Factors Affecting Patient Perceptions of Quality and Health-Seeking Behavior

In this dissertation, I address three issues related to patient-perceived quality of care: the impact of switching to the new World Health Organization (WHO) HIV treatment guidelines on patient perception of quality of care, the impact of rolling-out a quality improvement (QI) training intervention on mothers’ perception of the quality of postnatal care, and the association between patient perceptions of quality and their decisions to bypass healthcare facilities for care. Chapter one presents an overview as well as key insights form all three papers. In chapter two, I investigated the impact of early access to antiretroviral therapy (ART) versus national standard of care on patient satisfaction using data from a stepped-wedge cluster randomized controlled trial in Swaziland. The outcomes of interest included, patient ratings of perceptions of overall quality of care, wait time, consultation time, level of involvement in treatment decision-making, and respect received from the health worker. The results show no evidence of a causal impact of early initiation of ART on patient perception of overall quality of care, or perception of quality of care in the other domains measured. The results also showed a time trend of increasing negative perception of quality as the study progressed. In chapter three, I investigated the impact of a quality improvement training intervention on women’s perception of the quality of postnatal care using data from a stepped-wedge cluster randomized controlled trial in primary health care (PHC) clinics in rural South Africa. Results show no evidence of a causal impact of the QI training on patient perception of quality of postnatal care in any of the domains assessed. The results also showed time trends with increasing positive perception of quality over time in three out of the five domains assessed: patient-provider communication, consultation-time, and level of involvement in treatment decision making. In chapter four, I explored the associations between perceptions of quality of antenatal care and sick-child care on patients’ decisions to bypass healthcare facilities in nine low- and middle-income countries. The results showed that measures of structural quality were more consistent predictors of patients’ bypassing behavior compared to measures of technical quality

Aid Effectiveness in the Sustainable Development Goals Era Comment on ““It’s About the Idea Hitting the Bull’s Eye”: How Aid Effectiveness Can Catalyse the Scale-up of Health Innovations”

Over just a six-year period from 2005-2011, five aid effectiveness initiatives were launched: the Paris Declaration on Aid Effectiveness (2005), the International Health Partnership plus (2007), the Accra Agenda for Action (2008), the Busan Partnership for Effective Cooperation (2011), and the Global Partnership for Effective Development Cooperation (GPEDC) (2011). More recently, in 2015, the Addis Ababa Action Agenda (AAAA) was signed at the third international conference on financing for development and the Universal Health Coverage (UHC) 2030 Global Compact was signed in 2017. Both documents espouse principles of aid effectiveness and would most likely guide financing decisions in the Sustainable Development Goals (SDG) era. This is therefore a good moment to assess whether the aid effectiveness agenda made a difference in development and its relevance in the SDG era

Going beyond GDP with a parsimonious indicator : inequality-adjusted healthy lifetime income

Per capita GDP has limited use as a well-being indicator because it does not capture many dimensions that imply a good life, such as health and equality of opportunity. However, per capita GDP has the virtues of easy interpretation and can be calculated with manageable data requirements. Against this backdrop, a need exists for a measure of well-being that preserves the advantages of per capita GDP, but also includes health and equality. We propose a new parsimonious indicator to fill this gap and calculate it for 149 countries

Which delivery model innovations can support sustainable HIV treatment?

