Suchergebnisse

IntroductionHIV programme data from routine health information systems (RHIS) and personal health information (PHI) provide ample opportunities for secondary data analysis. However, these data pose unique opportunities and challenges for use in health system monitoring, along with process and impact evaluations.MethodsAnalyses focused on retrospective case reviews of four of the HIV‐related studies published in this JIAS supplement. We identify specific opportunities and challenges with respect to the secondary analysis of RHIS and PHI data.ResultsChallenges working with both HIV‐related RHIS and PHI included missing, inconsistent and implausible data; rapidly changing indicators; systematic differences in the utilization of services; and patient linkages over time and different data sources. Specific challenges among RHIS data included numerous registries and indicators, inconsistent data entry, gaps in data transmission, duplicate registry of information, numerator‐denominator incompatibility and infrequent use of data for decision‐making. Challenges specific to PHI included the time burden for busy providers, the culture of lax charting, overflowing archives for paper charts and infrequent chart review.ConclusionsMany of the challenges that undermine effective use of RHIS and PHI data for analyses are related to the processes and context of collecting the data, excessive data requirements, lack of knowledge of the purpose of data and the limited use of data among those generating the data. Recommendations include simplifying data sources, analysis and reporting; conducting systematic data quality audits; enhancing the use of data for decision‐making; promoting routine chart review linked with simple patient tracking systems; and encouraging open access to RHIS and PHI data for increased use.

BACKGROUND: Knowledge of the relation between health-system factors and child mortality could help to inform health policy in low-income and middle-income countries. We aimed to quantify modifiable health-system factors and their relation with provincial-level heterogeneity in under-5, infant, and neonatal mortality over time in Mozambique. METHODS: Using Demographic and Health Survey (2003 and 2011) and Multiple Indicator Cluster Survey (2008) data, we generated provincial-level time-series of child mortality in under-5 (ages 0-4 years), infant (younger than 1 year), and neonatal (younger than 1 month) age groups for 2000-10. We built negative binomial mixed models to examine health-system factors associated with changes in child mortality. FINDINGS: Under-5 mortality rate was heterogeneous across provinces, with yearly decreases ranging from 11·1% (Nampula) to 1·9% (Maputo Province). Heterogeneity was greater for neonatal mortality rate, with only seven of 11 provinces showing significant yearly decreases, ranging from 13·6% (Nampula) to 4·2% (Zambezia). Health workforce density (adjusted rate ratio 0·94, 95% CI 0·90-0·98) and maternal and child health nurse density (0·96, 0·92-0·99) were both associated with reduced under-5 mortality rate, as were institutional birth coverage (0·94, 0·90-0·98) and government financing per head (0·80, 0·65-0·98). Higher population per health facility was associated with increased under-5 mortality rate (1·14, 1·02-1·28). Neonatal mortality rate was most strongly associated with institutional birth attendance, maternal and child nurse density, and overall health workforce density. Infant mortality rate was most strongly associated with institutional birth attendance and population per health facility. INTERPRETATION: The large decreases in child mortality seen in Mozambique between 2000 and 2010 could have been partly caused by improvements in the public-sector health workforce, institutional birth coverage, and government health financing. Increased attention should be paid to service availability, because population per health facility is increasing across Mozambique and is associated with increased under-5 mortality. Investments in health information systems and new methods to track potentially increasing subnational health disparities are urgently needed. FUNDING: Doris Duke Charitable Foundation and Mozambican National Institute of Health.

