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The challenges facing efforts in Africa to increase access to antiretroviral HIV treatment underscore the urgent need to strengthen national health systems across the continent. However, donor aid to developing countries continues to be disproportionately channeled to international nongovernmental organizations (NGOs) rather than to ministries of health. The rapid proliferation of NGOs has provoked 'brain drain' from the public sector by luring workers away with higher salaries, fragmentation of services, and increased management burdens for local authorities in many countries. Projects by NGOs sometimes can undermine the strengthening of public primary health care systems. We argue for a return to a public focus for donor aid, and for NGOs to adopt a code of conduct that establishes standards and best practices for NGO relationships with public sector health systems. doi:10.2105/AJPH. 2007.125989 more...

Background The magnitude and burden of malaria infection during pregnancy (MiP) have been well documented. (1,2) The need for action has been recognized by WHO, which now recommends that sub-Saharan [...], Problem New WHO strategies for control of malaria in pregnancy (MiP) recommend intermittent preventive treatment (IPTp), bednet use and improved case management. Approach A pilot MiP programme in Mozambique was designed to determine requirements for scale-up. Local setting The Ministry of Health worked with a nongovernmental organization and an academic institution to establish and monitor a pilot programme in two impoverished malaria-endemic districts. Relevant changes Implementing the pilot programme required provision of additional sulfadoxine-pyrimethamine (SP), materials for directly observed SP administration, bednets and a modified antenatal card. National-level formulary restrictions on SP needed to be waived. The original protocol required modification because imprecision in estimation of gestational age led to missed SP doses. Multiple incompatibilities with other health initiatives (including programmes for control of syphilis, anaemia and HIV) were discovered and overcome. Key outputs and impacts were measured; 92.5% of 7911 women received at least 1 dose of SP, with the mean number of SP doses received being 2.2. At the second antenatal visit, 13.5% of women used bednets. In subgroups (1167 for laboratory analyses; 2600 births), SP use was significantly associated with higher haemoglobin levels (10.9 g/dL if 3 doses, 10.3 if none), less malaria parasitaemia (prevalence 7.5% if 3 doses, 39.3% if none), and fewer low-birth-weight infants (7.3% if 3 doses, 12.5% if none). Lessons learned National-level scale-up will require attention to staffing, supplies, bednet availability, drug policy, gestational-age estimation and harmonization of vertical initiatives. Resume Traitement preventif intermittent contre le paludisme des femmes enceintes dans le centre du Mozambique Problematique Les nouvelles strategies de l'OMS pour la lutte contre le paludisme pendant la grossesse preconisent un traitement antipaludique preventif intermittent, l'utilisation de moustiquaires de lit et une amelioration de la prise en charge des cas. Demarche Un programme pilote pour la Mozambique de lutte contre le paludisme pendant la grossesse a ete concu pour determiner les besoins lies au passage a l'echelle superieure. Contexte local Le ministere de la sante a collabore avec une organisation non gouvernementale et un etablissement d'enseignement superieur dans la mise au point et le suivi d'un programme pilote applique dans deux districts appauvris d'endemie du paludisme. Modifications pertinentes Pour la mise en oeuvre du programme pilote, il a fallu fournir une quantite supplementaire de sulfadoxine-pyrimethamine (SP), du materiel pour l'administration sous surveillance directe de ce medicament et des moustiquaires. Il a egalement fallu modifier la fiche antenatale et obtenir une derogation au guide national de prescription concernant la SP. Le protocole de depart a du etre modifie car l'imprecision dans l'evaluation de l'age gestationnel conduisait a une prise incomplete des doses de SP. Plusieurs incompatibilites avec d'autres initiatives sanitaires (y compris des programmes de lutte contre la syphilis, l'anemie et le VIH) ont ete decouvertes et surmontees. Les principaux resultats et effets ont ete mesures: 92,5 % des 7911 femmes enceintes ont recu au moins une dose de SP, le nombre moyen de doses de SP recues etant de 2,2. Lors de la deuxieme visite antenatale, 13,5 % des femmes utilisaient une moustiquaire de lit. Parmi les sous-groupes (1167 personnes pour les analyses en laboratoire, 2600 naissances), on a releve une association significative entre l'utilisation de SP et une elevation du taux d'hemoglobine (10,9 g/dl pour la prise de 3 doses de SP contre 10,3 g/dl en l'absence de toute dose de SP), une baisse de la prevalence des parasites du paludisme (7,5 % pour la prise de 3 doses contre 39,3 % en l'absence de toute prise de SP) et une baisse de la proportion d'enfants de petit poids a la naissance (7,3 % pour la prise de 3 doses contre 12,5 % en cas l'absence de toute prise de SP). Enseignements tires Le passage a l'echelle nationale du programme imposera de s'interesser aux besoins en personnel, en fournitures et en moustiquaires, a la politique en matiere de medicaments, a l'estimation de l'age gestationnel et a l'harmonisation des initiatives verticales. Une traduction en francais de ce resume figure a la fin de l'article. Resumen Tratamiento preventivo intermitente de la malaria durante el embarazo en el centro de Mozambique Problema En las nuevas estrategias de la OMS para combatir la malaria durante el embarazo se recomienda el tratamiento preventivo intermitente, el uso de mosquiteros y una mejor gestion de los casos. Enfoque Se diseno un programa piloto de control de la malaria en el embarazo en Mozambique a fin de determinar las condiciones necesarias para emprender una expansion masiva. Entorno local El Ministerio de Salud colaboro con una organizacion no gubernamental y una institucion academica para establecer y seguir de cerca un programa piloto en dos distritos pobres con malaria endemica. Cambios relevantes La aplicacion del programa piloto se baso en el suministro de sulfadoxina-pirimetamina (SP), material para la administracion de SP bajo observacion directa, mosquiteros y una tarjeta prenatal modificada. Fue necesario levantar las restricciones formales aplicables a nivel nacional a la SP, y hubo que modificar el protocolo original porque la imprecisiOn de las estimaciones de la edad gestacional conllevaba la omision de dosis de SP. Se descubrieron y resolvieron numerosas incompatibilidades con otras iniciativas de salud (incluidos programas de control de la sifilis, la anemia y el VIH), y se midieron diversos resultados e impactos: el 92,5% de 7911 mujeres recibieron al menos una dosis de SP, y el numero medio de dosis de SP recibidas fue de 2,2. En la segunda visita prenatal, el 13,5% de las mujeres usaban mosquiteros. Por subgrupos (1167 para analisis de laboratorio; 2600 nacimientos), el uso de SP se asocio de forma significativa a concentraciones de hemoglobina mayores (10,9 g/dl en caso de 3 dosis; 10,3 si no se habia recibido ninguna dosis), una menor parasitemia malarica (prevalencia del 7,5% en caso de 3 dosis; 39,3% si no se habia recibido ninguna dosis) y un menor nomero de lactantes con bajo peso al nacer (7,3% frente a 12,5% en caso de 3 o cero dosis, respectivamente). Ensenanzas extraidas Para extender masivamente las medidas de control a nivel nacional habra que prestar atencion al personal necesario, los suministros, la disponibilidad de mosquiteros, la politica farmaceutica, la estimacion de la edad gestacional y la armonizacion de las iniciativas verticales. Al final del articulo se facilita una traduccion al espanol. [TEXT NOT REPRODUCIBLE IN ASCII.] more...

