Assessing the impact of the president's emergency plan for AIDS relief on all-cause mortality.

This study estimated the impacts of PEPFAR on all-cause mortality (ACM) rates (deaths per 1,000 population) across PEPFAR recipient countries from 2004-2018. As PEPFAR moves into its 3rd decade, this study supplements the existing literature on PEPFAR 's overall effectiveness in saving lives by focusing impact estimates on the important subgroups of countries that received different intensities of aid, and provides estimates of impact for different phases of this 15-year period study. The study uses a country-level panel data set of 157 low- and middle-income countries (LMICs) from 1990-2018, including 90 PEPFAR recipient countries receiving bilateral aid from the U.S. government, employing difference-in-differences (DID) econometric models with several model specifications, including models with differing baseline covariates, and models with yearly covariates including other donor spending and domestic health spending. Using five different model specifications, a 10-21% decline in ACM rates from 2004 to 2018 is attributed to PEPFAR presence in the group of 90 recipient countries. Declines are somewhat larger (15-25%) in those countries that are subject to PEPFAR's country operational planning (COP) process, and where PEPFAR per capita aid amounts are largest (17-27%). Across the 90 recipient countries we study, the average impact across models is estimated to be a 7.6% reduction in ACM in the first 5-year period (2004-2008), somewhat smaller in the second 5-year period (5.5%) and in the third 5-year period (4.7%). In COP countries the impacts show decreases in ACM of 7.4% in the first period attributed to PEPFAR, 7.7% reductions in the second, and 6.6% reductions in the third. PEPFAR presence is correlated with large declines in the ACM rate, and the overall life-saving results persisted over time. The effects of PEFAR on ACM have been large, suggesting the possibility of spillover life-saving impacts of PEPFAR programming beyond HIV disease alone.

Equity of the HIV epidemic response in 13 African countries.

For over 25 years, new programs to attempt to stem the HIV epidemic have been developed in Africa by country governments as well as external donors. These programs and activities have built and operated facilities, trained clinicians, financed drugs and commodities, supported and helped finance government health planning and operations, and contributed in other ways. Who has benefited from this massive mobilization? While some single country and narrowly focused studies have been done, the issue of equity of HIV programs for vulnerable populations has not been examined in a large set of countries. Using Population-based HIV Impact Assessment (PHIA) data, we examine equity of the HIV programs in 13 African countries to determine if vulnerable groups (such as those with low wealth, rural populations, young adults, and females) have achieved comparable levels of access to HIV program services. In contrast, we also compare the equity of the HIV response to rural and low-wealth populations with the equity of corresponding domestic health systems using Demographic and Health Survey data.This study found that in over half of the countries, the HIV response indicators were equitable for vulnerable population segments including the low-wealth population (in seven countries) and rural population segment (in nine countries). In no country was the domestic health system equitable for these two groups. However, HIV programming does show some clear patterns of inequity for low-wealth and rural populations in some countries. For gender and young adults, the HIV response indicators show that in all 13 countries men and young adults are consistently underserved relative to their counterparts.

Analysis of maternal and child health spillover effects in PEPFAR countries.

OBJECTIVES: This study examined whether the US President's Emergency Plan for AIDS Relief (PEPFAR) funding had effects beyond HIV, specifically on several measures of maternal and child health in low-income and middle-income countries (LMICs). The results of previous research on the question of PEPFAR health spillovers have been inconsistent. This study, using a large, multicountry panel data set of 157 LMICs including 90 recipient countries, adds to the literature. DESIGN: Seven indicators including child and maternal mortality, several child vaccination rates and anaemia among childbearing-age women are important population health indicators. Panel data and difference-in-differences estimators (DID) were used to estimate the impact of the PEPFAR programme from inception in 2004 to 2018 using a comparison group of 67 LMICs. Several different models of baseline (2004) covariates were used to help balance the comparison and treatment groups. Staggered DID was used to estimate impacts since all countries did not start receiving aid at PEPFAR's inception. SETTING: All 157 LMICs from 1990 to 2018. PARTICIPANTS: 90 LMICs receiving PEPFAR aid and cohorts of those countries, including those required to submit annual country operational plans (COP), other recipient countries (non-COP), and three groupings of countries based on cumulative amount of per capita aid received (high, medium, low). INTERVENTIONS: PEPFAR aid to combat the HIV epidemic. PRIMARY OUTCOME MEASURES: Maternal mortality and child mortality rates, vaccination rates to protect children for diphtheria, whooping cough and tetanus, measles, HepB3, and tetanus, and prevalence of anaemia in women of childbearing age. RESULTS: Across PEPFAR recipient countries, large, favourable PEPFAR health effects were found for rates of childhood immunisation, child mortality and maternal mortality. These beneficial health effects were large and significant in all segments of PEPFAR recipient countries studied. We also found significant and favourable programme effects on the prevalence of anaemia in women of childbearing age in PEPFAR recipient countries receiving the most intensive financial support from the PEPFAR programme. Other recipient countries did not demonstrate significant effects on anaemia. CONCLUSIONS: This study demonstrated that important health indicators, beyond HIV, have been consistently and favourably influenced by PEPFAR presence. Child and maternal mortality have been substantially reduced, and childhood immunisation rates increased. We also found no evidence of 'crowding out' or negative spillovers in these resource-poor countries. These findings add to the body of evidence that PEPFAR has had favourable health effects beyond HIV. The implications of these findings are that foreign aid for health in one area may have favourable health effects in other areas in recipient countries. More research is needed on the influence of the mechanisms at work that create these spillover health effects of PEPFAR.

