Analysis of factors influencing technical efficiency of public district hospitals in KwaZulu-Natal province, South Africa.

BACKGROUND: District hospitals are crucial in supporting primary health care and serve as a gateway to more specialist care through a referral system. Majority of South Africans access health care services through the public sector district health system. Given the enormous task assigned to the public district hospital within the country, this study examined factors influencing their technical efficiency. METHOD: Data were collected for 38 public district hospitals in KwaZulu-Natal province from 2014/15 to 2016/17. Data envelopment analysis (DEA) was used to determine the technical efficiency of the hospitals, adopting both the constant return to scale (CRS) and variable return to scale (VRS) models. Tobit regression model was used to determine factors related to the technical efficiency of the district hospitals. RESULTS: This study showed that a significant proportion of the district hospitals were technically inefficient. The Tobit regression model identified catchment population, the proportion of inpatients treated per medical personnel, the proportion of inpatients treated per nursing personnel and expenditure per patient day equivalent as factors influencing technical efficiency of the district hospitals. CONCLUSION: Findings from this study suggest that the technical efficiency of the district hospitals can be enhanced through an effective referral system and improved peoples' health-seeking behaviour. In addition, a standard mix of clinical staff toward efficient service delivery and periodic cost analysis of health services with the view to saving cost and maintaining the quality of health care should be considered.

A double-blind, randomized controlled trial to examine the effect of Moringa oleifera leaf powder supplementation on the immune status and anthropometric parameters of adult HIV patients on antiretroviral therapy in a resource-limited setting.

BACKGROUND: People living with HIV (PLHIV) in resource-limited settings are vulnerable to malnutrition. Nutritional interventions aimed at improving food insecurity and malnutrition, together with antiretroviral therapy (ART), could improve treatment outcomes. In Nigeria, there is a high awareness of the nutraceutical benefits of Moringa oleifera. Thus, this study aimed to evaluate the effects of Moringa oleifera leaf supplementation on the CD4 counts, viral load and anthropometric of HIV-positive adults on ART. METHODS: This was a double-blind, randomized study. Two hundred HIV-positive patients were randomly allocated to either the Moringa Oleifera group (MOG) given Moringa oleifera leaf powder or the control group (COG) given a placebo. Changes in anthropometric parameters [weight; body mass index (BMI)] and CD4 cell counts were measured monthly for six months, while HIV-1 viral loads were measured at baseline and the end of the study for both groups. RESULTS: Over the study period, the treatment by time interaction shows a significant difference in CD4 counts by treatment group (p<0.0001). A further estimate of fixed effects showed that the CD4 counts among MOG were 10.33 folds greater than COG over the study period. However, the viral load (p = 0.9558) and all the anthropometric parameters (weight; p = 0.5556 and BMI; p = 0.5145) between the two groups were not significantly different over time. All tests were conducted at 95CI. CONCLUSION: This study revealed that Moringa oleifera leaf supplementation was associated with increased CD4 cell counts of PLHIV on ART in a resource-limited setting. Programs in low-resource settings, such as Nigeria, should consider nutritional supplementation as part of a comprehensive approach to ensure optimal treatment outcomes in PLHIV.

Impact of Moringa Oleifera leaves supplementation on quality of life of people living with HIV: A double-blind randomized controlled trial.

PURPOSE: Advances in antiretroviral therapy (ART) and increased interest on nutritional interventions have led to improvements in life expectancy of people living with HIV (PLHIV). These have led to greater emphasis on their quality of life (QoL). This study was aimed at exploring the effects of Moringa oleifera leaves supplementation on QoL of HIV-positive adults in Nigeria. METHOD: A double-blind randomized controlled trial was conducted to determine the six months' impact of consuming Moringa oleifera leaves powder as a nutritional supplement on the different domains of QoL of PLHIV that are on ART. Two hundred consented patients were randomly allocated to either Moringa Oleifera group (MOG) or control group (COG). The WHOQOL-HIV-BREF was used to assess QoL at baseline and at six-month follow-up. RESULTS: One hundred and seventy seven patients completed the study. At six-month follow-up, a significant (p < 0.05) increase in the mean scores of all the six domains of QoL was observed in the MOG. However, in the COG, a significant increase was observed in the social relationship, environment, and spirituality/religion/personal beliefs domains. The comparison between the MOG and COG at 6 months' follow-up showed a significant mean score difference in the MOG in the physical, psychological, level of independence, and social relationships domains of QoL. CONCLUSION: This study shows that supplementation with Moringa oleifera leaves for PLHIV that are on ART improves the QoL domains of physical, psychological, level of independence, and social relationships. Clinical Trial Registry registration number: PACTR201811722056449.

