Integrating tuberculosis and HIV services in low- and middle-income countries: a systematic review.

OBJECTIVES: Given the imperative to scale up integrated tuberculosis (TB) and HIV services in settings where both are of major public health importance, we aimed to synthesise knowledge concerning implementation of TB/HIV service integration. METHODS: Systematic review of studies describing a strategy to facilitate TB and HIV service integration, searching 15 bibliographic databases including Medline, Embase and the Cochrane library; and relevant conference abstracts. RESULTS: Sixty-three of 1936 peer-reviewed articles and 70 of 170 abstracts met our inclusion criteria. We identified five models: entry via TB service, with referral for HIV testing and care; entry via TB service, on-site HIV testing, and referral for HIV care; entry via HIV service with referral for TB screening and treatment; entry via HIV service, on-site TB screening, and referral for TB diagnosis and treatment; and TB and HIV services provided at a single facility. Referral-based models are most easily implemented, but referral failure is a key risk. Closer integration requires more staff training and additional infrastructure (e.g. private space for HIV counselling; integrated records). Infection control is a major concern. More integrated models hold potential efficiencies from both provider and user perspective. Most papers report 'outcomes' (e.g. proportion of TB patients tested for HIV); few report downstream 'impacts' such as outcomes of TB treatment or antiretroviral therapy. Very few studies address the perspectives of service users or staff, or costs or cost-effectiveness. CONCLUSIONS: While scaling up integrated services, robust comparisons of the impacts of different models are needed using standardised outcome measures

Working practices and incomes of health workers : evidence from an evaluation of a delivery fee exemption scheme in Ghana

Background: This article describes a survey of health workers and traditional birth attendants (TBAs) which was carried out in 2005 in two regions of Ghana. The objective of the survey was to ascertain the impact of the introduction of a delivery fee exemption scheme on both health workers and those providers who were excluded from the scheme (TBAs). This formed part of an overall evaluation of the delivery fee exemption scheme. The results shed light not only on the scheme itself but also on the general productivity of a range of health workers in Ghana. Methods: A structured questionnaire was developed, covering individual and household characteristics, working hours and practices, sources of income, and views of the exemptions scheme and general motivation. After field testing, this was administered to 374 respondents in 12 districts of Central and Volta regions. The respondents included doctors, medical assistants (MAs), public and private midwives, nurses, community health nurses (CHNs), and traditional birth attendants, both trained and untrained. Results: Health workers were well informed about the delivery fee exemptions scheme and their responses on its impact suggest a realistic view that it was a good scheme, but one that faces serious challenges regarding financial sustainability. Concerning its impact on their morale and working conditions, the responses were broadly neutral. Most public sector workers have seen an increased workload, but counterbalanced by increased pay. TBAs have suffered, in terms of client numbers and income, while the picture for private midwives is mixed. The survey also sheds light on pay and productivity. The respondents report long working hours, with a mean of 54 hours per week for community nurses and up to 129 hours per week for MAs. Weekly reported client loads in the public sector range from a mean of 86 for nurses to 269 for doctors. Over the past two years, reported working hours have been increasing, but so have pay and allowances (for doctors, allowances now make up 66% of their total pay). The lowest paid public health worker now earns almost ten times the average gross national income (GNI) per capita, while the doctors earn 38.5 times GNI per capita. This compares well with average government pay of four times GNI per capita. Comparing pay with outputs, the relatively high number of clients reported by doctors reduces their pay differential, so that the cost per client – $1.09 – is similar to a nurse's (and lower than a private midwife's). Conclusion: These findings show that a scheme which increases demand for public health services while also sustaining health worker income and morale, is workable, if well managed, even within the relatively constrained human resources environment of countries like Ghana. This may be linked to the fact that internal comparisons reveal Ghana's health workers to be well paid from public sector sources.This work was undertaken as part of an international research programme – IMMPACT (Initiative for Maternal Mortality Programme Assessment) – funded by the Bill & Melinda Gates Foundation, the Department for International Development, the European Commission and USAID

Future Partnership for the Acceleration of Health Development : report of a conference, 18-20 Oct. 1993, Ottawa, Canada

French version available in IDRC Digital Library: Futur partenariat pour accélérer l'amélioration de la santé : rapport de la conférence, 18-20 oct. 1993, Ottawa, Canad

Compliance with focused antenatal care services: do health workers in rural Burkina Faso, Uganda and Tanzania perform all ANC procedures?