Analysis of economic and educational spillover effects in PEPFAR countries.

The United States President's Emergency Plan for AIDS Relief (PEPFAR) has been credited with saving millions lives and helping to change the trajectory of the global human immunodeficiency virus (HIV) epidemic. This study assesses whether PEPFAR has had impacts beyond health by examining changes in five economic and educational outcomes in PEPFAR countries: the gross domestic product (GDP) per capita growth rate; the share of girls and share of boys, respectively, who are out of school; and female and male employment rates. We constructed a panel data set for 157 low- and middle-income countries between 1990 and 2018 to estimate the macroeconomic impacts of PEPFAR. Our PEPFAR group included 90 countries that had received PEPFAR support over the period. Our comparison group included 67 low- and middle-income countries that had not received any PEPFAR support or had received minimal PEPFAR support (<$1M or <$.05 per capita) between 2004 and 2018. We used differences in differences (DID) methods to estimate the program impacts on the five economic and educational outcome measures. This study finds that PEPFAR is associated with increases in the GDP per capita growth rate and educational outcomes. In some models, we find that PEPFAR is associated with reductions in male and female employment. However, these effects appear to be due to trends in the comparison group countries rather than programmatic impacts of PEPFAR. We show that these impacts are most pronounced in COP countries receiving the highest levels of PEPFAR investment.

Minority Participation of the Senior Management of Private U.S. Hospitals.

This article examines minority participation in hospital senior management and how participation varies across areas in response to demographic and other market influences. We use data from Equal Employment Opportunity Commission, United States from 2008 to 2014 reported by private hospitals in the United States, grouped into 381 metropolitan areas. Analysis shows minority participation is sensitive to some local market factors including total population, share of minorities in the population, relative number of minorities with bachelor's degrees in the population, and the concentration of local hospital markets. But, unlike markets for other hospital jobs (professionals, middle managers, and other jobs), changes in these factors create only small changes in minority participation for senior managers. Our results demonstrate that minority participation in senior management is not going to improve very much from future increases in minority populations and from educational parity. Public policies and deliberate organizational strategies will be required to make substantial improvements in diversity of senior management.

Between a Rock and a Hard Place: How poverty and lack of agency affect HIV risk behaviors among married women in 25 African countries: A cross-sectional study.

BACKGROUND: Gender inequality and poverty exacerbate the burden of HIV/AIDS among women in Africa. AIDS awareness and educational campaigns have been inadequate in many countries and rates of HIV testing and adherence to condom use remains considerably low, especially among married women. We investigate whether higher HIV knowledge is equally effective in lowering risky behaviors among groups of women with different levels of wealth and agency. METHODS: Pooled data on 113 151 adult married women from Demographic and Health Surveys (DHS) in 25 African countries was used (2010 to 2016). Agency was defined as women's ability to refuse sex and ask her partner to use a condom, plus have a role in decision making in household spending and health-related issues. The lowest tertile of DHS wealth index defined poverty. Questions about HIV prevention and mother-to-child transmission were used to create a scale for knowledge (0-5). Use of condom, HIV testing, absence of sexually transmitted disease (STD), and having one partner were dependent variables. Regression models investigated the effect of agency and knowledge as predictors of behaviors. Separate additional models were run to measure associations of each behavior with knowledge scores on groups of women divided by agency and poverty. Analyses were adjusted for demographic factors, history of pregnancy, wife-beating attitude, and country dummies. RESULTS: Significantly higher risk and lower level of protective factors exist for poor women who lack agency. Knowledge had positive associations with a better score in behavior, higher rate of condom use and testing for HIV both among poor and not poor women. When examining compound effects of agency and poverty, absence of agency reduces the positive effect of knowledge on lowering STD rate and overall behavior score among poor women. It also nullifies the effect of knowledge on condom use in both wealth groups. CONCLUSION: Knowledge of HIV does not exert its potential protective effect when women live in poverty compounded with lack of agency. Success of anti-HIV programs should be tailored to dynamics of risk and sociocultural and economic context of target populations.

