Cost-effectiveness of a nurse-based intervention (AIMS) to improve adherence among HIV-infected patients : Design of a multi-centre randomised controlled trial

Peer reviewedPublisher PD

Testing public health intervention guidance on increasing the uptake of HIV testing among men who have sex with men. Final fieldwork report

This guidance is for NHS and other commissioners, managers and practitioners who have a direct or indirect role in, and responsibility for, increasing the uptake of HIV testing among men who have sex with men. This includes those working in local authorities and the wider public, private, voluntary and community sectors. It will also be of interest to members of the public, in particular men who have sex with men. The focus of the guidance is on increasing the uptake of HIV testing to reduce undiagnosed infection and prevent transmission. The recommendations include advice on: planning services, including assessing local need and developing a strategy promoting HIV testing among men who have sex with men, including outreach schemes and providing rapid point-of-care tests offering and recommending an HIV test in primary care, secondary care and specialist sexual health services repeat testing HIV referral pathways

The delayed transformation: restructuring in the automobile, chemical, clothing and machine tool industries.

In this paper, we focus on the results of the Belgian Trend Study. The intention of this study was to examine the prevalence of new production concepts within the widest possible range of companies in the automobile, the machine-tool, the chemical and the clothing industries. The Trend Study aimed to answer the following questions : is the Taylorist division of labour a thing of the past ? What are the alternatives ? Are shifts in the division of labour accompanied by another type of personnel policy, and do traditional relations have to make way for this new approach ? The methodological concept used had to guarantee that the findings at the level of each industry could be generalized. Though the picture emerging from the empirical data collected in the four industrial sectors is inevitably diverse, the data make it possible merely to suggest a 'neo' rather than a 'post' Taylorist or Fordist concept.

Randomised trials at the level of the individual

In global health research, short-term, small-scale clinical trials with fixed, two-arm trial designs that generally do not allow for major changes throughout the trial are the most common study design. Building on the introductory paper of this Series, this paper discusses data-driven approaches to clinical trial research across several adaptive trial designs, as well as the master protocol framework that can help to harmonise clinical trial research efforts in global health research. We provide a general framework for more efficient trial research, and we discuss the importance of considering different study designs in the planning stage with statistical simulations. We conclude this second Series paper by discussing the methodological and operational complexity of adaptive trial designs and master protocols and the current funding challenges that could limit uptake of these approaches in global health research

What health care for undocumented migrants in Belgium?

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‘They say we are money minded’ exploring experiences of formal private for-profit health providers towards contribution to pro-poor access in post conflict Northern Uganda

From Crossref journal articles via Jisc Publications RouterSuzanne Fustukian - ORCID: 0000-0002-4570-5800 https://orcid.org/0000-0002-4570-5800Background: The perception within literature and populace is that the private for-profit sector is for the rich only, and this characteristic results in behaviours that hinder advancement of Universal health coverage (UHC) goals. The context of Northern Uganda presents an opportunity for understanding how the private sector continues to thrive in settings with high poverty levels and history of conflict.Objective: The study aimed at understanding access mechanisms employed by the formal private for-profit providers (FPFPs) to enable pro-poor access to health services in post conflict Northern Uganda.Methods: Data collection was conducted in Gulu municipality in 2015 using Organisational survey of 45 registered formal private for-profit providers (FPFPs),10 life histories, and 13 key informant interviews. Descriptive statistics were generated for the quantitative findings whereas qualitative findings were analysed thematically.Results: FPFPs pragmatically employed various access mechanisms and these included fee exemptions and provision of free services, fee reductions, use of loan books, breaking down doses and partial payments. Most mechanisms were preceded by managers’ subjective identification of the poor, while operationalisation heavily depended on the managers’ availability and trust between the provider and the customer. For a few FPFPs, partnerships with Non-governmental organisations (NGOs) and government enabled provision of free, albeit mainly preventive services, including immunisation, consultations, screening for blood pressure and family planning. Challenges such as quality issues, information asymmetry and standardisation of charges arose during implementation of the mechanisms.Conclusion: The identification of the poor by the FPFPs was subjective and unsystematic. FPFPs implemented various innovations to ensure pro-poor access to health services. However, they face a continuous dilemma of balancing the profit maximization and altruism objectives. Implementation of some pro-poor mechanisms raises concerns included those related to quality and standardisation of pricing.The publication of this work has also been funded as part of a supplement under SPEED project [HUM/2014/341-585], funding code is ZGHA-2020-C4168..pubpu

