Individual journeys to tuberculosis care in Nigeria's private sector during the COVID-19 pandemic.

BACKGROUND: Pre-COVID-19, individuals with tuberculosis (TB) in Nigeria were often underdiagnosed and untreated. TB services were mostly in the public sector with only 15% of new cases in 2019 reported from the private sector. Reports highlighted challenges in accessing care in the private sector, which accounted for 67% of all initial care-seeking. Our study examined patients' health seeking pathways for TB in Nigeria's private sector and explored any changes to care pathways during COVID-19. METHODS: We conducted 180 cross-sectional surveys and 20 in-depth interviews with individuals having chest symptoms attending 18 high-volume private clinics and hospitals in Kano and Lagos States. Questions focused on sociodemographic characteristics, health-seeking behaviour, and pathways to care during the COVID-19 pandemic. All surveys and interviews were conducted in May 2021. RESULTS: Most participants were male (111/180), with an average age of 37. Half (96/180) sought healthcare within a week of symptoms, while few (20/180) waited over 2 months. Individuals testing positive for TB had more health-seeking delays, and those testing negative for TB had more provider delays. On average, participants visited two providers in Kano and 1.69 in Lagos, with 61 of 180 in Kano and 48 of 180 in Lagos visiting other providers before the recruitment facility. Private providers were the initial encounters for most participants (60/180 in Kano, 83/180 in Lagos). Most respondents (164/180) experienced short-lived pandemic-related restrictions, affecting access to transportation, and closed facilities. CONCLUSIONS: This study showed a few challenges in accessing TB care, necessitating continued investment in healthcare infrastructure and resources, particularly in the private sector. Understanding the different care pathways and delays in care provides opportunities for targeted interventions to improve deployment of services closer to where patients first seek care.

Expanding the Role of Women in Vector Control: Case Studies From Madagascar, Rwanda, and Zambia.

BACKGROUND: Historically, vector control, including entomological monitoring, has been a field dominated by men. Each year, the U.S. President's Malaria Initiative (PMI) VectorLink project hires 50,000 to 70,000 seasonal workers across the countries in which it works to implement vector control activities, creating an economic opportunity for both men and women. Remaining barriers to women's employment in vector control include social and cultural norms regarding acceptability of formal employment for women, perceptions that women are not fit to serve as spray operators, and a historical context of male-dominated fields such as entomology. METHODS: We use PMI VectorLink project data from Madagascar, Rwanda, and Zambia for 2019-2021 and key informant interviews with project staff in these countries to examine levels of female employment, effectiveness and efficiency of female versus male malaria spray operators, and strategies to expand the role of women in vector control. RESULTS: The percentage of female seasonal employees ranges from 25% in Madagascar to 32% in Rwanda and 45% in Zambia. The percentage of women in leadership positions ranges from 32% in Madagascar and Rwanda to 38% in Zambia. Men and women are equally effective and efficient as spray operators. Best practices for recruiting and retaining women in vector control include engaging community leaders in recruitment, implementing affirmative action hiring policies, mentoring women to progress to leadership positions, and ensuring equitable, safe, and attractive workplaces. DISCUSSION: As vector control programs transition away from donor funding and are increasingly government led, sustaining gains in female empowerment is critical. Country programs should work closely with national, regional, district, and local leaders to demonstrate the importance of hiring women in vector control-including leadership positions-and the impact on female economic empowerment, community well-being, and success of vector control programs.

Tuberculosis service disruptions and adaptations during the first year of the COVID-19 pandemic in the private health sector of two urban settings in Nigeria-A mixed methods study.

