Melbourne School of Population and Global Health - Theses
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ItemHIV care decentralization in lower- and middle-income countries: outcomes, costs, and cost effectiveness( 2018)Decentralized provision of HIV care continuum – from diagnosis to chronic antiretroviral treatment (ART) – at primary health care facilities (PHCFs) is a critical step towards realizing optimal care coverage in national programs of lower- and middle-income countries (LMICs). Whether such a model of provision is justified depends on considerations of effectiveness, program costs, and cost-effectiveness. This research project aims to: a) examine the effectiveness of decentralized provision of HIV testing and counseling (HTC), pre-ART (ART initiation), and long-term ART care relative to hospital provision with the following outcomes: • Cascade of service receipt in HIV testing and counseling (HTC); • The timeliness of ART initiation by baseline CD4 count and clinical stage; • Treatment adherence during ART care. b) estimate and compare ART program costs of decentralized care at PHCFs and those of hospital care; c) estimate the cost-effectiveness of decentralized provision of routine, chronic ART care relative to hospital (centralized) provision. Data from national surveys and reviews of published studies in Indonesia and sub-Saharan Africa were analyzed using multivariate statistics, meta-analysis, and model-based cost-effectiveness analysis. In HTC, pregnant women were equally likely to receive a full HTC procedure, up to post-test counseling, at both hospitals and PHCFs in four high-prevalence countries (Lesotho, Malawi, Zambia, and Zimbabwe), with a positive implication for motivating regular HTC. In pre-ART care; CD4 counts at ART initiation increased over the calendar time for both hospital and PHCF patients, with fewer patients experiencing a late HIV stage. In ART care, hospital and PHCF patients exhibited at least similar adherence to ART, indicating a non-inferior performance of decentralized provision in Indonesia. In program costs, the average cost of providing ART care for PHCF patients was not lower than hospital provision in four sub-Saharan African countries (Rwanda, Malawi, Zambia, and Ethiopia), except in Ethiopia. Cost differences were largely attributable to differential prescribing of ART regimens between facility types and minimized with a switch to the recommended regimens. In terms of cost-effectiveness, decentralizing stable ART patients from hospitals to PHCFs for routine care (down-referral) was found to be cost-effective in Ethiopia. Economically, the extra program cost represents an affordable investment to advance the performance of the existing decentralization programming and population health. HIV care decentralization redistributes the care burden across the health system without compromising patient outcomes and favorable cost-effectiveness implications. Program expansion beyond decentralization and facility-based provision may be necessary to attain optimal coverage of HIV care in many LMICs. Identifying the optimal model of decentralization for given set of program characteristics is a key research area in the direction of optimizing program outcomes and efficiency.
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ItemMechanisms of effect: a health systems analysis of the impact of introducing treatment services for human immunodeficiency virus (HIV) into four public primary health centres in Zambia( 2013)Between 1996 and 2008 global funding for the treatment of human immuno-deficiency virus (HIV) and acquired immune deficiency syndrome (AIDS) increased from US$300 million to an estimated US$15.6 billion. Much of this money was directed to a small number of countries such as Zambia in sub-Saharan Africa, where HIV/AIDS constitutes a major health, social and economic threat. Although the necessity and urgency of responding to the HIV epidemics in these countries was not in question, the exceptional levels of HIV funding and the rapidity of the scale-up of HIV- services did reignite a debate regarding the impact of disease-specific programs on recipient countries’ health systems. Notwithstanding the high profile nature of this debate, little empirical research exists to inform policy makers or programmers in their efforts to meet the dual aims of improving disease-specific health outcomes and simultaneously strengthening health systems. Meeting a gap in the literature, this study examines the impact of introducing donor-funded HIV services into the Zambian health system, focusing specifically on the impact on primary health ‘micro-systems’. The conceptual framework for this study draws from theory developed in the application of complexity science and systems thinking to health systems analysis, which suggests that health systems are characterised by the interconnectedness of their component parts. The multi-disciplinary framework theorises that interactions between system ‘hardware’ and system ‘software’ influence mechanisms of accountability and trust, and through these, the quality and responsiveness of service delivery within health micro-systems. This approach challenges the implicit assumptions of more reductionist frameworks, which suggest that health systems – and particularly micro-level systems – are a simple composite of individual ‘building blocks’. This study adopted a multi-case study design, with four Zambian health centres purposefully selected based on the presence of an established HIV department (more than 3 years old), and urban, peri-urban and rural characteristics. Case data collected in each facility included facility audits, direct observation of facility operations and interviews with patients, staff, and District and non-government officials. Data were triangulated and analysed for each case first, and cross-case analysis subsequently carried out to improve the analytical generalisability of the findings. The findings from this study demonstrate that the rapid scale-up of HIV services in Zambia, which focused predominantly on investing in health system hardware, acted unevenly on mechanisms of accountability and trust and had mixed outcomes on the four health centres’ overall functionality. It was revealed, for example, that the short-term gains in health worker performance achieved through investment in system hardware for HIV services were difficult to sustain, as the lack of investment in underlying mechanisms of accountability such as improved answerability and enforceability or stronger patient-provider trust, enabled perverse work norms to flourish in ways that undermined quality and responsiveness of care. The study points to the critical importance of accounting for the ideas, values and norms of actors in the health system (system software) in order to plan and deliver disease-specific interventions that achieve both their programmatic aims as well as producing long-term, system-strengthening effects. The study constitutes an important contribution to the field of health policy and systems research providing empirical evidence of the complex, social and adaptive nature of health micro-systems and demonstrating the critical value of the hardware-software construct for analysing mechanisms of effect in this domain.