IntroductionLoss‐to‐follow‐up (LTFU) in the prevention of mother‐to‐child HIV transmission (PMTCT) programmes can occur at multiple stages of antenatal and follow‐up care. This paper presents findings from a national assessment aimed at identifying major bottlenecks in Côte d'Ivoire's PMTCT cascade, and to distinguish characteristics of high‐ and low‐performing health facilities.MethodsThis cross‐sectional study, based on a nationally representative sample of 30 health facilities in Côte d'Ivoire used multiple data sources (registries, patient charts, patient booklets, interviews) to determine the magnitude of LTFU in PMTCT services. A composite measure of retention – based on child prophylaxis, maternal treatment and infant testing – was used to identify high‐ and low‐performing sites and determine significant differences using Student's t‐tests.ResultsAmong 1,741 pregnant women newly recorded as HIV‐positive between June 2011 and May 2012, 43% had a CD4 count taken, 77% received appropriate prophylaxis and 70% received prophylaxis intended for their infant. During that time, 1,054 first infant HIV tests were recorded. A conservative rate of adherence to antiretroviral therapy was estimated at 50% (n=219 patient charts). Significant differences between high‐ and low‐performing sites included: duration of time elapsed between HIV testing and CD4 results (29.5 versus 56.3 days, p=0.001); and density (number per 100 first antenatal care visits) of full‐time physicians (6.7 versus 1.7, p=0.04), laboratory technicians (2.3 versus 0.7, p=0.046), staff trained in PMTCT (10.7 versus 4.7, p=0.01), and staff performing patient follow‐up activities (7.9 versus 2.5, p=0.02). Key informants highlighted staff presence and training, the availability of medical supplies and equipment (i.e., on‐site CD4 machine), and the adequacy of infrastructure (i.e., space and ventilation) as perceived key factors positively and negatively impacting retention in care.ConclusionsPatient LTFU occurred throughout the PMTCT cascade from maternal to infant testing, with retention scores ranging from 0.10 to 0.83. Sites that scored higher had more dedicated and trained frontline health workers, and emphasised patient follow‐up through outreach and the reduction of delays in care. Strategies to improve patient retention and decrease transmission should emphasise patient tracking systems that utilise critical human resources to both improve data quality and increase direct patient follow‐up.

IntroductionAccording to UNAIDS, the world currently has an adequate collection of proven HIV prevention, treatment and diagnostic tools, which, if scaled up, can lay the foundation for ending the AIDS epidemic. HIV operations research (OR) tests and promotes the use of interventions that can increase the demand for and supply of these tools. However, current publications of OR mainly focus on outcomes, leaving gaps in reporting of intervention characteristics, which are essential to address for the utilization of OR findings. This has prompted WHO and other international public health agencies to issue reporting requirements for OR studies. The objective of this commentary is to review experiences in HIV OR intervention design, implementation, process data collection and publication in order to identify gaps, contribute to the body of knowledge and propose a way forward to improve the focus on "implementation" in implementation research.DiscussionInterventions in OR, like ordinary service delivery programmes, are subject to the programme cycle, which continually uses insights from implementation and the local context to modify service delivery modalities. Given that some of these modifications in the intervention may influence study outcomes, the documentation of process data becomes vital in OR. However, a key challenge is that study resources tend to be skewed towards documentation and the reporting of study outcomes to the detriment of process data, even though process data is vital for understanding factors influencing the outcomes.ConclusionsInterventions in OR should be viewed using the lens of programme evaluation, which includes formative assessment (to determine concept and design), followed by process evaluation (to monitor inputs and outputs) and effectiveness evaluation (to assess outcomes and effectiveness). Study resources should be equitably used between process evaluation and outcome measurement to facilitate inclusion of data about fidelity and dose in publications in order to enable explanation of the relationship between dosing and study outcomes for purposes of scaling up and further refinement through research.

