Nossal Institute for Global Health - Theses
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ItemStrengthening the management and provision of public health services: an investigation of the recent healthcare reform using internal contracting in Cambodia( 2013)Introduction: Contracting, regarded as one of innovative approaches, has been used to address these issues. As part of larger national reform strategies to address poor public services, Cambodian government has piloted internal contracting as an approach to improve the management of district health system and services. The approach means parties from the same legal entity enter into a contract that is relational and based on trust and existing relationship. In Cambodia, a third of health districts, nominated as “Special Operating Agency - SOA”, are granted a semi-autonomous status with a greater degree of flexibility for decision-making. They receive additional funding to provide staff with financial incentives, recruit additional staff and engage communities and users. Using the Cambodian reform as a case study, this thesis examines the effectiveness of this approach in improving the management and provision of district health services. The effectiveness is judged by its being appropriate to and implementable in the context and able to overcome constraints and improve the conditions of staff and organisations, and the performance of service provision. It describes the design of the internal contracting arrangement, examines the implementation, changes in staff income and motivation, and assesses changes in the provision of primary health services. Methods: I reviewed the literature and available documents related to the reform, analysed data from interviews with officials and from a cross-sectional survey of 266 primary health care staff. Routine service data on child immunisation, antenatal care at second visit, newborn delivery by trained staff and outpatient consultation from four SOA districts were used to assess changes in primary care services before and after the reform. Findings: The implementation of internal contracting enabled facilities to maintain service delivery outputs elevated through other forms of contracting before the introduction of the current reform. The additional funding, carefully managed and utilised, made it possible to pay staff incentive; it along with performance contract made it possible to improve accountability addressing their underperformances and the functioning of health facilities. The incentive, albeit low, contributed to staff income and motivation. Coupled with job monitoring, incentive dissuaded many from private practice. Several challenges remained. System, tools and resources for management of performance and incentive and for contract monitoring were inadequate. Resource provision has been improved, but transparency of funding flow and information sharing was insufficient to tackle delays and cuts. Improvement in working conditions and organisational conditions was not optimal and their deficiencies continued to constrain staff performance. Analysis of provision primary care services (outpatient consultation, child immunisation, antenatal care and newborn delivery) showed mixed results, with most of the services increasing and stabilising after the introduction of the internal contracting. Conclusions: Internal contracting, when carefully packaged and designed, is effective in enhancing and sustaining service delivery for the long term. Adequate systems and tools for implementing performance contracts and managing resources are pre-requisites for improving staff performance and service delivery. Fine-tuning of the governance structure and the arrangements to ensure integrity of resource management and improve monitoring function would likely result in increased effectiveness of the local health system and service provision.
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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.
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ItemFactors influencing adherence to antiretroviral therapy in rural Zimbabwe: implications for health policy and practice( 2010)Background: The extraordinarily high thresholds of adherence (≥95% of doses taken) currently deemed essential for good control of HIV has proved daunting for patients and challenging to clinicians in antiretroviral therapy (ART) programmes. Typical average adherence in other chronic diseases is between 50%-70%. Non-adherence to ART leads to the possibility of increased viral load, threatening the survival of individual patients and potentially raising the incidence of HIV in the general population. Adherence to ART is further complicated by lack of a gold standard tool to measure it. This study was conducted in Zimbabwe, one of the eight Southern African countries with generalised HIV epidemics (estimated prevalence of 15.3% in 2007). ART roll out began in 2004 as part of responses to address the epidemic. The ART programme is being implemented within an unprecedented humanitarian crisis. Aim: The study aimed to contribute to public health policy and program development by documenting adherence levels and assessing patient, community and health delivery factors influencing adherence to anti-retroviral therapy among patients in rural Zimbabwe. Method: The study design was mixed methods