Health care delivery
Price JE, Leslie JA, Welsh M, Binagwaho A. Integrating HIV clinical services into primary health care in Rwanda: a measure of quantitative effects. AIDS Care. 2009;21(5):608-14.
With the intensive scale-up of care and treatment for HIV in developing countries, some fear that intensified attention to HIV programmes may overwhelm health care systems and lead to declines in delivery of other primary health care. Few data exist that confirm negative or positive synergies on health care provision generally resulting from HIV-dedicated programs. Using a retrospective observational design Price and colleagues compare aggregate service data in Rwandan health facilities before and after the introduction of HIV care on selected measures of primary health care. The study tests the hypothesis that non-HIV care does not decrease after the introduction of basic HIV care. Overall, no declines were observed in reproductive health services, services for children, laboratory tests, and curative care. Statistically significant increases were found in utilization and provision of some preventive services. Multivariate regression, including introduction of HIV care and two important health care financing initiatives in Rwanda, revealed positive associations of all with observed increases. Introduction of HIV services was especially associated with increases in reproductive health. While hospitalization rates increased for the whole sample, declines were observed at health facilities that offered basic HIV care plus highly active antiretroviral therapy. The authors indicate that their results partially counter fears that HIV programs are producing adverse effects in non-HIV service delivery. Rather than leading to declines in other primary health care delivery, they say their findings suggest that the integration of HIV clinical services may contribute to increases.
Editors’ note: This study of 30 primary health centres that had at least 6 months experience offering basic HIV care, defined as voluntary counselling and testing, prevention of mother-to-child transmission services, and preventive therapy with cotrimoxasole, found positive synergies between HIV care and the delivery of other primary care services, particularly antenatal care. This study would be strengthened by consideration of outcome indicators, such as maternal mortality and incidence of congenital syphilis, rather than solely service utilisation indicators. The changes documented here occurred against a backdrop of two important nationally coordinated health care financing programmes that the researchers did try to take into account– the mutuelle de santé, Rwanda’s nationwide primary health insurance system, and performance based financing of health centres. Both of these programmes would be expected to increase uptake and improve outcomes.
Hanefeld J, Musheke M. What impact do Global Health Initiatives have on human resources for antiretroviral treatment roll-out? A qualitative policy analysis of implementation processes in Zambia. Hum Resour Health. 2009 Feb 10;7(1):8. [Epub ahead of print]
Since the beginning of the 21st century, development assistance for AIDS has increasingly been provided through Global Health Initiatives (GHI), specifically the United States Presidential Emergency Plan for AIDS Relief, the Global Fund to Fight HIV, TB and Malaria and the World Bank Multi-country AIDS Programme. Zambia, like many of the countries heavily affected by HIV in southern Africa, also faces a shortage of human resources for health. The country receives significant amounts of funding from GHIs for the large-scale provision of antiretroviral treatment through the public and private sector. This paper examines the impact of GHIs on human resources for antiretroviral treatment roll-out in Zambia, at national level, in one province and two districts. Hanefeld and Musheke undertook a qualitative policy analysis relying on in-depth interviews with more than 90 policy-makers and implementers at all levels. Findings show that while GHIs do not provide significant funding for additional human resources, their interventions have significant impact on human resources for health at all levels. While GHIs successfully retrain a large number of health workers, evidence suggests that GHIs actively deplete the pool of skilled human resources for health by recruiting public sector staff to work for GHI-funded nongovernmental implementing agencies. The secondment of GHI staff into public sector facilities may help alleviate immediate staff shortages, but this practice risks undermining sustainability of programmes. GHI-supported programmes and initiatives add significantly to the workload of existing public sector staff at all levels, while incentives including salary top-ups and overtime payments mean that antiretroviral treatment programmes are more popular among staff than services for non-focal diseases. Research findings suggest that GHIs need to actively mediate against the potentially negative consequences of their funding on human resources for health. Evidence presented highlights the need for new strategies that integrate retraining of existing staff with longer-term staff development to ensure staff retention. The study results show that GHIs must provide significant new and longer-term funding for additional human resources to avoid negative consequences on the overall provision of health care services and to ensure sustainability and quality of programmes they support.
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