HIV Policy Advancements in PEPFAR Partner countries: a review of data from 2010-2016.

This paper aims to describe and analyse progress with domestic HIV-related policies in PEPFAR partner countries, utilising data collected as part of PEPFAR's routine annual program reporting from U.S. government fiscal years 2010 through 2016. 402 policies were monitored for one or more years across more than 50 countries using the PEPFAR policy tracking tool across five policy process stages: 1. Problem identification, 2. Policy development, 3. Policy endorsement, 4. Policy implementation, and 5. Policy evaluation. This included 219 policies that were adopted and implemented by partner governments, many in Africa. Policies were tracked across a wide variety of subject matter areas, with HIV Testing and Treatment being the most common. Our review also illustrates challenges with policy reform using varied, national examples. Challenges include the length of time (often years) it may take to reform policies, local customs that may differ from policy goals, and insufficient public funding for policy implementation. Limitations included incomplete data, variability in the amount of data provided due to partial reliance on open-ended text boxes, and data that reflect the viewpoints of submitting PEPFAR country teams.

The Medical Education Partnership Initiative: Strengthening Human Resources to End AIDS and Improve Health in Africa.

Faced with a critical shortage of physicians in Africa, which hampered the efforts of the U.S. President's Emergency Plan for AIDS Relief (PEPFAR), the Medical Education Partnership Initiative (MEPI) was established in 2010 to increase the number of medical graduates, the quality of their education, and their retention in Africa. To summarize the accomplishments of the initiative, lessons learned, and remaining challenges, the authors conducted a narrative review of MEPI-from the perspectives of the U.S. government funding agencies and implementing agencies-by reviewing reports from grantee institutions and conducting a search of scientific publications about MEPI. African institutions received 11 programmatic grants, totaling $100 million in PEPFAR funds, to implement MEPI from 2010 to 2015. The National Institutes of Health (NIH) provided an additional 8 linked and pilot grants, totaling $30 million, to strengthen medical research capacity. The 13 grant recipients (in 12 countries) partnered with dozens of additional government and academic institutions, including many in the United States, forming a robust community of practice in medical education and research. Interventions included increasing the number of medical school enrollees, revising curricula, recruiting new faculty, enhancing faculty development, expanding the use of clinical skills laboratories and community and rural training sites, strengthening computer and telecommunications capacity, and increasing e-learning. Research capacity and productivity increased through training and support. Additional support from NIH for faculty development, and from PEPFAR for health professions education and research, is sustaining and extending MEPI's transformative effect on medical education in select African sites.

Patient satisfaction with task shifting of antiretroviral services in Ethiopia: implications for universal health coverage.

Formalized task shifting structures have been used to rapidly scale up antiretroviral service delivery to underserved populations in several countries, and may be a promising mechanism for accomplishing universal health coverage. However, studies evaluating the quality of service delivery through task shifting have largely ignored the patient perspective, focusing on health outcomes and acceptability to health care providers and regulatory bodies, despite studies worldwide that have shown the significance of patient satisfaction as an indicator of quality. This study aimed to measure patient satisfaction with task shifting of antiretroviral services in hospitals and health centres in four regions of Ethiopia. This cross-sectional study used data collected from a time-motion study of patient services paired with 665 patient exit interviews in a stratified random sample of antiretroviral therapy clinics in 21 hospitals and 40 health centres in 2012. Data were analyzed using f-tests across provider types, and multivariate logistic regression to identify determinants of patient satisfaction. Most (528 of 665) patients were satisfied or somewhat satisfied with the services received, but patients who received services from nurses and health officers were significantly more likely to report satisfaction than those who received services from doctors [odds ratio (OR) 0.26, P < 0.01]. Investments in the health facility were associated with higher satisfaction (OR 1.07, P < 0.01), while costs to patients of over 120 birr were associated with lower satisfaction (OR 0.14, P < 0.05). This study showed high levels of patient satisfaction with task shifting in Ethiopia. The evidence generated by this study complements previous biomedical and health care provider/regulatory acceptability studies to support the inclusion of task shifting as a mechanism for scaling-up health services to achieve universal health coverage, particularly for underserved areas facing severe health worker shortages.

Assessing the costs and effects of antiretroviral therapy task shifting from physicians to other health professionals in ethiopia.

OBJECTIVE: To evaluate the effects, costs, and cost-effectiveness of different degrees of antiretroviral therapy task shifting from physician to other health professionals in Ethiopia. DESIGN: Two-year retrospective cohort analysis on antiretroviral therapy patients coupled with cost analysis. INTERVENTIONS: Facilities with minimal or moderate task shifting compared with facilities with maximal task shifting. Maximal task shifting is defined as nonphysician clinicians handling both severe drug reactions and antiretroviral drug regimen changes. Secondary analysis compares health centers to hospitals. MAIN OUTCOME MEASURES: The primary effectiveness measure is the probability of a patient remaining actively on antiretroviral therapy for 2 years; the cost measure is the cost per patient per year. RESULTS: All facilities had some task shifting. About 89% of patients were actively on treatment 2 years after antiretroviral treatment (ART) initiation, with no statistically significant differences between facilities with maximal and minimal or moderate task shifting. It cost about $206 per patient per year for ART, with no statistically significant difference between the comparison groups. The cost-effectiveness of maximal task shifting is similar to minimal or moderate task shifting, with the same results obtained using regression to control for facility characteristics. CONCLUSIONS: Shifting the handling of both severe drug reactions and antiretroviral drug regimen changes from physicians to other clinical officers is not associated with a significant change in the 2-year treatment success rate or the costs of ART care. As an observational study, these results are tentative, and more research is needed in determining the optimal patterns of task shifting.