How useful are current caries risk assessment tools in informing the oral health care decision-making process?

BACKGROUND: Caries risk assessment (CRA) tools could address oral health disparities and enhance the efficiency of the oral health care system. The authors aimed to explore the feasibility and limitations of using clinical CRA tools in informing oral health care policy-making processes. METHODS: The authors used the National Health and Nutrition Examination Survey to construct 10 CRA models from a sample of clinical CRA tools identified from the literature. They used these models to estimate the proportion of publicly insured people aged 1 through 20 years categorized as at low, moderate, and high risk, and they projected their oral health care costs. RESULTS: The authors found substantial variation among the selected models in assigning risk levels. The weighted average proportions (range) of people categorized as at low, moderate, and high risk were 25% (0%-66%), 14% (0%-50%), and 61% (11%-100%), respectively. Depending on the CRA model, the projected annual cost of covering this population ranged from $18 billion to $127 billion. CONCLUSIONS AND PRACTICAL IMPLICATIONS: Developing a valid, evidence-based, accurate, and reliable population-based CRA model could address the variability among clinical CRA tools, improve estimates of dental disease burden, help design targeted oral public health programs, and enable comparative effectiveness analyses among oral health care interventions.

A survey of physicians' experience and awareness of institutional provisions designed to foster patient engagement in KSA.

OBJECTIVES: To survey physicians' perceptions of their experience and awareness of institutional provisions that can potentially foster patient engagement (PE) in KSA. METHODS: In April 2017, an online survey was distributed to clinicians in KSA using Google Forms. The instrument contained questions about the physicians' awareness and experience of their institutions' provision of resources and support. RESULTS: Three hundred and twenty-five clinicians responded to the survey The results showed that 18.5% claimed that their institutions allowed online scheduling of appointments; 8.9% reported the institutions permitted contact between patients and physicians through email; 24.0% reported they provided patients with online access to health records and test results; 55.7% claimed they provided educational multimedia programming; and 74.8% confirmed they encouraged joint decision-making between physicians and patients. Only 34.5% of respondents claimed their institutions provided home visits for high-risk patients. Six of 10 respondents thought that such provisions would have positive outcomes for them and for their patients. CONCLUSIONS: Clinicians are aware of and value provisions that foster PE. However, several institutions in KSA do not support or have provisions in place to foster PE. Male clinicians with longer durations of practice and those with higher administrative positions are more likely to value the importance of PE and support and use it in their practice.

Modelling the returns on options for improving malaria case management in Ethiopia.

BACKGROUND: Diverse opinions have emerged about the best way to scale up malaria interventions. Three controversies seem most important: (1) should the scale-up focus on a broader target of febrile illness (including infectious disease and pneumonia)? (2) should the scale-up feature a single intervention or be targeted to the situation? (3) should scale-up have a preference for one kind of delivery mechanism or another? METHODS: A decision model of 576 nodes describes the patterns of access, treatment and outcomes of an episode of febrile illness for a child below 5 years. Incremental costs and outcomes relative to baseline (2010) are computed for particular scenarios for Ethiopia using data from the literature. Two perspectives define the relevant costs: society at large and financiers (government and donors) where the costs borne by households are not included. FINDINGS: Scaling up malaria interventions by one means or another is a very inexpensive way of saving young lives in poor countries. The low cost per life saved stems from two main reasons: the excessive baseline costs of presumptive use of antimalarial drugs for non-malaria cases, and the excessive costs of delayed treatment of pneumonia. A very limited policy of supplying antibiotics to facilities to eliminate stockouts would save 2100 lives, at a cost of only $615 a life. A much broader programme option, bundling malaria and pneumonia together for patients presenting with febrile illness [including rapid diagnostic test (RDT) for malaria, respiratory rate timers (RRTs) and free antibiotics], would save tens of thousands of young lives at and still cost society less than child fever management in the baseline situation! It is not clear that scale-up via community health workers (CHWs) is to be preferred to a facility-based intervention. The delivery through CHWs allows for a broader coverage of using RDT and RRT, but with limited effectiveness due to limited skills of CHWs in treating and managing patients.

