Annual cost of antiretroviral therapy among three service delivery models in Uganda.

INTRODUCTION: In response to the increasing burden of HIV, the Ugandan government has employed different service delivery models since 2004 that aim to reduce costs and remove barriers to accessing HIV care. These models include community-based approaches to delivering antiretroviral therapy (ART) and delegating tasks to lower-level health workers. This study aimed to provide data on annual ART cost per client among three different service delivery models in Uganda. METHODS: Costing data for the entire year 2012 were retrospectively collected as part of a larger task-shifting study conducted in three organizations in Uganda: Kitovu Mobile (KM), the AIDS Support Organisation (TASO) and Uganda Cares (UC). A standard cost data capture tool was developed and used to retrospectively collect cost information regarding antiretroviral (ARV) drugs and non-ARV drugs, ART-related lab tests, personnel and administrative costs. A random sample of four TASO centres (out of 11), four UC clinics (out of 29) and all KM outreach units were selected for the study. RESULTS: Cost varied across sites within each organization as well as across the three organizations. In addition, the number of annual ART visits was more frequent in rural areas and through KM (the community distribution model), which played a major part in the overall annual ART cost. The annual cost per client (in USD) was $404 for KM, $332 for TASO and $257 for UC. These estimates were lower than previous analyses in Uganda or the region compared to data from 2001 to 2009, but comparable with recent estimates using data from 2010 to 2013. ARVs accounted for the majority of the total cost, followed by personnel and operational costs. CONCLUSIONS: The study provides updated data on annual cost per ART visit for three service delivery models in Uganda. These data will be vital for in-country budgetary efforts to ensure that universal access to ART, as called for in the 2015 World Health Organization (WHO) guidelines, is achievable. The lower annual ART cost found in this study indicates that we may be able to treat all people with HIV as laid out in the 2015 WHO guidelines. The variation of costs across sites and the three models indicates the potential for efficiency gains.

Did PEPFAR investments result in health system strengthening? A retrospective longitudinal study measuring non-HIV health service utilization at the district level.

OBJECTIVES : PEPFAR's initial rapid scale-up approach was largely a vertical effort focused fairly exclusively on AIDS. The purpose of our research was to identify spill-over health system effects, if any, of investments intended to stem the HIV epidemic over a 6-year period with evidence from Uganda. The test of whether there were health system expansions (aside from direct HIV programming) was evidence of increases in utilization of non-HIV services-such as outpatient visits, in-facility births or immunizations-that could be associated with varying levels of PEPFAR investments at the district level. METHODS : Uganda's Health Management Information System article-based records were available from mid-2005 onwards. We visited all 112 District Health offices to collect routine monthly reports (which contain data aggregated from monthly facility reports) and annual reports (which contain data aggregated from annual facility reports). Counts of individuals on anti-retroviral therapy (ART) at year-end served as our primary predictor variable. We grouped district-months into tertiles of high, medium or low PEPFAR investment based on their total reported number of patients on ART at the end of the year. We generated incidence-rate ratios, interpreted as the relative rate of the outcome measure in relation to the lowest investment PEPFAR tertile, holding constant control variables in the model. RESULTS : We found PEPFAR investment overall was associated with small declines in service volumes in several key areas of non-HIV care (outpatient care for young children, TB tests and in-facility deliveries), after adjusting for sanitation, elementary education and HIV prevalence. For example, districts with medium and high ART investment had 11% fewer outpatient visits for children aged 4 and younger compared with low investment districts, incidence rate ratio (IRR) of 0.89 for high investment compared with low (95% CI, 0.85-0.94) and IRR of 0.93 for medium compared with low (0.90-0.96). Similarly, 22% fewer TB sputum tests were performed in high investment districts compared with low investment, [IRR 0.78 (0.72-0.85)] and 13% fewer in medium compared with low, [IRR 0.88 (0.83-0.94)]. Districts with medium and high ART investment had 5% fewer in-facility deliveries compared with low investment districts [IRR 0.95 for high compared with low, (91-1.00) and 0.96 for medium compared with low (0.93-0.99)]. Although not statistically significant, the rate of maternal deaths in high investment district-months was 13% lower than observed in low investment districts. CONCLUSIONS : This study sought to understand whether PEPFAR, as a vertical programme, may have had a spill-over effect on the health system generally, as measured by utilization. Our conclusion is that it did not, at least not in Uganda.

The burden of childhood injuries and evidence based strategies developed using the injury surveillance system in Pasto, Colombia.