\ud \ud To assess health workers' compliance with the procedures set in the focused antenatal care (ANC) guidelines in rural Uganda, Tanzania and Burkina Faso; to compare the compliance within and among the three study sites; and to appraise the logistic and supply of the respective health facilities (HF). The cross-sectional study was conducted in the rural HF in three African countries. This descriptive observational study took place in HF in Nouna, Burkina Faso (5), Iganga, Uganda (6) and Rufiji, Tanzania (7). In total, 788 ANC sessions and service provisions were observed, the duration of each ANC service provision was calculated, and the infrastructures of the respective HF were assessed. Health workers in all HF performed most of the procedures but also omitted certain practices stipulated in the focused ANC guidelines. There was a substantial variation in provision of ANC services among HF within and among the country sites. The findings also revealed that the duration of first visits was <15 min and health workers spent even less time in subsequent visits in all three sites. Reagents for laboratory tests and drugs as outlined in the focus ANC guidelines were often out of stock in most facilities. Health workers in all three country sites failed to perform all procedures stipulated in the focused ANC guideline; this could not be always explained by the lack of supplies. It is crucial to point out the necessity of the core procedures of ANC repeatedly

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

Health-industry linkages for local health: reframing policies for African health system strengthening

The benefits of local production of pharmaceuticals in Africa for local access to medicines and to effective treatment remain contested. There is scepticism among health systems experts internationally that production of pharmaceuticals in sub-Saharan Africa (SSA) can provide competitive prices, quality and reliability of supply. Meanwhile low-income African populations continue to suffer poor access to a broad range of medicines, despite major international funding efforts. A current wave of pharmaceutical industry investment in SSA is associated with active African government promotion of pharmaceuticals as a key sector in industrialization strategies. We present evidence from interviews in 2013–15 and 2017 in East Africa that health system actors perceive these investments in local production as an opportunity to improve access to medicines and supplies. We then identify key policies that can ensure that local health systems benefit from the investments. We argue for a ‘local health’ policy perspective, framed by concepts of proximity and positionality, which works with local priorities and distinct policy time scales and identifies scope for incentive alignment to generate mutually beneficial health–industry linkages and strengthening of both sectors. We argue that this local health perspective represents a distinctive shift in policy framing: it is not necessarily in conflict with ‘global health’ frameworks but poses a challenge to some of its underlying assumptions

Social Protection to Address the Drivers of Vulnerability: A Bridge too Far?

Social protection has moved high up on the development agenda and is increasingly considered to be an inherent part of the response to poverty reduction. At the same time, it has received criticism for its current tools and interventions not appropriately taking account of social differentiation and differential access to services. This overview addresses questions around the potential of social protection to be more ambitious and actually address underlying drivers of vulnerability across demographic and social groups. It does so by discussing the need for social protection to be ‘sensitive’ and concurrent issues around political commitment, practical implementation and understandings of impact of social protection

Apoyando el desarrollo en la primera infancia : de la ciencia a la aplicación a gran escala

Mensajes clave de la serie: Las consecuencias de salud y económicas de no actuar son elevadas. Un alarmante 43% de los niños menores de cinco años que viven en países de ingresos bajos y medianos (en total, unos 250 millones de niños) están en riesgo de tener un desarrollo inadecuado a causa de la pobreza y el retraso del crecimiento.1,4 En realidad, este porcentaje es más elevado porque hay otros factores que representan riesgos para la salud y el bienestar. Un mal comienzo en la vida puede afectar negativamente la salud, la nutrición y el aprendizaje. Estos efectos negativos se extienden a la edad adulta, resultando en bajos ingresos económicos y generando tensiones sociales. Además, estas consecuencias negativas repercuten no solo en la generación actual, sino también en las futuras. Se calcula que los individuos afectados por un mal comienzo en la vida sufren una pérdida de aproximadamente una cuarta parte del promedio anual de ingresos en la edad adulta, mientras que los países pueden perder hasta el doble de su gasto actual del PIB en salud y educación; Los niños pequeños necesitan recibir, desde el principio, un cuidado cariñoso y sensible a sus necesidades. El desarrollo empieza en el momento de la concepción. Los estudios demuestran que la primera infancia no es solamente el período de mayor vulnerabilidad a los factores de riesgo, sino también una etapa crítica en la que los efectos positivos de las intervenciones tempranas son más marcados y en la que se pueden reducir los efectos de los factores que afectan negativamente al desarrollo. La experiencia que influye más en el desarrollo de los niños pequeños es el cuidado cariñoso y sensible que le procuran sus padres, otros familiares, sus cuidadores y los servicios comunitarios. El cuidado cariñoso y sensible a las necesidades del niño se caracteriza por la existencia de un ambiente estable que facilita la buena salud y la nutrición de los niños, que protege al niño de posibles peligros y le ofrece la posibilidad de empezar su aprendizaje a una edad temprana, a través de relaciones e interacciones cariñosas. Los beneficios del cuidado cariñoso y sensible se extienden a toda la vida y se expresan en una mejor salud, mayor bienestar y mayor capacidad de aprender y de ganarse la vida. Las familias necesitan apoyo para proveer el cuidado cariñoso y sensible, incluyendo recursos materiales y económicos, políticas nacionales, como licencias de paternidad remuneradas, y prestación de diversos servicios, incluyendo servicios de salud, nutrición, educación y la protección infantil y social; Debemos de entregar intervenciones multisectoriales comenzando con el sector salud como punto de partida para llegar a los niños más pequeños. El objetivo de estas intervenciones, entre ellas el apoyo a las familias para que puedan proporcionar un cuidado cariñoso y sensible y hagan frente a los problemas que se puedan presentar, es proteger al niño de diversos riesgos que pueden afectar a su desarrollo. Para ello, se pueden integrar las intervenciones en los servicios de salud materno-infantil existentes. Estos servicios deben satisfacer las necesidades tanto del niño como de su cuidador principal. Por tanto, deben apoyar el desarrollo del niño y la salud y el bienestar de la madre y la familia. Este enfoque viable es un punto de partida esencial para establecer colaboraciones multisectoriales de ayuda a las familias que permitan llegar a los niños más pequeños. Estas intervenciones deben satisfacer necesidades básicas como la nutrición, el apoyo al crecimiento y la salud; la protección de los niños; la prevención de la violencia doméstica, la protección social que asegure la estabilidad económica de la familia y la capacidad para acceder a servicios; y la educación que brinde acceso a oportunidades de aprendizaje de calidad a una edad temprana; Debemos reforzar la capacidad de las autoridades gubernamentales para ampliar los servicios que funcionan. Cuatro estudios de casos realizados en países de distintas regiones del mundo demuestran que se pueden llevar a gran escala programas nacionales que son efectivos y sostenibles. Sin embargo, para que esto suceda es un requisito indispensable el contar con liderazgo de las autoridades y dar prioridad a las políticas adecuadas. Los gobiernos disponen de distintas opciones para alcanzar las metas y los objetivos fijados en relación con el desarrollo en la primera infancia, desde iniciativas que promuevan cambios y abarquen a diversos sectores gubernamentales hasta la ampliación progresiva de servicios existentes. Los servicios y las intervenciones en favor del desarrollo de los niños pequeños son fundamentales para que todos ellos alcancen el máximo de su potencial en el transcurso de su vida y para extender estos efectos a la siguiente generación. Este propósito es un elemento central de los Objetivos de Desarrollo Sostenible