Nigeria has the second largest share of undiagnosed TB cases in the world and a large private health sector estimated to be the point of initial care-seeking for 67% of TB patients. There is evidence that COVID-19 restrictions disrupted private healthcare provision, but insufficient data on how private healthcare provision changed as a result of the pandemic. We conducted qualitative interviews and a survey to assess the impact of the pandemic, and government response on private healthcare provision, and the disruptions providers experienced, particularly for TB services. Using mixed methods, we targeted policymakers, and a network of clinical facilities, laboratories, community pharmacies, and medicine vendors in Kano and Lagos, Nigeria. We interviewed 11 policymakers, surveyed participants in 2,412 private facilities. Most (n = 1,676, 70%) facilities remained open during the initial lockdown period, and most (n = 1,667, 69%) offered TB screening. TB notifications dipped during the lockdown periods but quickly recovered. Clinical facilities reported disruptions in availability of medical supplies, staff, required renovations, patient volume and income. Few private providers (n = 119, 11% in Kano; n = 323, 25% in Lagos) offered any COVID-19 screening up to the time of the survey, as these were only available in designated facilities. These findings aligned with the interviews as policymakers reported a gradual return to pre-COVID services after initial disruptions and diversion of resources to the pandemic response. Our results show that COVID-19 and control measures had a temporary impact on private sector TB care. Although some facilities saw decreases in TB notifications, private facilities continued to provide care for individuals with TB who otherwise might have been unable to seek care in the public sector. Our findings highlight resilience in the private sector as they recovered fairly quickly from pandemic-related disruptions, and the important role private providers can play in supporting TB control efforts.

Exploring the relationship between national governance indicators and speed of initial government response to COVID-19 in low- and middle-income countries.

Objectives: This study aimed to explore the relationship between national governance and country response to the COVID-19 pandemic in low- and middle-income countries, to support preparedness for the next pandemic. We conducted a statistical analysis of 116 countries, examining the relationship between speed of initial response and measures of national governance. Study design: Observational study, with individual countries as the unit of analysis. Methods: We used logistic regression to look for associations between quicker initial government response and four national governance indicators: Government Effectiveness, Political Stability and Absence of Violence/Terrorism, Voice and Accountability, and Corruption Perceptions Index. Results: A quicker initial government response was associated with countries with higher Government Effectiveness (OR 13.92 95% CI 3.69-52.48, p < 0.001) and lower Political Stability and Absence of Violence/Terrorism (OR 0.23, 95% CI 0.09-0.57, p = 0.002). There was no relationship observed between speed of initial government response and Voice and Accountability or Corruption Perceptions Index. Other factors associated with quicker initial response were small population size, experiencing first COVID-19 case after the pandemic declaration, not having previous experience with SARS-CoV1 or MERS and not being an island nation. Conclusions: This study shows that having higher state policy and implementation capacity, and lower political stability was associated with a quicker initial pandemic response. Limitations of this study include the use of crude national level indicators and broad categorisations of countries into quicker and slower responders. Deeper enquiry into the early decision-making processes taken at the national executive level within individual countries may help clarify the observed associations further.

Sources for and quality of neonatal care in 45 low- and middle-income countries.

Almost half of under-five deaths occur during the neonatal period. Delivery with a skilled attendant, adherence to essential newborn care (ENC) and postnatal care (PNC) standards, and immediate treatment of infections are essential to improve neonatal survival. This article uses Demographic and Health Survey data from 45 low- and middle-income countries to assess 1) levels of ENC and PNC that mothers and newborns receive and how this differs by place of delivery and 2) levels of and sources for care-seeking for neonates sick with fever. For five of the ten ENC and PNC indicators assessed, less than two-thirds of mothers and newborns received care in alignment with global standards. Adherence is higher in private facilities than public facilities for all indicators other than immediate breastfeeding and skin-to-skin contact. Except for immediate breastfeeding, adherence is lowest for newborns born at home with a skilled birth attendant (SBA). Socioeconomic disparities exist in access to skilled delivery and adherence to ENC and PNC, with the largest disparities among newborns delivered at home with a SBA. Private provider adherence to ENC and PNC standards was relatively high for newborns from the wealthiest families, indicating that meeting recommended guidelines is achievable. On average across the 45 countries, half of caregivers for neonates with fever sought care outside the home and 45 percent of those sought care from the private sector. There were substantial socioeconomic disparities in care-seeking for fever, but illness prevalence and sources of care seeking were consistent across wealth quintiles. Closing inequities in neonatal care and care seeking and ensuring that all families, including the poorest, can access high quality maternal and newborn care is crucial to ensure equity and accelerate reductions in neonatal and child mortality.

Incremental cost and cost-effectiveness of the addition of indoor residual spraying with pirimiphos-methyl in sub-Saharan Africa versus standard malaria control: results of data collection and analysis in the Next Generation Indoor Residual Sprays (NgenIRS) project, an economic-evaluation.