HCV epidemiology in high-risk groups and the risk of reinfection

Injecting risk behaviours among people who inject drugs (PWID) and high-risk sexual practices among men who have sex with men (MSM) are important routes of hepatitis C virus (HCV) transmission. Current direct-acting antiviral treatment offers unique opportunities for reductions in HCV-related liver disease burden and epidemic control in high-risk groups, but these prospects could be counteracted by HCV reinfection due to on-going risk behaviours after successful treatment. Based on existing data from small and heterogeneous studies of interferon-based treatment, the incidence of reinfection after sustained virological response range from 2-6/100 person years among PWID to 10-15/100 person years among human immunodeficiency virus-infected MSM. These differences mainly reflect heterogeneity in study populations with regards to risk behaviours, but also reflect variations in study designs and applied virological methods. Increasing levels of reinfection are to be expected as we enter the interferon-free treatment era. Individual- and population-level efforts to address and prevent reinfection should therefore be undertaken when providing HCV care for people with on-going risk behaviour. Constructive strategies include acknowledgement, education and counselling, harm reduction optimization, scaled-up treatment including treatment of injecting networks, post-treatment screening, and rapid retreatment of reinfections

Aligning vertical programmes with health systems: a case study of the HIV programme at district level in South Africa

Thesis submitted for the degree: Doctor of Philosophy School of Public Health Faculty of Heath Sciences University of the Witwatersrand, Johannesburg 9 October 2015Rationale It is widely recognised that population health can be improved by strengthening health system capacity to deliver health services that tackle a wide range of diseases and that people can use when they need them. However, many low- and middle-income countries (LMICs) have established disease control programmes (DCPs) that employ dedicated machinery (e.g. health workforce, drug delivery, health infrastructure) to deliver health services that tackle a specific disease (traditionally termed the ‘vertical’ approach). DCPs have beneficial (increased coverage of disease control interventions) as well as detrimental effects (hamper holistic care because patients are seen on the basis of their disease, increase duplication and fragmentation in service delivery, and draw scarce resources from overall health systems that are designed to tackle a wide range of diseases). Integrating DCP services within overall health systems (traditionally termed the ‘horizontal’ approach) is thus increasingly proposed. Some suggest that DCPs should also be integrated within other health system functions (e.g. planning, financing, monitoring and evaluation [M&E]) in order to minimise fragmentation in managing health services. With increasing interest in integration, research is needed to inform discussions on how to achieve it. Since integration is not necessarily about abolishing all elements of ‘verticality’ but rather about finding ways in which beneficial aspects of DCPs can exist with health systems in a fruitful symbiosis, research is needed on how different extents of DCP integration may affect health systems. Understanding the extent of integration is important as the acceptable degree of ‘verticality’ may vary across different contexts. In South Africa several DCPs exist – notably HIV, tuberculosis (TB), maternal and child health (MCH) – but it is official government policy to integrate them within the district health system. As such, DCP services (e.g. HIV testing, TB diagnosis and treatment) are supposed v to be integrated at the point of care – provided by multi-skilled health workers through multi-functional health facilities. Policy also advocates integration at managerial level – in a context where district managers have been delegated the authority for implementing health services (planning, supervision, monitoring). As such, DCP managers should relinquish responsibility for DCP interventions to district managers to whom they should provide specialist support. There is however no policy guidance on how to implement integration. Existing policy also makes no mention of DCP integration within district health system functions such as planning or M&E, and yet it seems important that district managers have administrative authority over these in order to effectively manage integrated services at district level. Evidence to inform implementation guidance is limited. While there is some research on service integration at the point of care, integration at managerial level (administrative integration) is less understood. The limited available evidence suggests there has been little progress with achieving administrative integration, but there is no research exploring why. For example, administrative integration may require changes to health system organisational structure (how roles are allocated and lines of authority), and culture (actor attitudes, behaviours and values). However, whether the prevailing health system organisational structure and culture would support integration has not been researched. Further, collaboration (communication, joint working) between programme and district managers is necessary for integration to succeed, but the extent to which it happens is little researched. This PhD addresses some of the afore-mentioned gaps in understanding by measuring the extent of integration between DCPs and the district health system in South Africa, and exploring how organisational structure and culture may influence integration. The four studies that make up this PhD explore these questions using the HIV programme as an vi example of a DCP and monitoring and evaluation (M&E) as an example of a health system function. Aims The aims of this PhD are: a) to explore the use of methods for measuring the nature and extent of HIV programme integration within district health system M&E in South Africa (studies 1 to 3); and b) to explore the influence of the health system organisational structure and culture on integration (study 4). HIV M&E is a system (people, technology, processes, and management structures) for producing HIV information and using it for monitoring HIV services. In the absence of policy guidance defining what M&E integration means, this research hypothesises a model of HIV M&E integration that has the following characteristics: a. Operational integration: processes, technology and personnel for producing HIV information (collecting, collating, analysing and disseminating) are integrated within the district health information system (DHIS); b. Administrative integration: district managers exercise administrative authority over HIV M&E – oversee HIV data collection and collation (check data quality, compile and submit reports) and use HIV data for monitoring progress with implementation of HIV interventions in districts; and DCP managers at sub-national level provide specialist support (e.g. on