Cara Smith Gueye, Gretchen Newby, Jim Tulloch, Laurence Slutsker · 6 authors
BACKGROUND: A malaria eradication goal has been proposed, at the same time as a new global strategy and implementation framework. Countries are considering the strategies and tools that will enable progress towards malaria goals. The eliminating malaria case-study series reports were reviewed to identify successful programme management components using a cross-case study analytic approach. METHODS: Nine out of ten case-study reports were included in the analysis (Bhutan, Cape Verde, Malaysia, Mauritius, Namibia, Philippines, Sri Lanka, Turkey, Turkmenistan). A conceptual framework for malaria elimination programme management was developed and data were extracted and synthesized. Findings were reviewed at a consultative workshop, which led to a revision of the framework and further data extraction and synthesis. Success factors of implementation, programme choices and changes, and enabling factors were distilled. RESULTS: Decentralized programmes enhanced engagement in malaria elimination by sub-national units and communities. Integration of the malaria programme into other health services was also common. Decentralization and integration were often challenging due to the skill and experience levels of newly tasked staff. Accountability for programme impact was not clarified for most programmes. Motivation of work force was a key factor in maintaining programme quality but there were few clear, detailed strategies provided. Different incentive schemes targeted various stakeholders. Training and supervision, although not well described, were prioritized by most programmes. Multi-sectoral collaboration helped some programmes share information, build strategies and interventions and achieve a higher quality of implementation. In most cases programme action was spurred by malaria outbreaks or a new elimination goal with strong leadership. Some programmes showed high capacity for flexibility through introduction of new strategies and tools. Several case-studies described methods for monitoring implementation quality and coverage; however analysis and feedback to those implementing malaria elimination in the periphery was not well described. Political commitment and sustained financing contributed to malaria programme success. Consistency of malaria programmes depends on political commitment, human and financial resources, and leadership. Operational capacity of the programme and the overall health system structure and strength are also important aspects. CONCLUSIONS: Malaria eradication will require adaptive, well-managed malaria programmes that are able to tailor implementation of evidence-based strategies, founded upon strong sub-national surveillance and response, with adequate funding and human resources.
For more than three decades healthcare decentralization has been promoted in developing countries as a way of improving the financing and delivery of public healthcare. Decision autonomy under healthcare decentralization would determine the role and scope of responsibility of local authorities. Jalal Mohammed, Nicola North, and Toni Ashton analyze decision autonomy within decentralized services in Fiji. They conclude that the narrow decision space allowed to local entities might have limited the benefits of decentralization on users and providers. To discuss the costs and benefits of healthcare decentralization this paper uses the U-form and M-form typology to further illustrate the role of decision autonomy under healthcare decentralization. This paper argues that when evaluating healthcare decentralization, it is important to determine whether the benefits from decentralization are greater than its costs. The U-form and M-form framework is proposed as a useful typology to evaluate different types of institutional arrangements under healthcare decentralization. Under this model, the more decentralized organizational form (M-form) is superior if the benefits from flexibility exceed the costs of duplication and the more centralized organizational form (U-form) is superior if the savings from economies of scale outweigh the costly decision-making process from the center to the regions. Budgetary and financial autonomy and effective mechanisms to maintain local governments accountable for their spending behavior are key decision autonomy variables that could sway the cost-benefit analysis of healthcare decentralization.
Ernest Mensah, Moses Aikins, Margaret Gyapong, Francis Anto · 6 authors
BACKGROUND: The global health system has a large arsenal of interventions, medical products and technologies to address current global health challenges. However, identifying the most effective and efficient strategies to deliver these resources to where they are most needed has been a challenge. Targeted and integrated interventions have been the main delivery strategies. However, the health system discourse increasingly favours integrated strategies in the context of functionally merging targeted interventions with multifunctional health care delivery systems with a focus on strengthening country health systems to deliver needed interventions. Neglected Tropical Diseases (NTD) have been identified to promote and perpetuate poverty hence there has been global effort to combat these diseases. The Neglected Tropical Diseases Programme (NTDP) in Ghana has a national programme team and office, however, it depends on the multifunctional health delivery system at the regional and district level to implement interventions. The NTDP seeks further health system integration to accelerate achievement of coverage targets. The study estimated the extent of integration of the NTDP at the national, regional and district levels to provide evidence to guide further integration. METHODOLOGY/PRINCIPAL FINDINGS: The research design was a descriptive case study that interviewed key persons involved in the programme at the three levels of the health system as well as extensive document review. Integration was assessed on two planes-across health system functions-stewardship and governance, financing, planning, service delivery, monitoring and evaluation and demand generation; and across three administrative levels of the health system-national, regional and district. A composite measure of integration designated Cumulative Integration Index (CII) with a range of 0.00-1.00 was used to estimate extent of integration at the three levels of the health system. Service delivery was most integrated while financing and planning were least integrated. Extent of integration was partial at all levels of the health system with a CII of 0.48-0.68; however it was higher at the district compared to the national and regional levels. CONCLUSIONS/SIGNIFICANCE: To ensure further integration of the NTDP, planning and finance management activities must be decentralized to involve regional and district levels of the health system. The study provides an empirical measure of extent of integration and indicators to guide further integration.
