Factors Associated with Outcomes of Pre-ART HIV Care.

The World Health Organization recommended removing all CD4 requirements for initiation of antiretroviral therapy (ART) in resource-limited settings. We examined the pre-ART period to identify and assess factors associated with outcomes of pre-ART care. Four modes of transition out of pre-ART care were considered. Beta estimates from the competing risks Cox models were used to investigate whether the effects of covariates differed by mode of transition. Median CD4 counts at entry showed no meaningful change over time. Advanced disease progression and presence of opportunistic infections were significant predictors of pre-ART mortality. Men were more likely to die before initiating ART, transfer to another facility, or be lost to follow-up than were women. Removing CD4 thresholds is not likely to substantially reduce program mortality prior to ART initiation unless and until patients enroll earlier in disease progression. Care programs should focus on diagnosis and treatment of opportunistic infections to reduce pre-ART mortality.

How can routine health information systems improve health systems functioning in low- and middle-income countries? Assessing the evidence base.

PURPOSE: Health system performance depends on production and use of quality health data and information. Routine health information systems (RHIS) are defined as systems that provide information at regular intervals of a year or less to meet predictable information needs. These include paper-based or electronic health records and facility- and district-level management information systems. RHIS are receiving increasing attention as an essential component of efficient, country-owned, integrated national systems. To guide investment decisions on RHIS, evidence is needed on which types of RHIS interventions work and which do not. DESIGN/METHODOLOGY/APPROACH: This chapter is a systematic review of the literature on the evaluation of RHIS interventions in low- and middle-income countries, starting from the premise that investments in RHIS could be better understood and so produce greater benefits than they currently do. FINDINGS: We describe the conceptual literature on the determinants of RHIS performance and its role in improving health systems functioning, discuss the evidence base on the effectiveness of strategies to improve RHIS performance, provide an overview of RHIS evaluation challenges, and make suggestions to improve the evidence base. ORIGINALITY/VALUE: The goal is to help ensure that (a) RHIS interventions are appropriately designed and implemented to improve health systems functioning and (b) resulting RHIS information is used more effectively.

The reliability and validity of willingness to pay surveys for reproductive health pricing decisions in developing countries.

This paper examines the reliability, theoretical and predictive validity of willingness to pay (WTP) surveys for setting prices for reproductive health services in developing countries. Four country applications were conducted; the surveys used similar elicitation methods (a series of three closed-ended questions to cover the range of target prices, followed by a single open ended question to elicit maximum WTP) and samples of current or potential users of family planning, gynecology, and prenatal care services. In all four applications, respondents were able to understand WTP questions and responded with high levels of internal consistency. Evidence supporting theoretical validity was also found in all surveys. Higher income and more highly motivated users had higher WTP than lower income and less motivated users. Predictive validity was assessed in one study. Services utilization predicted by a WTP survey was compared with actual post-price increase utilization. Adding WTP to information already possessed by program managers resulted in a threefold increase in ability to predict utilization change as a result of a price increase, and in nearly half of cases predicted percent change in utilization was within 10% of observed change. WTP surveys when used for reproductive services price setting appear reliable and valid, and improve a program manager's ability to predict client responses to price changes.