BACKGROUND: Malaria is a major cause of morbidity and mortality globally, especially in sub-Saharan Africa. Widespread resistance to pyrethroids threatens the gains achieved by vector control. To counter resistance to pyrethroids, third-generation indoor residual spraying (3GIRS) products have been developed. This study details the results of a multi-country cost and cost-effectiveness analysis of indoor residual spraying (IRS) programmes using Actellic®300CS, a 3GIRS product with pirimiphos-methyl, in sub-Saharan Africa in 2017 added to standard malaria control interventions including insecticide-treated bed nets versus standard malaria control interventions alone. METHODS: An economic evaluation of 3GIRS using Actellic®300CS in a broad range of sub-Saharan African settings was conducted using a variety of primary data collection and evidence synthesis methods. Four IRS programmes in Ghana, Mali, Uganda, and Zambia were included in the effectiveness analysis. Cost data come from six IRS programmes: one in each of the four countries where effect was measured plus Mozambique and a separate programme conducted by AngloGold Ashanti Malaria Control in Ghana. Financial and economic costs were quantified and valued. The main indicator for the cost was cost per person targeted. Country-specific case incidence rate ratios (IRRs), estimated by comparing IRS study districts to adjacent non-IRS study districts or facilities, were used to calculate cases averted in each study area. A deterministic analysis and sensitivity analysis were conducted in each of the four countries for which effectiveness evaluations were available. Probabilistic sensitivity analysis was used to generate plausibility bounds around the incremental cost-effectiveness ratio estimates for adding IRS to other standard interventions in each study setting as well as jointly utilizing data on effect and cost across all settings. RESULTS: Overall, IRRs from each country indicated that adding IRS with Actellic®300CS to the local standard intervention package was protective compared to the standard intervention package alone (IRR 0.67, [95% CI 0.50-0.91]). Results indicate that Actellic®300CS is expected to be a cost-effective (> 60% probability of being cost-effective in all settings) or highly cost-effective intervention across a range of transmission settings in sub-Saharan Africa. DISCUSSION: Variations in the incremental costs and cost-effectiveness likely result from several sources including: variation in the sprayed wall surfaces and house size relative to household population, the underlying malaria burden in the communities sprayed, the effectiveness of 3GIRS in different settings, and insecticide price. Programmes should be aware that current recommendations to rotate can mean variation and uncertainty in budgets; programmes should consider this in their insecticide-resistance management strategies. CONCLUSIONS: The optimal combination of 3GIRS delivery with other malaria control interventions will be highly context specific. 3GIRS using Actellic®300CS is expected to deliver acceptable value for money in a broad range of sub-Saharan African malaria transmission settings.

Tuberculosis care quality in urban Nigeria: A cross-sectional study of adherence to screening and treatment initiation guidelines in multi-cadre networks of private health service providers.

Nigeria has a high burden of tuberculosis (TB) and low case detection rates. Nigeria's large private health sector footprint represents an untapped resource for combating the disease. To examine the quality of private sector contributions to TB, the USAID-funded Sustaining Health Outcomes through the Private Sector (SHOPS) Plus program evaluated adherence to national standards for management of presumptive and confirmed TB among the clinical facilities, laboratories, pharmacies, and drug shops it trained to deliver TB services. The study used a standardized patient (SP) survey methodology to measure case management protocol adherence among 837 private and 206 public providers in urban Lagos and Kano. It examined two different scenarios: a "textbook" case of presumptive TB and a treatment initiation case where SPs presented as referred patients with confirmed TB diagnoses. Private sector results were benchmarked against public sector results. A bottleneck analysis examined protocol adherence departures at key points along the case management sequence that providers were trained to follow. Except for laboratories, few providers met the criteria for fully correct management of presumptive TB, though more than 70% of providers correctly engaged in TB screening. In the treatment initiation case 18% of clinical providers demonstrated fully correct case management. Private and public providers' adherence was not significantly different. Bottleneck analysis revealed that the most common deviations from correct management were failure to initiate sputum collection for presumptive patients and failure to conduct sufficiently thorough treatment initiation counseling for confirmed patients. This study found the quality of private providers' TB case management to be comparable to public providers in Nigeria, as well as to providers in other high burden countries. Findings support continued efforts to include private providers in Nigeria's national TB program. Though most providers fell short of desired quality, the bottleneck analysis points to specific issues that TB stakeholders can feasibly address with system- and provider-level interventions.

