Health systems analysis of eye care services in Zambia: evaluating progress towards VISION 2020 goals.

BACKGROUND: VISION 2020 is a global initiative launched in 1999 to eliminate avoidable blindness by 2020. The objective of this study was to undertake a situation analysis of the Zambian eye health system and assess VISION 2020 process indicators on human resources, equipment and infrastructure. METHODS: All eye health care providers were surveyed to determine location, financing sources, human resources and equipment. Key informants were interviewed regarding levels of service provision, management and leadership in the sector. Policy papers were reviewed. A health system dynamics framework was used to analyse findings. RESULTS: During 2011, 74 facilities provided eye care in Zambia; 39% were public, 37% private for-profit and 24% owned by Non-Governmental Organizations. Private facilities were solely located in major cities. A total of 191 people worked in eye care; 18 of these were ophthalmologists and eight cataract surgeons, equivalent to 0.34 and 0.15 per 250,000 population, respectively. VISION 2020 targets for inpatient beds and surgical theatres were met in six out of nine provinces, but human resources and spectacles manufacturing workshops were below target in every province. Inequalities in service provision between urban and rural areas were substantial. CONCLUSION: Shortage and maldistribution of human resources, lack of routine monitoring and inadequate financing mechanisms are the root causes of underperformance in the Zambian eye health system, which hinder the ability to achieve the VISION 2020 goals. We recommend that all VISION 2020 process indicators are evaluated simultaneously as these are not individually useful for monitoring progress

Incorporating feasibility in priority setting: a case study of tuberculosis control in South Africa

Priority setting for infectious disease control has evolved beyond simple descriptions of costs and consequences of single interventions. Applications of economic evaluation alongside disease transmission modelling now include user-friendly models, which account for setting-specific variations in input prices and epidemiological characteristics, as well as optimisation routines. These developments allow the straightforward assessment of the local cost-effectiveness of new health technologies and rankings of multiple intervention options. At the same time, priority setting increasingly recognises that policymakers may be fulfilling multiple objectives alongside efficient resource allocation, such as pursuing equity in health outcomes, access to health care and financial protection, and that they are faced with a range of health system constraints in any given settings. These constraints may encompass physical input shortages on the supply side (e.g. lack of skilled human resources or disruptions in procuring supplies) and lack of uptake on the demand side (e.g. financial or other barriers such as hesitancy or stigma). Failure to take these into account can result in unfeasible health interventions being recommended and, ultimately, in economic evaluation evidence being disregarded. Different methods for incorporating constraints in priority setting have been put forward, both within the traditional cost-effectiveness analysis framework and alongside it. All these methods present strengths and weaknesses in terms of how they deal with different types of constraints and priority setting contexts, as well as in the extent to which decisions are arrived at algorithmically or through a more deliberative process. My PhD thesis was conceived during two years spent on a project advising the South African National Department of Health on tuberculosis (TB) control policy and implementation. In 2015, the South African Deputy President announced plans for a comprehensive TB screening programme to tackle one of the world’s worst TB epidemics driven by HIV. A key question was how to implement such a complex and costly intervention as intensified TB case-finding (ICF) at full scale in an over-stretched health system. The aim of my thesis was therefore to explore and develop the methods for incorporating feasibility concerns, and specifically health systems constraints, in priority setting models both internally and externally to the traditional cost-effectiveness analysis framework, using priority setting around TB prevention and control in South Africa as a case study. The first step was to carry out a systematic review of the literature on the possible ways to restrict disease transmission model outputs to account for health system constraints that affect the achievable coverage and outputs of disease control interventions. I then carried out an incremental micro-costing exercise of the TB control interventions that the South African Department of Health was considering for inclusion in the latest National TB Plan. The costing covered all the resources needed to deliver the intervention at scale, including the costs of the extra resources needed to relax health system constraints, such as hiring additional clinical staff and budgeting for additional diagnostic equipment. These constraints were identified in consultation with experts on the South African TB Think Tank. Intervention costs were then attached to disease transmission model outputs to generate incremental cost-effectiveness ratios under three different scenarios: (1) without considering the constraints to implementation; (2) considering the constrains; and (3) including the costs of ‘relaxing’ the constraints to achieve unconstrained coverage. This exercise showed that the cost-effectiveness ranking of interventions is substantially affected by considering health system constraints. It also provided valuable information for policymakers on the practical feasibility of the proposed interventions. Lastly, the use of group model building, a qualitative system dynamics modelling technique, was explored to elicit information on the health system constraints that apply to a given setting and set of interventions. This approach was found to be superior to the unstructured expert elicitation usually employed to generate unit cost and quantities assumptions in economic evaluation, as it takes into account the dynamic interactions between the intervention and the health system. The approach was also more likely to identify high level health system constraints that are difficult to incorporate in quantitative analyses. Information on these constraints might be best presented to decisionmakers either alongside, but externally to cost-effectiveness analysis results; or in the form of disease transmission model ‘exemplary’ scenarios where intervention effects (but not costs) are restricted

