A consolidated and geolocated facility list in Senegal from triangulating secondary data.

Having a geolocated list of all facilities in a country - a "master facility list" (MFL) - can provide critical inputs for health program planning and implementation. To the best of our knowledge, Senegal has never had a centralized MFL, though many data sources currently exist within the broader Senegalese data landscape that could be leveraged and consolidated into a single database - a critical first step toward building a full MFL. We collated 12,965 facility observations from 16 separate datasets and lists in Senegal, and applied matching algorithms, manual checking and revisions as needed, and verification processes to identify unique facilities and triangulate corresponding GPS coordinates. Our resulting consolidated facility list has a total of 4,685 facilities, with 2,423 having at least one set of GPS coordinates. Developing approaches to leverage existing data toward future MFL establishment can help bridge data demands and inform more targeted approaches for completing a full facility census based on areas and facility types with the lowest coverage. Going forward, it is crucial to ensure routine updates of current facility lists, and to strengthen government-led mechanisms around such data collection demands and the need for timely data for health decision-making.

Maternal mortality, stillbirths, and neonatal mortality: a transition model based on analyses of 151 countries.

BACKGROUND: Maternal mortality, stillbirths, and neonatal mortality account for almost 5 million deaths a year and are often analysed separately, despite having overlapping causes and interventions. We propose a comprehensive five-phase mortality transition model to improve analyses of progress and inform strategic planning. METHODS: In this empirical data-driven study to develop a model transition, we used UN estimates for 151 countries to assess changes in maternal mortality, stillbirths, and neonatal deaths. On the basis of ratios of maternal to stillbirth and neonatal mortality, we identified five phases of transition, in which phase 1 has the highest mortality and phase 5 has the lowest. We used global databases to examine phase-specific characteristics during 2000-20 for causes of death, fertility rates, abortion policies, health workforce and financing, and socioeconomic indicators. We analysed 326 national surveys to assess service coverage and inequalities by transition phase. FINDINGS: Among 116 countries in phases 1 to 4 in 2000, 73 (63%) progressed at least one phase by 2020, six advanced two phases, and three regressed. The ratio of stillbirth and neonatal deaths to maternal deaths increased from less than 10 in phase 1 to well over 50 in phase 4 and phase 5. Progression was associated with a declining proportion of deaths caused by infectious diseases and peripartum complications, declining total and adolescent fertility rates, changes in health-workforce densities and skills mix (ie, ratio of nurses or midwives to physicians) from phase 3 onwards, increasing per-capita health spending, and reducing shares of out-of-pocket health expenditures. From phase 1 to 5, the median coverage of first antenatal care visits increased from 66% to 98%, four or more antenatal care visits from 44% to 94%, institutional births from 36% to 99%, and caesarean section rates from 2% to 25%. The transition out of high-mortality phases involved a major increase in institutional births, primarily in lower-level health facilities, whereas subsequent progress was characterised by rapid increases in hospital births. Wealth-related inequalities reduced strongly for institutional birth coverage from phase 3 onwards. INTERPRETATION: The five-phase maternal mortality, stillbirth, and neonatal mortality transition model can be used to benchmark the current indicators in comparison to typical patterns in the transition at national or sub-national level, identify outliers to better assess drivers of progress, and inform strategic planning and investments towards Sustainable Development Goal targets. It can also facilitate programming for integrated strategies to end preventable maternal mortality and neonatal mortality and stillbirths. FUNDING: Bill & Melinda Gates Foundation.

Assessing Potential Exemplars in Reducing Zero-Dose Children: A Novel Approach for Identifying Positive Outliers in Decreasing National Levels and Geographic Inequalities in Unvaccinated Children.

