UWCScholar :: Browsing by Author "Daviaud, Emmanuelle"

Browsing by Author "Daviaud, Emmanuelle"

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Addressing the tensions and complexities involved in commissioning and undertaking implementation research in low- and middle-income countries
(BMJ, 2018) Doherty, Tanya; Lewin, Simon; Kinney, Mary; Sanders, David; Mathews, Cathy; Daviaud, Emmanuelle; Goga, Ameena; Bhana, Arvin; Besada, Donela; Vanleeuw, Lieve; Loveday, Marian; Odendaal, Willem; Leon, Natalie
Rapid scale-up of new policies and guidelines, in the context of weak health systems in low/middle-income countries (LMIC), has led to greater interest and funding for implementation research. Implementation research in LMICs is often commissioned by institutions from high-income countries but increasingly undertaken by LMIC-based research institutions. Commissioned implementation research to evaluate large-scale, donor-funded health interventions in LMICs may hold tensions with respect to the interests of the researchers, the commissioning agency, implementers and the country government. We propose key questions that could help researchers navigate and minimise the potential conflicts of commissioned implementation research in an LMIC setting.
Applying a framework for assessing the health system challenges to scaling up mHealth in South Africa
(BioMed Central, 2012) Leon, Natalie; Schneider, Helen; Daviaud, Emmanuelle
Background: Mobile phone technology has demonstrated the potential to improve health service delivery, but there is little guidance to inform decisions about acquiring and implementing mHealth technology at scale in health systems. Using the case of community-based health services (CBS) in South Africa, we apply a framework to appraise the opportunities and challenges to effective implementation of mHealth at scale in health systems. Methods: A qualitative study reviewed the benefits and challenges of mHealth in community-based services in South Africa, through a combination of key informant interviews, site visits to local projects and document reviews. Using a framework adapted from three approaches to reviewing sustainable information and communication technology (ICT), the lessons from local experience and elsewhere formed the basis of a wider consideration of scale up challenges in South Africa. Results: Four key system dimensions were identified and assessed: government stewardship and the organisational, technological and financial systems. In South Africa, the opportunities for successful implementation of mHealth include the high prevalence of mobile phones, a supportive policy environment for eHealth, successful use of mHealth for CBS in a number of projects and a well-developed ICT industry. However there are weaknesses in other key health systems areas such as organisational culture and capacity for using health information for management, and the poor availability and use of ICT in primary health care. The technological challenges include the complexity of ensuring interoperability and integration of information systems and securing privacy of information. Finally, there are the challenges of sustainable financing required for large scale use of mobile phone technology in resource limited settings. Conclusion: Against a background of a health system with a weak ICT environment and limited implementation capacity, it remains uncertain that the potential benefits of mHealth for CBS would be retained with immediate large-scale implementation. Applying a health systems framework facilitated a systematic appraisal of potential challenges to scaling up mHealth for CBS in South Africa and may be useful for policy and practice decision-making in other low- and middle-income settings.
Costs of implementing integrated community case management (iCCM) in six African countries: implications for sustainability
(Edinburgh University Global Health Society, 2017) Daviaud, Emmanuelle; Besada, Donela; Leon, Natalie; Rohde, Sarah; Sanders, David; Oliphant, Nicholas; Doherty, Tanya
BACKGROUND Sub–Saharan Africa still reports the highest rates of under– five mortality. Low cost, high impact interventions exist, however poor access remains a challenge. Integrated community case management (iCCM) was introduced to improve access to essential services for children 2–59 months through diagnosis, treatment and referral services by community health workers for malaria, pneumonia and diarrhea. This paper presents the results of an economic analysis of iCCM implementation in regions supported by UNICEF in six countries and assesses country–level scale–up implications. The paper focuses on costs to provider (health system and donors) to inform planning and budgeting, and does not cover cost–effectiveness. METHODS The analysis combines annualised set–up costs and 1 year implementation costs to calculate incremental economic and financial costs per treatment from a provider perspective. Affordability is assessed by calculating the per capita financial cost of the program as a percentage of the public health expenditure per capita. Time and financial implications of a 30% increase in utilization were modeled. Country scale–up is modeled for all children under 5 in rural areas. RESULTS Utilization of iCCM services varied from 0.05 treatment/y/under– five in Ethiopia to over 1 in Niger. There were between 10 and 603 treatments/community health worker (CHW)/y. Consultation cost represented between 93% and 22% of economic costs per treatment influenced by the level of utilization. Weighted economic cost per treatment ranged from US$ 13 (2015 USD) in Ghana to US$ 2 in Malawi. CHWs spent from 1 to 9 hours a week on iCCM. A 30% increase in utilization would add up to 2 hours a week, but reduce cost per treatment (by 20% in countries with low utilization). Country scale up would amount to under US$ 0.8 per capita total population (US$ 0.06–US$0.74), between 0.5% and 2% of public health expenditure per capita but 8% in Niger. CONCLUSIONS iCCM addresses unmet needs and impacts on under 5 mortality. An economic cost of under US$ 1/capita/y represents a sound investment. Utilization remains low however, and strategies must be developed as a priority to improve demand. Continued donor support is required to sustain iCCM services and strengthen its integration within national health systems.