Abstract Background The growing AIDS epidemic in southern Africa is placing an increased strain on health systems, which are experiencing steadily rising patient loads. Health care systems are tackling the barriers to serving large populations in scaled-up operations. One of the most significant challenges in this effort is securing the health care workforce to deliver care in settings where the manpower is already in short supply. Methods We have produced a demand-driven staffing model using simple spreadsheet technology, based on treatment protocols for HIV-positive patients that adhere to Mozambican guidelines. The model can be adjusted for the volumes of patients at differing stages of their disease, varying provider productivity, proportion who are pregnant, attrition rates, and other variables. Results Our model projects the need for health workers using three different kinds of goals: 1) the number of patients to be placed on anti-retroviral therapy (ART), 2) the number of HIV-positive patients to be enrolled for treatment, and 3) the number of patients to be enrolled in a treatment facility per month. Conclusion We propose three scenarios, depending on numbers of patients enrolled. In the first scenario, we start with 8000 patients on ART and increase that number to 58 000 at the end of three years (those were the goals for the country of Mozambique). This would require thirteen clinicians and just over ten nurses by the end of the first year, and 67 clinicians and 47 nurses at the end of the third year. In a second scenario, we start with 34 000 patients enrolled for care (not all of them on ART), and increase to 94 000 by the end of the third year, requiring a growth in clinician staff from 18 to 28. In a third scenario, we start a new clinic and enrol 200 new patients per month for three years, requiring 1.2 clinicians in year 1 and 2.2 by the end of year 3. Other clinician types in the model include nurses, social workers, pharmacists, phlebotomists, and peer counsellors. This planning tool could lead to more realistic and appropriate estimates of workforce levels required to provide high-quality HIV care in a low-resource settings. more...

Abstract Background The most pressing challenge to achieving universal access to highly active anti-retroviral therapy (HAART) in sub-Saharan Africa is the shortage of trained personnel to handle the increased service requirements of rapid roll-out. Overcoming the human resource challenge requires developing innovative models of care provision that improve efficiency of service delivery and rationalize use of limited resources. Methods We conducted a time-series intervention trial in two HIV clinics in central Mozambique to discern whether expanding the role of basic-level nurses to stage HIV-positive patients using CD4 counts and WHO-defined criteria would lead to more rapid information on patient status (including identification of HAART eligible patients), increased efficiency in the use of higher-level clinical staff, and increased capacity to start HAART-eligible patients on treatment. Results Overall, 1,880 of the HAART-eligible patients were considered in the study of whom 48.5% started HAART, with a median time of 71 days from their initial blood draw. After adjusting for time, expanding the role of nurses to stage patients was associated with more rational use of higher-level clinical staff at one site (Beira OR 1.9, 95% CI 1.1–3.3; Chimoio OR 0.2, 95% CI 0.1–0.5). In multivariate analyses, the rate of starting HAART in patients with CD4 counts of less than 200/mm3 increased over time (HR = 1.07, 95% CI 1.02–1.13), as did the total number of new patients initiating HAART (β = 7.3, 95% CI 1.3–13.3). However, the intervention was not independently associated with either of these outcomes in multivariate analyses (HR = 0.9, 95% CI 0.7–1.2) for starting HAART in patients with CD4 counts of less than 200/mm3; (β = -5.2, p = 0.75) for the total number of new patients initiating HAART per month. No effect of the intervention was found in these outcomes when stratifying by site. Conclusion The CD4 nurse intervention, when implemented correctly, was associated with a more rational use of higher-level clinical providers, which may improve overall clinic flow and efficient use of the limited supply of human resources. However, this intervention did not lead to an increase in the number of patients starting HAART or a reduction in the time to HAART initiation. Study month appears to play an important role in all outcomes, suggesting that general improvements in clinic efficiency may have overshadowed the effect of the intervention. The lack of observed effect in these outcomes may be due to additional health systems bottlenecks that delay the initiation of treatment in HAART-eligible patients. more...