Brazil opted for decentralization in the provision of health services at the time of the 1988 Constitution´s promulgation. The municipalities became entirely responsible for primary healthcare provision, sharing financing responsibilities with the central government. The aim of this paper is to evaluate the impact of health spending autonomy on infant mortality rates, using Brazilian local data from 2000 to 2007. As a measure of spending autonomy we used the share (%) of overall health expenditures financed by municipalities’ own resources. The larger the share of health expenditures which is not financed by the central government (grants), the greater the autonomy, because local governments can decide how and on what to spend these resources, and most of intergovernmental transfers to the health sector are allocated to predefined specific purposes. The fixed effects estimates, through the use of an instrumental variables approach, show that, on average, greater spending autonomy is not associated with lower infant mortality rates. However, given that local governments and populations are different in many aspects, it is reasonable to expect a heterogeneous response to decentralization. Galiani et al. (2008), for instance, assess the hypothesis that decentralization of high schools in Argentina may have increased the difference in educational outcomes. Could the same have happened to the quality of health in Brazilian municipalities? In well-managed municipalities and in which individuals participate actively and can support their preferences, fiscal autonomy ought to improve the delivery of public services. Using a measure of efficiency in the delivery of health services to split the municipalities in two groups, we got significant results for the more efficient municipalities, implying an increase in inequality. This measure corresponds to efficiency scores estimated using data envelopment analysis (DEA). We also test for heterogeneous impacts of the Family Health Program (PSF), the most important Brazilian basic health care policy, which main expansion occurred until 2007. It is a federal Program that each municipality runs independently. Again, we find evidence of a heterogeneous response, since PSF only reduces infant mortality rates in efficient municipalities. We then confirm Galiani’s (2008) hypothesis that decentralization may help only the best to do even better.
Obinna Ositadimma Oleribe, Olabisi Oladipo, Iheaka Paul Ezieme, Mary Margaret Elizabeth · 5 authors
Access to quality care is essential for improved health outcomes. Decentralization improves access to healthcare services at lower levels of care, but it does not dismantle structural, funding and programming restrictions to access, resulting in inequity and inequality in population health. Unlike decentralization, Commonization Model of care reduces health inequalities and inequity, dismantles structural, funding and other program related obstacles to population health. Excellence and Friends Management Care Center (EFMC) using Commonization Model (CM), fully integrated HIV services into core health services in 121 supported facilities. This initiative improved access to care, treatment, support services, reduced stigmatization/discrimination, and improved uptake of HTC. We call on governments to adequately finance CM for health systems restructuring towards better health outcomes.
Aku Kwamie, Han van Dijk, Evelyn Ansah, Irène Akua Agyepong
The district health system in Ghana today is characterized by high resource-uncertainty and narrow decision-space. This article builds a theory-driven historical case study to describe the influence of path-dependent administrative, fiscal and political decentralization processes on development of the district health system and district manager decision-space. Methods included a non-exhaustive literature review of democratic governance in Ghana, and key informant interviews with high-level health system officials integral to the development of the district health system. Through our analysis we identified four periods of district health system progression: (1) development of the district health system (1970-85); (2) Strengthening District Health Systems Initiative (1986-93); (3) health sector reform planning and creation of the Ghana Health Service (1994-96) and (4) health sector reform implementation (1997-2007). It was observed that district manager decision-space steadily widened during periods (1) and (2), due to increases in managerial profile, and concerted efforts at managerial capacity strengthening. Periods (3) and (4) saw initial augmentation of district health system financing, further widening managerial decision-space. However, the latter half of period 4 witnessed district manager decision-space contraction. Formalization of Ghana Health Service structures influenced by self-reinforcing tendencies towards centralized decision-making, national and donor shifts in health sector financing, and changes in key policy actors all worked to the detriment of the district health system, reversing early gains from bottom-up development of the district health system. Policy feedback mechanisms have been influenced by historical and contemporary sequencing of local government and health sector decentralization. An initial act of administrative decentralization, followed by incomplete political and fiscal decentralization has ensured that the balance of power has remained at national level, with strong vertical accountabilities and dependence of the district on national level. This study demonstrates that the rhetoric of decentralization does not always mirror actual implementation, nor always result in empowered local actors.
Xiaoyun Liu, Lixia Dou, Huan Zhang, Yang Sun · 5 authors
BACKGROUND: Current literature systematically reports that interventions to attract and retain health workers in underserved areas need to be context specific but rarely defines what that means. In this systematic review, we try to summarize and analyse context factors influencing the implementation of interventions to attract and retain rural health workers. METHODS: We searched online databases, relevant websites and reference lists of selected literature to identify studies on compulsory rural service programmes and financial incentives. Forty studies were selected. Information regarding context factors at macro, meso and micro levels was extracted and synthesized. RESULTS: Macro-level context factors include political, economic and social factors. Meso-level factors include health system factors such as maldistribution of health workers, growing private sector, decentralization and health financing. Micro-level factors refer to the policy implementation process including funding sources, administrative agency, legislation process, monitoring and evaluation. CONCLUSIONS: Macro-, meso- and micro-level context factors can play different roles in agenda setting, policy formulation and implementation of health interventions to attract and retain rural health workers. These factors should be systematically considered in the different stages of policy process and evaluation.
