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The Rwandan Ministry of Health partnered with the Integrated Health Systems Strengthening Project (IHSSP) to strengthen and coordinate its health information system. In 2009, when IHSSP was launched, the ministry had multiple systems to gather data from the country’s health services, but the systems used to aggregate and analyze the information were weak and were not interoperable.

The Government of Rwanda’s vision for its health system is that every citizen will consistently use health services that are easily accessible, meet international standards of care, and directly respond to individuals’ perceived and actual needs.

Integrated community case management (iCCM) can be an effective strategy for expanding the provision of diarrhea, pneumonia, and malaria services to children under 5 years old but there are concerns in some countries about the corresponding cost and impact. This paper presents and compares findings from a multi–country analysis of iCCM program costs. Data were collected on iCCM programs in seven sub–Saharan African countries: Cameroon, the Democratic Republic of the Congo, Malawi, Senegal, Sierra Leone, South Sudan and Zambia. The data were used to compare some elements of program performance as well as costs per capita and costs per service (which are key indicators of resource allocation and efficiency). A comprehensive understanding of iCCM program costs and results can help countries obtain resources and use them efficiently. To be cost–effective and affordable, iCCM programs must be well utilized, while program management and supervision should be organized to minimize costs and ensure quality of care. iCCM programs will not always be low–cost, however, particularly in small, remote villages where supervision and supply challenges are greater.

Tuberculosis (TB) patients face many psychological, social and economic problems that complicate treatment and care. This may lead to decreasing adherence to prescribed treatment regimens and poorer clinical outcomes, including higher loss-to-follow-up, relapse and mortality rates. 

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In this third special issue published by the International Journal of Drug Policy, the authors of ten research papers and commentaries seek to provide additional knowledge on a range of issues related to illicit drugs in the region, including the epidemiology of drug use and drug-related infectious diseases and other consequences, drug treatment and harm reduction pro

The five-year anniversary of the Haitian earthquake brings Haiti to the forefront of international development conversations once again. Much of the dialogue has focused on the setbacks of large-scale infrastructure and rebuilding projects, but there has been important progress in some sectors, especially the health sector.

Given similar performance and knowledge of health workers trained in 7-day and 11-day courses, potential cost savings, the possibility of training more health workers and the relative ease with which health workers in remote settings might participate in a short course, it seems prudent to standardize the 7-day course in Afghanistan, where child mortality rates remain unacceptably high.

The importance of skilled management and inspired leadership are increasingly evident to those who are working to improve health system performance. Many of the critical challenges facing Kenya’s health system, including scarce resources and the changes resulting from devolution, are exacerbated by weak or absent management and leadership skills.

STRIDES for Family Health, 2009–2014

To reach communities underserved by the public health sector in Uganda, STRIDES for Family Health engaged private health care providers through a performance-based contracting (PBC) program. This intervention was one of STRIDES’ key strategies in providing access to quality health care for rural populations in Uganda.

In recent years, the global health community has been focusing more of its efforts and resources on fighting malnutrition—a complex problem that contributes to 45 percent of deaths among children under the age of five worldwide. Chronically malnourished children are, on average, nearly 20 percent less literate than those who have a nutritious diet.

STRIDES for Family Health built on this momentum when it began activities in Uganda two years later. STRIDES contributed to the Ugandan Government’s goal of improving the health of families and communities by reducing fertility and lowering maternal, newborn, infant, and child morbidity and mortality.

Uganda’s high maternal mortality ratio is one symptom of the inadequacies of the Ugandan health system. For every 100,000 live births in Uganda, 438 mothers die, compared to 320 in nearby Rwanda, for example, or 16 in developed countries.

