Monitoring and evaluation in global HIV/AIDS control - weighing incentives and disincentives for coordination among global and local actors

This paper discusses coordination efforts of both donors and recipient countries in the monitoring and evaluation (M&E) of health outcomes in the field of HIV/AIDS. The coordination of M&E is a much underdeveloped area in HIV/AIDS programming in which, however, important first steps towards better synchronisation have already been taken. In this paper, we review the concepts and meanings commonly applied to M&E, and approaches and strategies for better coordination of M&E in the field of HIV/AIDS. Most importantly, drawing on this analysis, we examine why the present structure of global health governance in this area is not creating strong enough incentives for effective coordination among global and local actors. Copyright © 2010 John Wiley & Sons, Ltd

Socially-marketed rapid diagnostic tests and ACT in the private sector: ten years of experience in Cambodia.

Whilst some populations have recently experienced dramatic declines in malaria, the majority of those most at risk of Plasmodium falciparum malaria still lack access to effective treatment with artemisinin combination therapy (ACT) and others are already facing parasites resistant to artemisinins.In this context, there is a crucial need to improve both access to and targeting of ACT through greater availability of good quality ACT and parasitological diagnosis. This is an issue of increasing urgency notably in the private commercial sector, which, in many countries, plays an important role in the provision of malaria treatment. The Affordable Medicines Facility for malaria (AMFm) is a recent initiative that aims to increase the provision of affordable ACT in public, private and NGO sectors through a manufacturer-level subsidy. However, to date, there is little documented experience in the programmatic implementation of subsidized ACT in the private sector. Cambodia is in the unique position of having more than 10 years of experience not only in implementing subsidized ACT, but also rapid diagnostic tests (RDT) as part of a nationwide social marketing programme. The programme includes behaviour change communication and the training of private providers as well as the sale and distribution of Malarine, the recommended ACT, and Malacheck, the RDT. This paper describes and evaluates this experience by drawing on the results of household and provider surveys conducted since the start of the programme. The available evidence suggests that providers' and consumers' awareness of Malarine increased rapidly, but that of Malacheck much less so. In addition, improvements in ACT and RDT availability and uptake were relatively slow, particularly in more remote areas.The lack of standardization in the survey methods and the gaps in the data highlight the importance of establishing a clear system for monitoring and evaluation for similar initiatives. Despite these limitations, a number of important lessons can still be learnt. These include the importance of a comprehensive communications strategy and of a sustained and reliable supply of products, with attention to the geographical reach of both. Other important challenges relate to the difficulty in incentivising providers and consumers not only to choose the recommended drug, but to precede this with a confirmatory blood test and ensure that providers adhere to the test results and patients to the treatment regime. In Cambodia, this is particularly complicated due to problems inherent to the drug itself and the emergence of artemisinin resistance

Utilization of insecticide treated nets during pregnancy among postpartum women in Ibadan, Nigeria: a cross-sectional study

<p>Abstract</p> <p>Background</p> <p>Pregnant women are susceptible to symptomatic malaria due to invasion of the placenta by plasmodium. Malaria increases the risk of adverse pregnancy outcomes for mothers, the foetuses and newborns. The effective use of Insecticide Treated Nets (ITNs) would be of benefit to these vulnerable women. Previous studies have focused on prenatal-women but this study sought to explore the actual trend of utilization of the proven strategy across all the pregnancy stages among postpartum women in Ibadan.</p> <p>Methods</p> <p>This cross-sectional survey utilized a validated structured questionnaire for data collection. A calculated sample of 335 postpartum women was proportionately recruited from three fee-paying facilities within Ibadan, Nigeria using a simple random sampling technique. These hospitals have high client flow for maternity cases and are known for provision of care under traditional ANC model. The data collected were analyzed using descriptive and inferential statistics by means of Statistical Package of Social Sciences (SPSS) version 15. The level of significance was set at = 0.05.</p> <p>Results</p> <p>The women's age ranged between 18 and 47 years, mean age was 29.4 ± 0.8 years. Various irregularities marked the traditional model of ANC provided at the settings and no exposure to preconception care. Also, 276 (82.4%) had heard of ITNs. Antenatal clinics formed the major source of information. Low utilization and compliance rates were observed. One hundred and twenty-seven (37.9%) of the women had high knowledge of Malaria in Pregnancy (MIP) but only 70 (20.9%) demonstrated positive attitude towards the use of ITNs. Participants' educational status, family types, employment and residential areas significantly influenced ITNs utilization.</p> <p>Conclusions</p> <p>The women knew and learned about ITNs from ANC visits. Majority of the women did not own ITNs because of lack of access to free distribution. The existing traditional model of ANC was marked by irregularities and none of the women was exposed to preconception care. In addition, negative attitude in spite of increased knowledge of MIP was observed among the women. Therefore, evaluation of free distribution of ITNs is recommended. Integration of focused ANC and preconception care are advocated to promote early access to health information.</p