Devolution, as other types of decentralization, profoundly changes governance relations in the health system. Devolution is meant to affect performance of the health system by transferring responsibilities and authority to locally elected governments. This study aimed to establish the effect of devolved governance on the performance of the health sector in Kenya. The guiding objectives included: To establish the influence of devolved procurement on the performance of the health sector; to determine the effect of devolved leadership on the performance of the health sector; to evaluate the effect of devolved resources on the performance of the health sector; and to establish the effect of devolved policy and regulatory framework on the performance of the health sector in Kenya. The study adopted the descriptive survey research design. The target population was 572 patients and health care providers from Nairobi and Mombasa County. Stratified sampling method was adopted at the rate of 10% to come up with a sample size of 57 respondents. Primary data was collected using questionnaires from all the respondents. Secondary data was sourced from health sector reports in Kenya from the year 2010 to 2014. The collected data was then analyzed through frequencies and percentages to enable the research come up with conclusions and recommendations for the study. The researcher employed the assistance of some computer tools, including the Statistical Programmes for Social Sciences (SPSS) and excel version 16 to analyze the data quantitatively. The analyzed data was presented in the form of graphs tables and charts. The Study established that devolution process has not been fully implemented and its effect has not been fully experienced in the health sector. The sector performance was averagely rated in the study and its contribution to GDP reduced by 0.5 percent by the end of the year 2013. The devolved procurement process, organizational leadership, resources allocation and availability as well as policy and regulatory framework had a significant influence on the performance of the level four hospitals and the overall health sector. It was recommended that the health sector players should improve in financing of critical health investment areas, particularly those relating to improving quality of care.
Evelyn Waweru, Catherine Goodman, Sarah Kedenge, Benjamin Tsofa · 5 authors
In many African countries, user fees have failed to achieve intended access and quality of care improvements. Subsequent user fee reduction or elimination policies have often been poorly planned, without alternative sources of income for facilities. We describe early implementation of an innovative national health financing intervention in Kenya; the health sector services fund (HSSF). In HSSF, central funds are credited directly into a facility's bank account quarterly, and facility funds are managed by health facility management committees (HFMCs) including community representatives. HSSF is therefore a finance mechanism with potential to increase access to funds for peripheral facilities, support user fee reduction and improve equity in access. We conducted a process evaluation of HSSF implementation based on a theory of change underpinning the intervention. Methods included interviews at national, district and facility levels, facility record reviews, a structured exit survey and a document review. We found impressive achievements: HSSF funds were reaching facilities; funds were being overseen and used in a way that strengthened transparency and community involvement; and health workers' motivation and patient satisfaction improved. Challenges or unintended outcomes included: complex and centralized accounting requirements undermining efficiency; interactions between HSSF and user fees leading to difficulties in accessing crucial user fee funds; and some relationship problems between key players. Although user fees charged had not increased, national reduction policies were still not being adhered to. Finance mechanisms can have a strong positive impact on peripheral facilities, and HFMCs can play a valuable role in managing facilities. Although fiduciary oversight is essential, mechanisms should allow for local decision-making and ensure that unmanageable paperwork is avoided. There are also limits to what can be achieved with relatively small funds in contexts of enormous need. Process evaluations tracking (un)intended consequences of interventions can contribute to regional financing and decentralization debates.
Renate Hartwig, Robert Sparrow, Sri Budiyati, Athia Yumna · 7 authors
We exploit variation in the design of subnational health-care financing initiatives in Indonesian districts to assess the effects of these local schemes on maternal care from 2004 to 2010. The analysis is based on a district pseudopanel, combining data from a unique survey among District Health Offices with the Indonesian Demographic and Health Surveys, the national socioeconomic household surveys, and the village census. Our results show that these district schemes contribute to an increase in antenatal care visits and the probability of receiving basic recommended antenatal care services for households that are not targeted by the national health insurance programs. We observe a decrease in home births. However, there is no effect on professional assistance at birth. We also observe variation in scheme design across districts as well as constraints to the effectiveness of local schemes. Including antenatal and delivery services explicitly in benefits packages and contracting local rather than national health-care providers increases the effects on maternal care. Increasing population coverage reduces effectiveness, delineating limitations to local funding and risk pooling. Furthermore, we do not find any effects for districts outside Java and Bali, where access to basic health care remains a key policy concern.
The Government of Lao PDR has formulated a National Growth and Poverty Eradication Strategy (NGPES) that links sustainable economic growth, human development, reduced vulnerability and poverty alleviation; and addresses the key issues of public sector governance and public sector management. Implementation of the overall strategy focuses on rural Districts and relies on decentralized authority and beneficiary participation. Health services are a vital component of the NGPES, which reiterates the Government’s commitment to achieving the Millennium Development Goals (MDGs) and identifies improved access, equity, quality and strengthening the health workforce as key goals. Ministry of Health (MOH) supported by the World Bank (WB) is implementing the Health Services Improvement Project-Additional Financing (HSIP-AF) with the objective to increase utilization and quality of health services, particularly for the poor women and children in rural areas. The consultations with ethnic groups during project implementation is necessary in order to assess whether the design of the HSIP-AF is succeeding in responding to the needs for MNCH services of ethnic groups in project provinces, understand the extent to which free delivery, and outreach activities impact health seeking behaviour of pregnant women and new-born children from ethnic groups and ascertain based on the result of such consultations, broad community support to project activities. The principle of SWOT Analysis was adapted in the consultation methodology. The Consultations however, indicated that ethnic communities were not fully informed of and understood project benefits available to them and requirements for participation. Communication is often particular problematic in areas with language barriers. A higher degree of inclusion in terms of community participation in the identification of problems and ways of solving them would demand bottomup implementation mechanisms and more flexibility to adapt project activities and supplied resources to local needs. The health service providers should preferably be female and members of local communities in order to overcome cultural and language barriers.