“If donors woke up tomorrow and said we can't fund you, what would we do?” A health system dynamics analysis of implementation of PMTCT option B+ in Uganda.
(BioMed Central, 2017) Doherty, Tanya; Besada, Donela; Goga, Ameena; Daviaud, Emmanuelle; Rohde, Sarah; Raphaely, Nika
BACKGROUND: In October 2012 Uganda extended its prevention of mother to child HIV transmission (PMTCT) policy to Option B+, providing lifelong antiretroviral treatment for HIV positive pregnant and breastfeeding women. The rapid changes and adoptions of new PMTCT policies have not been accompanied by health systems research to explore health system preparedness to implement such programmes. The implementation of Option B+ provides many lessons which can inform the shift to ‘Universal Test and Treat’, a policy which many sub-Saharan African countries are preparing to adopt, despite fragile health systems. METHODS: This qualitative study of PMTCT Option B+ implementation in Uganda three years following the policy adoption, uses the health system dynamics framework to explore the impacts of this programme on ten elements of the health system. Qualitative data were gathered through rapid appraisal during in-country field work. Key informant interviews and focus group discussions (FGDs) were undertaken with the Ministry of Health, implementing partners, multilateral agencies, district management teams, facility-based health workers and community cadres. A total of 82 individual interviews and 16 focus group discussions were completed. We conducted a simple manifest analysis, using the ten elements of a health system for grouping data into categories and themes. RESULTS: Of the ten elements in the health system dynamics framework, context and resources (finances, infrastructure & supplies, and human resources) were the most influential in the implementation of Option B+ in Uganda. Support from international actors and implementing partners attempted to strengthen resources at district level, but had unintended consequences of creating dependence and uncertainty regarding sustainability. CONCLUSIONS: The health system dynamics framework offers a novel approach to analysis of the effects of implementation of a new policy on critical elements of the health system. Its emphasis on relationships between system elements, population and context is helpful in unpacking impacts of and reactions to pressures on the system, which adds value beyond some previous frameworks.
The role of 'hidden' community volunteers in community-based health service delivery platforms: examples from sub-Saharan Africa
(Co-Action Publishing, 2015) Leon, Natalie; Sanders, David; Damme, Wim Van; Besada, Donela; Daviaud, Emmanuelle; Oliphant, Nicholas P.; Berzal, Rocio; Mason, John; Doherty, Tanya
Community-based research on child survival in sub-Saharan Africa has focussed on the increased provision of curative health services by a formalised cadre of lay community health workers (CHWs), but we have identified a particular configuration, that deserves closer scrutiny. We identified a two-tiered CHW system, with the first tier being the lessor known or 'hidden' community/village level volunteers and the second tier being formal, paid CHWs, in Ethiopia, Mali, and Niger. Whilst the disease-focussed tasks of the formal CHW tier may be more amenable to classic epidemiological surveillance, we postulate that understanding the relationship between formalised CHWs and volunteer cadres, in terms of scope, location of practice and ratio to population, would be important for a comprehensive evaluation of child survival in these countries.We report on the findings from our joint qualitative and quantitative investigations, highlighting the need to recognise the 'hidden' contribution of volunteers. We need to better characterize the volunteers' interaction with community-based and primary care services and to better understand ways to improve the volunteer systems with the right type of investments. This is particularly important for considering the models for scale-up of CHWs in sub-Saharan Africa.