Health expenditures, health outcomes and the role of good governance.

This paper examines the relationship between country health spending and selected health outcomes (infant mortality and child mortality), using data from 133 low and middle-income countries for the years 1995, 2000, 2005, and 2006. Health spending has a significant effect on reducing infant and under-5 child mortality with an elasticity of 0.13 to 0.33 for infant mortality and 0.15 to 0.38 for under-5 child mortality in models estimated using fixed effects methods (depending on models employed). Government health spending also has a significant effect on reducing infant and child mortality and the size of the coefficient depends on the level of good governance achieved by the country, indicating that good governance increases the effectiveness of health spending. This paper contributes to the new evidence pointing to the importance of investing in health care services and the importance of governance in improving health outcomes.

The income elasticity of health care spending in developing and developed countries.

To date, international analyses on the strength of the relationship between country-level per capita income and per capita health expenditures have predominantly used developed countries' data. This study expands this work using a panel data set for 173 countries for the 1995-2006 period. We found that health care has an income elasticity that qualifies it as a necessity good, which is consistent with results of the most recent studies. Furthermore, we found that health care spending is least responsive to changes in income in low-income countries and most responsive to in middle-income countries with high-income countries falling in the middle. Finally, we found that 'Voice and Accountability' as an indicator of good governance seems to play a role in mobilizing more funds for health.

Does funding from donors displace government spending for health in developing countries?

The notable increases in funding from various donors for health over the past several years have made examining the effectiveness of aid all the more important. We examine the extent to which donor funding for health substitutes for--rather than complements--health financing by recipient governments. We find evidence of a strong substitution effect. The proportionate decrease in government spending associated with an increase in donor funding is largest in low-income countries. The results suggest that aid needs to be structured in a way that better aligns donors' and recipient governments' incentives, using innovative approaches such as performance-based aid financing.

Geographic variation in minority participation in hospital management in the United States.

Minority participation in hospital management is, by all estimates, lower than almost anyone is prepared to accept. However, to date, there has been no published study of hospital management diversity using comprehensive national data. In the present study, the authors used data from the U.S. Equal Employment Opportunity Commission to estimate more directly and comprehensively how management diversity in private U.S. hospitals varies by geographic area. Although minorities constitute over 33% of the U.S. population, they constitute only 14% of all top-level managers and officials in private U.S. hospitals. There is enormous geographic variation in this average across cities and regions. The authors found that minority management participation is systematically related to market factors, including demographic and education variables. These systematic patterns explain about 90% of the Metropolitan Statistical Area differences in minority manager percentage. However, even after adjusting observed variations for these differences, the authors found important unexplained geographic variations in minority managerial employment in hospitals across U.S. cities.

A simple primary care information system featuring feedback to clinicians.

A simple information system for primary care clinics was designed to support the USAID funded health system strengthening project in the Suez Governorate in Egypt. This system (FACT-Feedback and Analytic Comparison Tool) was implemented in December 2003 in 14 primary care clinics. The MS Access-based system was designed and prototyped in several months, and was easily and cheaply modified several times after implementation. A total of 128 562 persons have been registered in the system (as of June 2005) and 36 083 visits have been documented. A key feature of FACT is the ease with which clinicians can conduct exploratory research about practice patterns, and variations in them across doctors and the other clinics. This analytic feature enables the clinicians to self-diagnose quality problems and take action accordingly. Several of the clinics have used this feature of FACT to identify important gaps in service use among patients, and have taken steps to remove barriers to promote more appropriate patterns of utilization. The paper reviews the design and implementation issues and early evidence of the system's utility in helping support quality improvement (QI) work in the clinics.

Use of information technology by advanced practice nurses.

The purpose of this study is to describe the use of information technology by advance practice nurses. A survey of 519 graduates of the Simmons College nurse practitioner program was conducted. Areas of investigation included the nurse practitioner's use of informatics technology, perception of information technology competence, adequacy of information technology training and support in the workplace, specific information technology health functions used in the workplace, and perceived benefits of using information technology. The data on the 249 usable responses were analyzed using descriptive statistics. These analyses compare the use of information technology by type of job, specialty, years of practice, and setting of work. Results indicate that more than 90% of nurse practitioners utilize computers at work, yet a large fraction of them still have low self-perception of information technology competence, believe initial training at the work site was inadequate, and believe that academic preparation for information technology was also inadequate. There is considerable variation in these measures across nurse practitioner specialties, settings of care, job characteristics, and experience.

Chiropractic users and nonusers: differences in use, attitudes, and willingness to use nonmedical doctors for primary care.