in two phases. The qualitative phase comprised six focus group discussions (FGDs) with 48 participants and 39 semi-structured interviews with the community and patients on ART, and one FGD with health staff; this phase was conducted to gain insight into influences on adherence in a specific context. The quantitative phase was a cross sectional survey with 180 patients on first line ART using an interviewer administered questionnaire that included three measures to estimate levels of adherence (visual analogue scale [VAS], seven day recall and unannounced pill counts [UPC] and questions exploring influences on adherence. Qualitative data were thematically analysed. Quantitative data were analysed using descriptive statistics, Chi-square and T tests to ascertain associations between variables Predictors of adherence were identified through binary logistic modelling. Results: Enablers of adherence identified qualitatively were: availability and accessibility of food; improved quality of life; hope of living longer; psychosocial support; and reliable drug supplies. Obstacles to adherence were: poverty, food unavailability and inaccessibility, alcohol use, denial and non-disclosure of HIV diagnosis, stigma and discrimination, lack of psychosocial support, cultural beliefs and practices, and lifelong duration of ART. Quantitative results showed levels of ≥95% adherence varied by method of measurement: 80.7%, 64.5% and 44.4% by VAS, seven day recall and UPC, respectively. Predictors of suboptimal adherence were: reported feelings of depression [OR 4.3, 95% CI 1.85-9.75]; need for a break from taking ARVs [OR 3.9, 95% CI 1.22- 12.15]; being female [OR 2.6, 95% CI 1.08-6.11]; feeling of not being listened to by health workers [OR 3.2, 95% CI 1.20-8.34]; having completed at least secondary education [OR 5.0, 95% CI 2.22-11.13]; perceived experience of stigma and discrimination as a disadvantage of disclosure [OR 2.5, 95% CI 1.15-5.20]; and difficulties travelling to the health centre for collection of ARVs and clinical review [OR 2.4, 95% CI 1.14-5.10]. Conclusions: Variations in adherence by measure indicate a need for further development of feasible tools. Patients alone do not hold the key to adherence. The complex problem of non-adherence should be urgently addressed from a multilayered, collaborative and complementary perspective that considers implications of the current humanitarian crisis. A range of context appropriate recommendations for patients, community and health provider levels are identified.
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ItemLessons learned: the Australian military and tropical medicine( 2013)Historically, prolonged battles were frequently lost and won because of the greater fitness of one of the combatant armies. This held true even in the twentieth century when illness was a major factor leading to the withdrawal from the Gallipoli Peninsula in the Great War and the near-defeat of the Allied armies due to malaria in the Pacific theatre during World War Two. Malaria emerged again a major problem in the Vietnam War. Many of the most crucial battles have taken place in tropical or subtropical locations with the result that participating troops succumbed to tropical diseases. As a result, it was imperative that a substantial amount of the scientific work to prevent and manage these diseases be done by military doctors. The benefit of their work extends well beyond the military community and has greatly improved health throughout the tropics and the wider world. Despite the expertise of the medical corps, serious health problems still occurred in most extended military campaigns until recent times. It is clear that medical lessons were not learnt from previous encounters, mainly in relation to prevention of disease by providing adequate sanitation, nutrition and care of participating soldiers and preparing to meet the threat of endemic diseases prevalent where troops were to be deployed. The Australian Army Medical Corps, founded in 1901, had the benefit of observing medical mistakes made by previous armies and in general has acquitted itself well. However, mistakes in this area leading to significant morbidity were still being made as recently as the year 2000 mainly in relation to malaria. For instance, lack of preparedness of doctors sent to New Guinea with the Australian force in the Great War, lack of prophylactic measures against malaria taken by the Allied force returning from the Middle East for deployment in New Guinea in World War Two, failure to perceive the threat from the emergence of drug resistant strains of malaria parasites in the 1960s and above all, the failure of military command to fully implement the recommendations of their medical advisors. Despite these shortcomings Australia has been served well by some exceptional military doctors who have led the world in their research particularly through the Land Headquarters Medical Research Unit initiated by Neil Hamilton Fairley and the Australian Malaria Institute by Robert Black. This study illuminates the need for the Australian Government and the Australian Defence Force to be cognizant of the past and appreciate the need for continuing army medical research so that the welfare of troops sent on deployment in the tropics is preserved and not seriously affected by familiar and emerging diseases.