Association between food insecurity and key metabolic risk factors for diet-sensitive non-communicable diseases in sub-Saharan Africa: a systematic review and meta-analysis.

In previous studies, food insecurity has been hypothesised to promote the prevalence of metabolic risk factors on the causal pathway to diet-sensitive non-communicable diseases (NCDs). This systematic review and meta-analysis aimed to determine the associations between food insecurity and key metabolic risk factors on the causal pathway to diet-sensitive NCDs and estimate the prevalence of key metabolic risk factors among the food-insecure patients in sub-Saharan Africa. This study was guided by the Centre for Reviews and Dissemination (CRD) guidelines for undertaking systematic reviews in healthcare. The following databases were searched for relevant literature: PubMed, EBSCOhost (CINAHL with full text, Health Source - Nursing, MedLine). Epidemiological studies published between January 2015 and June 2019, assessing the associations between food insecurity and metabolic risk outcomes in sub-Saharan African populations, were selected for inclusion. Meta-analysis was performed with DerSimonian-Laird's random-effect model at 95% confidence intervals (CIs). The I2 statistics reported the degree of heterogeneity between studies. Publication bias was assessed by visual inspection of the funnel plots for asymmetry, and sensitivity analyses were performed to assess the meta-analysis results' stability. The Mixed Methods Appraisal Tool (MMAT) - Version 2018 was used to appraise included studies critically. The initial searches yielded 11,803 articles, 22 cross-sectional studies were eligible for inclusion, presenting data from 26,609 (46.8% males) food-insecure participants, with 11,545 (42.1% males) reported prevalence of metabolic risk factors. Of the 22 included studies, we identified strong evidence of an adverse association between food insecurity and key metabolic risk factors for diet-sensitive NCDs, based on 20 studies. The meta-analysis showed a significantly high pooled prevalence estimate of key metabolic risk factors among food-insecure participants at 41.8% (95% CI: 33.2% to 50.8%, I2 = 99.5% p-value < 0.00) derived from 14 studies. The most prevalent type of metabolic risk factors was dyslipidaemia 27.6% (95% CI: 6.5% to 54.9%), hypertension 24.7% (95% CI: 15.6% to 35.1%), and overweight 15.8% (95% CI: 10.6% to 21.7%). Notably, the prevalence estimates of these metabolic risk factors were considerably more frequent in females than males. In this systematic review and meta-analysis, exposure to food insecurity was adversely associated with a wide spectrum of key metabolic risk factors, such as obesity, dyslipidaemia, hypertension, underweight, and overweight. These findings highlight the need to address food insecurity as an integral part of diet-sensitive NCDs prevention programmes. Further, these findings should guide recommendations on the initiation of food insecurity status screening and treatment in clinical settings as a basic, cost-effective tool in the practice of preventive medicine in sub-Saharan Africa.PROSPERO registration number: PROSPERO 2019 CRD42019136638.

Prevalence, healthcare costs and management of non-communicable diseases in people living with human immunodeficiency virus: A scoping review.

