School of Public Health

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https://hdl.handle.net/10566/10

With some exceptions, our work focuses on five inter-related programme areas – HIV/AIDS, TB, maternal and child health, public health nutrition, and non- communicable diseases – and three health systems areas which cut across all programmes – namely human resource development, health information systems and health promotion

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Adolescents’ utilization of reproductive health services in Kaduna, Nigeria: the role of stigma
(Vulnerable Children and Youth Studies, 2020) Nmadua, Awawu Grace; Mohamed, Suraya
The need to improve the sexual and reproductive health (SRH) and rights of adolescents is increasingly acknowledged. Unfortunately, many adolescents in Nigeria face significant barriers to accessing quality sexual and reproductive health services (SRHS), despite national policies promoting SRHS for adolescents. This paper explores the stigma influencing access to and utilization of SRHS among adolescents in Kaduna, Northwestern Nigeria. This qualitative study conducted semi-structured interviews with 14 adolescents and three nurses. Thematic analysis was employed for the study. The findings indicate that although the adolescents knew the importance of accessing SRHS, they were not inclined to utilize the services because of stigma.
Assessing and improving care for patients with TB/HIV/STIs in a rural district in KwaZulu-Natal South Africa
(Health and Medical Publishing Group (HMPG), 2011) Loveday, Marion; Scott, Vera; McLaughlin, Jennifer; Amien, Feroza; Virgina, Zweigenthal
Setting: Despite the prioritisation of TB, HIV and STI programmes in South Africa, service targets are not achieved, have had little effect, and the magnitude of the epidemics continues to escalate. Objective. To report on a participatory quality improvement intervention designed to evaluate these priority programmes in primary health care (PHC) clinics in a rural district in KwaZulu-Natal. Methods: A participatory quality improvement intervention with district health managers, PHC supervisors and researchers was used to modify a TB/HIV/STI audit tool for use in a rural area, conduct a district-wide clinic audit, assess performance, set targets and develop plans to address the problems identified. Results: We highlight weaknesses in training and support of staff at PHC clinics, pharmaceutical and laboratory failures, and inadequate monitoring of patients as contributing to poor TB, HIV and STI service implementation. In the 25 facilities audited, 71% of the clinical staff had received no training in TB diagnosis and management, and 46% of the facilities were visited monthly by a PHC supervisor. Eighty per cent of the facilities experienced non-availability of essential drugs and supplies; polymerase chain reaction (PCR) results were not documented for 54% of specimens assessed, and the mean length of time between eligibility for ART and starting treatment was 47 days. Conclusion: Through a participatory approach, a TB/HIV/STI audit tool was successfully adapted and implemented in a rural district. It yielded information enabling managers to identify obstacles to TB, HIV and STI service implementation and develop plans to address these. The audit can be used by the district to monitor priority services at a primary level.
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.
No one knows what will happen after these five years': narratives of ART, access and agency in Nigeria
(Sage Publications, 2013) Omenka, Charity; Zarowski, Christina
Rural Nigerians pursue a range of strategies to maximize current and future access to HIV treatment in the context of securing livelihoods and minimizing the social and economic risks of stigma. This study reports on qualitative interviews with service providers and anti-retroviral therapy (ART) patients accessing care in Benue State, Nigeria, or travelling several hours to Abuja for treatment (n = 34). Nigerians living with HIV are keenly aware of the fragility and complex global and local politics of funding. Their narratives of pervasive stigma, economic and health system barriers to access, growing fears that free ART will cease, and strategies to secure access to care reveal a sophisticated synthesis of social determinants of health and clinical care, and challenge practitioners, planners, and scholars to take a similarly robust and nuanced approach to vulnerability, access, and agency.
Public reporting on pharmaceutical industry-led access programs: Alignment with the WHO medicine programs evaluation checklist
(Springer Nature, 2020) Laing, Richard O.; Umeh, Chukwuemeka Anthony; Rockers, Peter C.
There has been increased demand for greater public accountability and transparency of private sector-led global health partnership programs. This study critically reviews and pilot tests the World Health Organization (WHO) medicine program checklist as a framework for public reporting and assessing of programs.
Unequal access to ART: exploratory results from rural and urban case studies of ART use
(BMJ Publishing Group, 2012) Cleary, Susan; Birch, Stephen; Moshabela, Mosa; Schneider, Helen
INTRODUCTION: South Africa has the world's largest antiretroviral treatment (ART) programme. While services in the public sector are free at the point of use, little is known about overall access barriers. This paper explores these barriers from the perspective of ART users enrolled in services in two rural and two urban settings. METHODS: Using a comprehensive framework of access, interviews were conducted with over 1200 ART users to assess barriers along three dimensions: availability, affordability and acceptability. Summary statistics were computed and comparisons of access barriers between sites were explored using multivariate linear and logistic regressions. RESULTS: While availability access barriers in rural settings were found to be mitigated through a more decentralised model of service provision in one site, affordability barriers were considerably higher in rural versus urban settings. 50% of respondents incurred catastrophic healthcare expenditure and 36% borrowed money to cover these expenses in one rural site. On acceptability, rural users were less likely to report feeling respected by health workers. Stigma was reported to be lowest in the two sites with the most decentralised services and the highest coverage of those in need. CONCLUSIONS: While results suggest inequitable access to ART for rural relative to urban users, nurse-led services offered through primary healthcare facilities mitigated these barriers in one rural site. This is an important finding given current policy emphasis on decentralised and nurse-led ART in South Africa. This study is one of the first to present comprehensive evidence on access barriers to assist in the design of policy solutions.
Using an equity-based framework for evaluating publicly funded health insurance programmes as an instrument of UHC in Chhattisgarh State, India
(Springer Nature, 2020) Nandi, Sulakshana; Schneider, Helen
Universal health coverage (UHC) has provided the impetus for the introduction of publicly funded health insurance (PFHI) schemes in the mixed health systems of India and many other low- and middle-income countries. There is a need for a holistic understanding of the pathways of impact of PFHI schemes, including their role in promoting equity of access. Methods: This paper applies an equity-oriented evaluation framework to assess the impacts of PFHI schemes in Chhattisgarh State by synthesising literature from various sources and highlighting knowledge gaps. Data were collected from an extensive review of publications on PFHI schemes in Chhattisgarh since 2009, including empirical studies from the first author's PhD and grey literature such as programme evaluation reports, media articles and civil society campaign documents. The framework was constructed using concepts and frameworks from the health policy and systems research literature on UHC, access and health system building blocks, and is underpinned by the values of equity, human rights and the right to health.

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