Roles played by community cadres to support retention in PMTCT Option B+ in four African countries: a qualitative rapid appraisal
(BMJ Publishing Group, 2018) Besada, Donela; Goga, Ameena; Daviaud, Emmanuelle; Rohde, Sarah; Chinkonde, Jacqueline Rose; Villeneuve, Susie; Clarysse, Guy; Raphaely, Nika; Okokwu, Steve; Tumwesigye, Nathan; Daries, Nathalie; Doherty, Tanya
OBJECTIVES To explore the roles of community cadres in improving access to and retention in care for PMTCT (prevent mother-to-child transmission of HIV) services in the context of PMTCT Option B+ treatment scale-up in high burden low-income and lower-middle income countries. DESIGN/METHODS Qualitative rapid appraisal study design using semistructured in-depth interviews and focus group discussions (FGDs) between 8 June and 31 July 2015. SETTING AND PARTICIPANTS Interviews were conducted in the offices of Ministry of Health Staff, Implementing partners, district offices and health facility sites across four low-income and lower-middle income countries: Cote D’Ivoire, Democratic Republic of Congo (DRC), Malawi and Uganda. A range of individual interviews and FGDs with key stakeholders including Ministry of Health employees, Implementation partners, district management teams, facility-based health workers and community cadres. A total number of 18, 28, 31 and 83 individual interviews were conducted in Malawi, Cote d’Ivoire, DRC and Uganda, respectively. A total number of 15, 9, 10 and 16 mixed gender FGDs were undertaken in Malawi, Cote d’Ivoire, DRC and Uganda, respectively. RESULTS Community cadres either operated solely in the community, worked from health centres or in combination and their mandates were PMTCT-specific or included general HIV support and other health issues. Community cadres included volunteers, those supported by implementing partners or employed directly by the Ministry of Health. Their complimentary roles along the continuum of HIV care and treatment include demand creation, household mapping of pregnant and lactating women, linkage to care, infant follow-up and adherence and retention support. CONCLUSIONS Community cadres provide an integral link between communities and health facilities, supporting overstretched health workers in HIV client support and follow-up. However, their role in health systems is neither standardised nor systematic and there is an urgent need to invest in the standardisation of and support to community cadres to maximise potential health impacts.
South-Africa (Goodstart III) trial: community based maternal and newborn care economic analysis
(Oxford University Press, 2017) Daviaud, Emmanuelle; Nkonki, Lungiswa; Ijumba, Petrida; Doherty, Tanya; Lawn, Joy E.; Owen, Helen; Jackson, Debra; Tomlinson, Mark
In light of South Africa’s generalized HIV/AIDS epidemic coupled with high infant mortality, we undertook a cluster Randomized Control Trial (2008–10) assessing the effect of Community Health Worker (CHW) antenatal and postnatal home visits on, amongst other indicators, levels of HIV-free survival, and exclusive and appropriate infant feeding at 12 weeks. Cost and time implications were calculated, by assessing the 15 participating CHWs, using financial records, mHealth and interviews. Sustainability and scalability were assessed, enabling identification of health system issues. The majority (96%) of women in the community received an average of 4.1 visits (target seven). The paid, single purpose CHWs spent 13 h/week on the programme. The financial cost per mother amounted to $94 ($23 per home visit). Modelling target coverage (95% mothers, seven visits) and increased efficiency showed that if CHWs spent 25 h/week on the programme, the number of CHWs required would decrease from 15 to 12. The intervention almost doubled exclusive breastfeeding (EBF) at 12 weeks and showed a 6% relative increase in EBF with each additional CHW visit. Home visit programmes improve access and prevention but are not an inexpensive alternative: the observed cost per home visit is twice that of a clinic visit and in target/efficiency scenario decreases to 70% of the cost of a clinic visit. Ensuring sustainability requires optimizing the design of programmes and deployment of human resources, whilst maintaining impact. However, low remuneration of CHWs leads to shorter working hours, low motivation and sub-optimal coverage even in a situation with well-resourced supervision. The community-based care programme in South-Africa is based on multi-purpose CHWs, its cost and impact should be compared with results from this study. Quality of support for multi-purpose CHWs may be the biggest challenge to address to achieving higher efficiency of community-based services.
South-Africa (Goodstart III) trial: community-based maternal and newborn care economic analysis
(Oxford University Press, 2017) Daviaud, Emmanuelle; Nkonki, Lungiswa L.; Ijumba, Petrida; Doherty, Tanya; Lawn, Joy E.; Owen, Helen; Jackson, Debra; Tomlinson, Mark
In light of South Africa’s generalized HIV/AIDS epidemic coupled with high infant mortality, we undertook a cluster Randomized Control Trial (2008–10) assessing the effect of Community Health Worker (CHW) antenatal and postnatal home visits on, amongst other indicators, levels of HIV-free survival, and exclusive and appropriate infant feeding at 12 weeks. Cost and time implications were calculated, by assessing the 15 participating CHWs, using financial records, mHealth and interviews. Sustainability and scalability were assessed, enabling identification of health system issues. The majority (96%) of women in the community received an average of 4.1 visits (target seven). The paid, single purpose CHWs spent 13 h/week on the programme. The financial cost per mother amounted to $94 ($23 per home visit). Modelling target coverage (95% mothers, seven visits) and increased efficiency showed that if CHWs spent 25h/week on the programme, the number of CHWs required would decrease from 15 to 12. The intervention almost doubled exclusive breastfeeding (EBF) at 12 weeks and showed a 6% relative increase in EBF with each additional CHW visit. Home visit programmes improve access and prevention but are not an inexpensive alternative: the observed cost per home visit is twice that of a clinic visit and in target/efficiency scenario decreases to 70% of the cost of a clinic visit. Ensuring sustainability requires optimizing the design of programmes and deployment of human resources, whilst maintaining impact. However, low remuneration of CHWs leads to shorter working hours, low motivation and sub-optimal coverage even in a situation with well-resourced supervision. The communitybased care programme in South-Africa is based on multi-purpose CHWs, its cost and impact should be compared with results from this study. Quality of support for multi-purpose CHWs may be the biggest challenge to address to achieving higher efficiency of community-based services.