BACKGROUND: Coexistence of human immunodeficiency virus (HIV) and non-communicable diseases (NCDs) is an important public health issue of increasing concern. However, the prevalence, healthcare costs and management protocols for NCDs in people living with HIV (PLHIV) remain unclear in most settings. AIM: To scope evidence on prevalence, healthcare costs and disease management protocols associated with NCDs in PLHIV from studies published before July 2019. METHODS: Electronic databases were searched for published articles, and reference lists were checked for relevant studies. Key terms included were HIV/AIDS, co-morbidity or multi-morbidity, NCDs, healthcare costs, treatment protocols, diabetes mellitus, hypertension in various combinations. RESULTS: A total of 152 records were assessed, and thereafter 25 studies were included in the final review after all the elimination. Twelve of the 25 studies mostly reported prevalence of NCDs in PLHIV, 4 reported impact of HIV-NCD co-morbidity on healthcare costs and 1 reported management protocols and capacity of antiretroviral therapy (ART) sites to manage HIV-NCD co-morbidity. CONCLUSIONS: Results showed higher prevalence rates of diabetes mellitus and hypertension in PLHIV compared with HIV-negative people. However, there was inconsistency in NCD prevalence data from studies conducted in sub-Saharan African (SSA) countries, and limited research evidence on capacity of ART sites to manage NCDs in PLHIV. Low prevalence rates of NCDs reported in SSA countries could be an indication of limited capacity to screen for NCDs because of the influence of health system and/or patient-level factors. Most studies were generally limited to cross-sectional studies, with very few interventional, longitudinal studies.

Effects of HIV and non-communicable disease comorbidity on healthcare costs and health experiences in people living with HIV in Zimbabwe.

BACKGROUND: The effects of HIV and non-communicable disease (NCD) comorbidities on healthcare costs and health experiences have been documented in most high-income countries. However, little similar data are available for Zimbabwe and most countries in sub-Saharan Africa. Untreated or under-treated NCDs can potentially negate the gains achieved from the control of HIV. OBJECTIVES: The study sought to determine the effects of HIV-NCD comorbidity on healthcare costs, health experiences and treatment options for people living with HIV (PLWH) in Zimbabwe. METHODS: A repeated-measures, quantitative study was conducted at six antiretroviral therapy (ART) sites in the Gweru District of Zimbabwe. Simple random sampling was used to enrol 100 PLWH concurrently diagnosed with hypertension and/or diabetes mellitus (cases). Cases were matched by age, sex and viral load to an equal number of PLWH without hypertension and/or diabetes mellitus (controls). Quantitative data were collected using an interviewer-administered questionnaire at monthly intervals for 6 months. The questionnaire survey sought to compare healthcare costs, health-related experiences and treatment options between cases and controls. Data were analysed using Stata Version 13.1®. A logistic model was used to examine other factors such as demographic, clinical and behavioural data that were assumed to be unchanged over the study period. A random-effects model, including costs and other covariates, was used to compare groups in the final analysis. RESULTS: Non-communicable disease status was associated with the length of time on ART. Cases spent significantly more on transport (p = 0.0001) and medication (adjusted odds ratio [AOR] = 4.4, 95% confidence interval [CI]: 3.2-7.3); spent more days without doing usual daily activities because of sickness (AOR = 4.2, 95% CI: 3.3-7.6) and were more likely to use alternative medication (AOR = 3.4, 95% CI: 2.3-4.6) when compared with controls. Unemployment, female gender, age of 60 years and above, and living in rural areas were associated with failure to purchase prescribed medication. CONCLUSIONS: HIV-NCD comorbidity causes an additional burden to PLWH because of increased transport costs, NCD prescribed medication expenses and more productive days lost due to illness. The success of HIV programmes does not only rely on improving access to the diagnosis and treatment of HIV. Addressing the complications of HIV-related NCDs, and the long-term costs of ART and its occasional potential for harm will be essential if health outcomes in Zimbabweans living with HIV are to be optimised.

Capacity of antiretroviral therapy sites for managing NCDs in people living with HIV in Zimbabwe.

BACKGROUND: There are marked inconsistencies in prevalence data for human immunodeficiency virus and non-communicable disease (HIV-NCD) comorbidity in Zimbabwe. OBJECTIVES: To explain these discrepancies, we investigated the capacity of antiretroviral therapy (ART) sites in managing hypertension (HTN) and diabetes mellitus (DM) in people living with HIV (PLWH) in Gweru district, Zimbabwe. METHOD: This was a qualitative research design in which key informant interviews were conducted with eight health managers, and 12 focus group discussions (FGDs) were conducted with 72 PLWH concurrently diagnosed with HTN and/or DM. Thematic data analysis was performed in NVivo version 12®. RESULTS: Routine screening for HTN and targeted screening for DM were often interrupted by dysfunctional machines and intermittent supply of necessary consumables, impacting negatively on the capacity of the sites to monitor and screen for the NCDs. Erratic hypertensive and diabetic medication availability at study sites were also reported, forcing patients to turn to other treatment options (medication rationing or overdose or sharing, use of home remedies and traditional medicines, and reliance on faith and traditional healers). CONCLUSION: Findings demonstrate that the quality of observed incidence and prevalence data for HTN and DM in LMICs is a function of the capacity of health centres to screen for NCDs. Given the ageing population of PLWH in sub-Saharan Africa, coupled with increasing trends in the prevalence of NCDs in HIV-infected people, HIV programmes have not evolved with the changing needs of PLWH. Attention to the holistic management of PLWH is long overdue.