Moving to Social Health Insurance Financing and Payment for HIV/AIDS Treatment in Vietnam.

This study estimates the amount antiretroviral therapy (ART) clients paid out of pocket for preventive and treatment services and the percentage of ART clients incurring catastrophic payments during the period when ART services were transitioning from donor funding to domestic social health insurance (SHI) in Vietnam. Using a cross-sectional facility-based survey in 9 provinces, a sample of 582 clients across 18 ART facilities representatives of all facilities where SHI-financed ART was being implemented were interviewed in 2019. Results indicated 13.4% (95% CI: 5.7%, 28.2%) of clients incurred a payment for outpatient ART care. The average out of pocket expenditures for outpatient visits and HIV related outpatient visits was USD $71.2 and $8 per year, respectively. The average out of pocket expenditure for inpatient admission and HIV related inpatient admission was $7.1 and $1.6, respectively. Only 0.1% clients currently experienced HIV-related catastrophic payment at the 25% of total expenditures threshold. The study confirms the transition from donor-financed ART to SHI-financed ART is not causing financial hardship for ART clients. However, more commitment from the Government of Vietnam to strengthen HIV-related services under SHI may be needed in the future, and there is still need to ensure universal SHI coverage among people with HIV/AIDs in Vietnam.

The cost of HIV services at health facilities in Cambodia.

BACKGROUND: Donor funding for HIV/AIDS services is declining in Cambodia, and domestic resources need to be mobilized to sustain and expand these services. However, the cost of delivering HIV/AIDS services is not well studied in Cambodia. This study aims to assess the costs of delivering HIV/AIDS services, identify the major components of costs, and sources of funding. METHODS: Four of the six highest HIV burden provinces were selected at random for this study. Within each province, four health centers and two hospitals were selected for detailed data collection. A mix of top-down and bottom-up methods were used to assess the costs for HIV testing and antiretroviral therapy (ART) from the provider perspective. We assessed the differences in the quantity and prices of inputs between health facilities of the same type to identify cost-drivers. RESULTS: The average cost per visit for HIV testing was $8.92 at health centers and $14.03 at referral hospitals. Differences in the number of visits per staff were the primary determinant of differences in the cost per visit. First-line ART costed about $250 per patient per year, and the number of patients per staff was an important cost driver. Second-line ART costed from $500 to $716 per patient per year, on average, across the types of facilities, with the quantity and mix of second-line antiretroviral drugs being an important cost driver. Inpatient care at referral and provincial hospitals in total represented less than 2 percent of costs of outpatient ART. DISCUSSION: Costs are similar to neighboring countries, but over 50% of the costs of ART are financed by donors. Cambodia now is scaling up social health insurance coverage; the data from this study could serve as one input when setting reimbursement rates for HIV/AIDS services to help ensure that providers are adequately reimbursed for their services.

The Costs and Cost-Effectiveness of a District-Strengthening Strategy to Mitigate the 3 Delays to Quality Maternal Health Care: Results From Uganda and Zambia.

The primary objective of this study was to estimate the costs and the incremental cost-effectiveness of maternal and newborn care associated with the Saving Mothers, Giving Life (SMGL) initiative-a comprehensive district-strengthening approach addressing the 3 delays associated with maternal mortality-in Uganda and Zambia. To assess effectiveness, we used a before-after design comparing facility outcome data from 2012 (before) and 2016 (after). To estimate costs, we used unit costs collected from comparison districts in 2016 coupled with data on health services utilization from 2012 in SMGL-supported districts to estimate the costs before the start of SMGL. We collected data from health facilities, ministerial health offices, and implementing partners for the year 2016 in 2 SMGL-supported districts in each country and in 3 comparison non-SMGL districts (2 in Zambia, 1 in Uganda). Incremental costs for maternal and newborn health care per SMGL-supported district in 2016 was estimated to be US$845,000 in Uganda and $760,000 in Zambia. The incremental cost per delivery was estimated to be $38 in Uganda and $95 in Zambia. For the districts included in this study, SMGL maternal and newborn health activities were associated with approximately 164 deaths averted in Uganda and 121 deaths averted in Zambia in 2016 compared to 2012. In Uganda, the cost per death averted was $10,311, or $177 per life-year gained. In Zambia, the cost per death averted was $12,514, or $206 per life-year gained. The SMGL approach can be very cost-effective, with the cost per life-year gained as a percentage of the gross domestic product (GDP) being 25.6% and 16.4% in Uganda and Zambia, respectively. In terms of affordability, the SMGL approach could be paid for by increasing health spending from 7.3% to 7.5% of GDP in Uganda and from 5.4% to 5.8% in Zambia.