IntroductionEfforts to implement and take to scale highly efficacious, low‐cost interventions to prevent mother‐to‐child HIV transmission (pMTCT) have been a cornerstone of reproductive health services in sub‐Saharan Africa for over a decade. Yet efforts to increase access and utilization of these services remain far from optimal. This study developed and applied an approach to systematically classify pMTCT performance to identify modifiable health system factors associated with pMTCT performance which may be replicated in other pMTCT systems.MethodsFacility‐level performance measures were collected at 30 sites over a 12‐month period and reviewed for consistency. Five combinations of three indicators (1. HIV testing; 2. CD4 testing; 3. antiretroviral prophylaxis and combined antiretroviral therapy initiation) were compared including a composite of all three, a combination of 1. and 3., and each individually. Approaches were visually assessed to describe facility performance, focusing on rank order consistency across high, medium and low categories. Modifiable and non‐modifiable factors were ascertained at each site and ranking process was reviewed to estimate association with facility performance through unadjusted Chi‐square tests and logistic regression. After describing factors associated with high versus low performing pMTCT clinics, the effect of inclusion of the 10 middle performers was assessed.ResultsThe indicator most consistently associated with the reference composite indicator (HIV testing, antiretroviral prophylaxis and combined antiretroviral therapy) was the single measure of antiretroviral prophylaxis and combined antiretroviral therapy. Lower performing pMTCT clinics ranked consistently low across measurement strategies; high and middle performing clinics demonstrated more variability. Association between clinic characteristics and high pMTCT performance varied markedly across ranking strategies. Using the reference composite indicator, larger catchment area, higher number of institutional deliveries, onsite CD4 point‐of‐care capacity, and higher numbers of nurses and doctors were associated with high clinic performance while clinic location, NGO support, women's support group, community linkages patient‐tracking systems and stock‐outs were not associated with high performance.ConclusionsClassifying high and low performance provided consistent results across ranking measures, though granularity was improved by aggregating middle performers with either high or low performers. Human resources, catchment size and utilization were positively associated with effective pMTCT service delivery.

Abstract Background Since the rapid scale-up of antiretroviral therapy (ART) programs in sub-Saharan Africa, electronic patient tracking systems (EPTS) have been deployed to respond to the growing demand for program monitoring, evaluation and reporting to governments and donors. These routinely collected data are often used in epidemiologic and operations research studies intended to improve programs. To ensure accurate reporting and good quality for research, the reliability and completeness of data systems need to be assessed and reported. We assessed the completeness and reliability of EPTS used in 16 HIV care and treatment clinics in Manica and Sofala provinces of Mozambique. Methods We conducted a cross-sectional study to assess the completeness and reliability of key variables in the electronic data system for patients enrolling in 16 public sector HIV treatment clinics between 1 July 2004 and 30 June 2008. Data from the electronic database was compared with data abstracted from a stratified random sample of 520 patient charts. Percent agreement, kappa scores and concordance correlation coefficients were calculated for specified variables. Percentile bootstrap confidence intervals were calculated to account for the stratified nature of our sampling. Results A total of 16,149 patients with a median age of 33 years and a median CD4 count of 151 enrolled in these 16 clinics between 1 July 2004 and 30 June 2008. The level of completeness was high for most variables with height (18.6%) and weight (11.5%) having the highest amount of missing data. The level of agreement for available data was also high with reliability statistics of 0.95 (95% CI: 0.92-0.98) for gender, 0.91 (95% CI: 0.80-1.00) for pre-ART CD4 value and 0.97 (95% CI: 0.95-0.99) for patient retention. Conclusions Electronic patient tracking systems have been deployed to respond to the growing monitoring, evaluation and reporting requirements. In our cross-sectional study of clinics in Manica and Sofala provinces of Mozambique, we found high levels of completeness and reliability for key variables indicating that these electronic databases provided adequate data not only for monitoring and evaluation but also for research. Routine evaluations of the completeness and reliability of these databases need to occur to ensure high quality data are being used for reporting and research.