Prevalence of diabetes mellitus and hypertension in people living with human immunodeficiency virus on antiretroviral therapy in Gweru district, Zimbabwe.

BACKGROUND: While antiretroviral therapy (ART) has markedly increased survival in people living with human immunodeficiency virus (PLHIV), emerging trends of co-existence of non-communicable diseases (NCDs) and HIV could negate the gains already achieved in controlling HIV. AIM: The study aimed to determine the prevalence of hypertension and diabetes mellitus in PLHIV on ART in Gweru district. SETTING: Six high-volume ART sites in Gweru district under Midlands province in Zimbabwe. METHODS: This was a cross-sectional study. Screening and data collection occurred over a 3-month cycle when all patients were expected to have visited the ART sites for their monthly ART drug supply. The process also allowed the identification of health system challenges regarding data management for HIV-NCD comorbidity. Poisson regression analysis was used to calculate NCD prevalence ratio (PR) in PLHIV. RESULTS: Nearly 18 000 PLHIV registered for ART were identified. Hypertension (19.5%) and diabetes mellitus (8.4%) were the most common NCDs identified with a high proportion of those who did not know their diagnosis (over 50%). The prevalence of hypertension and/or diabetes mellitus among women was 74.9% compared to 25.1% in men (PR 3.22; 95% CI: 3.07-5.51, p = 0.0000). Other factors associated with increased prevalence of hypertension and/or diabetes mellitus were age group of ≥ 60 years (PR 2.5; 95% CI: 1.42-3.22, p = 0.00023), and duration of ≥ 5 years on ART (PR 6.4; 95% CI: 4.70-8.01, p = 0.0011). Separate data collection for NCDs and HIV was a key challenge affecting quantification of magnitude of HIV-NCDs comorbidity and subsequently management of NCDs in PLHIV. CONCLUSIONS: Indications of increasing prevalence of NCDs in PLHIV call for integrated electronic data management for HIV, TB and NCDs. This will allow active NCD case finding, and eventually improve prevalence data and treatment for HIV-NCD comorbidity. Future studies should focus on the health experiences and access to treatment in PLHIV diagnosed with NCDs; and to establish the accurate manner in which HIV status, ART and NCDs might be associated, through conducting a case control or cohort study.

Technical efficiency and productivity of public district hospitals in KwaZulu-Natal province, South Africa.

Background: District hospitals (DHs) constitute a significant proportion of public hospitals and consume a more substantial percentage of the government's total hospital budget. With the level of resources disbursed to DHs, it is essential to ensure efficient allocation and utilization. Hence, this study set out to assess the technical efficiency and productivity of public DHs in KwaZulu- Natal province, South Africa. Methods: Data envelopment analysis (DEA) and Malmquist total factor productivity (MTFP) were used to assess technical efficiency, identify adjustments required to make inefficient facilities more efficient, and determine overall productivity growth. Input data such as medical personnel and output information such as outpatient visits were retrieved from the databases of the district health information system (DHIS), and personnel salary systems (PERSAL) for three consecutive financial years (2014/15, 2015/16 and 2016/17). A total of 38 district hospitals were included in the study. Results: The proportion of technically efficient facilities according to constant return to scale (CRS) were 12 (31.6%), 16 (42.1%) and 14 (36.8%) in 2014/15, 2015/16 and 2016/17 respectively while according to the variable return to scale (VRS) technically efficient facilities were 22 (57.9%), 19 (50.0) and 21 (55.2%) respectively for the three consecutive years. On average, the total productivity of DHs increased by 4.8 percent over the three years, which is attributed majorly to technical growth of 6.9 percent. Conclusion: This study showed that a significant proportion of the district hospitals were technically inefficiency. Also, steps that could enable more efficient use of healthcare resources to yield optimal health service delivery were recommended.