Although there is evidence of the effectiveness of needle and syringe programme (NSP), opioid substitution therapy (OST) and antiretroviral therapy (ART) in reducing HIV prevalence, most Central and Eastern European sub-regions still have low or no coverage of most or all of these interventions. We conducted a modelling analysis to consider the potential impact on HIV incidence and prevalence of OST, NSP, and ART in three illustrative epidemic scenarios: Russia (St. Petersburg), Estonia (Tallinn), and Tajikistan (Dushanbe). For each intervention, we consider the coverage needed of each intervention separately or in combination to: (1) achieve a 30% or 50% relative reduction in HIV incidence or prevalence over 10 years; and (2) reduce HIV incidence to below 1% or HIV prevalence below 10% after 20 years. A sensitivity analysis for St. Petersburg considered the implications of greater or no risk heterogeneity, none or more sexual HIV transmission, like-with-like mixing, different injecting cessation rates, and assuming a lower HIV acute phase cofactor. The projections suggest that high but achievable coverage levels of NSP can result in large decreases (30%) in HIV incidence in settings with high HIV prevalence among PWID. Required coverage levels are much lower when interventions are combined or in lower prevalence settings. However, even when all three interventions are combined, the targets of reducing HIV incidence to less than 1% or prevalence to less than 10% in 20 years may be hard to achieve except in lower prevalence settings.

Hypoglycemia is a major cause of morbidity and mortality among preterm infants, and its management remains a challenge in resource-limited settings.

Health data can be useful for effective service delivery, decision making, and evaluating existing programs in order to maintain high quality healthcare. Studies have shown variability in data quality from national health management information systems (HMIS) in sub-Saharan Africa, which threatens utility of these data as a tool to improve health systems.

Equipping medical graduates with the competence to manage tuberculosis is not just imperative, but also urgent as the disease has been consistently listed as one of the major causes of morbidity and mortality in Nigeria. However, there were no baseline studies done on knowledge of final year medical students on various aspects of TB diagnosis and management under directly observed treatment short course therapy (DOTS), which forms the basis of this study. A total of 241 final year medical students from three medical colleges in Nigeria were interviewed. The questions assessed their knowledge about various modes of transmission, symptoms, and management of tuberculosis under DOTS. The study reveals gross inadequacies in TB knowledge and management practices among Nigerian final year medical students. There is urgent need for incorporation of National TB guidelines into existing undergraduate medical education curriculum, as well as student rotations through activities in DOTS clinics.

Despite progress reducing maternal mortality, HIV-related maternal deaths remain high, accounting, for example, for up to 24 percent of all pregnancy-related deaths in sub-Saharan Africa. Antiretroviral therapy (ART) is effective in improving outcomes among HIV-infected pregnant and postpartum women, yet rates of initiation, adherence, and retention remain low. This systematic literature review synthesized evidence about individual and contextual factors affecting ART use among HIV-infected pregnant and postpartum women. Thirty-four studies were included in the review. Individual-level factors included both those within and outside a woman’s awareness and control (e.g., commitment to child’s health or age). Individual-level barriers included poor understanding of HIV, ART, and prevention of mother-to-child transmission; and difficulty managing practical demands of ART. At an interpersonal level, disclosure to a spouse and spousal involvement in treatment were associated with improved initiation, adherence, and retention. Fear of negative consequences was a barrier to disclosure. At a community level, stigma was a major barrier. Key structural barriers and enablers were related to health system use and engagement, including access to services and health worker attitudes. To be successful, programs seeking to expand access to and continued use of ART by integrating maternal health and HIV services must identify and address the relevant barriers and enablers in their own context that are described in this review. Further research on this population, including those who drop out of or never access health services, is needed to inform effective implementation.

Despite global progress in the fight to reduce maternal mortality, HIV-related maternal deaths remain persistently high, particularly in much of Africa. Lifelong antiretroviral therapy (ART) appears to be the most effective way to prevent these deaths, but the rates of three key outcomes—ART initiation, retention in care, and long-term ART adherence—remain low. This systematic review synthesized evidence on health systems factors affecting these outcomes in pregnant and postpartum women living with HIV. Low prioritization of maternal ART and persistent dropout along the maternal ART cascade were key findings. Service delivery barriers included poor communication and coordination among health system actors, poor clinical practices, and gaps in provider training. The few studies that assessed maternal ART interventions demonstrated the importance of multi-pronged, multi-leveled interventions. There has been a lack of emphasis on the experiences, needs, and vulnerabilities particular to HIV-infected pregnant and postpartum women. Supporting these women to successfully traverse the maternal ART cascade requires carefully designed and targeted interventions throughout the steps. Careful design of integrated service delivery models is of critical importance in this effort. Key knowledge gaps and research priorities were also identified, including definitions and indicators of adherence rates, and the importance of cumulative measures of dropout along the maternal ART cascade.