IntroductionIn 2004, Mozambique, supported by large increases in international disease‐specific funding, initiated a national rapid scale‐up of antiretroviral treatment (ART) and HIV care through a vertical "Day Hospital" approach. Though this model showed substantial increases in people receiving treatment, it diverted scarce resources away from the primary health care (PHC) system. In 2005, the Ministry of Health (MOH) began an effort to use HIV/AIDS treatment and care resources as a means to strengthen their PHC system. The MOH worked closely with a number of NGOs to integrate HIV programs more effectively into existing public‐sector PHC services.Case DescriptionIn 2005, the Ministry of Health and Health Alliance International initiated an effort in two provinces to integrate ART into the existing primary health care system through health units distributed across 23 districts. Integration included: a) placing ART services in existing units; b) retraining existing workers; c) strengthening laboratories, testing, and referral linkages; e) expanding testing in TB wards; f) integrating HIV and antenatal services; and g) improving district‐level management. Discussion: By 2008, treatment was available in nearly 67 health facilities in 23 districts. Nearly 30,000 adults were on ART. Over 80,000 enrolled in the HIV/AIDS program. Loss to follow‐up from antenatal and TB testing to ART services has declined from 70% to less than 10% in many integrated sites. Average time from HIV testing to ART initiation is significantly faster and adherence to ART is better in smaller peripheral clinics than in vertical day hospitals. Integration has also improved other non‐HIV aspects of primary health care.ConclusionThe integration approach enables the public sector PHC system to test more patients for HIV, place more patients on ART more quickly and efficiently, reduce loss‐to‐follow‐up, and achieve greater geographic HIV care coverage compared to the vertical model. Through the integration process, HIV resources have been used to rehabilitate PHC infrastructure (including laboratories and pharmacies), strengthen supervision, fill workforce gaps, and improve patient flow between services and facilities in ways that can benefit all programs. Using aid resources to integrate and better link HIV care with existing services can strengthen wider PHC systems.

IntroductionEffectiveness of the rapid expansion of antiretroviral therapy (ART) throughout sub‐Saharan Africa is highly dependent on adequate enrolment and retention in HIV care. However, the measurement of both has been challenging in these settings. This study aimed to assess enrolment and retention in HIV care (pre‐ART and ART) among HIV‐positive adults in Central Mozambique, including identification of barriers and facilitators.MethodsWe assessed linkages to and retention in HIV care using a mixed quantitative and qualitative approach in six districts of Manica and Sofala provinces. We analyzed routine district and health facility monthly reports and HIV care registries from April 2012 to March 2013 and used single imputation and trimmed means to adjust for missing values. In eight health facilities in the same districts and period, we assessed retention in HIV care among 795 randomly selected adult patient charts (15 years and older). We also conducted 25 focus group discussions and 53 in‐depth interviews with HIV‐positive adults, healthcare providers and community members to identify facilitators and barriers to enrolment and retention in HIV care.ResultsOverall, 46% of the monthly HIV testing reports expected at the district level were missing, compared to 6.4% of the pre‐ART registry reports. After adjustment for missing values, we estimated that the aggregate numbers of adults registered in pre‐ART was 75% of the number of persons tested HIV‐positive in the six districts. In the eight health facilities, 40% of the patient charts for adults enrolled in pre‐ART and 44% in ART were missing. Of those on ART for whom charts were found, retention in treatment within 90 and 60 days prior to the study team visit was 34 and 25%, respectively. Combining these multiple data sources, the overall estimated retention was 18% in our sample. Individual‐level factors were perceived to be key influences to enrolment in HIV care, while health facility and structural‐level factors were perceived to be key influences of retention.ConclusionsEfforts to increase linkages to and retention in HIV care should address individual, health facility, and structural‐level factors in Central Mozambique. However, their outcomes cannot be reliably assessed without improving the quality of routine health information systems.