Although there is a burgeoning empirical literature on the rapid growth of health expenditures, there has been little systematic examination of the influence of central government financing behavior. In addition, studies examining the effect of political variables are relatively few and, as they seem to suffer from the omitted variable bias problem, generate improper inferences on health financing dynamics. Moving from this literature, and drawing on recent developments in the coalition governance, as well as researching on fiscal decentralization, in this paper the authors aim to gain insight into the Italian health care financing scenario taking into account the behaviors of government intervention in the sector. Specifically, they analyze regional political fragmentation and competition for effective political power between majority and opposition coalitions and the authors test if the fragmentation of both coalitions is the key variables that determine their effective political power. The authors test their hypothesis in the Italian framework with a new dataset. Data include financial, demographic and political variables. The empirical analysis is conducted with a panel of 15 Italian regions from year 2000 to 2010.
Decentralization is assumed to be an important tool for a quality health care service delivery. The objective of the study was to assess the impacts of decentralization on the health care service delivery Gozamin District, Amhara State, Ethiopia. Primary data for this study were collected through questionnaire, interview, and focus group discussions. Whereas secondary data were collected from annual official health sector reports and documents. The analysis part was supported by legal and official documents. The findings of the study revealed that the health care service accessibility and coverage of the District in terms of expansion of health care institutions has shown an improvement, and it reaches 100 percent. However, shortage of health personnel (midwifery, lab technician and pharmacy technician), shortage of finance for duty service and perdiem payment, and drugs shortage are the challenges of the District health care delivery system that affects the quality of the services. The costs of health care treatment is high as compared to the ability of most beneficiaries incomes, the free service scheme-which is very impressive were abused by kebele officials are the challenges of Gozamin District health care service delivery system. Keywords: Decentralization, Health Care Service Delivery, health center, and health posts
Health is recognized by the Philippine constitution as a basic human right. The Philippines, compared to most Asian countries, produces more and better human resources for health. However, the Philippines are challenged by attracting and retaining staff in the under-served areas of the country. Philippine allotted 4.2-4.4% of its GDP to health from 2009 to 2011. Furthermore, considerable inequities in health care access and outcomes between Socio-economic groups remain. The Phil Health's limited breadth and depth of coverage has resulted in high levels of out of pocket payments. The implementation of the reforms in financing, service delivery and regulation which are aimed to tackle the inefficiencies and inequalities in the health system has been challenged by the decentralized environment and the presence of private sector, often creating fragmentation and variation in the quality of health services across the country.
Nader Markazi Moghaddam, Aidin Aryankhesal, Mohammad Arab
BACKGROUND: Liberalization and decentralization of public sector has been triggered in some developing countries and in Iran by the Ministry of Health and Medical Education (MOHME) that granted autonomy to 54 public hospitals. However, establishment of such a complex organizational reform was rather unsuccessful. We aimed to explore the obstacles and barriers caused such a failure and their mechanisms. METHODS: Using a qualitative approach in 2013, we consulted key informants at the autonomous hospitals and their affiliating universities. Data collection was done within two phases: (i) 276 unstructured questionnaires asking respondents of barriers, and (ii) 23 semi-structured interviews from the first phase's key respondents. The first phase data were analyzed using thematic analysis and the second's by framework approach based on the frame shaped at the first phase. RESULTS: Nine obstacles were recognized including "autonomous hospitals' board composition", "delay in announcing autonomous hospitals' charges by the MOHME", "lack of financing by the committed organizations", "poor follow up for implementation of the reform", "irregular board meetings", "lack of an external overseer", "shortage of full-time physicians", "lack of management stability", and "health insurance organizations' delayed payments". CONCLUSION: The MOHME and insurance organizations did not pay the reform expenses. There were some competing motives as well to slow the reform or to shut it down. The stages of policy formulation and implementation were done separately in Iran, so this big organizational reform encountered serious obstacles.
Background: In 2004, the health system in Iran initiated an organizational reform aiming to increase the autonomy \nof teaching hospitals and make them more decentralized. The policy led to the formation of a board of trustees in \neach hospital and significant modifications in hospitals’ financing. Since the reform aimed to improve its predecessor \npolicy (implementation of hospital autonomy began in 1995), it expected to increase user satisfaction, as well as \nenhance effectiveness and efficiency of healthcare services in targeted hospitals. However, such expectations were \nnever realized. In this research, we explored the perceptions and views of expert stakeholders as to why the board of \ntrustees’ policy did not achieve its perceived objectives. \nMethods:We conducted 47 semi-structured face-to-face interviews and two focus group discussions (involving 8 \nand 10 participants, respectively) with experts at high, middle, and low levels of Iran’s health system, using purposive \nand snowball sampling. We also collected a comprehensive set of relevant documents. Interviews were transcribed \nverbatim and analyzed thematically, following a mixed inductive-deductive approach. \nResults: Three main themes emerged from the analysis. The implementation approach (including the processes, views \nabout the policy and the links between the policy components), using research evidence about the policy (local and \nglobal), and policy context (health system structure, health insurers capacity, hospitals’ organization and capacity \nand actors’ interrelationships) affected the policy outcomes. Overall, the implementation of hospital decentralization \npolicies in Iran did not seem to achieve their intended targets as a result of assumed failure to take full consideration \nof the above factors in policy implementation into account. \nConclusion:The implementation of the board of trustees’ policy did not achieve its desired goals in teaching hospitals \nin Iran. Similar decentralization policies in the past and their outcomes were overlooked, while the context was not \nprepared appropriately and key stakeholders, particularly the government, did not support the decentralization of \nIran’s health system.