BACKGROUND: Understanding past successes in reaching unvaccinated or "zero-dose" children can help inform strategies for improving childhood immunization in other settings. Drawing from positive outlier methods, we developed a novel approach for identifying potential exemplars in reducing zero-dose children. METHODS: Focusing on 2000-2019, we assessed changes in the percentage of under-one children with no doses of the diphtheria-tetanus-pertussis vaccine (no-DTP) across two geographic dimensions in 56 low- or lower-middle-income countries: (1) national levels; (2) subnational gaps, as defined as the difference between the 5th and 95th percentiles of no-DTP prevalence across second administrative units. Countries with the largest reductions for both metrics were considered positive outliers or potential 'exemplars', demonstrating exception progress in reducing national no-DTP prevalence and subnational inequalities. Last, so-called "neighborhood analyses" were conducted for the Gavi Learning Hub countries (Nigeria, Mali, Uganda, and Bangladesh), comparing them with countries that had similar no-DTP measures in 2000 but different trajectories through 2019. RESULTS: From 2000 to 2019, the Democratic Republic of the Congo, Ethiopia, and India had the largest absolute decreases for the two no-DTP dimensions-national prevalence and subnational gaps-while Bangladesh and Burundi registered the largest relative reductions for each no-DTP metric. Neighborhood analyses highlighted possible opportunities for cross-country learning among Gavi Learning Hub countries and potential exemplars in reducing zero-dose children. CONCLUSIONS: Identifying where exceptional progress has occurred is the first step toward better understanding how such gains could be achieved elsewhere. Further examination of how countries have successfully reduced levels of zero-dose children-especially across variable contexts and different drivers of inequality-could support faster, sustainable advances toward greater vaccination equity worldwide.

Estimating total spending by source of funding on routine and supplementary immunisation activities in low-income and middle-income countries, 2000-17: a financial modelling study.

BACKGROUND: Childhood immunisation is one of the most cost-effective health interventions. However, despite its known value, global access to vaccines remains far from complete. Although supply-side constraints lead to inadequate vaccine coverage in many health systems, there is no comprehensive analysis of the funding for immunisation. We aimed to fill this gap by generating estimates of funding for immunisation disaggregated by the source of funding and the type of activities in order to highlight the funding landscape for immunisation and inform policy making. METHODS: For this financial modelling study, we estimated annual spending on immunisations for 135 low-income and middle-income countries (as determined by the World Bank) from 2000 to 2017, with a focus on government, donor, and out-of-pocket spending, and disaggregated spending for vaccines and delivery costs, and routine schedules and supplementary campaigns. To generate these estimates, we extracted data from National Health Accounts, the WHO-UNICEF Joint Reporting Forms, comprehensive multi-year plans, databases from Gavi, the Vaccine Alliance, and the Institute for Health Metrics and Evaluation's 2019 development assistance for health database. We estimated total spending on immunisation by aggregating the government, donor, prepaid private, and household spending estimates. FINDINGS: Between 2000 and 2017, funding for immunisation totalled US$112·4 billion (95% uncertainty interval 108·5-118·5). Aggregated across all low-income and middle-income countries, government spending consistently remained the largest source of funding, providing between 60·0% (57·7-61·9) and 79·3% (73·8-81·4) of total immunisation spending each year (corresponding to between $2·5 billion [2·3-2·8] and $6·4 billion [6·0-7·0] each year). Across income groups, immunisation spending per surviving infant was similar in low-income and lower-middle-income countries and territories, with average spending of $40 (38-42) in low-income countries and $42 (39-46) in lower-middle-income countries, in 2017. In low-income countries and territories, development assistance made up the largest share of total immunisation spending (69·4% [64·6-72·0]; $630·2 million) in 2017. Across the 135 countries, we observed higher vaccine coverage and increased government spending on immunisation over time, although in some countries, predominantly in Latin America and the Caribbean and in sub-Saharan Africa, vaccine coverage decreased over time, while spending increased. INTERPRETATION: These estimates highlight the progress over the past two decades in increasing spending on immunisation. However, many challenges still remain and will require dedication and commitment to ensure that the progress made in the previous decade is sustained and advanced in the next decade for the Immunization Agenda 2030. FUNDING: Bill & Melinda Gates Foundation.

'Learn from the lessons and don't forget them': identifying transferable lessons for COVID-19 from meningitis A, yellow fever and Ebola virus disease vaccination campaigns.