technical aspects of data quality, and interpretation of HIV data). c. Collaborative actor relations: district and sub-national DCP managers share task-related communication (talking one-on-one about HIV M&E tasks), and attend the same committees where HIV data are discussed and used for monitoring HIV services. vii Methods The research was conducted in two of nine provinces (one urban and one rural) during 2009 to 2012. One district per province was studied. Quantitative and qualitative data were collected in three phases through: a) interviews with 51 health managers located at sub-national level (health facility, sub-district, district and provincial) which included: district, programme (HIV, TB and maternal and child health) and health information managers; b) interviews with eight participants at national level (HIV programme, health information and health system managers); c) document reviews (policies, health plans, operating procedures, M&E tools and documents); and d) audits at 11 health facilities. Given the dearth of methods for measuring the extent of integration, the research adapts and applies existing health system research methods in new ways and uses methods traditionally used in organisation and social science research and applies these methods to health systems research. To assess operational integration, an existing analytical framework – developed by Atun and colleagues for measuring the extent of integration of DCPs within health system functions – was adapted and applied to rate the extent to which HIV data collection and collation forms and processes for reporting, analysing and disseminating HIV data were integrated within the DHIS as ‘no integration’, partial’ or ‘full integration’. To assess administrative integration, Bossert’s decision-space analysis – traditionally used to assess if and how managers exercise authority over health system functions following decentralisation – was adapted to quantify the degree of exercised authority over HIV M&E (the extent to which managers perform HIV M&E tasks) as ‘low’, ‘medium’, or ‘high’. The degree of exercised authority and HIV M&E knowledge were compared between district and programme managers. The extent of communication was quantified using social network analysis (SNA). SNA measures were computed to describe: actor centrality (identify actors with the lowest and highest number of communication links to others, and those who connect viii otherwise disconnected actors); density (quantify cohesiveness of task-related communication); and homophily (quantify extent of communication within versus outside manager groups). Block modelling was applied to identify management committees that link programme and district managers. Finally, Mintzberg’s organisational configurations framework was applied to describe three organisational parameters of the health system: a) the type of decentralisation (whether the locus of decision-making about the design of the HIV M&E system lies at higher or district level); b) the key part of the organisation (whether sub-national programme or district managers are the key role players in HIV monitoring); and c) coordination mechanisms used (highly formalised versus output-based mechanisms). The study then analysed how the observed organisational configuration influence integration. Key findings The results show that operationally the HIV M&E system has two separate sub-systems. One produces information only on anti-retroviral treatment (ART) services, is not integrated within the DHIS and limits availability of ART data at district level. The second produces information on non-ART services (e.g. HIV counselling and testing or prevention of mother to child transmission) and some aspects of it are not integrated (data collection forms) while others are partially (personnel) or fully integrated (software). District managers exercise high degrees of administrative authority over HIV data collection and collection, but there is duplication as programme managers perform some of these tasks as well and seldom perform HIV M&E specialist support roles (partial integration). HIV data use is not integrated as: district managers (many of whom have low HIV M&E knowledge) exercise low degrees of authority in using HIV data; while programme managers (usually with high HIV M&E knowledge) exercise high degrees of authority and use HIV data in silos excluding district managers. ix In both sites task-related communication networks of all managers are moderately cohesive, but provincial HIV programme managers as a group seldom talk to the district managers to whom they should provide specialist support. Though several management committees discuss and use HIV data for monitoring, few connect district and programme managers to potentially foster joint monitoring. Finally, the health system organisation is characterised as Mintzberg’s machine bureaucracy that is incongruous with integration policy objectives. It is centralised (district actors play a peripheral role in decisions regarding HIV M&E design); highly formalised (use rules to enforce compliance and control how M&E work gets done rather than defining outputs that should be achieved); . The organisational culture promotes programme managers as the lead role players (district actors not valued as key players, investment in capacitating programme and not district managers), and leadership styles fail to foster collaborative relations amongst programme and district managers. Implications High degrees of ‘verticality’ were observed which potentially hamper prospects of integrated health services within the district health system. First, the ART M&E system limits availability of HIV data at district level and district managers oversee the production of HIV information while programme managers use it, which limits the extent to which district managers can manage health services in a holistic manner. Setting up a parallel system to fast-track data submission to higher levels is a missed opportunity to strengthen DHIS capacity to produce HIV (and other) data in a timely manner. Second, provincial programme managers largely communicate amongst themselves and seldom with the district managers for whom they should provide specialist M&E support. This means the HIV M&E expertise resides at provincial level and is not available at district level where it is needed. Third, a centralised and highly formalised health system that promotes and values programme x managers as key role players in programme operations at district level undermines policy intentions of district managers assuming this leadership role. This research identifies where interventions can be targeted to achieve higher degrees of integration for district health system and potentially patients’ benefit, and recommends organisational change that is needed to better enable translation of stated policy intents into practice. Lessons learned from this specific HIV M&E case may be relevant for the integration of other programmes in South Africa, and applicable to other LMICs, particularly those seeking to integrate programmes within the health system at district level