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ItemHarm reduction and law enforcement in Vietnam: influences on street policing( 2013)Background and rationale: The HIV epidemic in Vietnam has from its start been concentrated among injecting drug users. Vietnam instituted the 2006 HIV/AIDS Law which includes comprehensive harm reduction measures, but these are unevenly accepted and inadequately implemented. Ward police are a major determinant of risk for injecting drug users (IDUs), required to participate in drug control practices (especially meeting quotas for detention centres) which impede support for harm reduction. Influences on ward level police regarding harm reduction were studied in Hanoi to learn how to better target education and structural change. Methods: After document review, key informants were interviewed from government, NGOs, INGOs, multilateral agencies, and police, using semi-structured guides. A survey was carried out among ward level police (n=27). Topics covered in both phases included perceptions of harm reduction and the police role in drug law enforcement, and harm reduction training and advocacy among police. Results: Police perceive conflicting responsibilities, but overwhelmingly see their responsibility as enforcing drug laws, identifying and knowing drug users, and selecting those for compulsory detention. Harm reduction training was very patchy, ward police not being seen as important to it; and understanding of harm reduction was limited, tending to reflect drug control priorities. Justification for methadone was as much crime prevention as HIV prevention. Competing pressures on ward police create much anxiety, with performance measures based around drug control; recourse to detention resolves competing pressures more safely. There is much recognition of the importance of discretion, and much use of it to maintain good social order. Policy dissemination approaches within the law enforcement sector were inconsistent, with little communication about harm reduction programs or approaches, and an unfounded assumption that training at senior levels would naturally reach to the street. Discussion: Ward police have not been systematically included in harm reduction advocacy or training strategies to support or operationalise legalised harm reduction interventions. The practices of street police challenge harm reduction policies, entirely understandably given the competing pressures on them. For harm reduction to be effective in Vietnam, it is essential that the ambiguities and contradictions between laws to control HIV and to control drugs be resolved for the street-level police.
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ItemAnaemia among young children in rural India( 2012)The World Health Organization estimates that globally, over 1.6 billion people are anaemic, with the prevalence highest among preschool children. Almost one third of the 293 million anaemic preschool children worldwide live in India. Despite rapid economic growth and long-standing anaemia control policies, the burden of anaemia in Indian children remains undiminished. In rural India, 80.9% of children aged 6-35 months are anaemic. Iron deficiency is believed to be the most important cause of anaemia in this population. However, other conditions, including deficiencies of folate, vitamins B12 and A, malarial and hookworm infection, and haemoglobinopathies, may also cause anaemia. The relative contribution of nutritional, infectious and genetic conditions to the burden of anaemia among Indian children has not been determined. A comprehensive understanding of the determinants of anaemia, including an appreciation of the performance of anaemia control programmes, is needed to address anaemia among young children in rural India. This thesis comprises two studies that aim to ultimately inform policy by understanding the determinants of anaemia, evaluating implementation of anaemia control strategies in the field, and ascertaining the value of screening for anaemia. The first project comprises a cross-sectional study investigating the determinants of anaemia and micronutrient concentrations, and evaluating the performance of anaemia control strategies in children 12-23 months of age in rural Karnataka, India. Of 401 children sampled, 75.3% were anaemic. A multiple regression model identified independent, positive associations between children’s haemoglobin and their ferritin, folate, age, maternal haemoglobin, and either family wealth or food security status; and negative associations with presence of beta thalassaemia trait, C-Reactive Protein (CRP) and male sex. Children’s ferritin was positively associated with maternal haemoglobin, iron intake and CRP, and negatively with continued breastfeeding and child’s energy intake. Children continuing to receive breastmilk had lower ferritin, B12 and vitamin A concentrations than their fully weaned counterparts, received less nutrition from complementary feeds and belonged to poorer, more food insecure families. Only 41.5% of children had ever received iron supplementation, and only 11.5% had received iron from a government source. Children who had received iron were more likely to be male, from wealthier families, and have mothers who had received iron. We found that measuring haemoglobin was not useful for identifying iron deficiency in this population. The second study investigated serum hepcidin as a new diagnostic test of iron deficiency. As this assay could not be performed using the Indian samples, this study was performed in a prospectively recruited sample of 261 adult Australian female blood donors. The AUCROC for hepcidin compared with the transferrin receptorferritin index was 0.89. A reference range for hepcidin and clinically useful cut-offs to diagnose iron deficiency were determined. Our findings suggest that improving iron intake is essential to alleviation of anaemia in this population, but that current policies are being inadequately implemented. Equitable delivery of iron, strategies that improve maternal haemoglobin, and efforts to reduce poverty and improve food security may help control the burden of anaemia among Indian children.