The rapid scale-up of antiretroviral treatment (ART) for HIV since the mid-2000s, mostly through disease-specific or “vertical” programmes, has been a highly successful undertaking, which averted millions of deaths and prevented many new infections. However, the dynamics of the HIV epidemic and changing political and financial commitment to fight the disease will likely require new models for the delivery of ART over the coming decades if the promises of universal treatment are to be met. Delivery model innovations for ART are intended to improve both the effectiveness and efficiency of the HIV treatment cascade, reaching new people who require ART and providing ART to more people without an increase in resources. We describe twelve models for ART delivery, which could be achieved through five categories of delivery innovations: integrating ART (“vertical ART plus”, “partially-integrated ART” and “fully-integrated ART”); modifying steps in the ART value chain (“professional task-shifted ART”, “people task-shifted ART” and “technology-supported ART”); eliminating steps in the ART value chain (“immediate ART” and “less frequent ART pick-up”); changing ART locations (“private-sector ART”, “traditional-sector ART” and “ART outside the health sector”); and keeping the status quo (“vertical ART”). The different delivery model innovations are not mutually exclusive and several could be combined, such as “vertical ART plus” with “task-shifted ART”. Suitability of the models will highly depend on local and national contexts, including existing health systems resources, available funding, and type of HIV epidemic. Future implementation research needs to identify which models are the best fit for different contexts

Investing in late-stage clinical trials and manufacturing of product candidates for five major infectious diseases: a modelling study of the benefits and costs of investment in three middle-income countries

BACKGROUND : Investing in late-stage clinical trials, trial sites, and production capacity for new health products could improve access to vaccines, therapeutics, and infectious disease diagnostics in middle-income countries. This study assesses the case for such investment in three of these countries: India, Kenya, and South Africa. METHODS: We applied investment case modelling and assessed how many cases, deaths, and disability-adjusted life years (DALYs) could be averted from the development and manufacturing of new technologies (therapeutics and vaccines) in these countries from 2021 to 2036, for five diseases—HIV, tuberculosis, malaria, pneumonia, and diarrhoeal diseases. We also estimated the economic benefits that might accrue from making these investments and we developed benefit–cost ratios for each of the three middle-income countries. Our modelling applies two investment case perspectives: a societal perspective with all costs and benefits measured at the societal level, and a country perspective to estimate how much health and economic benefit accrues to each middle-income country for every dollar invested in clinical trials and manufacturing by the middle-income country government. For each perspective, we modelled two scenarios: one that considers only domestic health and economic benefits; and one that includes regional health and economic benefits. In the regional scenarios, we assumed that new products developed and manufactured in India would benefit eight countries in south Asia, whereas new products developed and manufactured in Kenya would benefit all 21 countries in the Common Market for Eastern and Southern Africa (COMESA). We also assumed that all 16 countries in the Southern African Development Community (SADC) would benefit from products developed and manufactured in South Africa. FINDINGS : From 2021 to 2036, product development and manufacturing in Kenya could avert 4·44 million deaths and 206·27 million DALYs in the COMESA region. In South Africa, it could prevent 5·19 million deaths and 253·83 million DALYs in the SADC region. In India, it could avert 9·76 million deaths and 374·42 million DALYs in south Asia. Economic returns would be especially high if new tools were produced for regional markets rather than for domestic markets only. Under a societal perspective, regional returns outweigh investments by a factor of 20·51 in Kenya, 33·27 in South Africa, and 66·56 in India. Under a country perspective, the regional benefit–cost ratios amount to 60·71 in India, 8·78 in Kenya, and 11·88 in South Africa. INTERPRETATION : Our study supports the creation of regional hubs for clinical trials and product manufacturing compared with narrow national efforts.The Bill & Melinda Gates Foundation.https://www.thelancet.com/journals/langlo/homehttps://datahelpdesk.worldbank.org/knowledgebase/articles/906519-world-bank-country-and-lending-groupsam2023Graduate School of Technology Management (GSTM

The impact of continuous quality improvement on coverage of antenatal HIV care tests in rural South Africa: results of a stepped-wedge cluster-randomised controlled implementation trial