INTRODUCTION: COVID-19 vaccines are now being distributed to low- and middle-income countries (LMICs), with global urgency surrounding national vaccination plans. LMICs have significant experience implementing vaccination campaigns to respond to epidemic threats but are often hindered by chronic health system challenges. We sought to identify transferable lessons for COVID-19 vaccination from the rollout of three vaccines that targeted adult groups in Africa and South America: MenAfriVac (meningitis A); 17D (yellow fever) and rVSV-ZEBOV (Ebola virus disease). METHODS: We conducted a rapid literature review and 24 semi-structured interviews with technical experts who had direct implementation experience with the selected vaccines in Africa and South America. We identified barriers, enablers, and key lessons from the literature and from participants' experiences. Interview data were analysed thematically according to seven implementation domains. RESULTS: Participants highlighted multiple components of vaccination campaigns that are instrumental for achieving high coverage. Community engagement is an essential and effective tool, requiring dedicated time, funding and workforce. Involving local health workers is a key enabler, as is collaborating with community leaders to map social groups and tailor vaccination strategies to their needs. Vaccination team recruitment and training strategies need to be enhanced to support vaccination campaigns. Although recognised as challenging, integrating vaccination campaigns with other routine health services can be highly beneficial if well planned and coordinated across health programmes and with communities. CONCLUSION: As supplies of COVID-19 vaccines become available to LMICs, countries need to prepare to efficiently roll out the vaccine, encourage uptake among eligible groups and respond to potential community concerns. Lessons from the implementation of these three vaccines that targeted adults in LMICs can be used to inform best practice for COVID-19 and other epidemic vaccination campaigns.

Tracking government spending on immunization: The joint reporting forms, national health accounts, comprehensive multi-year plans and co-financing data.

BACKGROUND: Coverage rates for immunization have dropped in lower income countries during the COVID-19 pandemic, raising concerns regarding potential outbreaks and premature death. In order to re-invigorate immunization service delivery, sufficient financing must be made available from all sources, and particularly from government resources. This study utilizes the most recent data available to provide an updated comparison of available data sources on government spending on immunization. METHODS: We examined data from WHO/UNICEF's Joint Reporting Form (JRF), country Comprehensive Multi-Year Plan (cMYP), country co-financing data for Gavi, and WHO National Health Accounts (NHA) on government spending on immunization for consistency by comparing routine and vaccine spending where both values were reported. We also examined spending trends across time, quantified underreporting and utilized concordance analyses to assess the magnitude of difference between the data sources. RESULTS: Routine immunization spending reported through the cMYP was nearly double that reported through the JRF (rho = 0.64, 95% 0.53 to 0.77) and almost four times higher than that reported through the NHA on average (rho = 3.71, 95% 1.00 to 13.87). Routine immunization spending from the JRF was comparable to spending reported in the NHA (rho = 1.30, 95% 0.97 to 1.75) and vaccine spending from the JRF was comparable to that from the cMYP data (rho = 0.97, 95% 0.84 to 1.12). Vaccine spending from both the JRF and cMYP was higher than Gavi co-financing by a at least two (rho = 2.66, 95% 2.45 to 2.89) and (rho = 2.66, 95% 2.15 to 3.30), respectively. IMPLICATIONS: Overall, our comparative analysis provides a degree of confidence in the validity of existing reporting mechanisms for immunization spending while highlighting areas for potential improvements. Users of these data sources should factor these into consideration when utilizing the data. Additionally, partners should work with governments to encourage more reliable, comprehensive, and accurate reporting of vaccine and immunization spending.

Determinants of geographical inequalities for DTP3 vaccine coverage in sub-Saharan Africa.

Childhood immunization is one of the most effective health interventions, making it a key indicator of progress towards universal health coverage. In the last decade, improvements in coverage have been made globally, however, slow progress has been documented in sub-Saharan Africa with considerable subnational variations. We explore potential drivers of equitable immunization services based on subnational DTP3 coverage estimates. Using vaccine coverage at the 5 by 5 km area from 2000 to 2016, we quantify inequality using three measures. We assess the shortfall inequality which is the average deviation across subnational units from that with the highest coverage for each country. Secondly we estimate the threshold index, the proportion of children below a globally set subnational coverage target, and lastly, a Gini coefficient representing the within-country distribution of coverage. We use time series analyses to quantify associations with immunization expenditures controlling for country socio-economic and population characteristics. Development assistance, maternal education and governance were associated with reductions in inequality. Furthermore, high quality governance was associated with a stronger relationship between development assistance and reductions in inequality. Results from this analysis also indicate that countries with the lowest coverage suffer the highest inequalities. We highlight growing inequalities among countries which have met national coverage targets such as South Africa and Kenya. In 2016, values for the shortfall inequality ranged from 1% to 43%, the threshold index from 0% to 100% and Gini coefficient from 0.01 to 0.37. Burundi, Comoros, Eswatini, Lesotho, Namibia, Rwanda, and Sao Tome and Principe had the least shortfall inequality (<5%) while Angola, Ethiopia and Nigeria had values greater than 40%. A similar picture was noted for the other dimensions of inequality among these particular countries. Immunization program investments offer promise in addressing inequality, however, domestic mechanisms for resource implementation and accountability should be strengthened to maximize gains in coverage.

