The impact of COVID-19 and national pandemic responses on health service utilisation in seven low- and middle-income countries.

BACKGROUND: The COVID-19 pandemic has disrupted health services worldwide, which may have led to increased mortality and secondary disease outbreaks. Disruptions vary by patient population, geographic area, and service. While many reasons have been put forward to explain disruptions, few studies have empirically investigated their causes. OBJECTIVE: We quantify disruptions to outpatient services, facility-based deliveries, and family planning in seven low- and middle-income countries during the COVID-19 pandemic and quantify relationships between disruptions and the intensity of national pandemic responses. METHODS: We leveraged routine data from 104 Partners In Health-supported facilities from January 2016 to December 2021. We first quantified COVID-19-related disruptions in each country by month using negative binomial time series models. We then modelled the relationship between disruptions and the intensity of national pandemic responses, as measured by the stringency index from the Oxford COVID-19 Government Response Tracker. RESULTS: For all the studied countries, we observed at least one month with a significant decline in outpatient visits during the COVID-19 pandemic. We also observed significant cumulative drops in outpatient visits across all months in Lesotho, Liberia, Malawi, Rwanda, and Sierra Leone. A significant cumulative decrease in facility-based deliveries was observed in Haiti, Lesotho, Mexico, and Sierra Leone. No country had significant cumulative drops in family planning visits. For a 10-unit increase in the average monthly stringency index, the proportion deviation in monthly facility outpatient visits compared to expected fell by 3.9% (95% CI: -5.1%, -1.6%). No relationship between stringency of pandemic responses and utilisation was observed for facility-based deliveries or family planning. CONCLUSIONS: Context-specific strategies show the ability of health systems to sustain essential health services during the pandemic. The link between pandemic responses and healthcare utilisation can inform purposeful strategies to ensure communities have access to care and provide lessons for promoting the utilisation of health services elsewhere.

Adapting Lot Quality Assurance Sampling to accommodate imperfect diagnostic tests: application to COVID-19 serosurveillance in Haiti.

BACKGROUND: Lot Quality Assurance Sampling (LQAS), a tool used for monitoring health indicators in low resource settings resulting in "high" or "low" classifications, assumes that determination of the trait of interest is perfect. This is often not true for diagnostic tests, with imperfect sensitivity and specificity. Here, we develop Lot Quality Assurance Sampling for Imperfect Tests (LQAS-IMP) to address this issue and apply it to a COVID-19 serosurveillance study design in Haiti. METHODS: We first derive a modified procedure, LQAS-IMP, that accounts for the sensitivity and specificity of a diagnostic test to yield correct classification errors. We then apply the novel LQAS-IMP to design an LQAS system to classify prevalence of SARS-CoV-2 antibodies among healthcare workers at eleven Zanmia Lasante health facilities in Haiti. Finally, we show the performance of the LQAS-IMP procedure in a simulation study. RESULTS: We found that when an imperfect diagnostic test is used, the classification errors in the standard LQAS procedure are larger than specified. In the modified LQAS-IMP procedure, classification errors are consistent with the specified maximum classification error. We then utilized the LQAS-IMP procedure to define valid systems for sampling at eleven hospitals in Haiti. CONCLUSION: The LQAS-IMP procedure accounts for imperfect sensitivity and specificity in system design; if the accuracy of a test is known, the use of LQAS-IMP extends LQAS to applications for indicators that are based on laboratory tests, such as SARS-CoV-2 antibodies.

Childhood immunization during the COVID-19 pandemic: experiences in Haiti, Lesotho, Liberia and Malawi.

OBJECTIVE: To examine changes in vaccination of children younger than 1 year during the coronavirus disease 2019 (COVID-19) pandemic (March 2020-August 2021) in Haiti, Lesotho, Liberia and Malawi. METHODS: We used data from health management information systems on vaccination of children aged 12 months or younger in districts supported by Partners In Health. We used data from January 2016 to February 2020 and a linear model with negative binomial distribution to estimate the expected immunization counts for March 2020-August 2021 with 95% prediction intervals, assuming no pandemic. We compared these expected levels with observed values and estimated the immunization deficits or excesses during the pandemic months. FINDINGS: Baseline vaccination counts varied substantially by country, with Lesotho having the lowest count and Haiti the highest. We observed declines in vaccination administration early in the COVID-19 pandemic in Haiti, Lesotho and Liberia. Continued declines largely corresponded to high rates of COVID-19 infection and discrete stock-outs. By August 2021, vaccination levels had returned to close to or above expected levels in Haiti, Liberia and Lesotho; in Malawi levels remained below expected. CONCLUSION: Patterns of childhood immunization coverage varied by country over the course of the pandemic, with significantly lower than expected vaccination levels seen in one country during subsequent COVID-19 waves. Governments and health-care stakeholders should monitor vaccine coverage closely and consider interventions, such as community outreach, to avoid or combat the disruptions in childhood vaccination.

Going beyond the vertical: leveraging a national HIV quality improvement programme to address other health priorities in Haiti.