Across the Asian region, models of health administration vary from centralized management arrangements to more open decentralized systems. Utilizing a historical perspective, this review compares and contrasts health systems transition in seven countries (the Democratic People’s Republic of Korea, Myanmar, Timor Leste, Bhutan, Mongolia, Cambodia and the Philippines) against the background of macro-political and economic reform, and then considers the implications of these findings for approaches to health policy analysis. Four management areas are presented to demonstrate variation in health system design over the last 40 years: centralization and decentralization, human resource management, health financing and constituency emergence. Historical records illustrate that these functions have evolved through political reform eras of centralist, early reform, established reform and pluralist models of administration, with the main driver of system change being periodic historical shifts in the design of the macro-political and socio-economic order. The cross referencing of management variables with these stages of transition illustrates the degree to which health policy parameters are reset by periodic historical shifts in the political and social order. The findings in these case studies call for a more nuanced classificatory system for health systems and policy analysis that unites a technical perspective with a wider social and political field of vision, and, in doing so, builds a more comprehensive picture of the way in which health systems function in the real world.
James Kiarie, Carey Farquhar, Robert Redfield, Kefa O Bosire · 8 authors
Background: Lack and inequitable distribution of human resources for health (HRH) is a major health systems challenge in Sub-Saharan Africa.1,2 The Partnership for Innovative Medical Education for Kenya (PRIME-Kenya) is an innovative approach that seeks to strengthen health systems by increasing linkages and collaborations in health care, health education, and health research. This approach was informed by concerns of inadequate clinical exposure with increasing undergraduate student enrollment at a tertiary hospital; increasing demand for locally relevant health research; and the desire to retain health workers at nontertiary facilities during and after training. Intervention: We focused on three interventions as part of the PRIME-Kenya initiative: decentralized training of undergraduate students, building research capacity at 14 nontertiary health facilities, and a nurse training program based on an eLearning platform. Decentralized Training. We sought to improve medical education capacity at selected nontertiary health facilities by training facility staff that already had postgraduate clinical training by using e-resources (textbooks, guidelines, and online lectures). Staff that completed the training were appointed as adjunct faculty at the University of Nairobi (UoN). Building Research Capacity. We conducted two phases of implementation science research training. First, between December 2012 and August 2013, 354 staff (30–60 per facility) received three days of instruction at their facilities on how to develop research questions, write research proposals, and collect data. Second, in October and November 2013, 35 adjunct faculty (3–5 per facility) received two additional days of training during which they developed research proposals based on research questions developed during the first phase. These adjunct faculty will be mentored by UoN faculty to help them submit their proposals for ethics review, collect and analyze data, and disseminate results. eLearning. In 2012, the School of Nursing Sciences introduced an eLearning Bachelor of Nursing (eBScN) upgrading course for diploma-level nurses. Training is conducted in accredited county hospitals where students are supervised by UoN adjunct faculty. Outcomes: At 14 nontertiary health facilities, 182 adjunct faculty have been trained and 306 students have rotated. Adjunct faculty at 9 health facilities have developed draft research proposals covering various areas including the impact of national health financing policies, staff retention, and quality of services. At 28 county hospitals, 148 students are enrolled in the eBScN program, and initial exam results indicate that trainees are gaining expected knowledge and skills. Comment: According to the interviews, the students felt they had more opportunities to practice clinical skills, closer mentoring, and closer interactions with patients at the nontertiary facilities than at the tertiary hospital. Health workers at the nontertiary hospitals also reported improved quality of patient care, increased job satisfaction, and greater interest in research. Those working in the nontertiary health facilities prioritized research that was highly relevant to local practice and policy. In the eBScN training program, county hospitals have retained employees, and the nurses are upgrading their skills without losing income. This innovative approach is successfully addressing some of the HRH challenges in medical education, health care, and research. Acknowledgments: PRIME-Kenya Secretariat staff members included Collins Owek, Francis Njiri, Raphael Kinuthia, Samuel Runo, James Macharia, Wycliffe Ndege, Juliet Mwangi, Minnie Kibore, Linda Nyaga, Wycliffe Khaemba, Susan Wanja, and Luke D. Davies.