Effect of donor funding for immunization from Gavi and other development assistance channels on vaccine coverage: Evidence from 120 low and middle income recipient countries.

Donor assistance for immunization has remained resilient with increased resource mobilization efforts in recent years to achieve current global coverage targets. As a result, more countries continue to introduce new vaccines while optimizing coverage for traditional vaccines. Gavi the Vaccine Alliance has been at the forefront of immunization support specifically among low and middle income countries, alongside other channels of development assistance which continue to play a vital role in immunization. Using available recipient country level data from 1996 to 2016, we estimate the impact of Gavi support for vaccines and health systems strengthening on vaccine coverage for 3 dose DPT, 3 dose pneumococcal conjugate vaccine, 3 dose pentavalent, 2 dose measles and 2 dose rotavirus vaccines. We investigate the same effects of total aid for immunization from other channels of development assistance. Standard time series cross sectional analysis methods are applied to investigate the effects of vaccine support controlling for country income, governance and population, with robustness tests implemented using different model specifications. Double counting was eliminated and results are presented in real 2017 US dollars. We found significant positive effects of aid particularly among the newer vaccines. Using 2016 country specific disbursements and coverage levels as baseline, we estimated that among recipient countries below the universal target, additional DAH per capita required to reach 90%, ranged from 0.01USD to 4.33USD for PCV, 0.03USD to 9.06USD for pentavalent vaccine and 0.01USD to 2.57USD for rotavirus vaccine. The estimated number of children vaccinated through 2016, attributable to Gavi support totaled 46.6million, 75.2million and 12.3million for PCV, pentavalent and rotavirus vaccines respectively. Our analysis suggests substantial success both from a historical and prospective perspective in the implementation of global immunization initiatives thus far. As more vaccines are rolled out and countries transition from donor aid, strategies for fiscal sustainability and efficiency need to be strengthened in order to achieve universal immunization coverage.

Tracking donor funding towards achieving the Global Vaccine Action Plan (GVAP) goals: A landscape analysis (1990-2016).

Efforts driving universal coverage have recently been strengthened through implementation of the Global Vaccine Action Plan (GVAP) where cost estimates for immunization support were developed totaling US$40 billion of donor assistance by 2020. In addition to resource mobilization, there has been an increasing focus on improving both vaccine access and delivery systems. We track donor assistance for immunization by funding objective and channel from 1990 to 2016, and illustrate projections through 2020 to inform progress of the GVAP. Using available data from development agencies supporting immunization, we categorize funding by vaccine and quantify support for systems strengthening. We split time into four periods including the post universal childhood immunization era (1990-1999) and Gavi's three funding phases between 2000 and 2015, during which annualized funding changes are estimated. Lastly, we perform a linear extrapolation through 2020 to predict the success of stipulated resource mobilization targets. Double counting was eliminated and results presented in real 2017 US dollars. Over the last 27 years, funding for immunization increased by 10.5% annually, with non-Gavi funding increasing by 7.1% and Gavi funding by 23.6% in the last 17 years. Gavi disbursements targeting vaccines and health system improvements increased uniformly at 15%, compared to 22.5% for vaccines and 11.7% for system strengthening from non-Gavi channels. Funding fluctuated for non-Gavi channels with disbursements declining before 2000 and during Gavi funding phase II, while Gavi disbursements continued to grow relative the previous phase. New and underused vaccines were prioritized by Gavi whereas non-Gavi channels focused on elimination efforts. Projected funding targets were estimated to be on track for Gavi contrary to non-Gavi support which was estimated to remain 40% below the stipulated target. Renewed assessments for funding requirements need to be undertaken, while strengthening existing resource efficiencies in order to achieve current global universal coverage targets.

Small area estimation of under-5 mortality in Bangladesh, Cameroon, Chad, Mozambique, Uganda, and Zambia using spatially misaligned data.