Use of the new World Health Organization child growth standards to describe longitudinal growth of breastfed rural Bangladeshi infants and young children.

BACKGROUND: Although the National Center for Health Statistics (NCHS) reference has been widely used, in 2006 the World Health Organization (WHO) released new standards for assessing growth of infants and children worldwide. OBJECTIVE: To assess and compare the growth of breastfed rural Bangladeshi infants and young children based on the new WHO child growth standards and the NCHS reference. METHODS: We followed 1343 children in the Maternal and Infant Nutrition Intervention in Matlab (MINIMat) study from birth to 24 months of age. Weights and lengths of the children were measured monthly during infancy and quarterly in the second year of life. Anthropometric indices were calculated using both WHO standards and the NCHS reference. The growth pattern and estimates of undernutrition based on the WHO standards and the NCHS reference were compared. RESULTS: The mean birthweight was 2697 +/- 401 g, with 30% weighing <2500 g. The growth pattern of the MINIMat children more closely tracked the WHO standards than it did the NCHS reference. The rates of stunting based on the WHO standards were higher than the rates based on the NCHS reference throughout the first 24 months. The rates of underweight and wasting based on the WHO standards were significantly different from those based on the NCHS reference. CONCLUSIONS: This comparison confirms that use of the NCHS reference misidentifies undernutrition and the timing of growth faltering in infants and young children, which was a key rationale for constructing the new WHO standards. The new WHO child growth standards provide a benchmark for assessing the growth of breastfed infants and children

Prevalence and factors associated with non-utilization of healthcare facility for childbirth in rural and urban Nigeria: Analysis of a national population-based survey

Aim: The aim of this study was to assess the rural–urban differences in the prevalence and factors associated with non-utilization of healthcare facility for childbirth (home delivery) in Nigeria. Methods: Dataset from the Nigeria demographic and health survey, 2013, disaggregated by rural–urban residence were analyzed with appropriate adjustment for the cluster sampling design of the survey. Factors associated with home delivery were identified using multivariable logistic regression analysis. Results: In rural and urban residence, the prevalence of home delivery were 78.3% and 38.1%, respectively (p < 0.001). The lowest prevalence of home delivery occurred in the South-East region for rural residence (18.6%) and the South-West region for urban residence (17.9%). The North-West region had the highest prevalence of home delivery, 93.6% and 70.5% in rural and urban residence, respectively. Low maternal as well as paternal education, low antenatal attendance, being less wealthy, the practice of Islam, and living in the North-East, North-West and the South-South regions increased the likelihood of home delivery in both rural and urban residences. Whether in rural or urban residence, birth order of one decreased the likelihood of home delivery. In rural residence only, living in the North-Central region increased the chances of home delivery. In urban residence only, maternal age ⩾ 36 years decreased the likelihood of home delivery, while ‘Traditionalist/other’ religion and maternal age < 20 years increased it. Conclusion: The prevalence of home delivery was much higher in rural than urban Nigeria and the associated factors differ to varying degrees in the two residences. Future intervention efforts would need to prioritize findings in this study