Charles B. Holmes, Yogan Pillay, Albert Mwango, Jos Perriëns · 9 authors
Introduction To successfully implement the 2013 WHO consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection at country level, the implications for national and regional health systems need to be considered and addressed. The guidelines target the entire continuum of care for the HIV-infected individual, and in some cases, their partners, and those with unknown status. The guidelines include not only a more inclusive treatment initiation threshold of CD4+ T-cell count of 500 cells/μl or less for adults and adolescents, treatment for life for pregnant and breastfeeding women (or treatment for the duration of pregnancy and breastfeeding regardless of CD4+ T-cell count), treatment regardless of CD4+ T-cell count for children under 5 years of age, discordant couples, those co-infected with either tuberculosis (TB) or severe hepatitis B virus (HBV), and diversification of effective strategies to reach those with unknown status through couples testing and community-based testing. These changes, if fully enacted, will lead to an increase in treatment eligibility of over 60%, from 17.6 million globally, to 28.6 million globally, with variation in that increase by epidemic type and other epidemiologic factors [1]. However, within these increases in volume, health systems will be serving a healthier mix of patients starting antiretroviral therapy (ART), and greater proportions of pregnant women and children, and sexual partners seeking care together. The increased patient volumes and changes in the composition of those seeking care will require rapid attention to existing care delivery strategies in order to ensure that newly diagnosed individuals are served with the maximum efficiency and effectiveness, and others entering or already within the system under existing guidelines are not harmed. Additionally, to be successful over the long term, health systems and HIV programs will need strengthened adherence-support strategies. Systems of care that may already be stressed need to be further augmented through innovations, and in many cases provided with additional resources in order to become more efficient, resilient, robust and effective. The ‘Operations’ and ‘Service delivery’ sections (Chapter 9) of the guidelines address these challenges through recommendations for innovations in the models of service delivery, laboratory diagnostics and treatment delivery in the form of fixed-dose combinations (FDCs) to improve the efficiency, reach and quality of the prevention, care and treatment cascade. There are also potential gains from implementing the guidelines that could accrue to and strengthen health systems and communities, such as a healthier and more productive workforce and fewer new HIV infections, especially in newborns, and HIV-related hospitalizations, and these benefits must also be factored into HIV program and country-level decision-making surrounding adoption and adaptation of the new guidelines [2]. Our objective was to examine the implications of the new guidelines across the continuum of care for each of the elements of national health systems, starting with governance and the role of strategic planning and policy, and including diversification of service delivery models, generation and use of data, healthcare financing, human resource capacity, and supply chains for therapeutic and diagnostic commodities. Governance, strategic planning and policy The progress of discovery and change in the HIV epidemic have demanded a high degree of engagement with evolving evidence, as reflected in part by the 10 guidance documents on antiretroviral drug use issued by WHO since 2000. To date, national governments, with the support of civil society and cooperative partners, have employed a variety of approaches to new guideline adoption. Whereas earlier approaches often focused largely on clinical issues, there is now a need for much broader adoption processes to consider the complex interplay between clinical objectives, operational feasibility, issues related to equity, affordability and health systems capacity. In order to consider, adopt and implement new national guidelines with a broad coalition of support, Ministries of Health must take a strong leadership and governance role. When performed well, the key elements of the process at national level include the following: An inclusive and transparent consultative process that draws upon the best available resources, including program experts and managers, healthcare providers, civil society including people living with HIV, community and faith-based groups, key populations, technical specialists, other relevant government Ministries (e.g. Finance), budget experts and economists, researchers, academics, and health-related professional associations. Assembly, analysis and presentation of relevant clinical, programmatic and financial information. Consideration of guidelines changes in light of broader strategic policy frameworks cross-cutting a broader array of health, human rights and development issues. Clear decision-making mechanisms that allow consideration of competing demands. Clear articulation of roles and responsibility of various partners, in order to ensure accountability and oversight of the processes of change. Ensuring that the case for health in national development, including the potential benefits and risks of potential guidelines changes, is clearly communicated early and often to political leadership and external development partners. The recent process of developing and adopting new guidelines for antiretroviral drug use in pregnant and breastfeeding women in Zambia provides an instructive example of the range of activities needed to ensure that guidelines changes are made with broad stakeholder and health systems support (Fig. 1) [3,4]. National governments and civil society are encouraged to learn lessons from peers, and to participate in WHO's regional guidelines dissemination workshops that are designed to support strong national processes of guidelines change.Fig. 1: The process of changing prevention of mother-to-child transmission (PMTCT) guidelines in Zambia.Diversification and integration of service delivery models to manage patient volumes and improve retention and quality The expansion of HIV testing, care and eligibility for ART will require national governments and partners to consider how best to augment or modify their current health systems to accommodate increased volumes and new categories of patients, and to ensure retention across the care and treatment cascade. There is currently an over-reliance on a limited number service delivery models in many countries. Maximum expansion capacity and quality can be achieved by ensuring that a carefully selected variety of models are put in place and adapted strategically to take account of geography, epidemiology and local needs. Thus, it is an opportune time for governments and funders to focus on previously piloted models that are appropriate for scale-up, and to ensure that the most effective models are scaled up systematically in order to provide substantial complementary capacity to absorb new patients and provide ongoing care. Within the new guidelines, there is an increased emphasis on the importance of expanded national HIV testing and counseling strategies in order to identify ‘as many people living with HIV as early as possible after acquiring HIV infection, and link them appropriately and in a timely manner to prevention, care and treatment services’. The reality of most HIV-testing programs in most generalized epidemics is that they have been largely dominated by provider-initiated testing (most typically healthcare provider-initiated), which has been favored because of the ease of linkage to services and for its high yield and cost-effectiveness. However, it often identifies people living with HIV late in the course of HIV disease, in particular, men and adolescents, as well as key populations, who