Assessing the Efficiency of Health-care Facilities in Sub-Saharan Africa: A Systematic Review.

BACKGROUND: The provision of health-care services is dependent on the effective and efficient functioning of various components of a health-care system. It is therefore important to evaluate the functioning of these various components. Hence, the aim of this study was to review studies on health-care facilities efficiency in sub-Saharan Africa (SSA) with respect to the methodologies used as well as outcomes and factors influencing efficiency. METHODS: The review was conducted through a comprehensive search of electronic databases which included PubMed, Web of science, academic search complete via EBSCOhost, Science Direct, and Google scholar. A search was also conducted by looking into citations in the reference list of selected articles and through gray literature. Studies were screened by examining their titles, abstracts, and full-text based on stated inclusion and exclusion criteria. The concurrent screening and data extraction were conducted by the two authors. RESULTS: A total of 40 studies were shortlisted for the review. The majority (90.0%) of the studies employed the data envelopment analysis technique for their efficiency measurements. The input and output variables utilized by most of the studies were predominantly human resources and health-related services respectively. The outcome from majority of the studies showed that less than 40% of the studied facilities were efficient. The leading influencing factors reported by the studies were catchment population, facility ownership, and location. CONCLUSIONS: The review showed that there was a marked degree of inefficiency across the health-care facilities. Consequently, due to severe resource constraints facing SSA, there is a need to determine how to use the available resources optimally to improve health systems performance.

Prevalence of diabetes mellitus and hypertension in people living with human immunodeficiency virus on antiretroviral therapy in Gweru district, Zimbabwe

Background: While antiretroviral therapy (ART) has markedly increased survival in people living with human immunodeficiency virus (PLHIV), emerging trends of co-existence of non-communicable diseases (NCDs) and HIV could negate the gains already achieved in controlling HIV. Aim: The study aimed to determine the prevalence of hypertension and diabetes mellitus in PLHIV on ART in Gweru district. Setting: Six high-volume ART sites in Gweru district under Midlands province in Zimbabwe. Methods: This was a cross-sectional study. Screening and data collection occurred over a 3-month cycle when all patients were expected to have visited the ART sites for their monthly ART drug supply. The process also allowed the identification of health system challenges regarding data management for HIV-NCD comorbidity. Poisson regression analysis was used to calculate NCD prevalence ratio (PR) in PLHIV. Results: Nearly 18 000 PLHIV registered for ART were identified. Hypertension (19.5%) and diabetes mellitus (8.4%) were the most common NCDs identified with a high proportion of those who did not know their diagnosis (over 50%). The prevalence of hypertension and/or diabetes mellitus among women was 74.9% compared to 25.1% in men (PR 3.22; 95% CI: 3.07­5.51, p = 0.0000). Other factors associated with increased prevalence of hypertension and/or diabetes mellitus were age group of ≥ 60 years (PR 2.5; 95% CI: 1.42­3.22, p = 0.00023), and duration of ≥ 5 years on ART (PR 6.4; 95% CI: 4.70­8.01, p = 0.0011). Separate data collection for NCDs and HIV was a key challenge affecting quantification of magnitude of HIV-NCDs comorbidity and subsequently management of NCDs in PLHIV. Conclusions: Indications of increasing prevalence of NCDs in PLHIV call for integrated electronic data management for HIV, TB and NCDs. This will allow active NCD case finding, and eventually improve prevalence data and treatment for HIV-NCD comorbidity. Future studies should focus on the health experiences and access to treatment in PLHIV diagnosed with NCDs; and to establish the accurate manner in which HIV status, ART and NCDs might be associated, through conducting a case control or cohort study

Protocol for Investigating the Technical Efficiency of District Hospitals in the Public Health Sector of KwaZulu-Natal, South Africa.