Assessing the cost of providing a prevention of mother-to-child transmission of HIV/AIDS service in Ethiopia: urban-rural health facilities setting.

BACKGROUND: While local context costing evidence is relevant for healthcare planning, budgeting and cost-effectiveness analysis, it continues to be scarce in Ethiopia. This study assesses the cost of providing a prevention of mother-to-child transmission of HIV/AIDS (PMTCT) service across heterogeneous prevalence (high, low) and socio-economic (urban, rural) contexts. METHODS: A total of 12 health facilities from six regions in Ethiopia were purposively selected from the latest 2012 antenatal sentinel HIV prevalence report. Six health facilities with the highest HIV prevalence (8.1 to 17.3%) in urban settings and six health facilities with the lowest prevalence (0.0 to 0.1%) in rural settings were selected. A micro-costing approach was applied to identify, measure and value resources used for the provision of a comprehensive PMTCT service. The analysis was conducted across different PMTCT service packages. We also estimated national costs in urban and rural contexts. RESULTS: The average cost per pregnant woman-infant pair per year (PPY) ranged from ETB 6280 (USD 319) to ETB 21,620 (USD 1099) in the urban high HIV prevalence health facilities setting. In rural low HIV prevalence health facilities, the cost ranged from ETB 4323 (USD 220) to ETB 7539 (USD 383).PMTCT service provision in urban health facilities costs more than twice the cost in rural health facilities. The average cost per PPY in an urban setting was more than double the cost in a rural setting due to the higher cost of inputs and possible inefficiencies (although there were a higher number of visits). Consumables (including antiretroviral drugs) and infrastructure were the major cost drivers in both the urban and rural health facilities. Among PMTCT service components, anti-retroviral treatment Option B+ follow-up and counselling accounted for the highest proportion of costs, which ranged from 58 to 72%. Nationally, at the current coverage, the cost of PMTCT service was USD 6 million and USD 3 million in urban and rural settings, respectively. CONCLUSIONS: The analysis suggests that resources used for PMTCT service packages varied across health facilities and HIV prevalence contexts. Providing PMTCT service in the high HIV prevalence urban health facilities costs more than in the rural facilities. Context-specific costing was vital to provide locally sensitive evidence for health service management and priority setting.

Modelling the impact of a tax on sweetened beverages in the Philippines: an extended cost-effectiveness analysis.

OBJECTIVE: To assess the potential impact of a new tax on sweetened beverages on premature deaths associated with noncommunicable diseases in the Philippines. METHODS: In January 2018, the Philippines began imposing a tax of 6 Philippine pesos per litre (around 13%) on sweetened beverages to curb the obesity burden. Using national data sources, we conducted an extended cost-effectiveness analysis to estimate the effect of the tax on the numbers of premature deaths averted attributed to type 2 diabetes mellitus, ischaemic heart disease and stroke, across income quintiles over the period 2018-2037. We also estimated the financial benefits of the tax from reductions in out-of-pocket payments, direct medical costs averted and government health-care cost savings. FINDINGS: The tax could avert an estimated 5913 deaths related to diabetes, 10 339 deaths from ischaemic heart disease and 7950 deaths from stroke over 20 years. The largest number of deaths averted could be among the fourth and fifth (highest) income quintiles. The tax could generate total health-care savings of 31.6 billion Philippine pesos (627 million United States dollars, US$) over 20 years, and raise 41.0 billion Philippine pesos (US$ 813 million) in revenue per annum. The poorest quintile could bear the smallest tax burden increase (14% of the additional tax; 5.6 billion Philippine pesos) and have the lowest savings in out-of-pocket payments due to relatively large health-care subsidies. Finally, we estimated that 13 890 cases of catastrophic expenditure could be averted. CONCLUSION: The new sweetened beverage tax may help to reduce obesity-related premature deaths and improve financial well-being in the Philippines.

