to 2007, this study extended the DEA and developed an approach to estimate resource needs and decompose the performance gap into efficiency gap and resource gap. In the DEA, we considered national HIV/AIDS spending as the input and volume of voluntary counseling and testing (VCT), prevention of mother to child transmission (PMTCT) and antiretroviral treatment (ART) as the outputs. An input-oriented DEA model was constructed to project resource needs in achieving 2010 HIV/AIDS goal for 45 countries using the data in 2006, assuming that all study countries maximized efficiency. FINDINGS -The DEA approach demonstrated the potential to include efficiency of national HIV/AIDS programmes in resource needs estimation, using macro-level data. Under maximal efficiency, the annual projected resource needs for the 45 countries was $6.3 billion, ∼47% of their UNAIDS estimate of $13.5 billion. Given study countries' spending of $3.9 billion, improving efficiency could narrow the gap from $9.6 to $2.4 billion. The results suggest that along with continued financial commitment to HIV/AIDS, improving the efficiency of HIV/AIDS programmes would accelerate the pace to reach 2010 HIV/AIDS goals. The DEA approach provides a supplement to the AIDS RNM to inform policy making.
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Affiliation(s)
- Wu Zeng
- Schneider Institutes for Health Policy, Heller School, MS 035, Brandeis University, Waltham, MA 02454, USA,
| | - Donald S Shepard
- Schneider Institutes for Health Policy, Heller School, MS 035, Brandeis University, Waltham, MA 02454, USA
| | | | - Haksoon Ahn
- School of Social Work, University of Maryland, Baltimore, MD 21201, USA
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15
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Skiles MP, Curtis SL, Basinga P, Angeles G, Thirumurthy H. The effect of performance-based financing on illness, care-seeking and treatment among children: an impact evaluation in Rwanda. BMC Health Serv Res 2015; 15:375. [PMID: 26369410 PMCID: PMC4570690 DOI: 10.1186/s12913-015-1033-7] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2013] [Accepted: 09/03/2015] [Indexed: 11/14/2022] Open
Abstract
Background Performance-based financing (PBF) strategies are promoted as a supply-side, results-based financing mechanism to improve primary health care. This study estimated the effects of Rwanda’s PBF program on less-incentivized child health services and examined the differential program impact by household poverty. Methods Districts were allocated to intervention and comparison for PBF implementation in Rwanda. Using Demographic Health Survey data from 2005 to 2007–08, a community-level panel dataset of 5781 children less than 5 years of age from intervention and comparison districts was created. The impacts of PBF on reported childhood illness, facility care-seeking, and treatment received were estimated using a difference-in-differences model with community fixed effects. An interaction term between poverty and the program was estimated to identify the differential effect of PBF among children from poorer families. Results There was no measurable difference in estimated probability of reporting illness with diarrhea, fever or acute respiratory infections between the intervention and comparison groups. Seeking care at a facility for these illnesses increased over time, however no differential effect by PBF was seen. The estimated effect of PBF on receipt of treatment for poor children is 45 percentage points higher (p = 0.047) compared to the non-poor children seeking care for diarrhea or fever. Conclusions PBF, a supply-side incentive program, improved the quality of treatment received by poor children conditional on patients seeking care, but it did not impact the propensity to seek care. These findings provide additional evidence that PBF incentivizes the critical role staff play in assuring quality services, but does little to influence consumer demand for these services. Efforts to improve child health need to address both supply and demand, with additional attention to barriers due to poverty if equity in service use is a concern. Electronic supplementary material The online version of this article (doi:10.1186/s12913-015-1033-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Martha Priedeman Skiles
- The Carolina Population Center, University of North Carolina at Chapel Hill, 400 Meadowmont Village Circle, 3rd Floor, Chapel Hill, NC, 27517, USA.
| | - Siân L Curtis
- The Carolina Population Center, University of North Carolina at Chapel Hill, 400 Meadowmont Village Circle, 3rd Floor, Chapel Hill, NC, 27517, USA. .,Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA.
| | - Paulin Basinga
- Global Health Program, Bill and Melinda Gates Foundation, Seattle, WA, USA. .,Rwanda Biomedical Center, Ministry of Health, Kigali, Rwanda.
| | - Gustavo Angeles
- The Carolina Population Center, University of North Carolina at Chapel Hill, 400 Meadowmont Village Circle, 3rd Floor, Chapel Hill, NC, 27517, USA. .,Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA.
| | - Harsha Thirumurthy
- The Carolina Population Center, University of North Carolina at Chapel Hill, 400 Meadowmont Village Circle, 3rd Floor, Chapel Hill, NC, 27517, USA. .,Department Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA.