INTRODUCTION: In recent years, China has increased its international engagement in health. Nonetheless, the lack of data on contributions has limited efforts to examine contributions from China. Existing estimates that track development assistance for health (DAH) from China have relied primarily on one dataset. Furthermore, little is known about the disbursing agencies especially the multilaterals through which contributions are disbursed and how these are changing across time. In this study, we generated estimates of DAH from China from 2007 through 2017 and disaggregated those estimates by disbursing agency and health focus area. METHODS: We identified the major government agencies providing DAH. To estimate DAH provided by each agency, we leveraged publicly available development assistance data in government agencies' budgets and financial accounts, as well as revenue statements from key international development agencies such as the WHO. We reported trends in DAH from China, disaggregated contributions by disbursing bilateral and multilateral agencies, and compared DAH from China with other traditional donors. We also compared these estimates with existing estimates. RESULTS: DAH provided by China grew dramatically, from US$323.1 million in 2007 to $652.3 million in 2017. During this period, 91.8% of DAH from China was disbursed through its bilateral agencies, including the Ministry of Commerce ($3.7 billion, 64.1%) and the National Health Commission ($917.1 million, 16.1%); the other 8.2% was disbursed through multilateral agencies including the WHO ($236.5 million, 4.1%) and the World Bank ($123.1 million, 2.2%). Relative to its level of economic development, China provided substantially more DAH than would be expected. However, relative to population size and government spending, China's contributions are modest. CONCLUSION: In the current context of plateauing in the growth rate of DAH contributions, China has the potential to contribute to future global health financing, especially financing for health ...

Frontmatter -- Contents -- Figures -- Foreword / Navarro, Vicente -- Acknowledgments -- Part I. Health Comrades in Context -- Chapter 1. Introduction: Health Comrades, Abroad and at Home / Birn, Anne-Emanuelle / Brown, Theodore M. -- Chapter 2. The Making of Health Internationalists / Brown, Theodore M. / Birn, Anne-Emanuelle -- Part II. Generation Born in the 1870s–1910s -- Chapter 3. The Perils of Unconstrained Enthusiasm: John Kingsbury, Soviet Public Health, and 1930s America / Gross Solomon, Susan -- Chapter 4. American Medical Support for Spanish Democracy, 1936–1938 / Lear, Walter J. -- Chapter 5. Medical McCarthyism and the Punishment of Internationalist Physicians in the United States / Brickman, Jane Pacht -- Part III. Generation Born in the 1920s–1930s -- Chapter 6. Contesting Racism and Innovating Community Health Centers: Approaches on Two Continents / Geiger, H. Jack -- Chapter 7. Barefoot in China, the Bronx, and Beyond / Sidel, Victor W. / Sidel, Ruth -- Chapter 8. Medical Internationalism and the "Last Epidemic" / Lown, Bernard -- Part IV. Generation Born in the 1940s–1960s -- Chapter 9. Social Medicine, at Home and Abroad / Waitzkin, Howard -- Chapter 10. Find the Best People and Support Them / Braveman, Paula -- Chapter 11. Cooperantes, Solidarity, and the Fight for Health in Mozambique / Gloyd, Stephen / Pfeiffer, James / Johnson, Wendy -- Chapter 12. From Harlem to Harare: Lessons in How Social Movements and Social Policy Change Health / Travis Bassett, Mary -- Part V. Generation Born in the 1960s–1970s -- Chapter 13. Brigadistas and Revolutionaries: Health and Social Justice in El Salvador / Terry, Michael / Turiano, Laura -- Chapter 14. Health and Human Rights in Latin America, and Beyond: A Lawyer's Experience with Public Health Internationalism / Yamin, Alicia Ely -- Chapter 15 History, Theory, and Praxis in Pacific Islands Health / Yamada, Seiji -- Chapter 16. Doctors for Global Health: Applying Liberation Medicine and Accompanying Communities in Their Struggles for Health and Social Justice / Lanford Smith, Lanny Clyde / Kasper, Jennifer / Holtz, Timothy H. -- Chapter 17. Doctors Across Blockades: American Medical Students in Cuba / Remen, Razel / Bondi-Boyd, Brea -- Part VI Conclusion -- Chapter 18 Across the Generations: Lessons from Health Internationalism / Birn, Anne-Emanuelle / Brown, Theodore M. -- Notes on Contributors -- Index