BACKGROUND: The central objective of policy makers and health managers is efficiency in the delivery of health care. With frequent reports of global economic crises, there is a need to continuously measure the performance of various sectors of the health care system. This can inform the decision-making process toward allocating scarce resources with the aim of maximizing output. OBJECTIVE: The aim of this study is to determine the technical efficiency (TE) of public sector district hospitals in the province of KwaZulu-Natal, South Africa to provide information that will assist in policy formulation that may further assist in more efficient resource allocation decisions. METHODS: This is a health system research based on a quantitative research approach. All 38 public district hospitals in the 11 municipalities of the province will be included in this study. The data for the study will include inputs from hospitals' operations that contribute toward subsequent outputs. The input data will include information such as the number of health professionals (doctors, nurses, and other personnel) and number of hospital beds, whereas the output data will include information such as outpatient visits and number of admissions or discharge. Other data categories to be included will be determined by data availability and will be uniform for all facilities. Data for each facility for a 3-year period from 2014 to 2017 will be obtained from databases of the district health information, basic accounting, and personnel salary systems. On the basis of the data obtained, a model will be developed that can be used to assess how TE of public districts hospitals may be improved. TE will be determined using Data Envelopment Analysis, and factors influencing efficiency will be computed using StataCorp statistical package. RESULTS: As of February 2019, the study is at the data collection, data input, and analysis stages. The results are expected to be available from the second quarter of 2019. CONCLUSIONS: Findings from this study can add to tools available to policy makers, health planners, and managers in making decisions about resource allocation in health care systems. Moreover, these findings will be disseminated electronically and in print. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/12037.

Part 1: A review of using photovoice as a disability research method: Implications for eliciting the experiences of persons with disabilities on the Community Based Rehabilitation programme in Namibia.

BACKGROUND: Although the Community Based Rehabilitation (CBR) programme in Namibia was formally adopted in 1997, the effectiveness of the programme, including the experiences of persons with disabilities on the programme, has not been assessed to date. OBJECTIVES: To explore the need for a qualitative evaluation tool for the CBR programme that can elicit the experiences of persons with disabilities. METHODS: A scoping review was conducted on the use of photovoice as a disability research method and its potential use in eliciting the experiences of persons with disabilities participating in the CBR programme. A comprehensive literature search was conducted on electronic databases as a part of the scoping review. RESULTS: Twenty-one studies were selected for review. Six studies followed the exact steps of the traditional photovoice process, and the remaining 15 studies modified the process. Seventeen studies used photovoice as the only research method, 3 combined photovoice with a qualitative method and only one study combined photovoice with a quantitative method. Seven studies had a sample size ranging from 6 to 10 participants as suggested by the traditional photovoice process. The duration of the studies ranged from 2 weeks to 2 years. Thirteen studies investigated life experiences of persons with various disabilities and 17 studies suggested that the photovoice process increases empowerment. CONCLUSION: Photovoice is a versatile research method and has the potential to be utilised in effectively eliciting the experiences of persons with disabilities on the CBR programme in Namibia.

Part 2: The feasibility of utilising photovoice method and the World Health Organization Quality of Life instrument in evaluating the Community-Based Rehabilitation programme in Namibia: A pilot study.

BACKGROUND: Evaluation of Community-Based Rehabilitation (CBR) programmes in Namibia has been primarily quantitative, focusing mainly on outputs, including numbers of persons with disabilities served, referrals made and activities implemented. Little or no evidence is available on experiences and quality of life of persons with disabilities, despite the CBR programme being operational for more than 20 years. The 2011 World Report on Disability recommended the use of appropriate tools to fill the research gap by integrating the experiences of persons with disabilities and their quality of life. OBJECTIVES: The overall objective of the larger cohort study is to develop a monitoring and evaluation tool that can measure and integrate the experiences of persons with disabilities and their quality of life within the context of the CBR Programme in Namibia. METHOD: An adapted photovoice process was conducted with six purposively selected participants over a period of 1 month. The World Health Organization Community-Based Rehabilitation (WHO CBR) Matrix was used to identify the themes and subthemes. Participants were requested to complete the World Health Organization Quality of Life (abbreviated version) (WHOQOL-BREF) instrument at the end of the photovoice process to determine their quality of life. RESULTS: Administering the WHOQOL-BREF instrument at the end of the photovoice process measured both the quality of life of persons with disabilities and at the same time indicated the convergence and divergence in the two data collection methods. The study demonstrated a stronger convergence than divergence of the two methods. A feasibility criterion was mapped for future studies. CONCLUSION: This study demonstrated that photovoice is a flexible method that can be used with a variety of disabilities and has the potential of being combined with the WHOQOL-BREF assessment form. A larger cohort study may consider implementing photovoice and WHOQOL-BREF on multiple study sites and be able to compare results, considering geographical and demographic variables. The feasibility of utilising each method alone and in combination offered valuable insights on future conceptual framing of CBR programme evaluation. This conceptual framing will allow CBR practitioners to appreciate how these two methods contribute to a rigorous process of CBR programme evaluation.