Human resource governance: what does governance mean for the health workforce in low- and middle-income countries?

BACKGROUND: Research on practical and effective governance of the health workforce is limited. This paper examines health system strengthening as it occurs in the intersection between the health workforce and governance by presenting a framework to examine health workforce issues related to eight governance principles: strategic vision, accountability, transparency, information, efficiency, equity/fairness, responsiveness and citizen voice and participation. METHODS: This study builds off of a literature review that informed the development of a framework that describes linkages and assigns indicators between governance and the health workforce. A qualitative analysis of Health System Assessment (HSA) data, a rapid indicator-based methodology that determines the key strengths and weaknesses of a health system using a set of internationally recognized indicators, was completed to determine how 20 low- and middle-income countries are operationalizing health governance to improve health workforce performance. RESULTS/DISCUSSION: The 20 countries assessed showed mixed progress in implementing the eight governance principles. Strengths highlighted include increasing the transparency of financial flows from sources to providers by implementing and institutionalizing the National Health Accounts methodology; increasing responsiveness to population health needs by training new cadres of health workers to address shortages and deliver care to remote and rural populations; having structures in place to register and provide licensure to medical professionals upon entry into the public sector; and implementing pilot programs that apply financial and non-financial incentives as a means to increase efficiency. Common weaknesses emerging in the HSAs include difficulties with developing, implementing and evaluating health workforce policies that outline a strategic vision for the health workforce; implementing continuous licensure and regulation systems to hold health workers accountable after they enter the workforce; and making use of health information systems to acquire data from providers and deliver it to policymakers. CONCLUSIONS: The breadth of challenges facing the health workforce requires strengthening health governance as well as human resource systems in order to effect change in the health system. Further research into the effectiveness of specific interventions that enhance the link between the health workforce and governance are warranted to determine approaches to strengthening the health system.

PEPFAR, health system strengthening, and promoting sustainability and country ownership.

Evidence demonstrates that scale-up of HIV services has produced stronger health systems and, conversely, that stronger health systems were critical to the success of the HIV scale-up. Increased access to and effectiveness of HIV treatment and care programs, attention to long-term sustainability, and recognition of the importance of national governance, and country ownership of HIV programs have resulted in an increased focus on structures that compromise the broader health system. Based on a review published literature and expert opinion, the article proposes 4 key health systems strengthening issues as a means to promote sustainability and country ownership of President's Emergency Plan for AIDS Relief and other global health initiatives. First, development partners need provide capacity building support and to recognize and align resources with national government health strategies and operational plans. Second, investments in human capital, particularly human resources for health, need to be guided by national institutions and supported to ensure the training and retention of skilled, qualified, and relevant health care providers. Third, a range of financing strategies, both new resources and improved efficiencies, need to be pursued as a means to create more fiscal space to ensure sustainable and self-reliant systems. Finally, service delivery models must adjust to recent advancements in areas of HIV prevention and treatment and aim to establish evidence-based delivery models to reduce HIV transmission rates and the overall burden of disease. The article concludes that there needs to be ongoing efforts to identify and implement strategic health systems strengthening interventions and address the inherent tension and debate over investments in health systems.

Can the deployment of community health workers for the delivery of HIV services represent an effective and sustainable response to health workforce shortages? Results of a multicountry study.

In countries severely affected by HIV/AIDS, shortages of health workers present a major obstacle to scaling up HIV services. Adopting a task shifting approach for the deployment of community health workers (CHWs) represents one strategy for rapid expansion of the health workforce. This study aimed to evaluate the contribution of CHWs with a focus on identifying the critical elements of an enabling environment that can ensure they provide quality services in a manner that is sustainable. The method of work included a collection of primary data in five countries: Brazil, Ethiopia, Malawi, Namibia, and Uganda. The findings show that delegation of specific tasks to cadres of CHWs with limited training can increase access to HIV services, particularly in rural areas and among underserved communities, and can improve the quality of care for HIV. There is also evidence that CHWs can make a significant contribution to the delivery of a wide range of other health services. The findings also show that certain conditions must be observed if CHWs are to contribute to well-functioning and sustainable service delivery. These conditions involve adequate systems integration with significant attention to: political will and commitment; collaborative planning; definition of scope of practice; selection and educational requirements; registration, licensure and certification; recruitment and deployment; adequate and sustainable remuneration; mentoring and supervision including referral system; career path and continuous education; performance evaluation; supply of equipment and commodities. The study concludes that, where there is the necessary support, the potential contribution of CHWs can be optimized and represents a valuable addition to the urgent expansion of human resources for health, and to universal coverage of HIV services.