Cluster randomized evaluation of Adolescent Girls Empowerment Programme (AGEP): study protocol.

BACKGROUND: Adolescents in less developed countries such as Zambia often face multi-faceted challenges for achieving successful transitions through adolescence to early adulthood. The literature has noted the need to introduce interventions during this period, particularly for adolescent girls, with the perspective that such investments have significant economic, social and health returns to society. The Adolescent Girls Empowerment Programme (AGEP) was an intervention designed as a catalyst for change for adolescent girls through themselves, to their family and community. METHODS/DESIGN: AGEP was a multi-sectoral intervention targeting over 10,000 vulnerable adolescent girls ages 10-19 in rural and urban areas, in four of the ten provinces of Zambia. At the core of AGEP were mentor-led, weekly girls' group meetings of 20 to 30 adolescent girls participating over two years. Three curricula - sexual and reproductive health and lifeskills, financial literacy, and nutrition - guided the meetings. An engaging and participatory pedagogical approach was used. Two additional program components, a health voucher and a bank account, were offered to some girls to provide direct mechanisms to improve access to health and financial services. Embedded within AGEP was a rigorous multi-arm randomised cluster trial with randomization to different combinations of programme arms. The study was powered to assess the impact across a set of key longer-term outcomes, including early marriage and first birth, contraceptive use, educational attainment and acquisition of HIV and HSV-2. Baseline behavioural surveys and biological specimen collection were initiated in 2013. Impact was evaluated immediately after the program ended in 2015 and will be evaluated again after two additional years of follow-up in 2017. The primary analysis is intent-to-treat. Qualitative data are being collected in 2013, 2015 and 2017 to inform the programme implementation and the quantitative findings. An economic evaluation will evaluate the incremental cost-effectiveness of each component of the intervention. DISCUSSION: The AGEP program and embedded evaluation will provide detailed information regarding interventions for adolescent girls in developing country settings. It will provide a rich information and data source on adolescent girls and its related findings will inform policy-makers, health professionals, donors and other stakeholders. TRIAL REGISTRATION: ISRCTN29322231 . March 04 2016; retrospectively registered

N-3 fatty acids in patients with multiple cardiovascular risk factors

BACKGROUND: Trials have shown a beneficial effect of n-3 polyunsaturated fatty acids in patients with a previous myocardial infarction or heart failure. We evaluated the potential benefit of such therapy in patients with multiple cardiovascular risk factors or atherosclerotic vascular disease who had not had a myocardial infarction. METHODS: In this double-blind, placebo-controlled clinical trial, we enrolled a cohort of patients who were followed by a network of 860 general practitioners in Italy. Eligible patients were men and women with multiple cardiovascular risk factors or atherosclerotic vascular disease but not myocardial infarction. Patients were randomly assigned to n-3 fatty acids (1 g daily) or placebo (olive oil). The initially specified primary end point was the cumulative rate of death, nonfatal myocardial infarction, and nonfatal stroke. At 1 year, after the event rate was found to be lower than anticipated, the primary end point was revised as time to death from cardiovascular causes or admission to the hospital for cardiovascular causes. RESULTS: Of the 12,513 patients enrolled, 6244 were randomly assigned to n-3 fatty acids and 6269 to placebo. With a median of 5 years of follow-up, the primary end point occurred in 1478 of 12,505 patients included in the analysis (11.8%), of whom 733 of 6239 (11.7%) had received n-3 fatty acids and 745 of 6266 (11.9%) had received placebo (adjusted hazard ratio with n-3 fatty acids, 0.97; 95% confidence interval, 0.88 to 1.08; P=0.58). The same null results were observed for all the secondary end points. CONCLUSIONS: In a large general-practice cohort of patients with multiple cardiovascular risk factors, daily treatment with n-3 fatty acids did not reduce cardiovascular mortality and morbidity. Copyright © 2013 Massachusetts Medical Society