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Decentralizing health services, including those for HIV prevention and treatment, is one strategy for maximizing the use of limited resources and expanding treatment options; yet few methods exist for systematically identifying where investments for service expansion might be most effective, in terms of meeting needs and rapid availability of improved services. The Nigerian Government, the United States Government under the President's Emergency Plan for AIDS Relief (PEPFAR) program and other donors are expanding services for prevention of mother-to-child transmission (PMTCT) of HIV to primary health care facilities in Nigeria. Nigerian primary care facilities vary greatly in their readiness to deliver HIV/AIDS services. In 2012, MEASURE Evaluation assessed 268 PEPFAR-supported primary health care facilities in Nigeria and developed a systematic method for prioritizing these facilities for expansion of PMTCT services. Each assessed facility was scored based on two indices with multiple, weighted variables: one measured facility readiness to provide PMTCT services, the other measured local need for the services and feasibility of expansion. These two scores were compiled and the summary score used as the basis for prioritizing facilities for PMTCT service expansion. The rationale was that using need and readiness to identify where to expand PMTCT services would result in more efficient allocation of resources. A review of the results showed that the indices achieved the desired effect-that is prioritizing facilities with high need even when readiness was problematic and also prioritizing facilities where rapid scale-up was feasible. This article describes the development of the two-part index and discusses advantages of using this approach when planning service expansion. The authors' objective is to contribute to development of methodologies for prioritizing investments in HIV, as well as other public health arenas, that should improve cost-effectiveness and strengthen services and systems in resource-limited countries., (© The Author 2015. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine.)

The 2011 United Nations (UN) General Assembly Political Declaration on Prevention and Control of Non-Communicable Diseases (NCDs) brought NCDs to the global health agenda. Essential medicines are central to treating chronic diseases such as hypertension and diabetes. Our study aimed to quantify access to essential medicines for people with chronic conditions in five low- and middle-income countries and to evaluate how household socioeconomic status and perceptions about medicines availability and affordability influence access. We analysed data for 1867 individuals with chronic diseases from national surveys (Ghana, Jordan, Kenya, Philippines and Uganda) conducted in 2007-10 using a standard World Health Organization (WHO) methodology to measure medicines access and use. We defined individuals as having access to medicines if they reported regularly taking medicine for a diagnosed chronic disease and data collectors found a medicine indicated for that disease in their homes. We used logistic regression models accounting for the clustered survey design to investigate determinants of keeping medicines at home and predictors of access to medicines for chronic diseases. Less than half of individuals previously diagnosed with a chronic disease had access to medicines for their condition in every country, from 16% in Uganda to 49% in Jordan. Other than reporting a chronic disease, higher household socioeconomic level was the most significant predictor of having any medicines available at home. The likelihood of having access to medicines for chronic diseases was higher for those with medicines insurance coverage [highest adjusted odds ratio (OR) 3.12 (95% confidence intervals (CI): 1.38, 7.07)] and lower for those with past history of borrowing money to pay for medicines [lowest adjusted OR 0.56 (95% CI: 0.34, 0.92)]. Our study documents poor access to essential medicines for chronic conditions in five resource-constrained settings. It highlights the importance of financial risk protection and consumer education about generic medicines in global efforts towards improving treatment of chronic diseases., (Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine © The Author 2014; all rights reserved.)

Over the past two decades, multilateral organizations have encouraged increased engagement with private healthcare providers in developing countries. As these efforts progress, there are concerns regarding how private delivery care may effect maternal health outcomes. Currently available data do not allow for an in-depth study of the direct effect of increasing private sector use on maternal health across countries. As a first step, however, we use demographic and health surveys (DHS) data to (1) examine trends in growth of delivery care provided by private facilities and (2) describe who is using the private sector within the healthcare system. As Asia has shown strong increases in institutional coverage of delivery care in the last decade, we will examine trends in six Asian countries. We hypothesize that if the private sector competes for clients based on perceived quality, their clientele will be wealthier, more educated and live in an area where there are enough health facilities to allow for competition. We test this hypothesis by examining factors of socio-demographic, economic and physical access and actual/perceived need related to a mother's choice to deliver in a health facility and then, among women delivering in a facility, their use of a private provider. Results show a significant trend towards greater use of private sector delivery care over the last decade. Wealth and education are related to private sector delivery care in about half of our countries, but are not as universally related to use as we would expect. A previous private facility birth predicted repeat private facility use across nearly all countries. In two countries (Cambodia and India), primiparity also predicted private facility use. More in-depth work is needed to truly understand the behaviour of the private sector in these countries; these results warn against making generalizations about private sector delivery care., (Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine © The Author 2014; all rights reserved.)

The utility and effectiveness of routine health information systems (RHIS) in improving health system performance in developing countries has been questioned. This paper argues that the health system needs internal mechanisms to develop performance targets, track progress, and create and manage knowledge for continuous improvement. Based on documented RHIS weaknesses, we have developed the Performance of Routine Information System Management (PRISM) framework, an innovative approach to design, strengthen and evaluate RHIS. The PRISM framework offers a paradigm shift by putting emphasis on RHIS performance and incorporating the organizational, technical and behavioural determinants of performance. By describing causal pathways of these determinants, the PRISM framework encourages and guides the development of interventions for strengthening or reforming RHIS. Furthermore, it conceptualizes and proposes a methodology for measuring the impact of RHIS on health system performance. Ultimately, the PRISM framework, in spite of its challenges and competing paradigms, proposes a new agenda for building and sustaining information systems, for the promotion of an information culture, and for encouraging accountability in health systems.