Positive spill-over effects of ART scale up on wider health systems development: evidence from Ethiopia and Malawi

<p>Abstract</p> <p>Background</p> <p>Global health initiatives have enabled the scale up of antiretroviral treatment (ART) over recent years. The impact of HIV-specific funds and programmes on non-HIV-related health services and health systems in genera has been debated extensively. Drawing on evidence from Malawi and Ethiopia, this article analyses the effects of ART scale-up interventions on human resources policies, service delivery and general health outcomes, and explores how synergies can be maximized.</p> <p>Methods</p> <p>Data from Malawi and Ethiopia were compiled between 2004 and 2009 and between 2005 and 2009, respectively. We developed a conceptual health systems framework for the analysis. We used the major changes in human resources policies as an entry point to explore the wider health systems changes.</p> <p>Results</p> <p>In both countries, the need for an HIV response triggered an overhaul of human resources policies. As a result, the health workforce at health facility and community level was reinforced. The impact of this human resources trend was felt beyond the scale up of ART services; it also contributed to an overall increase in functional health facilities providing curative, mother and child health, and ART services. In addition to a significant increase in ART coverage, we observed a remarkable rise in user rates of non-HIV health services and an improvement in overall health outcomes.</p> <p>Conclusions</p> <p>Interventions aimed at the expansion of ART services and improvement of long-term retention of patients in ART care can have positive spill-over effects on the health system. The responses of Malawi and Ethiopia to their human resources crises was exceptional in many respects, and some of the lessons learnt can be useful in other contexts. The case studies show the feasibility of obtaining improved health outcomes beyond HIV through scaled-up ART interventions when these are part of a long-term, system-wide health plan supported by all decision makers and funders.</p

Retention of health workers in Malawi: perspectives of health workers and district management

<p>Abstract</p> <p>Background</p> <p>Shortage of human resources is a major problem facing Malawi, where more than 50% of the population lives in rural areas. Most of the district health services are provided by clinical health officers specially trained to provide services that would normally be provided by fully qualified doctors or specialists. As this cadre and the cadre of enrolled nurses are the mainstay of the Malawian health service at the district level, it is important that they are supported and motivated to deliver a good standard of service to the population. This study explores how these cadres are managed and motivated and the impact this has on their performance.</p> <p>Methods</p> <p>A quantitative survey measured health workers' job satisfaction, perceptions of the work environment and sense of justice in the workplace, and was reported elsewhere. It emerged that health workers were particularly dissatisfied with what they perceived as unfair access to continuous education and career advancement opportunities, as well as inadequate supervision. These issues and their contribution to demotivation, from the perspective of both management and health workers, were further explored by means of qualitative techniques.</p> <p>Focus group discussions were held with health workers, and key-informant interviews were conducted with members of district health management teams and human resource officers in the Ministry of Health. The focus groups used convenience sampling that included all the different cadres of health workers available and willing to participate on the day the research team visited the health facility. The interviews targeted district health management teams in three districts and the human resources personnel in the Ministry of Health, also sampling those who were available and agreed to participate.</p> <p>Results</p> <p>The results showed that health workers consider continuous education and career progression strategies to be inadequate. Standard human resource management practices such as performance appraisal and the provision of job descriptions were not present in many cases. Health workers felt that they were inadequately supervised, with no feedback on performance. In contrast to health workers, managers did not perceive these human resources management deficiencies in the system as having an impact on motivation.</p> <p>Conclusion</p> <p>A strong human resource management function operating at the district level is likely to improve worker motivation and performance.</p

Assessing the use of an essential health package in a sector wide approach in Malawi

<p>Abstract</p> <p>Background</p> <p>The sector wide approach (SWAp) used in many developing countries is difficult to assess. One way is to consider the essential health package (EHP) which is commonly the vehicle for a SWAp's policies and plans. It is not possible to measure the impact of an EHP by measuring health outcomes in countries such as Malawi. But it is possible to assess the choice of interventions and their delivery in terms of coverage. This paper describes an attempt to assess the Malawi SWAp through its EHP using these available measures of technical efficiency.</p> <p>Methods</p> <p>A burden of disease model was used to identify the priority diseases and their estimated incidence. Data from the health management information system (HMIS) were used to measure the coverage of these interventions. A review of the cost-effectiveness of the chosen and potential interventions was undertaken to assess the appropriateness of each intervention used in the EHP. Expenditure data were used to assess the level of funding of the EHP.</p> <p>Results</p> <p>33 of the 55 EHP interventions were found to be potentially cost-effective (<$150/DALY), 12 were not so cost-effective (>$150/DALY) and cost-effective estimates were not available for ten. 15 potential interventions, which were cost-effective and tackling one of the top 20 ranked diseases, were identified.</p> <p>Provision had increased in nearly all EHP services over the period of the SWAp. The rates of out patient attendances and inpatient days per 1000 population had both increased from 929 attendances in 2002/3 to 1135 in 2007/08 and from 124 inpatient days in 2002/03 to 179 in 2007/08.</p> <p>However, by 2007/08 the mean gap between what was required and what was provided was 0.68 of the estimated need. Two services involving the treatment of malaria were overprovided, but the majority were underprovided, with some such as maternity care providing less than half of what was required.</p> <p>The EHP was under-funded throughout the period covering on average 57% of necessary costs. By 2007/08 the funding paid by SWAp partners including the government of Malawi to fund the EHP was at US$13.5 per capita per annum, which was almost half of the revised EHP estimated required expenditure per capita per annum.</p> <p>Discussion</p> <p>The SWAp had invested in some very cost-effective health interventions. In terms of numbers of patients treated, the EHP had delivered two thirds of the services required. This was despite serious under-funding of the EHP, an increase in the population and shortage of staff.</p> <p>Conclusions</p> <p>The identification of interventions of proven effectiveness and good value for money and earmarked funding through a SWAp process can produce measurable improvement in health service delivery at extremely low cost.</p