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16
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Nsanzimana S, Remera E, Kanters S, Forrest JI, Ford N, Condo J, Binagwaho A, Bucher H, Thorlund K, Vitoria M, Mills EJ. Effect of baseline CD4 cell count at linkage to HIV care and at initiation of antiretroviral therapy on mortality in HIV-positive adult patients in Rwanda: a nationwide cohort study. Lancet HIV 2015; 2:e376-84. [PMID: 26423551 DOI: 10.1016/s2352-3018(15)00112-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Revised: 05/06/2015] [Accepted: 06/02/2015] [Indexed: 11/19/2022]
Abstract
BACKGROUND Continued debate exists about whether initiation of antiretroviral therapy (ART) in symptom-free patients at higher baseline CD4 cell counts results in important clinical benefits. We aimed to examine to what extent baseline CD4 cell count at linkage to HIV care and at ART initiation predicts mortality in adults with HIV in Rwanda. METHODS We included data for patients with HIV in Rwanda who were aged 15 years or older and linked to care or initiated ART between Jan 1, 1997, and April 30, 2014, from nationally representative databases. We analysed the effect on mortality of baseline CD4 cell count at ART initiation and at linkage to care. Follow-up time was measured from time of ART initiation and from linkage to HIV care to study exit. To account for effect modification by time, we stratified by era of linkage (before 2008 vs 2008 or after) and for other indications for initiation of ART. We also stratified CD4 cell count by indication to initiate ART other than CD4 cell count status. We used Cox proportional hazard regressions to examine the effect of CD4 cell count at linkage and at ART initiation on mortality. FINDINGS Our analysis was based on data from 50,147 patients who initiated ART and 72,061 patients linked to care. In the late era (2008 and after), linkage to care at a CD4 cell count of 100-199 cells per μL without any further indication was associated with higher mortality than linkage at 200-349 cells per μL (hazard ratio [HR] 1·37, 95% CI 0·95-1·97); the effect was much the same for initiation of ART in this CD4 stratum (1·37, 0·92-2·04). For higher CD4 strata, linkage to care at 500 cells per μL or more was protective (0·53, 0·39-0·72), whereas the reported effect of initiation of ART on mortality was not distinguishable from chance alone (0·82, 0·21-3·20). INTERPRETATION Efforts are needed to link and retain patients early in pre-ART HIV care. In settings where ART is not yet available for immediate treatment, retention in a strong pre-ART programme is effective at improving survival. FUNDING The Bill & Melinda Gates Foundation.
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Affiliation(s)
- Sabin Nsanzimana
- University of Basel, Swiss Tropical and Public health institute and Institute for Clinical Epidemiology and Biostatistics, Basel Switzerland
| | - Eric Remera
- Institute of HIV Disease Prevention and Control, Rwanda Biomedical Centre, Kigali, Rwanda
| | - Steve Kanters
- Global Evaluative Sciences, Vancouver, BC, Canada; School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Jamie I Forrest
- Global Evaluative Sciences, Vancouver, BC, Canada; School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Nathan Ford
- Department of HIV/AIDS, World Health Organization, Geneva, Switzerland
| | - Jeanine Condo
- School of Public Health, College of Medicine & Health Sciences, University of Rwanda, Kigali, Rwanda
| | | | - Heiner Bucher
- Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital of Basel, Basel, Switzerland
| | | | - Marco Vitoria
- Department of HIV/AIDS, World Health Organization, Geneva, Switzerland
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