Scaling up malaria intervention "packages" in Senegal: using cost effectiveness data for improving allocative efficiency and programmatic decision-making.

BACKGROUND: Senegal's National Malaria Control Programme (NMCP) implements control interventions in the form of targeted packages: (1) scale-up for impact (SUFI), which includes bed nets, intermittent preventive treatment in pregnancy, rapid diagnostic tests, and artemisinin combination therapy; (2) SUFI + reactive case investigation (focal test and treat); (3) SUFI + indoor residual spraying (IRS); (4) SUFI + seasonal malaria chemoprophylaxis (SMC); and, (5) SUFI + SMC + IRS. This study estimates the cost effectiveness of each of these packages to provide the NMCP with data for improving allocative efficiency and programmatic decision-making. METHODS: This study is a retrospective analysis for the period 2013-2014 covering all 76 Senegal districts. The yearly implementation cost for each intervention was estimated and the information was aggregated into a package cost for all covered districts. The change in the burden of malaria associated with each package was estimated using the number of disability adjusted life-years (DALYs) averted. The cost effectiveness (cost per DALY averted) was then calculated for each package. RESULTS: The cost per DALY averted ranged from $76 to $1591 across packages. Using World Health Organization standards, 4 of the 5 packages were "very cost effective" (less than Senegal's GDP per capita). Relative to the 2 other packages implemented in malaria control districts, the SUFI + SMC package was the most cost-effective package at $76 per DALY averted. SMC seems to make IRS more cost effective: $582 per DALY averted for SUFI + IRS compared with $272 for the SUFI + IRS + SMC package. The SUFI + focal test and treat, implemented in malaria elimination districts, had a cost per DALY averted of $1591 and was only "cost-effective" (less than three times Senegal's per capita GDP). CONCLUSION: Senegal's choice of deploying malaria interventions by packages seems to be effectively targeting high burden areas with a wide range of interventions. However, not all districts showed the same level of performance, indicating that efficiency gains are still possible.

Multi-country assessment of residual bio-efficacy of insecticides used for indoor residual spraying in malaria control on different surface types: results from program monitoring in 17 PMI/USAID-supported IRS countries.

