Health systems and HIV treatment in sub-Saharan Africa: Matching intervention and program evaluation strategies

Objectives International donors financing the delivery of antiretroviral treatment (ART) in developing countries have recently emphasized their commitment to rigorous evaluation of ART impact on population health. In the same time frame but different contexts, they have announced that they will shift funding from vertically-structured (i.e., disease-specific) interventions to horizontally-structured interventions (i.e., staff, systems and infrastructure that can deliver care for many diseases). We analyze likely effects of the latter shift on the feasibility of impact evaluation. Methods We examine the effect of the shift in intervention strategy on (i) outcome measurement, (ii) cost measurement, (iii) study-design options, and the (iv) technical and (v) political feasibility of program evaluation. Results As intervention structure changes from vertical to horizontal, outcome and cost measurement are likely to become more difficult (because the number of relevant outcomes and costs increases and the sources holding data on these measures become more diverse); study design options become more limited (because it is often impossible to identify a rigorously defined counterfactual in horizontal interventions); the technical feasibility of interventions is reduced (because lag times between intervention and impact increase in length and effect mediating and modifying factors increase in number); and political feasibility of evaluation is decreased (because national policymakers may be reluctant to support the evaluation). Conclusions In the choice of intervention strategy, policymakers need to consider the effect of intervention strategy on impact evaluation. Methodological studies are needed to identify the best approaches to evaluate the population health impact of horizontal interventions.Impact evaluation, health systems, HIV, antiretroviral treatment, Africa

Estimating health worker need to provide antiretroviral treatment in the developing world

Despite recent international efforts to increase antiretroviral treatment (ART) coverage, more than 5 million people who need ART in developing countries do not receive such treatment. Shortages of human resources to treat HIV/AIDS (referred to herein as HRHA) are one of the main constraints to further scaling up ART. Planning expansion of ART depends on the ability to predict how many HRHA will be needed in the future. We investigate whether taking into account positive feedback from the current supply of HRHA to future HRHA need substantially alters predictions. This feedback occurs because an increase in the number of HRHA implies an increase in the number of individuals receiving ART and – because ART is a lifelong treatment and is effective in prolonging the lives of HIV-positive people – a rise over time in the number of people requiring ART.Disease, control, global health, HIV/AIDS, Africa.

A Mathematical Model for Estimating the Number of Health Workers Required for Universal Antiretroviral Treatment

Despite recent international efforts to increase antiretroviral treatment (ART) coverage, it is estimated that more than 5 million people who need ART in developing countries do not receive such treatment. Shortages of human resources to treat HIV/AIDS (HRHA) are one of the main constraints to scaling up ART. We develop a discrete-time Markovian model to project the numbers of HRHA required to achieve universal ART coverage, taking into account the positive feedback from HRHA numbers to future HRHA need. Feedback occurs because ART is effective in prolonging the lives of HIVpositive people who need treatment, so that an increase in the number of people receiving treatment leads to an increase in the number of people needing it in future periods. We investigate the steady-state behavior of our model and apply it to different regions in the developing world. We find that taking into account the feedback from the current supply of HRHA to the future HRHA need substantially increases the projected numbers of HRHA required to achieve universal ART coverage. We discuss the policy implications of our model.Mathematical model, health workers, universal antiretroviral treatment

Medicine and Economics: Accounting for the full benefits of childhood vaccination in South Africa

While remarkable gains in health have been achieved since the mid-20th century, these have been unequally distributed, and mortality and morbidity burdens in some regions remain enormous. Of the almost 10 million children under 5 years of age who died in 2006, only 100 000 died in industrialised countries, while 4.8 million died in sub-Saharan Africa.1 In deciding whether to finance an intervention, policy makers commonly weigh the expected population health gains against its costs. Most vaccinations included in national immunisation schedules are inexpensive2 and health gains to costs are very favourable compared with other health interventions. Newer vaccinations, such as those with pneumococcal conjugate vaccine (PCV) or rotavirus vaccine, are also effective in averting child mortality and morbidity but are expensive relative to those commonly included in national immunisation schedules. Policy makers may therefore decide that – at current prices – the comparison of health gains with costs does not justify the free public provision of these vaccinations. The authors of this paper argue that in addition to the health benefits of vaccinations, their effects on education and income3 and benefits for unvaccinated community members are considerable and should be included in calculations to establish their value.Disease, control, global health, vaccination, HIV/AIDS, Africa.

