Suchergebnisse

Background: In 2011, a decision was made to scale up a pilot innovation involving 'adherence clubs' as a form of differentiated care for HIV positive people in the public sector antiretroviral therapy programme in the Western Cape Province of South Africa. In 2016 we were involved in the qualitative aspect of an evaluation of the adherence club model, the overall objective of which was to assess the health outcomes for patients accessing clubs through epidemiological analysis, and to conduct a health systems analysis to evaluate how the model of care performed at scale. In this paper we adopt a complex adaptive systems lens to analyse planned organisational change through intervention in a state health system. We explore the challenges associated with taking to scale a pilot that began as a relatively simple innovation by a non-governmental organisation. Results: Our analysis reveals how a programme initially representing a simple, unitary system in terms of management and clinical governance had evolved into a complex, differentiated care system. An innovation that was assessed as an excellent idea and received political backing, worked well whilst supported on a small scale. However, as scaling up progressed, challenges have emerged at the same time as support has waned. We identified a 'tipping point' at which the system was more likely to fail, as vulnerabilities magnified and the capacity for adaptation was exceeded. Yet the study also revealed the impressive capacity that a health system can have for catalysing novel approaches. Conclusions: We argue that innovation in largescale, complex programmes in health systems is a continuous process that requires ongoing support and attention to new innovation as challenges emerge. Rapid scaling up is also likely to require recourse to further resources, and a culture of iterative learning to address emerging challenges and mitigate complex system errors. These are necessary steps to the future success of adherence clubs as a cornerstone of differentiated care. Further research is needed to assess the equity and quality outcomes of a differentiated care model and to ensure the inclusive distribution of the benefits to all categories of people living with HIV.

AbstractGovernment crop data have been shown to contribute to the efficient operation of agricultural commodity markets. In 2013, the USDA curtailed its crop report publication for the first time in decades due to an appropriations lapse, thereby offering the chance to study the impact on markets of missing government data. As expected, derivatives markets for corn and soybeans did not display characteristic short‐run patterns in terms of uncertainty resolution and price changes that are normally observed around scheduled USDA release times. We are unable to detect evidence of a prolonged period of heightened uncertainty, realized volatility around the missing report, or abnormal pricing errors in the absence of government data. However, an unsurprisingly large 2013 corn and soybean crop could confound that attempt.

The majority of India's rural drinking water supply is sourced from groundwater, which also plays a critical role in irrigated agriculture, supporting the livelihoods of millions of users. However, recent high abstractions are threatening the sustainable use of groundwater, and action is needed to ensure continued supply. Increased managed aquifer recharge (MAR) using the > 200,000 existing tanks (artificially created surface water bodies) is one of the Indian government's key initiatives to combat declining groundwater levels. However, few studies have directly examined the effectiveness of tank recharge, particularly in the complex fractured hydrogeology of Peninsular India. To address this gap, this study examined the impact of tanks in three crystalline bedrock catchments in Karnataka, southern India, by analysing the isotopic and hydrochemical composition of surface waters and groundwaters, combined with groundwater level observations. The results indicate that tanks have limited impact on regional groundwater recharge and quality in rural areas, where recharge from precipitation and groundwater recycling from irrigation dominate the recharge signal. In the urban setting (Bengaluru), impermeable surfaces increased the relative effect of recharge from point sources such as tanks and rivers, but where present, pipe leakage from public-water-supply accounted for the majority of recharge. Shallow groundwater levels in the inner parts of the city may lead to groundwater discharge to tanks, particularly in the dry season. We conclude that the importance of aquifer recharge from tanks is limited compared to other recharge sources and highly dependent on the specific setting. Additional studies to quantify tank recharge and revisions to the current guidelines for national groundwater recharge estimations, using a less generalised approach, are recommended to avoid over-estimating the role tanks play in groundwater recharge.

Acknowledgements AAS, TA, and MDW acknowledge support from the NIHR Newcastle Biomedical Research Centre. AA acknowledges support from the Health Services Research Unit, which is core funded by the Chief Scientist Office of the Scottish Government Health and Social Care Directorate. The authors acknowledge support from the NIHR Ageing Clinical Research Network and the NHS Scotland Support for Science programme. The authors would also thank the efforts of all the research nurses and other site research staff who recruited participants to the trial, all the participants, and all the staff of the Tayside Clinical Trials Unit for their support of the trial. Funding The LACE trial (project reference 13/53/03) is funded by the Efficacy and Mechanism Evaluation (EME) Programme, an MRC and NIHR partnership. The views expressed in this publication are those of the authors and not necessarily those of the MRC, NIHR or the Department of Health and Social Care. ; Peer reviewed ; Publisher PDF

Acknowledgements: AAS, TA and MDW acknowledge support from the NIHR Newcastle Biomedical Research Centre. AA acknowledges support from the Health Services Research Unit which is core funded by the Chief Scientist Office of the Scottish Government Health and Social Care Directorate. The authors acknowledge support from the NIHR Ageing Clinical Research Network and the NHS Scotland Support for Science programme, The authors would also thank the efforts of all the research nurses and other ants to the trial, all the participants, and all the staff of the Tayside Clinical Trials Unit for their support of the trial. Funding: The LACE trial (project reference 13/53/03) is funded by the Efficacy and Mechanism Evaluation (EME) Programme, an MRC and NIHR partnership. The views expressed in this publication are those of the authors and not necessarily those of the MRC, NIHR or the Department of Health and Social Care. ; Peer reviewed ; Publisher PDF