Emily Dansereau

Supply-Side Barriers to Maternity-Care in India: A Facility-Based Analysis

Background Health facilities in many low- and middle-income countries face several types of barriers in delivering quality health services. Availability of resources at the facility may significantly affect the volume and quality of services provided. This study investigates the effect of supply-side determinants of maternity-care provision in India. Methods Health facility data from the District-Level Household Survey collected in 2007–2008 were analyzed to explore the effects of supply-side factors on the volume of delivery care provided at Indian health facilities. A negative binomial regression model was applied to the data due to the count and over-dispersion property of the outcome variable (number of deliveries performed at the facility). Results Availability of a labor room (Incidence Rate Ratio [IRR]: 1.81; 95% Confidence Interval [CI]: 1.68–1.95) and facility opening hours (IRR: 1.43; CI: 1.35–1.51) were the most significant predictors of the volume of delivery care at the health facilities. Medical and paramedical staff were found to be positively associated with institutional deliveries. The volume of deliveries was also higher if adequate beds, essential obstetric drugs, medical equipment, electricity, and communication infrastructures were available at the facility. Findings were robust to the inclusion of facilitys catchment area population and district-level education, health insurance coverage, religion, wealth, and fertility. Separate analyses were performed for facilities with and without a labor room and results were qualitatively similar across these two types of facilities. Conclusions Our study highlights the importance of supply-side barriers to maternity-care India. To meet Millennium Development Goals 4 and 5, policymakers should make additional investments in improving the availability of medical drugs and equipment at primary health centers (PHCs) in India.

The clock is ticking: the rate and timeliness of antiretroviral therapy initiation from the time of treatment eligibility in Kenya.

Understanding the determinants of timely antiretroviral therapy (ART) initiation is useful for HIV programmes intent on developing models of care that reduce delays in treatment initiation while maintaining a high quality of care. We analysed patient‐ and facility‐level determinants of time to ART initiation among patients who initiated ART in Kenya.

Patient satisfaction and perceived quality of care: evidence from a cross-sectional national exit survey of HIV and non-HIV service users in Zambia

Objective To examine the associations between perceived quality of care and patient satisfaction among HIV and non-HIV patients in Zambia. Setting Patient exit survey conducted at 104 primary, secondary and tertiary health clinics across 16 Zambian districts. Participants 2789 exiting patients. Primary independent variables Five dimensions of perceived quality of care (health personnel practice and conduct, adequacy of resources and services, healthcare delivery, accessibility of care, and cost of care). Secondary independent variables Respondent, visit-related, and facility characteristics. Primary outcome measure Patient satisfaction measured on a 1–10 scale. Methods Indices of perceived quality of care were modelled using principal component analysis. Statistical associations between perceived quality of care and patient satisfaction were examined using random-effect ordered logistic regression models, adjusting for demographic, socioeconomic, visit and facility characteristics. Results Average satisfaction was 6.9 on a 10-point scale for non-HIV services and 7.3 for HIV services. Favourable perceptions of health personnel conduct were associated with higher odds of overall satisfaction for non-HIV (OR=3.53, 95% CI 2.34 to 5.33) and HIV (OR=11.00, 95% CI 3.97 to 30.51) visits. Better perceptions of resources and services were also associated with higher odds of satisfaction for both non-HIV (OR=1.66, 95% CI 1.08 to 2.55) and HIV (OR=4.68, 95% CI 1.81 to 12.10) visits. Two additional dimensions of perceived quality of care—healthcare delivery and accessibility of care—were positively associated with higher satisfaction for non-HIV patients. The odds of overall satisfaction were lower in rural facilities for non-HIV patients (OR 0.69; 95% CI 0.48 to 0.99) and HIV patients (OR=0.26, 95% CI 0.16 to 0.41). For non-HIV patients, the odds of satisfaction were greater in hospitals compared with health centres/posts (OR 1.78; 95% CI 1.27 to 2.48) and lower at publicly-managed facilities (OR=0.41, 95% CI=0.27 to 0.64). Conclusions Perceived quality of care is an important driver of patient satisfaction with health service delivery in Zambia.

Does Distance Matter for Institutional Delivery in Rural India

This article estimates the causal effect of distance to health facility on in-facility birth in rural India, taking into account the endogenous placement of the health facility. We find that women living farther away from the health facilities are less likely to give birth at a health facility. Each additional kilometre from the nearest health facility is associated with a 4.4% decline in the probability of in-facility birth. Policy simulation results indicate that providing access to a health facility within 5 km would increase institutional delivery by 10%. Overall, our findings confirm that distance is an important barrier to in-facility births in rural India.

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.

Healthy competition drives success in results-based aid: Lessons from the Salud Mesoamérica Initiative

Objectives The Salud Mesoamérica Initiative (SMI) is a three-operation strategy, and is a pioneer in the world of results-based aid (RBA) in terms of the success it has achieved in improving health system inputs following its initial operation. This success in meeting pre-defined targets is rare in the world of financial assistance for health. We investigated the influential aspects of SMI that could have contributed to its effectiveness in improving health systems, with the aim of providing international donors, bilateral organizations, philanthropies, and recipient countries with new perspectives that can help increase the effectiveness of future assistance for health, specifically in the arena of RBA. Methods Qualitative methods based on the criteria of relevance and effectiveness proposed by the Development Assistance Committee of the Organization for Economic Co-operation and Development. Our methods included document review, key informant interviews, a focus group discussion, and a partnership analysis. Participants A purposive sample of 113 key informants, comprising donors, representatives from the Inter-American Development Bank, ministries of health, technical assistance organizations, evaluation organizations, and health care providers. Results During May–October 2016, we interviewed regarding the relevance and effectiveness of SMI. Themes emerged relative to the topics we investigated, and covered the design and the drivers of success of the initiative. The success is due to 1) the initiative’s regional approach, which pressured recipient countries to compete toward meeting targets, 2) a robust and flexible design that incorporated the richness of input from stakeholders at all levels, 3) the design-embedded evaluation component that created a culture of accountability among recipient countries, and 4) the reflective knowledge environment that created a culture of evidence-based decision-making. Conclusions A regional approach involving all appropriate stakeholders, and based on knowledge sharing and embedded evaluation can help ensure the effectiveness of future results-based aid programs for health in global settings.