OBJECTIVE: This article characterises the burden of childhood injuries and provides examples of evidence-based injury prevention strategies developed using a citywide injury surveillance system in Pasto, Colombia. METHODS: Fatal (2003-2007) and non-fatal (2006-2007) childhood injury data were analysed by age, sex, cause, intent, place of occurrence, and disposition. RESULTS: Boys accounted for 71.5% of fatal and 64.9% of non-fatal injuries. The overall fatality rate for all injuries was 170.8 per 100,000 and the non-fatal injury rate was 4,053 per 100,000. Unintentional injuries were the leading causes of fatal injuries for all age groups, except for those 15-19 years whose top four leading causes were violence-related. Among non-fatal injuries, falls was the leading mechanism in the group 0-14 years. Interpersonal violence with a sharp object was the most important cause for boys aged 15-19 years. Home was the most frequent place of occurrence for both fatal and non-fatal injuries for young children 0-4 years old. Home, school and public places became an important place for injuries for boys in the age group 5-15 years. The highest case-fatality rate was for self-inflicted injuries (8.9%). CONCLUSIONS: Although some interventions have been implemented in Pasto to reduce injuries, it is necessary to further explore risk factors to better focus prevention strategies and their evaluation. We discuss three evidence-based strategies developed to prevent firework-related injuries during festival, self-inflicted injuries, and road traffic-related injuries, designed and implemented based on the injury surveillance data.

Childhood drowning in low- and middle-income countries: Urgent need for intervention trials.

Data available for low- and middle-income countries (LMICs) indicate that the burden of drowning in children is significant and becoming a leading public health problem. At the same time, interventions for drowning are not well documented in LMICs. The overall purpose of this paper is to make the case for research investments in conducting intervention trials to prevent child drowning in LMICs. In high-income countries (HICs), existing drowning prevention interventions include among others: pool fencing, supervision, lifeguards and water safety training at a young age. However, these measures may not be the most relevant in curtailing the number of drowning deaths in LMICs. There are differences with regard to geographical, social, cultural and behavioural factors associated with drowning between HICs and LMICs, often making it inappropriate to apply existing interventions directly in LMIC settings. This paper focuses on drowning from LMICs and reveals a dearth of data on incidence rates and risk factors; absence of public health interventions; lack of research on intervention effectiveness and cost-effectiveness; and paucity of national drowning prevention programs. Based on this evidence, this paper calls for immediate attention to drowning prevention by increasing research investments. This paper specifically discusses Bangladesh as a case study and proposes a drowning intervention study focusing on children less than 5 years in LMICs as an example of appropriate research investment.

Dignified dying: phenomenon and actions among nurses in India.

PURPOSE: This study contributes to the ongoing efforts of the International Classification for Nursing Practice (ICNP) to describe the phenomenon of dignified dying, to describe nursing actions used to promote dignified dying, and to evaluate the validity of a dignified dying scale among practising nurses in India. DESIGN AND SAMPLE: This descriptive study surveyed 229 nurses who had cared for dying patients and were currently practising in government and private hospitals in India. METHODS: Nurses were recruited to complete a survey in either Hindi or English. The survey included demographic, open-ended questions, and a dignified dying scale of Likert-like items. Nurses also identified nursing interventions used in practice to promote dignified dying. FINDINGS: The descriptions of dignified dying phenomenon fit within the three major areas of the Dignity-Conserving Model of Care. A variety of interventions were reported, with more focusing on spiritual than physical factors. The 14 items selected reliably measured dignified dying, with a Cronbach's alpha of 0.79. Factor analysis yielded a 4-factor solution, with 11 items accounting for 56% of the variance. CONCLUSIONS: Nurses in India endorsed spirituality as an essential aspect of the phenomenon of dignified dying. Nursing actions to promote dignified dying supported finding spiritual comfort at end of life. These results contribute to an understanding of nursing phenomena and actions worldwide.

Psychometric evaluation of the cultural competence assessment instrument among healthcare providers.

BACKGROUND: The relevance of healthcare provider cultural competency to the achievement of goals for reduction in extant health disparities has been demonstrated; however, there are deficits with regard to cultural competency measurement. OBJECTIVES: To examine the test-retest reliability of the cultural competence assessment instrument (CCA) among hospice providers, and to examine the reliability and validity of the CCA among healthcare providers in nonhospice settings. METHOD: Test-retest reliability of the CCA was assessed using a sample of 51 hospice respondents who completed the CCA at two time points. The internal consistency reliability and construct validity of the CCA for healthcare providers in nonhospice settings were evaluated using a convenience sample of 405 healthcare providers. RESULTS: The CCA demonstrated adequate test-retest reliability (r = .85, p = .002) in hospice providers over 4 months. Among healthcare providers in nonhospice settings, the CCA had an internal consistency reliability of .89 overall (.91 and .75 for the two subscales). Construct validity was supported by principal axis factor analysis, which showed two factors with item loadings above .40, explaining 56% of the variance. Mean scores of the CCA were significantly higher for providers who reported previous diversity training compared to those who had not. DISCUSSION: Findings for the psychometric properties of the CCA supported its potential as an instrument for measuring provider cultural competence. Knowledge gained will be useful for developing future research studies and specific cultural competence intervention approaches for healthcare providers that may decrease health disparities.