Background: Evidence for the effectiveness of continuous quality improvement (CQI) in resource-poor settings is very limited. We aimed to establish the effects of CQI on quality of antenatal HIV care in primary care clinics in rural South Africa. Methods and findings: We conducted a stepped-wedge cluster-randomised controlled trial (RCT) comparing CQI to usual standard of antenatal care (ANC) in 7 nurse-led, public-sector primary care clinics—combined into 6 clusters—over 8 steps and 19 months. Clusters randomly switched from comparator to intervention on pre-specified dates until all had rolled over to the CQI intervention. Investigators and clusters were blinded to randomisation until 2 weeks prior to each step. The intervention was delivered by trained CQI mentors and included standard CQI tools (process maps, fishbone diagrams, run charts, Plan-Do-Study-Act [PDSA] cycles, and action learning sessions). CQI mentors worked with health workers, including nurses and HIV lay counsellors. The mentors used the standard CQI tools flexibly, tailored to local clinic needs. Health workers were the direct recipients of the intervention, whereas the ultimate beneficiaries were pregnant women attending ANC. Our 2 registered primary endpoints were viral load (VL) monitoring (which is critical for elimination of mother-to-child transmission of HIV [eMTCT] and the health of pregnant women living with HIV) and repeat HIV testing (which is necessary to identify and treat women who seroconvert during pregnancy). All pregnant women who attended their first antenatal visit at one of the 7 study clinics and were ≥18 years old at delivery were eligible for endpoint assessment. We performed intention-to-treat (ITT) analyses using modified Poisson generalised linear mixed effects models. We estimated effect sizes with time-step fixed effects and clinic random effects (Model 1). In separate models, we added a nested random clinic–time step interaction term (Model 2) or individual random effects (Model 3). Between 15 July 2015 and 30 January 2017, 2,160 participants with 13,212 ANC visits (intervention n = 6,877, control n = 6,335) were eligible for ITT analysis. No adverse events were reported. Median age at first booking was 25 years (interquartile range [IQR] 21 to 30), and median parity was 1 (IQR 0 to 2). HIV prevalence was 47% (95% CI 42% to 53%). In Model 1, CQI significantly increased VL monitoring (relative risk [RR] 1.38, 95% CI 1.21 to 1.57, p < 0.001) but did not improve repeat HIV testing (RR 1.00, 95% CI 0.88 to 1.13, p = 0.958). These results remained essentially the same in both Model 2 and Model 3. Limitations of our study include that we did not establish impact beyond the duration of the relatively short study period of 19 months, and that transition steps may have been too short to achieve the full potential impact of the CQI intervention. Conclusions: We found that CQI can be effective at increasing quality of primary care in rural Africa. Policy makers should consider CQI as a routine intervention to boost quality of primary care in rural African communities. Implementation research should accompany future CQI use to elucidate mechanisms of action and to identify factors supporting long-term success. Trial registration: This trial is registered at ClinicalTrials.gov under registration number NCT02626351

Rethinking how development assistance for health can catalyse progress on primary health care

Global campaigns to control HIV, tuberculosis, malaria, and vaccine-preventable illnesses showed that large-scale impact can be achieved by using additional international financing to support selected, evidence-based, high-impact investment areas and to catalyse domestic resource mobilisation. Building on this paradigm, we make the case for targeting additional international funding for selected high-impact investments in primary health care. We have identified and costed a set of concrete, evidence-based investments that donors could support, which would be expected to have major impacts at an affordable cost. These investments are in: (1) individuals and communities empowered to engage in health decision making, (2) a new model of people-centred primary care, and (3) next generation community health workers. These three areas would be supported by strengthening two cross-cutting elements of national systems. The first is the digital tools and data that support facility, district, and national managers to improve processes, quality of care, and accountability across primary health care. The second is the educational, training, and supervisory systems needed to improve the quality of care. We estimate that with an additional international investment of between US$1·87 billion in a low-investment scenario and$3·85 billion in a high-investment scenario annually over the next 3 years, the international community could support the scale-up of this evidence-based package of investments in the 59 low-income and middle-income countries that are eligible for external financing from the World Bank Group's International Development Association

Are households with under-five children in Nigeria socioeconomically disadvantaged?

