Resources, attitudes and culture: an understanding of the factors that influence the functioning of accountability mechanisms in primary health care settings.

BACKGROUND: District level health system governance is recognised as an important but challenging element of health system development in low and middle-income countries. Accountability is a more recent focus in health system debates. Accountability mechanisms are governance tools that seek to regulate answerability between the health system and the community (external accountability) and/or between different levels of the health system (bureaucratic accountability). External accountability has attracted significant attention in recent years, but bureaucratic accountability mechanisms, and the interactions between the two forms of accountability, have been relatively neglected. This is an important gap given that webs of accountability relationships exist within every health system. There is a need to strike a balance between achieving accountability upwards within the health system (for example through information reporting arrangements) while at the same time allowing for the local level innovation that could improve quality of care and patient responsiveness. METHODS: Using a descriptive literature review, this paper examines the factors that influence the functioning of accountability mechanisms and relationships within the district health system, and draws out the implications for responsiveness to patients and communities. We also seek to understand the practices that might strengthen accountability in ways that improve responsiveness--of the health system to citizens' needs and rights, and of providers to patients. RESULTS: The review highlights the ways in which bureaucratic accountability mechanisms often constrain the functioning of external accountability mechanisms. For example, meeting the expectations of relatively powerful managers further up the system may crowd out efforts to respond to citizens and patients. Organisational cultures characterized by supervision and management systems focused on compliance to centrally defined outputs and targets can constrain front line managers and providers from responding to patient and population priorities. CONCLUSION: Findings suggest that it is important to limit the potential negative impacts on responsiveness of new bureaucratic accountability mechanisms, and identify how these or other interventions might leverage the shifts in organizational culture necessary to encourage innovation and patient-centered care.

Factors associated with patterns of plural healthcare utilization among patients taking antiretroviral therapy in rural and urban South Africa: a cross-sectional study.

BACKGROUND: In low-resource settings, patients' use of multiple healthcare sources may complicate chronic care and clinical outcomes as antiretroviral therapy (ART) continues to expand. However, little is known regarding patterns, drivers and consequences of using multiple healthcare sources. We therefore investigated factors associated with patterns of plural healthcare usage among patients taking ART in diverse South African settings. METHODS: A cross-sectional study of patients taking ART was conducted in two rural and two urban sub-districts, involving 13 accredited facilities and 1266 participants selected through systematic random sampling. Structured questionnaires were used in interviews, and participant's clinic records were reviewed. Data collected included household assets, healthcare access dimensions (availability, affordability and acceptability), healthcare utilization and pluralism, and laboratory-based outcomes. Multiple logistic regression models were fitted to identify predictors of healthcare pluralism and associations with treatment outcomes. Prior ethical approval and informed consent were obtained. RESULTS: Nineteen percent of respondents reported use of additional healthcare providers over and above their regular ART visits in the prior month. A further 15% of respondents reported additional expenditure on self-care (e.g. special foods). Access to health insurance (Adjusted odds ratio [aOR] 6.15) and disability grants (aOR 1.35) increased plural healthcare use. However, plural healthcare users were more likely to borrow money to finance healthcare (aOR 2.68), and incur catastrophic levels of healthcare expenditure (27%) than non-plural users (7%). Quality of care factors, such as perceived disrespect by staff (aOR 2.07) and lack of privacy (aOR 1.50) increased plural healthcare utilization. Plural healthcare utilization was associated with rural residence (aOR 1.97). Healthcare pluralism was not associated with missed visits or biological outcomes. CONCLUSION: Increased plural healthcare utilization, inequitably distributed between rural and urban areas, is largely a function of higher socioeconomic status, better ability to finance healthcare and factors related to poor quality of care in ART clinics. Plural healthcare utilization may be an indication of patients' dissatisfaction with perceived quality of ART care provided. Healthcare expenditure of a catastrophic nature remained a persistent complication. Plural healthcare utilization did not appear to influence clinical outcomes. However, there were potential negative impacts on the livelihoods of patients and their households.

Socioeconomic status and barriers to the use of free antiretroviral treatment for HIV/AIDS in Enugu State, south-eastern Nigeria.

With about 3 million people living with HIV, Nigeria has approximately 8% of the global burden of HIV cases. In 2009, only about 34% of those in need of antiretroviral treatment (ART) were able to access care, which means that Nigeria was far from achieving the United Nations target of 'universal access' by 2010. This study aimed to describe the barriers to accessibility and the coping strategies employed to overcome these barriers among users of free ART services overall and by socioeconomic status (SES). Data were collected from 240 people receiving ART at one urban and one peri-urban health facility in Enugu State, south-eastern Nigeria. Information on SES, demographic characteristics, and barriers and coping mechanisms for accessing ART were elicited from the respondents. The high cost of transportation, HIV stigma, and long waiting hours were found to be key barriers to the use of ART services. On average, ART clients spent just under four hours at the clinic during their monthly appointments. The use of personal savings and financial support from relatives were the main means to access treatment. When the data were analysed according to clients' SES, transportation costs were a chief concern among the poorest while those who were better off were more likely to be concerned about stigma and discrimination. These findings should be borne in mind when designing and locating services to maximise ongoing accessibility to ART.

Does accessibility to antiretroviral care improve after down-referral of patients from hospitals to health centres in rural South Africa?

