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Objective To evaluate resource allocation and costs associated with delivery of human Immunodeficiency virus (HIV) services In Uganda and the United Republic of Tanzania. Methods We used time-driven activity-based costing to determine the resources consumed and costs of providing five HIV services in Uganda and the United Republic of Tanzania: antiretroviral therapy (ART); HIV testing and counselling; prevention of mother-to-child transmission; voluntary male medical circumcision; and pre-exposure prophylaxis. Findings Country-based teams undertook time-driven activity-based costing with 1119 adults in Uganda and 886 adults in the United Republic of Tanzania. In Uganda, service delivery costs ranged from 8.18 United States dollars (US$) per visit for HIV testing and counselling to US$ 43.43 for ART (for clients in whom HIV was suppressed). In the United Republic of Tanzania, these costs ranged from US$ 3.67 per visit for HIV testing and counselling to US$ 28.00 for voluntary male medical circumcision. In both countries, consumables were the main cost driver, accounting for more than 60% of expenditure. Process maps showed that in both countries, registration, measurement of vital signs, consultation and medication dispensing were the steps that occurred most frequently for ART clients. Conclusion Establishing a rigorous, longitudinal system for tracking investments in HIV services that includes thousands of clients and numerous facilities is achievable in different settings with a high HIV burden. Consistent engagement of implementation partners and standardized training and data collection instruments proved essential for the success of these exercises. Objectif Analyser l'allocation des ressources et les couts lies a la fourniture de services de prise en charge du virus de l'immunodeficience humaine (VIH) en Ouganda et en Republique-Unie de Tanzanie. Methodes Nous avons utilise un systeme de calcul des couts par activite pilote par le temps (TDABC), pour identifier les ressources consommees et les couts engendres par cinq services de prise en charge du VIH en Ouganda et en Republique-Unie de Tanzanie: le traitement antiretroviral (TAR); le depistage du VIH et les conseils en la matiere; la prevention de la transmission de la mere a l'enfant; la pratique volontaire de la circoncision masculine medicalisee; et enfin, la prophylaxie preexposition. Resultats Des equipes deployees dans chaque pays ont mene un calcul des couts par activite pilote par le temps aupres de 1119 adultes en Ouganda et 886 adultes en Republique-Unie de Tanzanie. En Ouganda, les couts de prestation des services etaient compris entre 8,18 dollars americains (USD) par visite de depistage du VIH et de conseils en la matiere, et 43,43 USD pour un TAR (sur les patients chez qui la charge virale a ete supprimee). En Republique-Unie de Tanzanie, ces couts variaient entre 3,67 USD par visite de depistage du VIH et de conseils en la matiere a 28,00 USD pour la pratique volontaire de la circoncision masculine medicalisee. Dans les deux pays, les consommables representaient le principal facteur de cout, avec plus de 60% des depenses. Les schemas de procedure ont montre que, dans les deux pays, l'enregistrement, la mesure des signes vitaux, la consultation et l'administration du traitement constituaient les etapes les plus frequentes chez les patients faisant l'objet d'un TAR. Conclusion Il est possible d'etablir un dispositif longitudinal rigoureux pour suivre les investissements realises dans les services de prise en charge du VIH, qui inclut des milliers de patients et de nombreux etablissements dans differents endroits fortement touches par le VIH. Limplication constante des partenaires de mise en oeuvre et la standardisation des formations et instruments de collecte des donnees se sont revelees essentielles a la reussite de ces demarches. Objetivo Analizar la asignacion de recursos y los costes asociados a la prestacion de servicios por el virus de la inmunodeficiencia humana (VIH) en Uganda y en la Republica Unida de Tanzania. Metodos Utilizamos los costes basados en el tiempo invertido por actividad, con el fin de determinar los recursos consumidos y los costes de la prestacion de cinco servicios por VIH en Uganda y en la Republica Unida de Tanzania: terapia antirretroviral (TAR); pruebas y asesoramiento sobre el VIH; prevencion de la transmision de madre a hijo; circuncision medica masculina de caracter voluntario y profilaxis previa a la exposicion. Resultados Los equipos fundados en el pais se encargaron de analizar los costes basados en el tiempo invertido por actividad con 1119 adultos en Uganda y 886 adultos en la Republica Unida de Tanzania. En Uganda, los costes por la prestacion de servicios oscilaron entre 8,18 dolares estadounidenses (USD) por visita destinada a pruebas y asesoramiento sobre VIH, y 43,43 USD por TAR (para clientes en los que se habia erradicado el VIH). En la Republica Unida de Tanzania, estos costes estuvieron comprendidos entre 3,67 USD por visita destinada a pruebas y asesoramiento sobre VIH, y 28,00 USD por circuncision medica masculina de caracter voluntario. En ambos paises, los consumibles fueron los principales generadores de costes, representando mas del 60% del gasto. Los mapas de procesos mostraron que en ambos paises el registro, la medicion de las constantes vitales, asi como las consultas y la dispensacion de medicacion fueron los pasos que mas se repitieron entre los clientes con TAR. Conclusion Implantar un sistema riguroso y longitudinal para realizar un seguimiento de las inversiones en servicios por VIH, lo que engloba a miles de clientes y numerosas instalaciones, es algo que se puede lograr en aquellos centros con una elevada incidencia de VIH. Quedo demostrado que el compromiso constante de los socios encargados de la implementacion, asi como la existencia de instrumentos estandarizados de formacion y de recopilacion de datos resultaban esenciales para el exito de estos ejercicios., Introduction Despite evolving epidemiological trends, human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) are still responsible for one of the largest disease burdens in sub-Saharan Africa. (1) In low-income [...]