OBJECTIVE: To determine the differences in attitudes and other determinants of care-seeking behavior between persons who have used chiropractic services and persons who have not. A second objective is to determine the interest in members of these 2 groups in choosing nonmedical doctors for providing routine services. METHODS: In 1998, a nationwide telephone survey of randomly selected households in the United States was done, including 400 adults who have used chiropractic services and 400 adults who have not. Survey participants were asked about their use, knowledge, and attitudes about chiropractic care, attitudes about personal role in health care, current source of obtaining usual and routine care, and willingness to consider use of nonmedical doctors as the usual source of such care. The analysis compares persons who have used with those who have not used chiropractic services by using a chi2 test to determine significance of differences between the responses of the 2 groups. A multivariate analysis is done of willingness to use alternative providers for routine care. RESULTS: Persons who have seen a doctor of chiropractic before have different attitudes and preferences about health and health care than others who have never seen a doctor of chiropractic. Almost all of persons in both groups have medical doctors that they use for routine care, and a sizeable portion of both groups would be willing to consider using a nonmedical doctor for this role. Although willingness to use a chiropractor in this role is much higher among persons who have used a chiropractor before, both groups would prefer physician assistants and nurse practitioners to chiropractors in this role. CONCLUSION: For persons participating in this survey, unwillingness to accept the idea of a chiropractor in a primary care role may be largely due to poor knowledge about chiropractic care.

Factors associated with patient satisfaction with chiropractic care: survey and review of the literature.

OBJECTIVE: The purpose of this study is to review the recent literature on satisfaction with chiropractic care and offer a multivariate analysis of a national household survey data to understand which aspects of care and behavior contribute most to patient satisfaction with chiropractors. METHODS: A national phone survey of households was done to measure attitudes, utilization, and health practices of chiropractic users and nonusers. A 73% response rate was achieved. Satisfaction with chiropractic services is analyzed using both descriptive and multivariate methods. RESULTS: Satisfaction levels with chiropractic care are quite high (83% of persons are satisfied or very satisfied). High satisfaction is related to several factors, including whether the chiropractor orders and interprets laboratory tests, whether the chiropractor displays concern about patient's overall health, and the extent to which the chiropractor explains the condition and the treatment. CONCLUSIONS: The evidence about the factors that underlie high levels of chiropractic satisfaction is not consistent. Communication quality seems to be a consistent predictor of patient satisfaction with chiropractors. More research is needed to understand the role of perceived effectiveness of treatment, intensity of use, accessibility, and financing issues in determining patient satisfaction levels.

Barriers to expanding primary care roles for chiropractors: The role of chiropractic as primary care gatekeeper.

OBJECTIVE: To examine the feasibility of broader and more frequent primary care roles for chiropractors. DATA COLLECTION: Literature review and analysis of existing databases. Six types of barriers were examined, including legal, financial, professional, accessibility or geographic location, consumer preference, and self-imposed barriers. RESULTS: Although research into the barriers of an expanded primary care role for chiropractors is inconclusive, several inferences can be drawn from this analysis. First, prevailing state practice acts preclude only a limited number of activities that are necessary for chiropractors to serve in a primary care capacity. The self-perception by a portion of the chiropractic profession that as neuromusculoskeletal system specialists, they are either uninterested or ill-prepared for providing primary care serves as a second barrier. Third, payment provisions that do not permit chiropractors to be reimbursed for primary care services significantly limit their ability to expand primary care capacity. Fourth, consumer perceptions of chiropractors as neuromusculoskeletal system specialists are a persistent barrier to expanding status. Given the current importance of managed care, the fifth and most crucial barrier for chiropractic may be managed care organizations' lack of interest in having chiropractors in primary care roles. CONCLUSION: Research on the barriers to a more expanded primary care role for chiropractors is incomplete. The available research helps little in ruling out plausible barriers that might make it possible to narrow the scope of subsequent research.

Medicare's prospective payment system: A critical appraisal.

Implementation of the Medicare prospective payment system (PPS) for hospital payment has produced major changes in the hospital industry and in the way hospital services are used by physicians and their patients. The substantial published literature that examines these changes is reviewed in this article. This literature suggests that most of the intended effects of PPS on costs and intensity of care have been realized. But the literature fails to answer fundamental questions about the effectiveness and equity of administered pricing as a policy tool for cost containment. The literature offers some hope that the worst fears about the effects of PPS on quality of care and the health of the hospital industry have not materialized. But because of data lags, the studies done to date seem to tell us more about the effects of the early, more generous period of PPS than about the opportunity costs of reducing hospital cost inflation.