Fresh money for health? The (false?) promise of “innovative financing” for health in Malawi

Since 2013, the Government of Malawi has been pursuing a number of health reforms which includes plans to increase domestic financing for health through “innovative financing.” As part of these reforms, Malawi has sought to raise additional tax revenue through existing and new sources with a view of earmarking the revenue generated to the health sector. In this article, a systematic approach to assessing feasibility, and quantifying the amount of revenue that could be generated from potential sources is devised and applied. Specifically, the study applies the Delphi forecasting method to generate a qualitative assessment of the potential for raising additional tax revenues from existing and new sources, and the Gross Domestic Product (GDP)-based effective tax rate forecasting method to quantify the amount of tax revenue that would be generated. The results show that an annual average of 0.30 USD, 0.46 USD, and 0.63 USD per capita could be generated from taxes on fuel and motor vehicle insurance over the period 2016/17-2021/22 under the low, medium, and high scenarios, respectively. However, the proposed tax reform has not been officially adopted despite empirical evidence on the revenue potential. This could be attributed to the low amount of tax revenue that would be generated. The conclusion is that revenue generation potential of innovative financing for health mechanisms in Malawi is limited; and the study calls for efforts to expand fiscal space for health in Malawi to focus on efficiency enhancing measures, including strengthening of governance and public financial management

The duty to make abortion law transparent: A Malawi case study

Despite adopting a progressive legal and policy framework informed by internationally recognized human rights norms and values, Malawi has not complied with the obligation to explain its abortion law in accordance with legal and human rights standards. In 1930, the colonial government adopted a Penal Code derived from English criminal law, containing provisions regulating access to abortion, but has not undertaken measures to explain when abortion is lawful. What constitutes legal abortion has never been clarified for health providers and potential clients. Consequently, eligible girls and women fail to access safe and legal abortion. The Malawi Law Commission, following its review of the colonial abortion law, has proposed liberal changes which, if implemented, would expand access to safe abortion. However, the immediate step the government ought to take is to clarify the current abortion law, and not to wait for a new law expected to materialize in the indeterminate future.Regional Team for Sexual and Reproductive Health and Rights, Embassy of Sweden, Lusaka, Zambiahttp://wileyonlinelibrary.com/journal/ijgo2019-12-01hj2019Private La

Transactional sex and HIV: understanding the gendered structural drivers of HIV in fishing communities in Southern Malawi.

BACKGROUND: In Southern Malawi, the fishing industry is highly gendered, with men carrying out the fishing and women processing, drying and selling the fish. Research has shown that individuals living in fishing communities in low-income countries are particularly vulnerable to HIV infection. One of the key drivers of HIV in fishing communities is transactional sex. In the fishing industry this takes the form of "fish-for-sex" networks where female fish traders exchange sex with fishermen for access to or more favourable prices of fish. By controlling the means of production, the power dynamics in these exchanges favour men and can make it more difficult for women to negotiate safe sex. METHODS: Qualitative methods were used to collect data on gendered drivers of transactional sex in the fishing community and how different groups perceive HIV risk in these transactions. Observation, focus group discussions and semi-structured interviews were undertaken with members of the fishing communities, including men and women directly and indirectly involved in fishing. RESULTS: In fishing communities transactional sex was prevalent across a spectrum ranging from gift giving within relationships, to sex for fish exchanges, to sex worker encounters. Power differences between couples in transactional sexual encounters shape individual's abilities to negotiate condom use (with women being at a particularly disadvantaged negotiating position). The context and motivations for transactional sex varied and was mediated by economic need and social position both of men and women. Female fish traders new to the industry and boat crew members who travelled for work and experienced difficult living conditions often engaged in transactional sex. CONCLUSIONS: Transactional sex is common in Malawian fishing communities, with women particularly vulnerable in negotiations because of existing gendered power structures. Although knowledge and understanding of the HIV risk associated with transactional sex was common, this did not appear to result in the adoption of risk reduction strategies. This suggests that specially targeted strategies to increase women's economic empowerment and tackle the structural drivers of women's HIV risk could be important in fishing communities

Implementation assessment in confidential enquiry programmes: A scoping review.

Background Response should be a key part of maternal death surveillance and response (MDSR) programmes, which include confidential enquiries into maternal deaths. The programmes investigate avoidable factors in maternal deaths and make recommendations for improving maternity care. There is a gap in information on how these recommendations are transformed into practice. Objective To explore the methods used to assess the implementation status of recommendations made in confidential enquiries into maternal deaths and other health outcomes. Data sources We searched PubMed, Web of Science, CINAHL, and Google Scholar databases and general web for grey literature using the “Arksey and O’Malley framework” in all major scientific databases and search engines. Study selection and data extraction An initial screening was followed by extraction of information using a data chart. Variables in the chart were based on the response component of maternal death and surveillance systems. Synthesis Information collected was summarised using content analysis method. Results We reviewed 13 confidential enquiry systems into maternal deaths. Many confidential enquiries into maternal deaths published reports with their recommendations and dissemination often involved national‐level scientific presentations. Only five reports provided strategies for implementing the recommendations. Follow‐up of previous recommendations was routinely published in only two reports. However, impact assessment of recommendations on other health outcomes was found only in the UK. Conclusion There is a gap in monitoring the response generated by confidential enquiries into maternal deaths. Actions to develop this are therefore needed