Global Health Governance and Tropical Diseases

Global Health Governance (GHG) comprises the means adopted to promote decision making on actions to protect and promote global health, along with the underlying architecture of global health institutions, initiatives, and actors that facilitate these means. GHG is a key factor influencing health outcomes throughout the world. Over the past decade, the GHG system has increased dramatically in size and complexity. In the past half century, GHG has achieved successes against some tropical diseases, but going forward, it faces new challenges. The current GHG system has several weaknesses lack of participation, transparency, accountability, and efficiency but the system also has several strengths capacity for innovation, flexibility, and the ability to attract a motivated workforce and to encourage entrepreneurship. To adequately address tropical diseases in the future, GHG reforms will need to address some of the weaknesses while preserving the strengths

An approach to solving constraint satisfaction problems using asynchronous teams of autonomous agents

Thesis (M.S.)--Massachusetts Institute of Technology, Dept. of Civil and Environmental Engineering, 1994.Includes bibliographical references (leaves 145-147).by Salal Humair.M.S

A Mathematical Model for Estimating the Number of Health Workers Required for Universal Antiretroviral Treatment

Despite recent international efforts to increase antiretroviral treatment (ART) coverage, it is estimated that more than 5 million people who need ART in developing countries do not receive such treatment. Shortages of human resources to treat HIV/AIDS (HRHA) are one of the main constraints to scaling up ART. We develop a discrete-time Markovian model to project the numbers of HRHA required to achieve universal ART coverage, taking into account the positive feedback from HRHA numbers to future HRHA need. Feedback occurs because ART is effective in prolonging the lives of HIV-positive people who need treatment, so that an increase in the number of people receiving treatment leads to an increase in the number of people needing it in future periods. We investigate the steady-state behavior of our model and apply it to different regions in the developing world. We find that taking into account the feedback from the current supply of HRHA to the future HRHA need substantially increases the projected numbers of HRHA required to achieve universal ART coverage. We discuss the policy implications of our model.

Increasing Coverage of Antiretroviral Therapy and Male Medical Circumcision in HIV Hyperendemic Countries: A Cost-Benefit Analysis

HIV continues to cause the largest number of disability-adjusted life years of any disease in HIV hyperendemic countries (i.e., countries with an adult HIV prevalence >15%). We compare the benefits and costs of two proven biological interventions to reduce the health losses due to the HIV epidemic in hyperendemic countries from 2015 through 2030: 1) increasing ART coverage to 90% among HIV-infected adults with a CD4-cell count <350 cells/microliter, before expanding the HIV treatment scale-up to people with higher CD4-cell counts; and 2) increasing male medical circumcision coverage to at least 90% among HIV-uninfected adult men. We developed a mathematical model to determine the benefits and costs of increasing the coverage of both ART under different CD4-cell count thresholds and of circumcision in HIV-hyperendemic countries. The results show that scaling up ART and circumcision are both cost-beneficial. However, the benefit-to-cost ratio (BCR) for circumcision is significantly higher than for ART: 7.4 vs. 3.0 (at US$1,000 per life year and a 5$5,000 per life year and a 3% discount rate). The additional cost of scaling up circumcision is approximately $US500 million while the additional cost of increasing ART coverage lies between$US17 and $US19 billion. We conclude that increasing the coverage of ART among HIV-infected adults with a CD4-cell count <350 cells/microliter and, in particular, scaling up male medical circumcision among HIV-negative men are both highly cost-beneficial interventions to reduce the health burdens resulting from the HIV epidemic in hyperendemic countries over the next 15 years

A Demographic Dividend for Sub-Saharan Africa: Source, Magnitude, and Realization

Managing rapid population growth and spurring economic growth are among the most pressing policy challenges for Sub-Saharan Africa. We discuss the links between them and investigate the potential of family planning programs to address these challenges. Specifically, we estimate the impact of family planning programs on income per capita that can arise via the demographic dividend (DD), a boost to per capita income that operates through a chain of causality related to declining fertility. We develop a model to determine the impact of meeting unmet need (MUN) for modern contraceptive methods on fertility and hence on the population age structure in the coming years. We also estimate empirically the DD that has been observed in other countries, using a cross-country regression with panel data covering 40 years. Using the age structure projected by MUN and the empirical estimates of the DD, we estimate the potential for additional economic growth in Kenya, Nigeria, and Senegal. We find that in 2030, these countries can enjoy an increase in per capita income of 8-13% by meeting one-third of their unmet need for modern contraception and can enjoy a 31-65% higher income per capita by meeting all of the unmet need. By 2050, these ranges become 13-22% and 47-87% respectively. We discuss the policy implications of our findings