Although the central role of quality to achieve targeted population health goals is widely recognized, how to spread the capacity to measure and improve quality across programmes has not been widely studied. We describe the successful leveraging of expertise and framework of a national HIV quality improvement programme to spread capacity and improve quality across a network of clinics in HIV and other targeted areas of healthcare delivery in rural Haiti.The work was led by Zamni LaSante, a Haitian nongovernment organization and its sister organization, Partners In Health working in partnership with the Haitian Ministry of Health in the Plateau Central and Lower Artibonite regions in 12 public sector facilities.Data included routinely collected organizational assessments of facility quality improvement capacity, national HIV performance measures and Zamni LaSante programme records.We found that facility quality improvement capacity increased with spread from HIV to other areas of inpatient and outpatient care, including tuberculosis (TB), maternal health and inpatient services in all 12 supported healthcare facilities. A significant increase in the quality of HIV care was also seen in most areas, including CD4 monitoring, TB screening, HIV treatment (all P < 0.01) and nutritional assessment and prevention of mother-to-child transmission (both P < .05), with an increase in average facility performance from 39 to 72% (P < .01).In conclusion, using a diagonal approach to leverage a national vertical programme for wider benefit resulted in accelerated change in professional culture and increased capacity to spread quality improvement activities across facilities and areas of healthcare delivery. This led to improvement within and beyond HIV care and contributed to the goal of quality of care for all.

Task-shifting in HIV care: a case study of nurse-centered community-based care in Rural Haiti.

INTRODUCTION: At least 36 countries are suffering from severe shortages of healthcare workers and this crisis of human resources in developing countries is a major obstacle to scale-up of HIV care. We performed a case study to evaluate a health service delivery model where a task-shifting approach to HIV care had been undertaken with tasks shifted from doctors to nurses and community health workers in rural Haiti. METHODS: Data were collected using mixed quantitative and qualitative methods at three clinics in rural Haiti. Distribution of tasks for HIV services delivery; types of tasks performed by different cadres of healthcare workers; HIV program outcomes; access to HIV care and acceptability of the model to staff were measured. RESULTS: A shift of tasks occurred from doctors to nurses and to community health workers compared to a traditional doctor-based model of care. Nurses performed most HIV-related tasks except initiation of TB therapy for smear-negative suspects with HIV. Community health workers were involved in over half of HIV-related tasks. HIV services were rapidly scaled-up in the areas served; loss to follow-up of patients living with HIV was less than 5% at 24 months and staff were satisfied with the model of care. CONCLUSION: Task-shifting using a community-based, nurse-centered model of HIV care in rural Haiti is an effective model for scale-up of HIV services with good clinical and program outcomes. Community health workers can provide essential health services that are otherwise unavailable particularly in rural, poor areas.

Perceived discrimination and stigma toward children affected by HIV/AIDS and their HIV-positive caregivers in central Haiti.

In many settings worldwide, HIV-positive individuals have experienced a significant level of stigma and discrimination. This discrimination may also impact other family members affected by the disease, including children. The aim of our study was to identify factors associated with stigma and/or discrimination among HIV-affected youth and their HIV-positive caregivers in central Haiti. Recruitment of HIV-positive patients with children aged 10-17 years was conducted in 2006-2007. Data on HIV-related stigma and/or discrimination were based on interviews with 451 youth and 292 caregivers. Thirty-two percent of caregivers reported that children were discriminated against because of HIV/AIDS. Commune of residence was associated with discrimination against children affected by HIV/AIDS and HIV-related stigma among HIV-positive caregivers, suggesting variability across communities. Multivariable regression models showed that lacking social support, being an orphan, and caregiver HIV-related stigma were associated with discrimination in HIV-affected children. Caregiver HIV-related stigma demonstrated a strong association with depressive symptoms. The results could inform strategies for potential interventions to reduce HIV-related stigma and discrimination. These may include increasing social and caregiver support of children affected by HIV, enhancing support of caregivers to reduce burden of depressive symptoms, and promoting reduction of HIV-related stigma and discrimination at the community-level.

Integrated HIV prevention and care strengthens primary health care: lessons from rural Haiti.

Three decades ago, the world's ministries of health declared primary health care--the delivery of basic preventive and curative services--a top priority. Since then, however, the world's poorest countries have not met most primary health care goals. Twenty-six years after the Declaration of Alma Ata, we are said to be living in a time of "limited resources," a phrase that construes various health interventions as competing priorities. As HIV has become the leading infectious cause of adult death in much of the world, it is difficult to argue that AIDS prevention and care are not ranking priorities for primary health care, yet precisely such arguments have held sway among international health policy makers. We present new information emerging from the scale-up of an established and integrated AIDS prevention-and-care program, based initially in a squatter settlement in central Haiti, to a second site in rural Haiti. The program includes robust prevention efforts as well as community-based therapy for advanced AIDS; three related components--women's health and active case finding and therapy for tuberculosis and sexually transmitted infections--were central to this effort. We tracked changes in key indices over the 14 months following the introduction of these services to a public clinic in central Haiti. We found that integrated AIDS prevention and care, including the use of antiretroviral agents, to be feasible in resource-poor settings and that such efforts may have favorable and readily measured impact on a number of primary health care goals, including vaccination, family planning, tuberculosis case finding and cure, and health promotion. Other collateral benefits, though less readily measured, include improved staff morale and enhanced confidence in public health and medicine. We conclude that improving AIDS prevention and treatment can help to reinvigorate flagging efforts to promote universal primary health care.