have low utilization of healthcare services. With the guidelines’ strong recommendation for community-based HIV testing and counseling with linkage to prevention, care and treatment services, governments should consider systematically expanding a number of approaches tailored for their settings, including mobile, door-to-door, index, campaign, workplace and school-based HIV testing and counseling approaches, and other strategies that ensure the inclusion of underserved groups such as children, adolescents and men. It is also important to recognize that the yield of nonclinic-based testing can be lower and more expensive from a human resource perspective, requiring a careful balance to be struck. For concentrated and low-level epidemics, governments are urged to consider guidelines that reflect WHO's strong recommendation to increase the number and diversity of the facilities in which provider-initiated testing and counseling are available, including sexually transmitted infection clinics, hepatitis and TB sites, antenatal care settings and services for key populations, notably MSM, transgender people, sex workers and people who inject drugs (Fig. 2) [5].Fig. 2: Innovative service delivery models to increase diagnosis and early antiretroviral therapy (ART) initiation among key populations in Indonesia.The capacity of national health systems to absorb the greater numbers of healthier, pregnant and individuals accompanied by partners eligible for treatment will be directly related to the extent to which ART sites are diversified, decentralized (and in some cases integrated into primary care services) and generally expanded. Extending care through different models will also relieve traditional ART sites and higher-level facilities and allow a greater focus on the sickest patients, especially in high-burden generalized epidemics. Models for consideration and rapid scale-up include ART initiation and maintenance for mothers and children in high HIV-prevalence settings integrated into antenatal care, and maternal and child health clinics, and for HIV/TB co-infected individuals into TB clinics, and other approaches that reduce the need of patients to come to clinics through community-based treatment clubs with rotating antiretroviral drug pick-up and home delivery, especially in remote rural areas. A systematic review on the impact of decentralization of ART delivery identified evidence from both randomized controlled trials and observational studies, and found that patients initiated at a hospital and maintained at a health center were more likely to be retained [6]. No difference in attrition was observed between those initiated and maintained on ART at a hospital compared to at a health center. Comparable attrition was observed after 12 months in the two trials in which ART maintenance was in the community [6]. Regions with measurable injection drug use may also consider the new strong recommendation for ART initiation integrated into clinics and sites in which opioid substitution therapy (OST) is provided. In areas with strong general outpatient services, integration of HIV services may yield greater equity with other health services, and may more directly enable HIV's chronic care models to benefit care and management responses to other chronic diseases such as diabetes and hypertension. These integrated sites must also be capacitated with on-site laboratories and referrals with a rapid turnaround for results reporting, especially for viral load, CD4+ T-cell count testing, TB testing and safety laboratories. Tiered laboratory systems must work closely with program leadership to ensure strategic investments in the best technologies for sites providing ART. Intentional analyses should be conducted to balance the convenience of point-of-care (e.g. CD4+ T-cell testing) technologies with the use of centralized high-throughput instruments. With anticipated rapid expansion of demand for viral load testing, it is essential to use internationally acceptable methods to locally validate the use of dry blood spots, as a means of viral load testing, which will allow expansion of this capacity without phlebotomy and cold chain capacity – the imminent availability of point-of-care viral load testing will also strengthen the health system's ability to provide good quality care. It is also critical to close the loop with results reporting via short message service or other secure electronic communication. Existing and new models also need to be chosen in order to intentionally retain patients in care and treatment, and ensure adherence to ART. Structural interventions such as increasing access points and decentralization through community-based models can address some of the most commonly cited reasons for disengagement with care (e.g. transport expenses, overcrowding of vertical sites). At an individual level, substantial evidence has demonstrated the benefits of two-way mobile phone text message systems, and WHO has made a strong recommendation for consideration of this approach [7]. As with numerous other proven methodologies, very few countries have systematically evaluated the needs of various vulnerable groups such as pregnant women, adolescents, key populations and healthy individuals starting ART and systematically taken appropriate packages of cost-effective adherence and retention interventions from the pilot phase, to scale. Generation and use of data for monitoring, evaluation, efficiency and quality improvement National and regional health systems of program monitoring and evaluation are fundamental to public health approaches to HIV prevention, care and treatment, and other chronic illnesses. When they work well, systems of measurement serve to provide actionable data for decision-making, starting with the clinician and service delivery sites, to regional and national program managers, related sectors (e.g. Ministries of Finance), and development partners [8]. Although the HIV response has focused substantial investments on monitoring and evaluation, the nature of the emergency response combined with weak health systems and the sheer volume of chronically ill patients have resulted in greater than expected challenges for many national systems. These challenges have been highlighted in recent studies demonstrating serious gaps in the ability of these systems to report on indicators that meaningfully measure program quality, and a lack of consistent data use at the site and regional levels to improve program quality [9]. With the influx of individuals seeking testing and care, and through sites and models not traditionally reporting on ART use (e.g. community-based antiretroviral drug pick-up and antenatal care sites), there are actions that must be taken coincident with guidelines adoption to ensure effective monitoring and evaluation of program quality. National governments and supportive cooperative partners must redouble efforts to harmonize and strengthen platforms for the use of data at levels of the health system to ensure that guidelines changes are as expected and that quality of care and patient are not models include or by the of health and development partners their implementing to review care and treatment at the and local These processes should be to and quality improvement processes that ensure clinical sites review their on critical elements of the care and treatment and have to to to quality and access to technical as on data use also to attention on the volume and of indicators and the systems that data A of potential indicators over the years has in some cases attention from those indicators considered at regional and national and countries are encouraged to their most critical indicators with the and ensure in the WHO's early indicators for HIV drug system of key indicators designed to quality improvement of ART services at level, with for and of the results for program management National governments and development partners also need to ensure systems are to allow reporting and use of the