Impacts of COVID-19-related service disruptions on TB incidence and deaths in Indonesia, Kyrgyzstan, Malawi, Mozambique, and Peru: Implications for national TB responses.

Initial global-level estimates reported in June 2020 by the World Health Organization suggested that levels of disruption to TB service delivery could be as high as 25%-50% and result in an additional 6·3 million cases of tuberculosis (TB) and an additional 1·4 million TB-related deaths attributable to COVID-19 between 2020 and 2025. Quarterly epidemiological estimates and programmatic TB data capturing disruption levels to each TB service were collected by National TB Programmes in Indonesia, Kyrgyzstan, Malawi, Mozambique, and Peru. Data from 2019, for a pre-COVID-19 baseline, and throughout 2020, together with the NTP's COVID-19 response plans, were used within Optima TB models to project TB incidence and deaths over five years because of COVID-19-related disruptions, and the extent to which those impacts may be mitigated through proposed catch-up strategies in each country. Countries reported disruptions of up to 64% to demand-driven TB diagnosis. However, TB service availability disruptions were shorter and less severe, with TB treatment experiencing levels of disruption of up to 21%. We predicted that under the worse-case scenario cumulative new latent TB infections, new active TB infections, and TB-related deaths could increase by up to 23%, 11%, and 20%, respectively, by 2024. However, three of the five countries were on track to mitigate these increases to 3% or less by maintaining TB services in 2021 and 2022 and by implementing proposed catch-up strategies. Indonesia was already experiencing the worse-case scenario, which could lead to 270,000 additional active TB infections and 36,000 additional TB-related deaths by the end of 2024. The COVID-19 pandemic is projected to negatively affect progress towards 2035 End TB targets, especially in countries already off-track. Findings highlight both successful TB service delivery adaptions in 2020 and the need to proactively maintain TB service availability despite potential future waves of more transmissible COVID-19 variants.

Evaluating the effectiveness of incentives to improve HIV prevention outcomes for young females in Eswatini: Sitakhela Likusasa impact evaluation protocol and baseline results.

BACKGROUND: Eswatini continues to have the highest prevalence of HIV in the world, and one of the highest HIV incidences among adult populations (aged 15-49). This analysis reports on both key elements of study design/protocol and baseline results from an impact evaluation of an intervention incentivizing (i) initiation, enrolment, attendance or completion of some form of education, and (ii) lower risk sexual behaviour. METHODS: The impact evaluation employs a two by two factorial design in which participants are enrolled in either the incentive for education arm ('education treatment arm' providing a conditional cash incentive) or the control arm ('education control arm'). In each of these arms, 50% of participants were randomized to also be eligible for selection - three times a year - to participate in a conditional raffle conditional on testing negative for curable STIs (syphilis and Trichomonas vaginalis). RESULTS: Baseline recruitment and screening occurred in 2016 when a total of 6055 individuals were screened of which 4863 participated in the baseline survey, and 4819 individuals were randomized into one of the study arms. The baseline prevalence of HIV, Trichomonas vaginalis, and syphilis among adolescent girls and young women 8.20% (397/4840), 3.31% (150/4533) and 0.17% (8/4830) respectively. CONCLUSIONS: An educational cash incentive and raffle incentive impact evaluation that addresses adolescent girls and young women who are in-education and out-of-education has the potential to reduce HIV risk in adolescent girls and young women in Eswatini. TRIAL REGISTRATION: Name of the registry: Pan African Clinical Trials Registry. TRIAL REGISTRATION NUMBER: PACTR201811609257043 . Date of registration: May 11, 2018 'Retrospectively registered'. URL of trial registry record: https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=4685.

On the road to universal health care in Indonesia, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016.

BACKGROUND: As Indonesia moves to provide health coverage for all citizens, understanding patterns of morbidity and mortality is important to allocate resources and address inequality. The Global Burden of Disease 2016 study (GBD 2016) estimates sources of early death and disability, which can inform policies to improve health care. METHODS: We used GBD 2016 results for cause-specific deaths, years of life lost, years lived with disability, disability-adjusted life-years (DALYs), life expectancy at birth, healthy life expectancy, and risk factors for 333 causes in Indonesia and in seven comparator countries. Estimates were produced by location, year, age, and sex using methods outlined in GBD 2016. Using the Socio-demographic Index, we generated expected values for each metric and compared these against observed results. FINDINGS: In Indonesia between 1990 and 2016, life expectancy increased by 8·0 years (95% uncertainty interval [UI] 7·3-8·8) to 71·7 years (71·0-72·3): the increase was 7·4 years (6·4-8·6) for males and 8·7 years (7·8-9·5) for females. Total DALYs due to communicable, maternal, neonatal, and nutritional causes decreased by 58·6% (95% UI 55·6-61·6), from 43·8 million (95% UI 41·4-46·5) to 18·1 million (16·8-19·6), whereas total DALYs from non-communicable diseases rose. DALYs due to injuries decreased, both in crude rates and in age-standardised rates. The three leading causes of DALYs in 2016 were ischaemic heart disease, cerebrovascular disease, and diabetes. Dietary risks were a leading contributor to the DALY burden, accounting for 13·6% (11·8-15·4) of DALYs in 2016. INTERPRETATION: Over the past 27 years, health across many indicators has improved in Indonesia. Improvements are partly offset by rising deaths and a growing burden of non-communicable diseases. To maintain and increase health gains, further work is needed to identify successful interventions and improve health equity. FUNDING: The Bill & Melinda Gates Foundation.

Differences in access to high-quality outpatient care in Indonesia.

Using a representative cross-section of health care providers in Indonesia, we describe variations in prenatal, child, and adult care quality. Quality is measured as knowledge about clinical guidelines. Public health centers offer above-average-quality prenatal care, and private physicians provide high-quality curative care. Private nurses offer below-average care, as do most providers in the more remote regions of Outer Java-Bali. The poor and wealthy have access to the same levels of quality; however, the poorest women report receiving fewer prenatal procedures. Recommendations include improving the professional development of nurses in private settings, testing quality improvements in Outer Java-Bali, and investigating wealth disparities in quality received.

The contribution of human resources for health to the quality of care in Indonesia.

Using a representative sample of public facilities surveyed in 1993 and 1997, we took advantage of exogenous changes imposed on the Indonesian health system to evaluate the contribution of physicians, nurses, and midwives to the quality of primary care. We found that quality depends on the availability, type, and number of health workers, which, in turn, is affected by public policies about deployment. We conclude that staff deployment could be refined by analyses of the skill-mix needed to provide quality care. Professional nurses in particular could play an important role in promoting quality.