In response to concerns about the emergence of HIV drug resistance (HIVDR), the World Health Organization (WHO) has developed a comprehensive set of early warning indicators (EWIs) to monitor HIV drug resistance and good programme practice at antiretroviral therapy (ART) sites. In 2012, Namibia utilized the updated WHO EWI guidance and abstracted data from adult and pediatric patients from 50 ART sites for the following EWIs: 1. On-time Pill Pick-up, 2. Retention in Care, 3. Pharmacy Stock-outs, 4. Dispensing Practices, and 5. Virological Suppression. The successful 2012 EWI exercise provides Namibia a solid evidence base, which can be used to make national statements about programmatic functioning and possible HIVDR. This evidence base will serve to contextualize results from Namibia's surveys of HIVDR, which involves genotype testing. EWI abstraction has prompted the national program and its counterparts to engage sites in dialogue regarding the need to strengthen adherence and retention of patients on ART. The EWI collection process and EWI results will serve to optimize patient care and support Namibia in making evidence-based recommendations and take action to minimize the emergence of preventable HIVDR.

Tajikistan and other Central Asian republics are facing intertwined epidemics of injecting drug use and HIV. This paper aims to examine drug scene, drug use, drug-related infectious diseases, drug treatment and other responses to health consequences of drug injecting in two Tajik cities of Kulob (Khatlon Region) and Khorog (Gorno-Badakhshan Autonomous Oblast). We conducted 12 focus group discussions in Kulob and Khorog and analysed peer-reviewed literature, published and unpublished programme and country reports and other publications that focused on substance use and/or HIV/AIDS in Tajikistan and included the Khatlon and Gorno-Badakhshan regions. Tajikistan IBBS data point to the potential problems in using composite national prevalence as an adequate reflection of the HIV epidemic among PWID in the country and highlight the importance of examining site-specific prevalence rates for better understanding of the dynamics of the epidemic over time, as well as potential problems related to the reliability of data. Furthermore, our analysis highlights that in a country where almost all PWID inject opiates, agonist treatment should be an intervention of choice. Scaling-up both OST and ART coverage must be seen as the top priority for reducing HIV prevalence and incidence in Tajikistan. Naloxone distribution programmes need to be expanded and drug treatment, harm reduction, and HIV services that meet the specific needs of female injecting drug users should be put in place.

We assessed adherence to standards of HIV care among health workers in the West Nile Region of Uganda. We conducted a cross-sectional study in nine health facilities and assessed records of a cohort of 270 HIV clients that enrolled on ART 12 months prior. The performance of each health facility on the different indicators of standards of HIV/AIDS care was determined and compared with the recommended national guidelines. Adherence to standards of HIV/AIDS care at facilities was inadequate. Performance was better at the start of ART but declined during the follow-up period. Higher level facilities were more likely to adhere to standards like CD4 monitoring and maintaining HIV clients on a standard ARV regimen. Efforts geared towards strengthening the health system, including support supervision and provision of care guidelines and job aides are needed, especially for lower level facilities.

We piloted an intervention that placed a people-centred health systems governance approach in the hands of multi-stakeholder committees that govern provincial and district health systems in Afghanistan. We report the results of this intervention from three provinces and eleven districts in Afghanistan over a six month period. This mixed-methods exploratory case study uses analysis of governance self-assessment scores, health management information system data on health system performance, and focus group discussions. The outcomes of interest are governance scores and health system performance indicators. We document the application of a people-centred health systems governance conceptual model based on applying four effective governing practices: cultivating accountability, engaging with stakeholders, setting a shared strategic direction, and stewarding resources responsibly. We found that health systems governance can be improved in fragile and conflict affected environments, and that consistent application of the effective governing practices is key to improving governance. Intervention was associated with a 20% increase in antenatal care visit rate in pilot provinces.

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