Novel strategies lead to pre-elimination of malaria in previously high-risk areas in Suriname, South America

<p>Abstract</p> <p>Background</p> <p>Suriname was a high malaria risk country before the introduction of a new five-year malaria control program in 2005, the Medical Mission Malaria Programme (MM-MP). Malaria was endemic in the forested interior, where especially the stabile village communities were affected.</p> <p>Case description</p> <p>The interventions of the MM-MP included new strategies for prevention, vector control, case management, behavioral change communication (BCC)/information, education and communication (IEC), and strengthening of the health system (surveillance, monitoring and evaluation and epidemic detection system). After a slow first year with non-satisfying scores for the performance indicators, the MM-MP truly engaged in its intervention activities in 2006 and kept its performance up until the end of 2009. A total of 69,994 long-lasting insecticide-treated nets were distributed and more than 15,000 nets re-impregnated. In high-risk areas, this was complemented with residual spraying of insecticides. Over 10,000 people were screened with active case detection in outbreak and high-risk areas. Additional notification points were established and the national health system was strengthened.</p> <p>Discussion and evaluation</p> <p>In the current paper, the MM-MP is evaluated both on account of the targets established within the programme and on account of its impact on the malaria situation in Suriname. Malaria vector populations, monitored in sentinel sites, collapsed after 2006 and concurrently the number of national malaria cases decreased from 8,618 in 2005 to 1,509 in 2009. Malaria transmission risk shifted from the stabile village communities to the mobile gold mining communities, especially those along the French Guiana border.</p> <p>Conclusions</p> <p>The novel strategies for malaria control introduced in Suriname within the MM-MP have led to a significant decrease in the national malaria burden. The challenge is to further reduce malaria using the available strategies as appropriate in the affected areas and populations. Elimination of malaria in the country will require a thorough understanding of transmission dynamics and a dedicated investment in key effective interventions.</p

The Macroeconomic Consequences of Renouncing to Universal Access to Antiretroviral Treatment for HIV in Africa: A Micro-Simulation Model

AIM: Previous economic literature on the cost-effectiveness of antiretroviral treatment (ART) programs has been mainly focused on the microeconomic consequences of alternative use of resources devoted to the fight against the HIV pandemic. We rather aim at forecasting the consequences of alternative scenarios for the macroeconomic performance of countries. METHODS: We used a micro-simulation model based on individuals aged 15-49 selected from nationally representative surveys (DHS for Cameroon, Tanzania and Swaziland) to compare alternative scenarios : 1-freezing of ART programs to current levels of access, 2- universal access (scaling up to 100% coverage by 2015, with two variants defining ART eligibility according to previous or current WHO guidelines). We introduced an "artificial" ageing process by programming methods. Individuals could evolve through different health states: HIV negative, HIV positive (with different stages of the syndrome). Scenarios of ART procurement determine this dynamics. The macroeconomic impact is obtained using sample weights that take into account the resulting age-structure of the population in each scenario and modeling of the consequences on total growth of the economy. RESULTS: Increased levels of ART coverage result in decreasing HIV incidence and related mortality. Universal access to ART has a positive impact on workers' productivity; the evaluations performed for Swaziland and Cameroon show that universal access would imply net cost-savings at the scale of the society, when the full macroeconomic consequences are introduced in the calculations. In Tanzania, ART access programs imply a net cost for the economy, but 70% of costs are covered by GDP gains at the 2034 horizon, even in the extended coverage option promoted by WHO guidelines initiating ART at levels of 350 cc/mm(3) CD4 cell counts. CONCLUSION: Universal Access ART scaling-up strategies, which are more costly in the short term, remain the best economic choice in the long term. Renouncing or significantly delaying the achievement of this goal, due to "legitimate" short term budgetary constraints would be a misguided choice