BACKGROUND: The under-5 mortality rate (U5MR) is an important metric of child health and survival. Country-level estimates of U5MR are readily available, but efforts to estimate U5MR subnationally have been limited, in part, due to spatial misalignment of available data sources (e.g., use of different administrative levels, or as a result of historical boundary changes). METHODS: We analyzed all available complete and summary birth history data in surveys and censuses in six countries (Bangladesh, Cameroon, Chad, Mozambique, Uganda, and Zambia) at the finest geographic level available in each data source. We then developed small area estimation models capable of incorporating spatially misaligned data. These small area estimation models were applied to the birth history data in order to estimate trends in U5MR from 1980 to 2015 at the second administrative level in Cameroon, Chad, Mozambique, Uganda, and Zambia and at the third administrative level in Bangladesh. RESULTS: We found substantial variation in U5MR in all six countries: there was more than a two-fold difference in U5MR between the area with the highest rate and the area with the lowest rate in every country. All areas in all countries experienced declines in U5MR between 1980 and 2015, but the degree varied both within and between countries. In Cameroon, Chad, Mozambique, and Zambia we found areas with U5MRs in 2015 that were higher than in other parts of the same country in 1980. Comparing subnational U5MR to country-level targets for the Millennium Development Goals (MDG), we find that 12.8% of areas in Bangladesh did not meet the country-level target, although the country as whole did. A minority of areas in Chad, Mozambique, Uganda, and Zambia met the country-level MDG targets while these countries as a whole did not. CONCLUSIONS: Subnational estimates of U5MR reveal significant within-country variation. These estimates could be used for identifying high-need areas and positive deviants, tracking trends in geographic inequalities, and evaluating progress towards international development targets such as the Sustainable Development Goals.

The effect of facility-based antiretroviral therapy programs on outpatient services in Kenya and Uganda.

BACKGROUND: Considerable debate exists concerning the effects of antiretroviral therapy (ART) service scale-up on non-HIV services and overall health system performance in sub-Saharan Africa. In this study, we examined whether ART services affected trends in non-ART outpatient department (OPD) visits in Kenya and Uganda. METHODS: Using a nationally representative sample of health facilities in Kenya and Uganda, we estimated the effect of ART programs on OPD visits from 2007 to 2012. We modeled the annual percent change in non-ART OPD visits using hierarchical mixed-effects linear regressions, controlling for a range of facility characteristics. We used four different constructs of ART services to capture the different ways in which the presence, growth, overall, and relative size of ART programs may affect non-ART OPD services. RESULTS: Our final sample included 321 health facilities (140 in Kenya and 181 in Uganda). On average, OPD and ART visits increased steadily in Kenya and Uganda between 2007 and 2012. For facilities where ART services were not offered, the average annual increase in OPD visits was 4·2% in Kenya and 13·5% in Uganda. Among facilities that provided ART services, we found average annual OPD volume increases of 7·2% in Kenya and 5·6% in Uganda, with simultaneous annual increases of 13·7% and 12·5% in ART volumes. We did not find a statistically significant relationship between annual changes in OPD services and the presence, growth, overall, or relative size of ART services. However, in a subgroup analysis, we found that Ugandan hospitals that offered ART services had statistically significantly less growth in OPD visits than Ugandan hospitals that did not provide ART services. CONCLUSIONS: Our findings suggest that ART services in Kenya and Uganda did not have a statistically significant deleterious effects on OPD services between 2007 and 2012, although subgroup analyses indicate variation by facility type. Our findings are encouraging, particularly given recent recommendations for universal access to ART, demonstrating that expanding ART services is not inherently linked to declines in other health services in sub-Saharan Africa.

Capacity for diagnosis and treatment of heart failure in sub-Saharan Africa.

OBJECTIVE: Heart failure is a major cause of disease burden in sub-Saharan Africa (SSA). There is an urgent need for better strategies for heart failure management in this region. However, there is little information on the capacity to diagnose and treat heart failure in SSA. We aim to provide a better understanding of the capacity to diagnose and treat heart failure in Kenya and Uganda to inform policy planning and interventions. METHODS: We analysed data from a nationally representative survey of health facilities in Kenya and Uganda (197 health facilities in Uganda and 143 in Kenya). We report on the availability of cardiac diagnostic technologies and select medications for heart failure (ß-blockers, ACE inhibitors and furosemide). Facility-level data were analysed by country and platform type (hospital vs ambulatory facilities). RESULTS: Functional and staffed radiography, ultrasound and ECG were available in less than half of hospitals in Kenya and Uganda combined. Of the hospitals surveyed, 49% of Kenyan and 77% of Ugandan hospitals reported availability of the heart failure medication package. ACE inhibitors were only available in 51% of Kenyan and 79% of Ugandan hospitals. Almost one-third of the hospitals in each country had a stock-out of at least one of the medication classes in the prior quarter. CONCLUSIONS: Few facilities in Kenya and Uganda were prepared to diagnose and manage heart failure. Medication shortages and stock-outs were common. Our findings call for increased investment in cardiac care to reduce the growing burden of heart failure.