We conducted an evaluation of healthcare accessibility among patients taking antiretroviral treatment (ART) after they were 'down-referred' from hospital-based programmes to primary healthcare (PHC) centres in a rural South African setting. A cross-sectional design was used to study 109 PHC users compared to a randomly selected control group of 220 hospital-based users. Both groups were matched for a minimum duration on ART of six months. Using a comprehensive healthcare-accessibility framework, the participants were asked about availability, affordability and acceptability of their ART care in structured exit interviews that were linked to their ART-clinic record reviews. Unadjusted and adjusted regression models were used. Down-referral was associated with reduced transportation and meal costs (p = 0.001) and travel time to an ART facility (p =0.043). The down-referred users were less likely to complain of long queues (adjusted odds ratio [AOR] 0.06; 95% confidence interval [95% CI]: 0.01-0.29), were more likely to feel respected by health providers (AOR 4.43; 95% CI: 1.07-18.02), perceived lower stigma (AOR 0.25; 95% CI: 0.07-0.91), and showed a higher level of ART adherence (AOR 8.71; 95% CI: 1.16-65.22) than the hospital-based users. However, the down-referred users preferred to consult with doctors rather than nurses (AOR 3.43; 95% CI: 1.22-9.55) and they were more likely to visit private physicians (AOR 7.09; 95% CI: 3.86-13.04) and practice self-care (AOR 4.91; 95% CI: 2.37-10.17), resulting in increased health-related expenditure (p = 0.001). Therefore, the results indicate both gains and losses in ART care for the patients, and suggest that down-referred patients save time and money, feel more respected, perceive lower stigma and show better adherence levels. However, unintended consequences include increased costs of using private physicians and self-care, highlighting the need to further promote the potential gains of down-referral interventions in resource-poor settings.

Claims on health care: a decision-making framework for equity, with application to treatment for HIV/AIDS in South Africa.

Trying to determine how best to allocate resources in health care is especially difficult when resources are severely constrained, as is the case in all developing countries. This is particularly true in South Africa currently where the HIV epidemic adds significantly to a health service already overstretched by the demands made upon it. This paper proposes a framework for determining how best to allocate scarce health care resources in such circumstances. This is based on communitarian claims. The basis of possible claims considered include: the need for health care, specified both as illness and capacity to benefit; whether or not claimants have personal responsibility in the conditions that have generated their health care need; relative deprivation or disadvantage; and the impact of services on the health of society and on the social fabric. Ways of determining these different claims in practice and the weights to be attached to them are also discussed. The implications for the treatment of HIV/AIDS in South Africa are spelt out.

Assessing efficiency and costs of scaling up HIV treatment.

INTRODUCTION: Whereas cost-effectiveness/utility analyses theoretically assess efficiency in HIV treatment, in practice they are of limited use to policy makers who are also concerned with the total costs of scaling up. This paper proposes an approach to simultaneously assessing both factors when setting priorities for HIV treatment. METHODS: Three interventions were assessed: a no antiretroviral therapy (ART) status quo, ART including first-line only, and ART including first and second-line regimens. Data were from a cohort receiving healthcare in a poor South African setting. Markov modelling was used to calculate patient-level lifetime costs and quality-adjusted life-years (QALY) as well as population-level total costs and QALY in each intervention. Linear programming was used to assess efficiency at the population level. RESULTS: First-line ART costs US$795 per QALY gained compared to no ART, while first and second-line costs US$1625 compared to first-line alone. The efficiency of either ART strategy depends on the HIV treatment budget. If this is less than US$10 billion during the planning period, first-line ART is most efficient. A combination of first-line with first and second-line treatment is most efficient if the budget is US$10-12 billion. Using both first and second-line treatment for everyone becomes efficient as the main strategy only at budgets greater than US$13 billion. CONCLUSION: An approach has been developed to HIV treatment priority setting that simultaneously considers efficiency and the costs of scaling up. This can help to establish explicit and evidence-based priorities and budgets to meet scaling up challenges.

The cost-effectiveness of antiretroviral treatment in Khayelitsha, South Africa--a primary data analysis.

BACKGROUND: Given the size of the HIV epidemic in South Africa and other developing countries, scaling up antiretroviral treatment (ART) represents one of the key public health challenges of the next decade. Appropriate priority setting and budgeting can be assisted by economic data on the costs and cost-effectiveness of ART. The objectives of this research were therefore to estimate HIV healthcare utilisation, the unit costs of HIV services and the cost per life year (LY) and quality adjusted life year (QALY) gained of HIV treatment interventions from a provider's perspective. METHODS: Data on service utilisation, outcomes and costs were collected in the Western Cape Province of South Africa. Utilisation of a full range of HIV healthcare services was estimated from 1,729 patients in the Khayelitsha cohort (1,146 No-ART patient-years, 2,229 ART patient-years) using a before and after study design. Full economic costs of HIV-related services were calculated and were complemented by appropriate secondary data. ART effects (deaths, therapy discontinuation and switching to second-line) were from the same 1,729 patients followed for a maximum of 4 years on ART. No-ART outcomes were estimated from a local natural history cohort. Health-related quality of life was assessed on a sub-sample of 95 patients. Markov modelling was used to calculate lifetime costs, LYs and QALYs and uncertainty was assessed through probabilistic sensitivity analysis on all utilisation and outcome variables. An alternative scenario was constructed to enhance generalizability. RESULTS: Discounted lifetime costs for No-ART and ART were US$2,743 and US$9,435 over 2 and 8 QALYs respectively. The incremental cost-effectiveness ratio through the use of ART versus No-ART was US$1,102 (95% CI 1,043-1,210) per QALY and US$984 (95% CI 913-1,078) per life year gained. In an alternative scenario where adjustments were made across cost, outcome and utilisation parameters, costs and outcomes were lower, but the ICER was similar. CONCLUSION: Decisions to scale-up ART across sub-Saharan Africa have been made in the absence of incremental lifetime cost and cost-effectiveness data which seriously limits attempts to secure funds at the global level for HIV treatment or to set priorities at the country level. This article presents baseline cost-effectiveness data from one of the longest running public healthcare antiretroviral treatment programmes in Africa that could assist in enhancing efficient resource allocation and equitable access to HIV treatment.