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ItemEpidemiology of pulmonary tuberculosis in Beira city, Mozambique( 2011)Objectives: The present study had the following objectives: to identify risk factors associated with diagnostic and treatment delay and with poor treatment outcomes among patients with pulmonary tuberculosis; to describe the role of health workers in the management of patients with tuberculosis; and to describe the genotypic characteristics of Mycobacterium tuberculosis strains circulating among patients with pulmonary tuberculosis. Methods: The study was carried out in Beira city, Mozambique using a mix of quantitative and qualitative methods. The quantitative component was based on a consecutive cohort of newly registered pulmonary tuberculosis patients recruited from five diagnostic and treatment centres. Patients were included in the study if they were at least 18 years of age at enrolment and lived in Beira City. The qualitative study was carried out in one TB clinic and it was based on an ethnographic study of health workers. Results: TB delay was assessed in 774 patients. Total delay, defined as the sum of patient delay and health system delay, varied from 30 to 780 days and the median total delay for new smear-positive, new smear-negative and retreatment patients was 123, 180 and 150 days, respectively. The median patient delay for new smear-positive patients, new smear-negative patients and re-treatment patients was 56 days, 68 days and 58 days, respectively. The median health system delay for new smear-positive patients, new smear-negative patients and re-treatment patients was 52 days, 73 days and 65 days, respectively. Patient delay was associated with farming, visiting first a traditional healer, low TB knowledge and presence of a concomitant chronic disease. Health system delay was associated with multiple visits to primary health care facilities, farming and presence of a concomitant chronic disease. Age, negative sputum smear result and poor access to health services also played a role in total delay. The treatment outcomes of 843 patients were assessed. The treatment success rate for new smear-positive, new smear-negative and relapse patients was 91.4 percent, 95.5 percent and 82.0 percent, respectively. Male sex and HIV infection had a strong association with a poor treatment outcome and total delay was associated with an increased rate of death. The death rate for new smear-positive, new smear-negative and retreatment patients was 30, 23 and 34 per 100 000 population, respectively. The identification and characterization of genotype families was based on samples obtained from 67 patients. A method known as mycobacterial interspersed repeat units-variable number of tandem repeats was used and the results showed that the M. tuberculosis strains circulating in Beira city are a mix of ancestral and modern strains, with a predominance of the East African-Indian and Latin American families. Ancestral strains are characterized by the presence of the TbD1 region which is absent in the modern strain. Among both the ancestral and modern strains, a high genetic diversity was observed, suggesting that these strains have been in circulation in Beira city for a long period of time. This was the first study carried out in Mozambique that used an ethnographic approach to identify enabling factors and barriers to a successful management of TB patients. The study was based on participant observation of one TB clinic and interviews with seven key informants. The high level of organization of the TB clinic; the low level of perceived TB stigma; the presence of auxiliary workers; and the appropriateness of the TB messages provided to patients found in this study were considered enabling factors. Potential barriers included the presence of misconceptions related to TB; the difficulties in the classification of retreatment patients and management of side effects; treatment interruptions; the lack of clarity in relation to infection control measures; and the lost opportunity to screen TB patients for co-morbidities other than those related to HIV & AIDS. Conclusions: The TB programme in Beira city is strong and well organized and it has been very successful in treating patients. However, there is a need to implement interventions to reduce patient delay and to improve TB diagnosis at the health facility level, especially at the primary health care level.