The role of implementation science training in global health: from the perspective of graduates of the field's first dedicated doctoral program.

Bridging the 'know-do gap' is an enormous challenge for global health practitioners. They must be able to understand local health dynamics within the operational and social contexts that engender them, test and adjust approaches to implementation in collaboration with communities and stakeholders, interpret data to inform policy decisions, and design adaptive and resilient health systems at scale. These skills and methods have been formalized within the nascent field of Implementation Science (IS). As graduates of the world's first PhD program dedicated explicitly to IS, we have a unique perspective on the value of IS and the training, knowledge, and skills essential to bridging the 'know-do gap'. In this article, we describe the philosophy and curricula at the core of our program, outline the methods vital to IS in a global health context, and detail the role that we believe IS will increasingly play in global health practice. At this junction of enormous challenges and opportunities, we believe that IS offers the necessary tools for global health professionals to address complex problems in context and raises the bar of success for the global health programs of the future.

Growth Recovery Among HIV-infected Children Randomized to Lopinavir/Ritonavir or NNRTI-based Antiretroviral Therapy.

BACKGROUND: Diminished growth is highly prevalent among HIV-infected children and might be improved by antiretroviral therapy (ART). We examined growth recovery in a rural Ugandan cohort of HIV-infected children randomized to lopinavir/ritonavir (LPV/r) or non nucleoside reverse transcription inhibitor-based ART. METHODS: HIV-infected children 2 months to 6 years of age were randomized to LPV/r- or non nucleoside reverse transcription inhibitor-based ART. Changes in weight-for-age (WAZ), height-for-age (HAZ) and weight-for-height Z-scores for 24 months were evaluated using generalized linear repeated measures models. Recovery from being underweight (WAZ<-2), stunted (HAZ<-2) and wasted (weight-for-height <-2) to Z-scores greater than -2 was also compared by arm using Kaplan-Meier survival and Cox proportional hazard modeling. RESULTS: A total of 129 children with median age of 3 years initiated therapy; 64 received LPV/r-based and 65 non nucleoside reverse transcription inhibitor-based ART (nevirapine: 36 and efavirenz: 29). The median (interquartile range) difference in growth measures between baseline and 24 months for LPV/r (n = 45) versus non nucleoside reverse transcription inhibitor-based therapy (n = 40) were as follows: WAZ, 0.47 (0.10, 1.62) versus 0.53 (0.03, 1.14) (P = 0.59) and HAZ, median 1.55 (0.78, 1.86) versus 1.19 (0.62, 1.65) (P = 0.23), respectively. ART regimen was not predictive of change in WAZ (ß: -0.02, 95% confidence interval: -0.25, 0.20) or HAZ (ß: 0.05, 95% confidence interval: -0.10, 0.19). The presence of confirmed virologic failure was not associated with growth. CONCLUSIONS: Most ART-naive children experienced recovery of both WAZ and HAZ over the 24 months after ART initiation, with no significant difference between those receiving LPV/r versus non nucleoside reverse transcriptase inhibitor-based ART. However, the persistence of median Z-scores below 0 underscores the need for additional strategies to improve growth outcomes in HIV+ African children.

The potential to expand antiretroviral therapy by improving health facility efficiency: evidence from Kenya, Uganda, and Zambia.