Review of policy and legislative framework for disability services in Namibia.

BACKGROUND: The Namibian policies and legislative framework were reviewed to determine the extent to which the needs of persons with disabilities were met and aligned with the United Nations Convention on the Rights of Persons with Disabilities (UNCRPD). Further, the disability legislative framework of Namibia is compared with that of other southern African countries. METHODS: We conducted a retrospective analysis of policy and legal framework which addresses the needs and rights of persons with disabilities in Namibia from 1990 to 2016. A qualitative approach employing a case study design was used. Furthermore, a comparative analysis of the policies and legislation for alignment with the UNCRPD and how Namibia compares with other southern African countries is discussed. RESULTS: Four policies, one piece of legislation and one international instrument were identified as directly related to disability. Community-based rehabilitation was adopted as the main strategy for rehabilitation. Alignment of the policy and legal framework with the UNCRPD was found to be minimal. Furthermore, most of the legislation in southern Africa was formulated before the existence of the UNCRPD in 2006. CONCLUSION: Although much progress has been made in meeting the needs of persons with disabilities, key implementation issues to be addressed include central coordination, overlapping strategies, disability models and gender differences. There is a need for the policy and legal framework of Namibia and other southern African countries to be more responsive to the human rights needs of persons with disabilities. CLINICAL IMPLICATIONS: The study offers insights in reviewing disability policy and legal frameworks in southern Africa for influencing disability service delivery. Future studies can investigate the progress of implementation of disability policy and legal framework from the perspectives of implementers and recipients of services.

Implementation of disability policy framework in Namibia: A qualitative study.

BACKGROUND: This study explores some of the experiences of national programme managers, heads of national organisations of persons with disabilities (OPDs) and persons with disabilities in the implementation of the disability policies and legal framework in Namibia. METHOD: In-depth interviews were conducted with multiple key stakeholders mentioned above. Interviews were digitally recorded and transcribed verbatim. The Community Based Rehabilitation (CBR) matrix (health, education, livelihood, social and empowerment) was utilised to guide the development of themes and subthemes. RESULTS: Twenty-one key informants participated in the study. Participants stated that while Namibia has made significant progress in addressing the medical and social needs of persons with disabilities, further progress can be achieved through better coordination, capacity building, review and updating of policies which allows for the inclusion of personal assistance, access to justice, improving supply chain management for a wide range of assistive devices, mainstreaming HIV prevention and treatment programmes, improved access to sexual reproduction and family planning, improved access to higher education, curricula reviews and effective monitoring and evaluating of the CBR programme. CONCLUSIONS: The study revealed key issues that need to be addressed in reviewing the policy and legal framework so that it is responsive to the current needs of persons with disabilities. Further, the CBR programme needs an evaluation tool to assess its effectiveness and efficiency in meeting the needs of persons with disabilities and also to elicit their experiences and satisfaction.

The costs of delivering human papillomavirus vaccination to Grade 4 learners in KwaZulu-Natal, South Africa.

