Cancer-related electronic support groups as navigation-aids: Overcoming geographic barriers

Cancer-related electronic support groups (ESGs) may be regarded as a complement to face-to-face groups when the latter are available, and as an alternative when they are not. Advantages over face-to-face groups include an absence of barriers imposed by geographic location, opportunities for anonymity that permit sensitive issues to be discussed, and opportunities to find peers online. ESGs can be especially valuable as navigation aids for those trying to find a way through the healthcare system and as a guide to the cancer journey. Outcome indicators that could be used to evaluate the quality of ESGs as navigation aids need to be developed and tested. Conceptual models for the navigator role, such as the Facilitating Navigator Model, are appropriate for ESGs designed specifically for research purposes. A Shared or Tacit Model may be more appropriate for unmoderated ESGs. Both conceptual models raise issues in Internet research ethics that need to be addres

“Conditional scholarships” for HIV/AIDS health workers: educating and retaining the workforce to provide antiretroviral treatment in sub- Saharan Africa

In spite of recent large-scale efforts to roll out ART in developing countries, millions of people who need ART currently do not receive it. Without large increases in the number of health workers to treat HIV/AIDS (HAHW) in the next few years, most developing countries will be unable to achieve universal coverage with ART, leading to large numbers of potentially avoidable deaths. We investigate the economic value of a scholarship for health care education that is conditional on the recipient entering into a contract to work for a number of years after graduation delivering ART in sub-Saharan Africa. Such a scholarship could address two of the main reasons for the low numbers of health workers in developing countries. First, the “scholarship” could increase the number of health workers educated in the country. Second, the “condition” could decrease the probability of emigration of HAHW. We use Markov Monte Carlo microsimulation to estimate the expected net present value (eNPV) of “conditional scholarships” in sub-Saharan Africa. We find that under a wide range of plausible assumptions the scholarships are highly eNPV positive. “Conditional scholarships” for a team of health workers sufficient to provide ART for 500 patients have an eNPV of 1.23 million year-2000 US dollars, assuming that the scholarship recipients are in addition to the health workers who would have been educated without scholarships and that the scholarships reduce annual HAHW emigration probabilities from 15% to 5% for five years. When individual variable values are varied from this base case within plausible bounds suggested by the literature, eNPV of the “conditional scholarships” never falls below 0.5 million year-2000 US dollars. When we assume that the scholarships do not increase HAHW education output, but merely reduce annual HAHW emigration probabilities from 15% to 5% for five years, their eNPV remains highly positive at 0.29 million year-2000 US dollars. Although the “conditional scholarships” are a socially desirable investment, implementation success will likely depend on the sources of finance, selection of candidates, specification of the condition, enforcement mechanisms, and supporting interventions.AIDS, ART.

Financial incentives for return of service in underserved areas: a systematic review

Of the 42 reviewed studies 33 investigated financial-incentive programs in the US. The remaining studies evaluated programs in Japan (five studies), Canada (two), New Zealand (one) and South Africa (one). The programs started between 1930 and 1998. We identified five different types of programs (service-requiring scholarships, educational loans with service requirements, service-option educational loans, loan repayment programs, and direct financial incentives). Financial incentives ranged from year-2000 United States dollars 1,358 to 28,470. All reviewed studies were observational. The random-effects estimate of the pooled proportion of all eligible program participants who had either fulfilled their obligation or were fulfilling it at the time of the study was 71% (95% confidence interval 60-80%). Seven studies compared retention in the same underserved area between program participants and non-participants. Six studies found that participants were less likely to remain in the same underserved area (five studies reported the difference to be statistically significant, while one study did not report a significance level); one study did not find a significant difference in retention in the same area. Twelve studies compared provision of care/retention in any underserved area between participants and non-participants. Ten studies found that participants were more likely to continue to practice in any underserved area (eight studies reported the difference to be statistically significant, while two studies did not provide the results of significance tests); two studies found that program participants were significantly less likely than non-participants to remain in any underserved area. Seven studies investigated the satisfaction of participants with aspects of their enrolment in financial-incentive programs; three studies examined the satisfaction of members of participants’ families with their lives in the undeserved area.Financial incentives, underserved areas,review

"Conditional scholarships" for HIV/AIDS Health Workers: Educating and Retaining the Workforce to Provide Antiretroviral Treatment in Sub-Saharan Africa

Without large increases in the number of health workers to treat HIV/AIDS (HAHW), most developing countries will be unable to achieve universal coverage with antiretroviral treatment (ART), leading to large numbers of potentially avoidable deaths among people living with HIV/AIDS. We use Markov Monte Carlo microsimulation to estimate the expected net present value (eNPV) of a scholarship for health care education that is conditional on the recipient entering into a contract to work for a number of years after graduation delivering ART in sub-Saharan Africa. Such a scholarship could increase the number of health workers educated in the region and decrease the probability of HAHW emigration. "Conditional scholarships" for a team of health workers sufficient to provide ART for 500 patients have an eNPV of 1.23 million year-2000 US dollars, assuming that the scholarship recipients are in addition to the health workers who would have been educated without scholarships and that the scholarships reduce annual HAHW emigration probabilities from 15% to 5% for five years. When individual variable values are varied from this base case within plausible bounds suggested by the literature, eNPV of the "conditional scholarships" never falls below 0.5 million year-2000 US dollars.

Financial incentives for return of service in underserved areas: a systematic review

In many geographical regions, both in developing and in developed countries, the number of health workers is insufficient to achieve population health goals. Financial incentives for return of service are intended to alleviate health worker shortages: A (future) health worker enters into a contract to work for a number of years in an underserved area in exchange for a financial pay-off. The authors of this paper carried out a systematic literature search of PubMed for studies evaluating outcomes of financial-incentive programs published between 1957 and 2007.Disease, control, global health, financial-incentive programs.

Designing financial-incentive programmes for return of medical service in underserved areas of sub-Saharan Africa

In many countries in sub-Saharan Africa health worker shortages are one of the main constraints in achieving population health goals. Financial-incentive programmes for return of service, whereby participants receive payments in return for a commitment to practice for a period of time in a medically underserved area, can alleviate local and regional health worker shortages through two mechanisms. First, they can redirect the flow of those health workers who would have been educated without financial incentive from well-served to underserved areas. Second, they can add health workers to the pool of workers who would have been educated without financial incentives and place them in underserved areas. While financial-incentive programmes are an attractive option to increase the supply of health workers to medically underserved areas – they offer students who otherwise would not have the means to finance a health care education an opportunity to do so, establish legally enforceable commitments to work in underserved areas, and work without compulsion – these programmes may be difficult to implement.Disease, control, global health, financial-incentive programs, 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.

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

Universal antiretroviral treatment: the challenge of human resources

WHO’s Towards Universal Access 2009 report documents a remarkable worldwide increase in the number of people receiving antiretrviral treatment (ART) – from 3 million in 2007 to 4 million in 2008 – creating hope that with sustained energy, universal ART coverage might be achievable (1). At the same time, the report emphasizes many challenges in delivering ART on a more massive scale. One challenge – the number and types of human resources that will be required to achieve universal coverage – deserves attention from a new perspective.  In particular, we discuss the effect of feedback from current ART coverage to future ART human resources need on the sustainability of high lvels of ART coverage. But in order to think about the future, we first try to understand the past.Antiretroviral treatment, human resources

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