Evidence base for children affected by HIV and AIDS in low prevalence and concentrated epidemic countries: applicability to programming guidance from high prevalence countries.

As global commitment grows to protect and support children affected by HIV and AIDS, questions remain about how best to meet the needs of these children in low prevalence settings and whether information from high prevalence countries can appropriately guide programming in these settings. A 2007 search for the evidence in low prevalence settings on situational challenges of HIV and AIDS-affected children and interventions to address these challenges identified 413 documents. They were reviewed and judged for quality of documentation and scientific rigor. Information was compiled across eight types of challenges (health and health care, nutrition and food security, education, protection, placement, psychosocial development, socioeconomic status, and stigma/discrimination); and also assessed was strength of evidence for situational and intervention findings. Results were compared to three programming principles drawn from research in high prevalence countries: family-centered preventive efforts, treatment, and care; family-focused support to ensure capacity to care for and protect these children; and sustaining economic livelihood of HIV and AIDS-affected households. Findings show that children affected by HIV and AIDS in low prevalence settings face increased vulnerabilities similar to those in high prevalence settings. These findings support seeking and testing programmatic directions for interventions identified in high prevalence settings. However, low prevalence settings/countries are extremely diverse, and the strength of the evidence base among them was mixed (strong, moderate, and weak in study design and documentation), geographically limited, and had insufficient evidence on interventions to draw conclusions about how best to reduce additional vulnerabilities of affected children. Information on family, economic, sociocultural, and political factors within local contexts will be vital in the development of appropriate strategies to mitigate vulnerabilities.

Effects of mutual health organizations on use of priority health-care services in urban and rural Mali: a case-control study.

OBJECTIVE: To examine the effects of a community-based mutual health organization (MHO) on utilization of priority health services, financial protection of its members and inclusion of the poor and other target groups. METHODS: Four MHOs were established in two districts in Mali. A case-control study was carried out in which household survey data were collected from 817 MHO member households, 787 non-member households in MHO catchment areas, and 676 control households in areas without MHOs. We compiled MHO register data by household for a 22-month period. Outcome measures included utilization of priority services, health expenditures and out-of-pocket payments. Independent variables included individual, household and community demographic, socioeconomic and access characteristics, as determined through a household survey in 2004. FINDINGS: MHO members who were up to date on premium payments (controlling for education, distance to the nearest health facility and other factors) were 1.7 times more likely to get treated for fevers in modern facilities; three times more likely to take children with diarrhoea to a health facility and/or treat them with oral rehydration salts at home; twice as likely to make four or more prenatal visits; and twice as likely, if pregnant or younger than 5 years, to sleep under an insecticide-treated net (P < 0.10 or better in all cases). However, distance was also a significant negative predictor for the utilization of many services, particularly assisted deliveries. Household and individual enrolment in an MHO were not significantly associated with socioeconomic status (with the exception of the highest quintile), and MHOs seemed to provide some financial protection for their members. CONCLUSIONS: MHOs are one mechanism that countries strengthening the supply of primary care can use to increase financial access to - and equity in - priority health services.

The impact of self-assessment on provider performance in Mali.

Improving the quality of clinical care in developing country settings is a difficult task, both in public sector settings where supervision is infrequent and in private sector settings where supervision and certification are non-existent. This study tested a low-cost method, self-assessment, for improving the quality of care that providers offer in a peri-urban area in Mali. The study was a cross-sectional, case-control study on the impact of self-assessment on compliance with the quality of care standards. The two indicators of interest were the compliance with fever care standards and the compliance with structural quality standards. Both standards were derived from the Ministry of Health of Mali's standards for health care delivery. The study examined 36 providers, 12 of whom were part of the intervention and 24 of whom were part of the control group over a 3 month period from May to July 2001. Overall, the research team found a significant difference between the intervention and control groups in terms of overall compliance (p < 0.001) and in terms of assessment of fever (p < 0.005). The total costs for the intervention for 36 providers was less than US$250, which translated to approximately $6 per provider. The data appear to suggest that self-assessment, when used in a regular fashion, can have a significant effect on compliance with standards. However, it is clear that self-assessment is not a resource-neutral intervention. All of the individuals from the intervention pool interviewed cited the extra work that they had to do to comply with the intervention protocol as a burden. In particular, study participants put an emphasis on the 'long duration' of the study that 'discouraged' the study participants. Future research on self-assessment should include a larger sample of providers and should examine the impact of self-assessment over time.