Although the sociodemographic and economic contributors to under-five mortality are well established, very little research has been done to assess the levels of disadvantage under-five children in Nigeria face along these dimensions. Nigeria has the second-highest under-five mortality rate (U5MR) in the world (111 deaths per 1000 live births) and contributed to the highest number of annual under-five deaths globally in 2020 (844,321 deaths). The country has also implemented several decades of policy interventions to reduce under-five mortality by improving sociodemographic and economic conditions at the household level. In this paper, we assess the sociodemographic and economic disadvantages that households with children under-five face compared to other households and discuss the implications for health policy. Using the Nigeria Living Standard Survey 2018-19, we conducted a bivariate analysis to compare the sociodemographic and economic characteristics of households with and without under-five children. We performed independent samples t-test and proportions test to assess whether these sociodemographic and economic factors were significantly different for both groups. We found that households with under-five children typically had larger sizes (6.6 vs. 3.6), lower mean adult age (36.5 vs. 45.3), and male household heads (91.3% vs. 71.5%) than households without under-five children. Furthermore, households with under-five children were less likely to have access to improved drinking water (77.2% vs. 86.0%) and sanitation sources (54.0% vs. 61.9%) than those without under-five children. Despite having more adult working members, 71.2% of households with under-five children lived below the poverty line compared to 37.7% of other households. Although their total consumption expenditure was lower than households without under-five children, they spent a higher proportion of their expenditure on health care and were at a higher risk of experiencing catastrophic health expenditure. Our study has shown that households with children under five are disproportionately disadvantaged than other households in Nigeria. The households with under-five children are larger, younger, and poorer than those without children. We also show a wide variation in the proportion of households with children under five by state. Any efforts to reduce under-five mortality and morbidity in Nigeria should recognize these sociodemographic and economic differences

Replication Data for: Modest Improvements in Skilled Birth Attendants at Delivery with Increased Mutuelles Coverage

We revisit the question of the role health insurance coverage played in increasing use of Skilled Birth Attendants (SBA) at delivery in Rwanda. Previous studies have suggested that enrollment in Mutuelles health insurance increased the odds of using an SBA by up to 163%. We take advantage of latest Rwanda Demographic Health Survey (RDHS 2010) to increase the sample size and extend the time frame of analysis to five years (2005 to 2010). We also adopt stronger matching methods to control for model dependence. We find that although enrollment in Mutuelles insurance increases use of SBAs at delivery, the size of the effect is orders of magnitude lower than previously published (12 to 18 percent versus 78 to 163 percent). We also find that the effect of education on use of SBA is similar in magnitude and direction as that of Mutuelles insurance enrollment. Our findings lead us to conclude that Mutuelles only had a modest effect on increasing use of SBA at delivery and therefore insurance alone may not be the “magic gullet” that solves the problem of non-use of SBA at delivery

Trends in the completeness of birth registration in Nigeria: 2002-2010

Background: Nigeria is a signatory to the Convention on the Rights of the Child, which identifies birth registration as a child's right. However, it is unclear how much progress has been made toward attaining universal birth registration in the country. Methods: This paper reports findings from a secondary analysis of data from the 2007 and 2011 UNICEF Multiple Indicator Cluster Survey in Nigeria. Trends in birth registration completeness based on year of birth of children and age at survey were computed, tabulated, and graphed. Results: Birth registration completeness was 31.5Š and 41.5Š in 2007 and 2011 respectively. Children had better odds of registration across Nigeria in 2011 than in 2007 (OR 1.79, 95Š CI 1.59-2.01), except in the North East geopolitical zone (OR 0.76, 95Š CI 0.55-1.07). Likewise, older children had better odds of registration than those aged less than one year. Female children had worse chances of registration than their male counterparts (OR 0.92, 95Š CI 0.85-0.99). Conclusions: Birth registration improved in 2011 over 2007 across Nigeria except in the North East region. However, much still needs to be done to achieve universal birth registration. Birth registration appears to still be influenced by the gender and age of the child. Designing and implementing a strategic communication program to educate the population about the processes and benefits of early birth registration may further improve birth registration. Contribution: This paper provides a rigorous assessment of the progress made toward universal birth registration, which has not been previously demonstrated