Does Distance Matter for Institutional Delivery in Rural India: An Instrumental Variable Approach

Skilled attendance at childbirth is crucial for decreasing maternal and neonatal mortality, yet many women in low- and middle-income countries deliver outside of health facilities, without skilled help. Distance to health facility is considered to be an important non-monetary barrier that impede utilization of health facilities. In this paper, we examine if access to health facilities affects institutional births in a resource-constrained country like India. We use Two-Stage Residual Inclusion (2SRI) and IV-Probit models to account for endogenous placement of health facilities. Our findings indicate that women living closer to health facilities have a higher probability of giving birth in health facility. An increase of one kilometer in the distance to the nearest health facility decreases the probability of institutional delivery by 4.4%. The results from policy simulation suggest that restricting the maximum distance to 5 kilometers would increase institutional delivery by 10%. Overall, our findings show that distance is an important barrier to service utilization and increasing the density of health facilities or improving transport infrastructure may be an important policy tool to improve facility-based delivery in developing countries.

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.

Missed Opportunities for Measles, Mumps, and Rubella (MMR) Immunization in Mesoamerica: Potential Impact on Coverage and Days at Risk

Background Recent outbreaks of measles in the Americas have received news and popular attention, noting the importance of vaccination to population health. To estimate the potential increase in immunization coverage and reduction in days at risk if every opportunity to vaccinate a child was used, we analyzed vaccination histories of children 11–59 months of age from large household surveys in Mesoamerica. Methods Our study included 22,234 children aged less than 59 months in El Salvador, Guatemala, Honduras, Mexico, Nicaragua, and Panama. Child vaccination cards were used to calculate coverage of measles, mumps, and rubella (MMR) and to compute the number of days lived at risk. A child had a missed opportunity for vaccination if their card indicated a visit for vaccinations at which the child was not caught up to schedule for MMR. A Cox proportional hazards model was used to compute the hazard ratio associated with the reduction in days at risk, accounting for missed opportunities. Results El Salvador had the highest proportion of children with a vaccine card (91.2%) while Nicaragua had the lowest (76.5%). Card MMR coverage ranged from 44.6% in Mexico to 79.6% in Honduras while potential coverage accounting for missed opportunities ranged from 70.8% in Nicaragua to 96.4% in El Salvador. Younger children were less likely to have a missed opportunity. In Panama, children from households with higher expenditure were more likely to have a missed opportunity for MMR vaccination compared to the poorest (OR 1.62, 95% CI: 1.06–2.47). In Nicaragua, compared to children of mothers with no education, children of mothers with primary education and secondary education were less likely to have a missed opportunity (OR 0.46, 95% CI: 0.24–0.88 and OR 0.25, 95% CI: 0.096–0.65, respectively). Mean days at risk for MMR ranged from 158 in Panama to 483 in Mexico while potential days at risk ranged from 92 in Panama to 239 in El Salvador. Conclusions Our study found high levels of missed opportunities for immunizing children in Mesoamerica. Our findings cause great concern, as they indicate that families are bringing their children to health facilities, but these children are not receiving all appropriate vaccinations during visits. This points to serious problems in current immunization practices and protocols in poor areas in Mesoamerica. Our study calls for programs to ensure that vaccines are available and that health professionals use every opportunity to vaccinate a child.

Assessing vaccine cold chain storage quality: a cross-sectional study of health facilities in three African countries

Abstract Background Proper refrigeration at health facilities is an essential element in maintaining the integrity of vaccine cold chains. We use vaccine refrigerator and cold box temperature data, recently collected from health facilities in Ghana, Kenya, and Uganda, to assess cold chain quality in these countries. Methods Data were collected from a nationally representative sample of health facilities in Ghana, Kenya, and Uganda from mid-2012 to late 2012. Temperature was recorded from each facilitys refrigerator or cold box where pentavalent vaccines were stored. Results were compared to established vaccine storage guidelines, which recommend maintaining a temperature between 2°C and 8°C. We use logistic regression to test the association between proper storage temperature and vaccine storage location, facility characteristics, and availability of a temperature-monitoring chart. Findings Overall, 661 facilities were surveyed and 441 claimed to regularly store vaccines. Only 4% of facilities stored vaccines in cold boxes, while the remainder used refrigerators. In total, we observed storage outside the recommended range in 16·6% (71 of 429) of the sampled facilities, though significant variation was observed between countries (26·2% [34 of 130], 16·3% [26 of 160], and 7·9% [11 of 139] for Ghana, Kenya, and Uganda, respectively). Of those facilities that were not compliant with the guidelines, half were 4°C or more outside the recommended range. While most facility-level characteristics, such as size, management, and location, were not found to be associated with vaccine storage temperature, facilities that had a written chart to monitor their storage equipment were associated with 6·42 (95% CI 3·09–13·32) times higher odds of storing their vaccines within the recommended range compared with those without a chart. Interpretation There remains significant room to improve vaccine storage temperature in Ghana, Kenya, and Uganda. Maintaining a log was associated with appropriate temperature storage, regardless of duration since last check. While more investigation into the nature of this relation is needed, new technologies such as vial monitoring strips may be promising interventions for maintaining cold chain integrity. Funding Bill & Melinda Gates Foundation.