BACKGROUND: Since 2000, international funding for HIV has supported scaling up antiretroviral therapy (ART) in sub-Saharan Africa. However, such funding has stagnated for years, threatening the sustainability and reach of ART programs amid efforts to achieve universal treatment. Improving health system efficiencies, particularly at the facility level, is an increasingly critical avenue for extending limited resources for ART; nevertheless, the potential impact of increased facility efficiency on ART capacity remains largely unknown. Through the present study, we sought to quantify facility-level technical efficiency across countries, assess potential determinants of efficiency, and predict the potential for additional ART expansion. METHODS: Using nationally-representative facility datasets from Kenya, Uganda and Zambia, and measures adjusting for structural quality, we estimated facility-level technical efficiency using an ensemble approach that combined restricted versions of Data Envelopment Analysis and Stochastic Distance Function. We then conducted a series of bivariate and multivariate regression analyses to evaluate possible determinants of higher or lower technical efficiency. Finally, we predicted the potential for ART expansion across efficiency improvement scenarios, estimating how many additional ART visits could be accommodated if facilities with low efficiency thresholds reached those levels of efficiency. RESULTS: In each country, national averages of efficiency fell below 50 % and facility-level efficiency markedly varied. Among facilities providing ART, average efficiency scores spanned from 50 % (95 % uncertainty interval (UI), 48-62 %) in Uganda to 59 % (95 % UI, 53-67 %) in Zambia. Of the facility determinants analyzed, few were consistently associated with higher or lower technical efficiency scores, suggesting that other factors may be more strongly related to facility-level efficiency. Based on observed facility resources and an efficiency improvement scenario where all facilities providing ART reached 80 % efficiency, we predicted a 33 % potential increase in ART visits in Kenya, 62 % in Uganda, and 33 % in Zambia. Given observed resources in facilities offering ART, we estimated that 459,000 new ART patients could be seen if facilities in these countries reached 80 % efficiency, equating to a 40 % increase in new patients. CONCLUSIONS: Health facilities in Kenya, Uganda, and Zambia could notably expand ART services if the efficiency with which they operate increased. Improving how facility resources are used, and not simply increasing their quantity, has the potential to substantially elevate the impact of global health investments and reduce treatment gaps for people living with HIV.

Evaluating facility-based antiretroviral therapy programme effectiveness: a pilot study comparing viral load suppression and retention rates.

OBJECTIVES: Increased demand for antiretroviral therapy (ART) services combined with plateaued levels of development assistance for HIV/AIDS requires that national ART programmes monitor programme effectiveness. In this pilot study, we compared commonly utilised performance metrics of 12- and 24-month retention with rates of viral load (VL) suppression at 15 health facilities in Uganda. METHODS: Retrospective chart review from which 12- and 24-month retention rates were estimated, and parallel HIV RNA VL testing on consecutive adult patients who presented to clinics and had been on ART for a minimum of six months. Rates of VL suppression were then calculated at each facility and compared to retention rates to assess the correlation between performance metrics. Multilevel logistic regression models predicting VL suppression and 12- and 24-month retention were constructed to estimate facility effects. RESULTS: We collected VL samples from 2961 patients and found that 88% had a VL ≤1000 copies/ml. Facility rates of VL suppression varied between 77% and 96%. When controlling for patient mix, a significant variation in facility performance persisted. Retention rates at 12 and 24 months were 91% and 79%, respectively, with a comparable facility-level variation. However, neither 12-month (ρ = 0.16) nor 24-month (ρ = -0.19) retention rates were correlated with facility rates of VL suppression. CONCLUSIONS: Retaining patients in care and suppressing VL are both critical outcomes. Given the lack of correlation noted in this study, the utilisation of VL monitoring may be necessary to truly assess the effectiveness of health facilities delivering ART services.

Benchmarking health system performance across regions in Uganda: a systematic analysis of levels and trends in key maternal and child health interventions, 1990-2011.

BACKGROUND: Globally, countries are increasingly prioritizing the reduction of health inequalities and provision of universal health coverage. While national benchmarking has become more common, such work at subnational levels is rare. The timely and rigorous measurement of local levels and trends in key health interventions and outcomes is vital to identifying areas of progress and detecting early signs of stalled or declining health system performance. Previous studies have yet to provide a comprehensive assessment of Uganda's maternal and child health (MCH) landscape at the subnational level. METHODS: By triangulating a number of different data sources - population censuses, household surveys, and administrative data - we generated regional estimates of 27 key MCH outcomes, interventions, and socioeconomic indicators from 1990 to 2011. After calculating source-specific estimates of intervention coverage, we used a two-step statistical model involving a mixed-effects linear model as an input to Gaussian process regression to produce regional-level trends. We also generated national-level estimates and constructed an indicator of overall intervention coverage based on the average of 11 high-priority interventions. RESULTS: National estimates often veiled large differences in coverage levels and trends across Uganda's regions. Under-5 mortality declined dramatically, from 163 deaths per 1,000 live births in 1990 to 85 deaths per 1,000 live births in 2011, but a large gap between Kampala and the rest of the country persisted. Uganda rapidly scaled up a subset of interventions across regions, including household ownership of insecticide-treated nets, receipt of artemisinin-based combination therapies among children under 5, and pentavalent immunization. Conversely, most regions saw minimal increases, if not actual declines, in the coverage of indicators that required multiple contacts with the health system, such as four or more antenatal care visits, three doses of oral polio vaccine, and two doses of intermittent preventive therapy during pregnancy. Some of the regions with the lowest levels of overall intervention coverage in 1990, such as North and West Nile, saw marked progress by 2011; nonetheless, sizeable disparities remained between Kampala and the rest of the country. Countrywide, overall coverage increased from 40% in 1990 to 64% in 2011, but coverage in 2011 ranged from 57% to 70% across regions. CONCLUSIONS: The MCH landscape in Uganda has, for the most part, improved between 1990 and 2011. Subnational benchmarking quantified the persistence of geographic health inequalities and identified regions in need of additional health systems strengthening. The tracking and analysis of subnational health trends should be conducted regularly to better guide policy decisions and strengthen responsiveness to local health needs.