There are numerous and systems in few are fully integrated across the of care and treatment and at a national WHO is with numerous countries to improve integration of systems the Systems for HIV a of and guidelines to countries and implement a system that patient and and the impact in an integrated across maternal and child health of mother-to-child transmission and In WHO will consolidated strategic guidance that will a of indicators across the continuum of prevention, treatment and these will the key of quality HIV With this HIV program will have access to the critical indicators within with other When data are not to and important areas of the other methods may be including use of to more on critical issues that can with program quality, and traditional indicators and studies to the of critical program changes (e.g. studies of pregnant women starting ART CD4+ T-cell count of models and efficiency The HIV response ongoing and attention to to ensure the availability of for effective and with the Although the new guidelines will have much greater impact on health and of new and have the potential to reduce the of their are [1]. Ministries of Health and have critical challenges with new guideline to the and financial of potential guidelines changes in order to with local planning and to secure to support ongoing and changes to and to ensure the use of available of the of potential guidelines changes can be a variety of models, and some countries have been these of for As in of the guidelines, the of models is of the most commonly and its and resource needs models can be to the impact of guidelines changes on number of number of infections, and the of changing guidelines or approaches in a variety of epidemic models include the Health and models by the Health and for each with various and potential are encouraged to consider that is only as good as its ease of level of support, and attention must be in to ensuring the of local programmatic and Although has the of for the HIV response over the 10 years of the response in many low and some national governments have to increase their The ability of the in low and countries to further support the HIV and broader health response will be especially if traditional to These new guidelines a case for changing the course of the HIV and further resource may be by the of (e.g. more in antiretroviral drugs in the may reduce HIV that are less at for These may also be in the of such as the for Health and as for development of national that have the potential to provide a more for the HIV response and general health The has a to with to increase for methods for the efficiency by which the healthcare system resources to key and will also to and further resource For to the range of to provide ART to an individual, or provide an HIV testing and counseling by or of and for activities partners have made investments in developing these methods over recent and national governments are encouraged to to and resource use as the new guidelines are Ensuring human resource capacity to support evolving service delivery models of to the range of services to quality healthcare are a chronic in many countries. in many low and with of patients, are in some cases by only clinical and to long and for patients and a lack of attention to quality the new guidelines have many of the HIV interventions (e.g. a available in for HIV-infected and a focus on ensuring patients ART they HIV-related illnesses. These will further allow national programs to care delivery to who require less and to service delivery models and community delivery of The new guidelines also include recommendations for ART initiation to and for and community health workers to ART between has been a in the evidence for these recommendations and has successfully as a means of increasing the number of sites and to serve HIV-infected individuals (Fig. The effective use of in as a means of and expanding access to HIV care and as countries and scale-up new models of delivery, the guidelines changes provide a good to the current of various levels of and to use rapid evaluation to For the has that allow national governments to the need for additional healthcare workers on various guidelines These can also countries to approaches to and healthcare including laboratory These can form the for with professional of laboratory and and programs for other including community health workers and In order to the potential of the health including substantial numbers of new of health governments must to monitoring of program and ongoing support for the development of healthcare It is also important to frameworks to enable support and for new of health workers that have proven essential to the HIV including and community health These with the to have often been considered now are upon for delivery of services and must or and for Ensuring national supply chains are for the increase in volumes and changes in the mix of of the critical interventions in the new guidelines are on a consistent supply of essential commodities. Although national supply chains have in the 10 years of the HIV especially for antiretroviral drug there serious challenges in ensuring that clinics have For of rapid at the site level the efficiency and of and testing and prevention programs With more and expanded testing capacity for individuals their CD4+ T-cell count 500 cells/μl the case of and rapid expansion of viral load capacity, countries will to ensure that and related are with the of as antiretroviral activities for the of new guidelines include of the capacity of the and human resource capacity for transport and data management of the national supply for and need to include on antiretroviral drug that the use of fixed-dose in order to ensure adherence and supply the potential for viral load testing to up demand for and for additional HIV rapid (and other of care diagnostic such as point-of-care CD4+ T-cell and TB testing and and antiretroviral drug of of the of supply and of available technical and national of of with accountability at the levels of government and will likely have the with ensuring of key such as HIV rapid antiretroviral drugs and critical laboratory if their demand are communicated to their or supply and into The is important because the them and the to TB and work with to the demand for various of which the to the demand for their In the this and financial to of by of health services as well as civil society should be encouraged by national governments to ensure that are as early as possible that may be In the new WHO consolidated guidelines reflect not only evolving clinical also in the and of service delivery and program The most effective processes of guidelines change are by and reflect consultative processes in which and can be by partners with a in the It is expected that most countries will that there is a need to investments in the diversification of service delivery models, use and of data, development of human resources, and supply chains in order to accommodate increased patient volumes and to quality across the care and treatment cascade. and with careful for the essential elements of national health systems, the new guidelines could yield substantial for individuals living with HIV and public of There are of
The purpose of this paper is to examine the effect of financial incentives on the level of inappropriateness in health care. The case of the Italian NHS seems to be especially interesting when considering the effects of financial incentives on providers behaviors, as decentralization processes have progressively increased the variability among Regional Health Authorities in both the financing and the delivery of health care. In particular, we investigate the effect of DRG tariff differentials on hospital risk-adjusted cesarean rates for first-time mothers during the period 2009–2011. Our main finding is that Italian hospitals respond to financial incentives in obstetrics and that the strategic behavioral response varies by hospital type.