Implementation of an insecticide-treated net subsidy scheme under a public-private partnership for malaria control in Tanzania – challenges in implementation

BACKGROUND: In the past decade there has been increasing visibility of malaria control efforts at the national and international levels. The factors that have enhanced this scenario are the availability of proven interventions such as artemisinin-based combination therapy, the wide scale use of insecticide-treated nets (ITNs) and a renewed emphasis in indoor residual house-spraying. Concurrently, there has been a window of opportunity of financial commitments from organizations such as the Global Fund for HIV/AIDS, Tuberculosis and Malaria (GFATM), the President's Malaria Initiative and the World Bank Booster programme. METHODS: The case study uses the health policy analysis framework to analyse the implementation of a public-private partnership approach embarked upon by the government of Tanzania in malaria control - 'The Tanzania National Voucher Scheme'- and in this synthesis, emphasis is on the challenges faced by the scheme during the pre-implementation (2001 - 2004) and implementation phases (2004 - 2005). Qualitative research tools used include: document review, interview with key informants, stakeholder's analysis, force-field analysis, time line of events, policy characteristic analysis and focus group discussions. The study is also complemented by a cross-sectional survey, which was conducted at the Rufiji Health Demographic Surveillance Site, where a cohort of women of child-bearing age were followed up regarding access and use of ITNs. RESULTS: The major challenges observed include: the re-introduction of taxes on mosquito nets and related products, procurement and tendering procedures in the implementation of the GFATM, and organizational arrangements and free delivery of mosquito nets through a Presidential initiative. CONCLUSION: The lessons gleaned from this synthesis include: (a) the consistency of the stakeholders with a common vision, was an important strength in overcoming obstacles, (b) senior politicians often steered the policy agenda when the policy in question was a 'crisis event', the stakes and the visibility were high, (c) national stakeholders in policy making have an advantage in strengthening alliances with international organizations, where the latter can become extremely influential in solving bottlenecks as the need arises, and (d) conflict can be turned into an opportunity, for example the Presidential initiative has inadvertently provided Tanzania with important lessons in the organization of 'catch-up' campaigns

"More money for health - more health for the money": a human resources for health perspective

<p>Abstract</p> <p>Background</p> <p>At the MDG Summit in September 2010, the UN Secretary-General launched the Global Strategy for Women's and Children's Health. Central within the Global Strategy are the ambitions of "more money for health" and "more health for the money". These aim to leverage more resources for health financing whilst simultaneously generating more results from existing resources - core tenets of public expenditure management and governance. This paper considers these ambitions from a human resources for health (HRH) perspective.</p> <p>Methods</p> <p>Using data from the UK Department for International Development (DFID) we set out to quantify and qualify the British government's contributions on HRH in developing countries and to establish a baseline.. To determine whether activities and financing could be included in the categorisation of 'HRH strengthening' we adopted the Agenda for Global Action on HRH and a WHO approach to the 'working lifespan' of health workers as our guiding frameworks. To establish a baseline we reviewed available data on Official Development Assistance (ODA) and country reports, undertook a new survey of HRH programming and sought information from multilateral partners.</p> <p>Results</p> <p>In financial year 2008/9 DFID spent £901 million on direct 'aid to health'. Due to the nature of the Creditor Reporting System (CRS) of the Organisation for Economic Co-operation and Development (OECD) it is not feasible to directly report on HRH spending. We therefore employed a process of imputed percentages supported by detailed assessment in twelve countries. This followed the model adopted by the G8 to estimate ODA on maternal, newborn and child health. Using the G8's model, and cognisant of its limitations, we concluded that UK 'aid to health' on HRH strengthening is approximately 25%.</p> <p>Conclusions</p> <p>In quantifying DFID's disbursements on HRH we encountered the constraints of the current CRS framework. This limits standardised measurement of ODA on HRH. This is a governance issue that will benefit from further analysis within more comprehensive programmes of workforce science, surveillance and strategic intelligence. The Commission on Information and Accountability for Women's and Children's Health may present an opportunity to partially address the limitations in reporting on ODA for HRH and present solutions to establish a global baseline.</p