BACKGROUND: Indoor residual spraying (IRS) is the application of insecticide to the interior walls of household structures that often serve as resting sites for mosquito vectors of malaria. Human exposure to malaria vectors is reduced when IRS involves proper application of pre-determined concentrations of the active ingredient specific to the insecticide formulation of choice. The impact of IRS can be affected by the dosage of insecticide, spray coverage, vector behavior, vector susceptibility to insecticides, and the residual efficacy of the insecticide applied. This report compiles data on the residual efficacy of insecticides used in IRS campaigns implemented by the United States President's Malaria Initiative (PMI)/United States Agency for International Development (USAID) in 17 African countries and compares observed length of efficacy to ranges proposed in World Health Organization (WHO) guidelines. Additionally, this study provides initial analysis on variation of mosquito mortality depending on the surface material of sprayed structures, country spray program, year of implementation, source of tested mosquitoes, and type of insecticide. METHODS: Residual efficacy of the insecticides used for PMI/USAID-supported IRS campaigns was measured in Benin, Burkina Faso, Ethiopia, Ghana, Kenya, Liberia, Madagascar, Malawi, Mali, Mozambique, Nigeria, Rwanda, Senegal, Tanzania, Uganda, Zambia and Zimbabwe. The WHO cone bioassay tests were used to assess the mortality rate of mosquitoes exposed to insecticide-treated mud, wood, cement, and other commonly used housing materials. Baseline tests were performed within weeks of IRS application and follow-up tests were continued until the mortality of exposed mosquitoes dropped below 80% or the program monitoring period ended. Residual efficacy in months was then evaluated with respect to WHO guidelines that provide suggested ranges of residual efficacy for insecticide formulations recommended for use in IRS. Where the data allowed, direct comparisons of mosquito mortality rates were then made to determine any significant differences when comparing insecticide formulation, country, year, surface type, and the source of the mosquitoes used in testing. RESULTS: The residual efficacy of alpha-cypermethrin ranged from 4 to 10 months (average = 6.4 months), with no reported incidents of underperformance when compared to the efficacy range provided in WHO guidelines. Deltamethrin residual efficacy results reported a range of 1 to 10 months (average = 4.9 months), with two instances of underperformance. The residual efficacy of bendiocarb ranged from 2 weeks to 7 months (average = 2.8 months) and failed to achieve proposed minimum efficacy on 14 occasions. Lastly, long-lasting pirimiphos-methyl efficacy ranged from 2 months to 9 months (average = 5.3 months), but reported 13 incidents of underperformance. CONCLUSIONS: Much of the data used to determine application rate and expected efficacy of insecticides approved for use in IRS programs are collected in controlled laboratory or pilot field studies. However, the generalizability of the results obtained under controlled conditions are limited and unlikely to account for variation in locally sourced housing materials, climate, and the myriad other factors that may influence the bio-efficacy of insecticides. Here, data are presented that confirm the variation in residual efficacy observed when monitoring household surfaces sprayed during PMI/USAID-supported IRS campaigns. All insecticides except alpha-cypermethrin showed evidence of failing to meet the minimum range of residual efficacy proposed in WHO criteria at least once. However, this initial effort in characterizing program-wide insecticide bio-efficacy indicates that some insecticides, such as bendiocarb and pirimiphos-methyl, may be vulnerable to variations in the local environment. Additionally, the comparative analysis performed in this study provides evidence that mosquito mortality rates differ with respect to factors including: the types of insecticide sprayed, surface material, geographical location, year of spraying, and tested mosquitoes. It is, therefore, important to locally assess the residual efficacy of insecticides on various surfaces to inform IRS programming.

Draft Genome Sequence of Pseudomonas aeruginosa ATCC 9027, Originally Isolated from an Outer Ear Infection.

Pseudomonas aeruginosa ATCC 9027 was isolated in 1943 from a case of otitis externa and is commonly employed as a quality control strain for sterility, assessment of antibiofilm agents, and in vitro study of wound infection. Here, we present the 6.34-Mb draft genome sequence and highlight some pertinent genes that are associated with virulence.

The importance of assessing out-of-pocket payments when the financing of antiretroviral therapy is transitioned to domestic funding: findings from Vietnam.

OBJECTIVE: To assess out-of-pocket payments and catastrophic health expenditures among antiretroviral therapy (ART) patients in Vietnam, and to model catastrophic payments under different copayment scenarios when the primary financing of ART changes to social health insurance. METHODS: Cross-sectional facility-based survey of 843 patients at 42 health facilities representative of 87% of ART patients in 2015. RESULTS: Because of donor and government funding, no payments were made for antiretroviral drugs. Other health expenditures were about $66 per person per year (95% CI: $30-$102), of which $15 ($7-$22) were directly for HIV-related health services, largely laboratory tests. These payments resulted in a 4.9% (95% CI: 3.1-6.8%) catastrophic payment rate and 2.5% (95% CI: 0.9-4.1%) catastrophic payment rate for HIV-related health services. About 32% of respondents reported, they were eligible for SHI without copayments. If patients had to pay 20% of costs of ART under social health insurance, the catastrophic payment rate would increase to 8% (95% CI: 5.5-10.0%), and if patients without health insurance had to pay the full costs of ART, the catastrophic payment rate among all patients would be 24% (95% CI: 21.1-27.4%). CONCLUSIONS: Health and catastrophic expenditures were substantially lower than in previous studies, although different methods may explain some of the discrepancy. The 20% copayments required by social health insurance would present a financial burden to an additional 0.6% to 5.1% of ART patients. Ensuring access to health insurance for all ART patients will prevent an even higher level of financial hardship.

The Cost-Effectiveness of Integrating HIV Counseling and Testing into Primary Health Care in the Ukraine.