Trends and Determinants of Antiretroviral Therapy Patient Monitoring Practices in Kenya and Uganda.

INTRODUCTION: Patients receiving antiretroviral therapy (ART) require routine monitoring to track response to treatment and assess for treatment failure. This study aims to identify gaps in monitoring practices in Kenya and Uganda. METHODS: We conducted a systematic retrospective chart review of adults who initiated ART between 2007 and 2012. We assessed the availability of baseline measurements (CD4 count, weight, and WHO stage) and ongoing CD4 and weight monitoring according to national guidelines in place at the time. Mixed-effects logistic regression models were used to analyze facility and patient factors associated with meeting monitoring guidelines. RESULTS: From 2007 to 2012, at least 88% of patients per year in Uganda had a recorded weight at initiation, while in Kenya there was a notable increase from 69% to 90%. Patients with a documented baseline CD4 count increased from 69% to about 80% in both countries. In 2012, 83% and 86% of established patients received the recommended quarterly weight monitoring in Kenya and Uganda, respectively, while semiannual CD4 monitoring was less common (49% in Kenya and 38% in Uganda). Initiating at a more advanced WHO stage was associated with a lower odds of baseline CD4 testing. On-site CD4 analysis capacity was associated with increased odds of CD4 testing at baseline and in the future. DISCUSSION: Substantial gaps were noted in ongoing CD4 monitoring of patients on ART. Although guidelines have since changed, limited laboratory capacity is likely to remain a significant issue in monitoring patients on ART, with important implications for ensuring quality care.

Uptake of WHO recommendations for first-line antiretroviral therapy in Kenya, Uganda, and Zambia.

INTRODUCTION: Antiretroviral therapy (ART) guidelines were significantly changed by the World Health Organization in 2010. It is largely unknown to what extent these guidelines were adopted into clinical practice. METHODS: This was a retrospective observational analysis of first-line ART regimens in a sample of health facilities providing ART in Kenya, Uganda, and Zambia between 2007-2008 and 2011-2012. Data were analyzed for changes in regimen over time and assessed for key patient- and facility-level determinants of tenofovir (TDF) utilization in Kenya and Uganda using a mixed effects model. RESULTS: Data were obtained from 29,507 patients from 146 facilities. The overall percentage of patients initiated on TDF-based therapy increased between 2007-2008 and 2011-2012 from 3% to 37% in Kenya, 2% to 34% in Uganda, and 64% to 87% in Zambia. A simultaneous decrease in stavudine (d4T) utilization was also noted, but its use was not eliminated, and there remained significant variation in facility prescribing patterns. For patients initiating ART in 2011-2012, we found increased odds of TDF use with more advanced disease at initiation in both Kenya (odds ratio [OR]: 2.78; 95% confidence interval [CI]: 1.73-4.48) and Uganda (OR: 2.15; 95% CI: 1.46-3.17). Having a CD4 test performed at initiation was also a significant predictor in Uganda (OR: 1.43; 95% CI: 1.16-1.76). No facility-level determinants of TDF utilization were seen in Kenya, but private facilities (OR: 2.86; 95% CI: 1.45-5.66) and those employing a doctor (OR: 2.86; 95% CI: 1.48-5.51) were more likely to initiate patients on TDF in Uganda. DISCUSSION: d4T-based ART has largely been phased out over the study period. However, significant in-country and cross-country variation exists. Among the most recently initiated patients, those with more advanced disease at initiation were most likely to start TDF-based treatment. No facility-level determinants were consistent across countries to explain the observed facility-level variation.