Cascade Analysis: An Adaptable Implementation Strategy Across HIV and Non-HIV Delivery Platforms.

BACKGROUND: Cascades have been used to characterize sequential steps within a complex health system and are used in diverse disease areas and across prevention, testing, and treatment. Routine data have great potential to inform prioritization within a system, but are often inaccessible to frontline health care workers (HCWs) who may have the greatest opportunity to innovate health system improvement. METHODS: The cascade analysis tool (CAT) is an Excel-based, simple simulation model with an optimization function. It identifies the step within a cascade that could most improve the system. The original CAT was developed for HIV treatment and the prevention of mother-to-child transmission of HIV. RESULTS: CAT has been adapted 7 times: to a mobile application for prevention of mother-to-child transmission; for hypertension screening and management and for mental health outpatient services in Mozambique; for pediatric and adolescent HIV testing and treatment, HIV testing in family planning, and cervical cancer screening and treatment in Kenya; and for naloxone distribution and opioid overdose reversal in the United States. The main domains of adaptation have been technical-estimating denominators and structuring steps to be binary sequential steps-as well as logistical-identifying acceptable approaches for data abstraction and aggregation, and not overburdening HCW. DISCUSSION: CAT allows for prompt feedback to HCWs, increases HCW autonomy, and allows managers to allocate resources and time in an equitable manner. CAT is an effective, feasible, and acceptable implementation strategy to prioritize areas most requiring improvement within complex health systems, although adaptations are being currently evaluated.

Scaling up antenatal syphilis screening in Mozambique: transforming policy to action.

OBJECTIVES: This paper examines the decade-long scale-up process of antenatal syphilis screening through Mozambique's National Health System. GOAL: The primary goal is to provide lessons learned in the provision of integrated antenatal care resource-poor settings and identify key challenges to successful scale-up. STUDY DESIGN: We documented health systems activities associated with improvements in the proportion of women tested, treated, and partners treated for syphilis. RESULTS: The proportion of women in antenatal visit screened for syphilis in the two target provinces has risen from 5% in 1992 to between 60% and 95% consistently since 1999. This success required multiple levels of health system strengthening. CONCLUSIONS: The Mozambique experience shows that key elements to effective antenatal syphilis screening include adequate workforce, facilities, coherent systems of care, community involvement, donor management, advocacy, and leadership.

Analysis of the operational costs of using rapid syphilis tests for the detection of maternal syphilis in Bolivia and Mozambique.

OBJECTIVE: The objective of this study was to compare the costs of antenatal syphilis screening with the rapid plasma reagin (RPR) test and the immunochromatographic strip (ICS) test in low-resource settings. GOAL: The goal of this study was to assess the costs of introducing rapid syphilis tests to reduce maternal and congenital syphilis. STUDY DESIGN: Cost data were collected from participating study hospitals and antenatal clinics during 4 field visits to the 2 countries in 2003 and 2004. Health utilization outcome data on the number of women screened and treated routinely during the demonstration projects were used with unit cost data to estimate the incremental costs and average cost per woman screened and treated for maternal syphilis. RESULTS: In Mozambique, the average cost per woman screened was U.S. $0.91 and U.S. $1.05 for the RPR and ICS tests, respectively. In Bolivia, the average cost of screening was U.S. $1.48 and U.S. $1.91 using the RPR and ICS test, respectively. In health centers without laboratories, the cost per woman screened using the ICS test ranged from U.S. $1.02 in Mozambique to U.S. $2.84 in Bolivia. CONCLUSIONS: It is feasible to introduce rapid syphilis testing in settings without laboratory services at a small incremental cost per woman screened. In settings with laboratories, the cost of ICS is similar to that of RPR.