We estimate the number of HIV cases diagnosed, costs, and cost per HIV case detected associated with integrating HIV counseling and testing (HCT) into primary health care facilities in Ukraine. The study uses a difference-in-difference design with four districts implementing the intervention compared to 20 districts where HCT were offered only at specialized HIV clinics. There was a 2.01 (95 % CI: 1.12-3.61) times increase in the number of HIV cases detected per capita in intervention districts compared to other districts. The incremental cost of the intervention was $21,017 and the incremental cost per HIV case detected was $369. The average cost per HIV case detected before the intervention was $558. Engaging primary health care facilities to provide HCT is likely desirable from an efficiency point-of-view. However, the affordability of the intervention needs to be assessed because expansion will require additional investment.

Indoor Residual Spraying Delivery Models to Prevent Malaria: Comparison of Community- and District-Based Approaches in Ethiopia.

BACKGROUND: Indoor residual spraying (IRS) for malaria prevention has traditionally been implemented in Ethiopia by the district health office with technical and operational inputs from regional, zonal, and central health offices. The United States President's Malaria Initiative (PMI) in collaboration with the Government of Ethiopia tested the effectiveness and efficiency of integrating IRS into the government-funded community-based rural health services program. METHODS: Between 2012 and 2014, PMI conducted a mixed-methods study in 11 districts of Oromia region to compare district-based IRS (DB IRS) and community-based IRS (CB IRS) models. In the DB IRS model, each district included 2 centrally located operational sites where spray teams camped during the IRS campaign and from which they traveled to the villages to conduct spraying. In the CB IRS model, spray team members were hired from the communities in which they operated, thus eliminating the need for transport and camping facilities. The study team evaluated spray coverage, the quality of spraying, compliance with environmental and safety standards, and cost and performance efficiency. RESULTS: The average number of eligible structures found and sprayed in the CB IRS districts increased by 19.6% and 20.3%, respectively, between 2012 (before CB IRS) and 2013 (during CB IRS). Between 2013 and 2014, the numbers increased by about 14%. In contrast, in the DB IRS districts the number of eligible structures found increased by only 8.1% between 2012 and 2013 and by 0.4% between 2013 and 2014. The quality of CB IRS operations was good and comparable to that in the DB IRS model, according to wall bioassay tests. Some compliance issues in the first year of CB IRS implementation were corrected in the second year, bringing compliance up to the level of the DB IRS model. The CB IRS model had, on average, higher amortized costs per district than the DB IRS model but lower unit costs per structure sprayed and per person protected because the community-based model found and sprayed more structures. CONCLUSION: Established community-based service delivery systems can be adapted to include a seasonal IRS campaign alongside the community-based health workers' routine activities to improve performance efficiency. Further modifications of the community-based IRS model may reduce the total cost of the intervention and increase its financial sustainability.

The effects of decentralizing anti-retroviral services in Nigeria on costs and service utilization: two case studies.

Nigeria launched a 'hub and spoke' decentralization pilot in March 2010 for the provision of anti-retroviral therapy (ART). In this programme, stable ART patients at hospitals (hubs) were referred to primary health care centres (spokes) for the continued provision of ART. The objectives of this study are to compare the cost of ART care provided through the two levels of care. We also assess if decentralization was associated with changes in patients' service utilization. Data were collected from facilities and patient records from Kaduna and Cross Rivers States. Costs were collected from the provider perspective. In Cross River, 398 patients and 528 from Kaduna were included in the retrospective cohort. The analysis utilizes separate fixed effect regressions for each state to assess differences in costs and service utilization among patients that decentralized. Uptake of decentralized services was ∼3% in Cross Rivers and ∼9% in Kaduna among active ART patients in April 2011. Patients electing to decentralize had 40% (95% CI: 13% to 67%) higher costs in Cross Rivers and 29% (-44% to -14%) lower costs in Kaduna as compared with patients that did not decentralize. Lower costs in Kaduna appear to result from shifting care to less expensive cadres of health workers (task shifting) rather than decentralization. Decentralization of health services is a complicated process and broad generalizations across settings and processes, concerning whether or not it reduces unit costs, are likely over-simplifications. Similarly, decentralization of ART services does not automatically increase access to ART care, and may limit access to ART laboratory services. This study is limited by not including costs incurred above the facility level, such as training, or costs borne by patients.