Strategies to improve male involvement in PMTCT Option B+ in four African countries: a qualitative rapid appraisal
(Taylor & Francis Open, 2016) Besada, Donela; Rohde, Sarah; Goga, Ameena; Raphaely, Nika; Daviaud, Emmanuelle; Ramokolo, Vundli; Magasana, Vuyolwethu; Noveve, Nobuntu; Doherty, Tanya
BACKGROUND: The World Health Organization recommends that antiretroviral therapy be started as soon as possible, irrespective of stage of HIV infection. This ‘test and treat’ approach highlights the need to ensure that men are involved in prevention of mother-to-child HIV transmission (PMTCT). This article presents findings from a rapid appraisal of strategies to increase male partner involvement in PMTCT services in Uganda, Democratic Republic of Congo, Malawi, and Coˆ te d’Ivoire in the context of scale-up of Option B protocol. DESIGN: Data were collected through qualitative rapid appraisal using focus groups and individual interviews during field visits to the four countries. Interviews were conducted in the capital city with Ministry of Health staff and implementing partners (IPs) and at district level with district management teams, facility-based health workers and community health cadres in each country. RESULTS: Common strategies were adopted across the countries to effect social change and engender greater participation of men in maternal, child and women’s health, and PMTCT services. Community-based strategies included engagement of community leaders through dialogue and social mobilization, involving community health workers and the creation and strengthening of male peer cadres. Facility-based strategies included provision of incentives such as shorter waiting time, facilitating access for men by altering clinic hours, and creation of family support groups. CONCLUSIONS: The approaches implemented at both community and facility levels were tailored to the local context, taking into account cultural norms and geographic regional variations. Although intentions behind such strategies aim to have positive impacts on families, unintended negative consequences do occur, and these need to be addressed and strategies adapted. A consistent definition of ‘male involvement’ in PMTCT services and a framework of indicators would be helpful to capture the impact of strategies on cultural and behavioral shifts. National policies around male involvement would be beneficial to streamline approaches across IPs and ensure wide-scale implementation, to achieve significant improvements in family health outcomes.
Utilisation of private general practitioners to provide caesarean deliveries in five rural district public hospitals in South Africa: A mixed-methods study
(BMJ Publishing Group, 2023) Doherty, Tanya; Solanki, Geetesh; Daviaud, Emmanuelle
Researching how public–private engagements may promote universal access to safe obstetric care including caesarean delivery is essential. The aim of this research was to document the utilisation of private general practitioners (GPs) contracted to provide caesarean delivery services in five rural district hospitals in the Western Cape, the profile and outcomes of caesarean deliveries. We also describe stakeholder experiences of these arrangements in order to inform potential models of public–private contracting for obstetric services.
Ward-based primary health care outreach teams in South Africa: developments, challenges and future directions
(Health Systems Trust, 2018) Schneider, Helen; Besada, Donela; Sanders, David; Daviaud, Emmanuelle; Rohde, Sarah
In 2011, South Africa adopted the Ward-based Primary Health Care Outreach Team (WBPHCOT) Strategy. The WBPHCOTs are made up of generalist community health workers (CHWs) supported by nurse team leaders, and linked to local primary health care (PHC) facilities (via referral, support and oversight). These outreach teams build on a pre-existing NGO-based community care and support system that emerged in response to HIV and AIDS in South Africa. By early 2017, 42% of the estimated required total of 7 800 teams were reporting activity data through the District Health Information System. The WBPHCOTs are envisaged as a key element of PHC in the future National Health Insurance (NHI) system, and a WBPHCOT Policy Framework was launched in December 2017. An accredited curriculum for a comprehensive CHW cadre has been approved nationally and is being implemented through a decentralised training infrastructure. Although an investment case for the WBPHCOT policy has been finalised, additional resources have yet to be allocated for rollout of the strategy. This chapter draws on policy documents, research conducted by the authors, and grey and published literature to recap the history of CHW programmes in South Africa and the emergence of the WBPHCOT strategy and policy. Key dimensions of WBPHCOT policy and implementation are reviewed, including scope of work, selection, supervision, training, financing and monitoring and evaluation. The chapter concludes with a set of recommendations addressing a number of significant constraints on performance and future development of WBPHCOTs in light of their intended role in NHI.

Browsing by Author "Daviaud, Emmanuelle"

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