BACKGROUND: The national human papillomavirus (HPV) vaccination roll-out in South Africa provides two doses of Cervarix to all female Grade 4 learners in state schools. This study estimated the costs of vaccinating all learners in KwaZulu-Natal Province (females or males and females) using either the two- or three-dose strategies for both the bivalent and quadrivalent vaccines. OBJECTIVE: To determine costs of the HPV vaccination programme in KwaZulu-Natal. METHODS: Costs were determined adapting World Health Organization vaccination costing guidelines. RESULTS: The 2014 current cost of delivering three doses of Gardasil was ZAR510 per learner. The projected cost of delivering Cervarix to female learners at two or three doses over the period 2014 - 2018, adjusted for inflation, was ZAR172 717 342 and ZAR250 048 426, respectively. Similarly, the cost for Gardasil at these doses was ZAR197 482 200 and ZAR287 194 361, respectively. For male and female learners the cost for Cervarix over this period at two or three doses was ZAR337 101 132 and ZAR540 150 713, respectively. Similarly, the cost for Gardasil at these doses was ZAR426 597 971 and ZAR620 392 784, respectively. Accounting for population variation for females over 5 years, the cost of two doses of Cervarix ranged from ZAR168 888 677 to ZAR 176 545 977 at the lower and upper 95% confidence intervals (CIs), respectively. For three doses the cost ranged from ZAR244 505 544 to ZAR255 591 263 at the lower and upper 95% CIs, respectively. Similarly, the cost for two doses of Gardasil ranged from ZAR193 104 566 to ZAR201 859 798. For three doses the cost ranged from ZAR280 828 057 to ZAR293 560 614. CONCLUSION: This study gives decision makers a basis for structured planning and cost apportionment to ensure effective roll-out of the HPV vaccination programme.

Cell-based Assays for Assessing Toxicity: A Basic Guide.

Assessment of toxicity is an important component of the drug discovery process. Cellbased assays are a popular choice for assessing cytotoxicity. However, these assays are complex because of the wide variety of formats and methods that are available, lack of standardization, confusing terminology and the inherent variability of biological systems and measurement. This review is intended as a guide on how to take these factors into account when planning, conducting and/or interpreting cell based toxicity assays.

Cost-effectiveness of staff and workload profiles in retaining patients on antiretroviral therapy in KwaZulu-Natal, South Africa.

BACKGROUND: There is paucity of information on the cost-effectiveness of delivery strategies to retain patients on antiretroviral therapy (ART) and this study tries to fill this gap. METHODS: The analysis is based on a representative sample of 2835 patients attending 32 ART sites in KwaZulu-Natal (KZN), South Africa. Extended Cox regression and Kaplan Meier were used to estimate the transition probabilities to remain on ART among patients who attended sites with different staff and workload profiles. Annual costs per patient-year of observation for these delivery profiles were estimated. Probabilistic sensitivity analysis took into account parameters' uncertainty. RESULTS: The delivery sites with a full-time doctor and a full-time senior professional nurse and an intake of less than 200 new patients per doctor per year were the most cost-effective in retaining patients on ART. If 1000 new patients were followed up by this type of site, 724 patients would still be on ART after 10 years at a discounted cost of US$8.41 million at 2006 value with an incremental cost-effectiveness ratio of US$12,271 per extra retained patient over the second not dominated site profile. CONCLUSIONS: The results could be used to estimate the human resources needed for a sustainable scaling up of ART in KZN.

Retrospective study on the critical factors for retaining patients on antiretroviral therapy in KwaZulu-Natal, South Africa.

OBJECTIVE: To analyze the critical factors favoring the retention of patients under antiretroviral therapy (ART) in KwaZulu-Natal (KZN), South Africa. DESIGN AND METHODS: This retrospective study was based on the review of a representative sample of patients who began ART between March 2004 and May 2006 in 32 public sector sites and were followed up to July 1, 2007. Extended Cox proportional hazard models were used to identify the factors which significantly influenced treatment retention during the first 2 years of treatment. Kaplan-Meyer provided the probabilities of remaining on ART if these factors were present. RESULTS: The 2835 sampled patients corresponded to about 10% of the universe of patients under ART in the 32 sites; 929 (33%) were males, and the median age of the sampled patients was 34 (interquartile range: 28-41). The analysis identified factors that significantly decreased the probability of remaining on ART. Patients' risk factors were initial CD4 <100 cells per microliter, lack of a telephone contact number, and being male. Sites' risk factors were the presence of a part time (PT) versus a full time (FT) senior professional nurse, a PT versus FT doctor, and intakes of 200 or more new patients per doctor per year. The probability of remaining on ART declined significantly for each increasing level of workload, but having a FT versus a PT doctor made a significant difference only for level of workload of 200 or more new patients per year. CONCLUSIONS: The analysis has identified the conditions influencing retention of ART patients in KZN. This has provided a method to estimate absorption capacity of the ART delivery sites, which is of added value for a sustainable expansion of the ART coverage.