ObjectiveFood insecurity impedes antiretroviral therapy (ART) adherence. We previously demonstrated that short-term cash and food incentives increased ART possession and retention in HIV services in Tanzania. To elucidate potential pathways that led to these achievements, we examined whether incentives also improved food insecurity.DesignThree-arm randomized controlled trial.MethodsFrom 2013 to 2015, 805 food-insecure adult ART initiates (≤90 days) at three clinics were randomized to receive cash or food transfers (∼$11 per month for ≤6 months, conditional on visit attendance) or standard-of-care (SOC) services. We assessed changes from baseline to 6 and 12 months in: food insecurity (severe; access; dietary diversity), nutritional status (body weight; BMI), and work status. Difference-in-differences average treatment effects were estimated using inverse-probability-of-censoring-weighted longitudinal regression models.ResultsThe modified intention-to-treat analysis included 777 nonpregnant participants with 41.6% severe food insecurity. All three study groups experienced improvements from baseline in food insecurity, nutritional status, and work status. After 6 months, severe food insecurity declined within the cash (-31.4% points to 11.5%) and food (-30.3 to 10.4%) groups, but not within the SOC. Relative to the SOC, severe food insecurity decreased by an additional 24.3% points for cash (95% CI -45.0 to -3.5) and 23.3% percent points for food (95% CI -43.8 to -2.7). Neither intervention augmented improvements in severe food insecurity at 12 months, nor food access, dietary diversity, nutritional status, or work status at 6 or 12 months.ConclusionSmall cash and food transfers provided at treatment initiation may mitigate severe food insecurity. These effects may have facilitated previously observed improvements in ART adherence.

A recently concluded randomized study in Tanzania found that short-term conditional cash and food transfers significantly improved HIV-infected patients’ possession of antiretroviral therapy (ART) and reduced patient loss to follow-up (LTFU) (McCoy, S. I., Njau, P. F., Fahey, C., Kapologwe, N., Kadiyala, S., Jewell, N. P., & Padian, N. S. (2017). Cash vs. food assistance to improve adherence to antiretroviral therapy among HIV-infected adults in Tanzania. AIDS, 31(6), 815–825. doi:10.1097/QAD.0000000000001406 ). We examined whether these transfers had differential effects within population subgroups. In the parent study, 805 individuals were randomized to one of three study arms: standard-of-care (SOC) HIV services, food assistance, or cash transfer. We compared achievement of the medication possession ratio (MPR) ≥ 95% at 6 and 12 months and patient LTFU at 12 months between those receiving the SOC and those receiving food or cash (combined). Using a threshold value of p

ObjectiveWe evaluated the effectiveness of short-term cash and food assistance to improve adherence to antiretroviral therapy (ART) and retention in care among people living with HIV in Tanzania.MethodsAt three clinics, 805 participants were randomized to three groups in a 3 : 3 : 1 ratio, stratified by site : nutrition assessment and counseling (NAC) and cash transfers (∼$11/month, n = 347), NAC and food baskets (n = 345), and NAC-only (comparison group, n = 113, clinicaltrials.gov NCT01957917). Eligible people living with HIV were at least 18 years, initiated ART 90 days or less prior, and food insecure. Cash or food was provided for 6 or less consecutive months, conditional on visit attendance. The primary outcome was medication possession ratio (MPR ≥ 95%) at 6 months. Secondary outcomes were appointment attendance and loss to follow-up (LTFU) at 6 and 12 months.ResultsThe primary intent-to-treat analysis included 800 participants. Achievement of MPR ≥ 95% at 6 months was higher in the NAC + cash group compared with NAC-only (85.0 vs. 63.4%), a 21.6 percentage point difference [95% confidence interval (CI): 9.8, 33.4, P

BackgroundInterventions incorporating constructs from behavioral economics and psychology have the potential to enhance HIV 'treatment as prevention' (TasP) strategies. To test this hypothesis, we evaluated an intervention to improve antiretroviral therapy (ART) adherence based on the concepts of social norms and priming.MethodsWe used tools from marketing research and patient-centered design to develop a combination intervention that included visual feedback about clinic-level retention in care, a self-relevant prime, and useful take-home items with the priming image. The intervention was implemented at two HIV primary clinics in Shinyanga, Tanzania in 2-week intervals for six months. We conducted a quasi-experimental pilot study with a random sample of exposed and unexposed adult patients living with HIV infection (PLHIV) to compare retention and the proportion of patients with medication possession ratio (MPR) ≥95% after six months. Intervention acceptability was determined with a convenience sample of 405 PLHIV at baseline (n = 189) and endline (n = 216).ResultsMedical records were reviewed for 438 PLHIV (320 intervention, 118 standard of care). In adjusted analyses, PLHIV exposed to the intervention were significantly more likely to be in care after 6 months (87% vs. 79%, adjusted odds ratio (ORa) = 1.73, 95% CI: 1.08, 2.78, p

Background: The use of data in decision making and planning in primary health care settings is critical for improving efficiency and health outcomes for patients and communities. Implementation research can be used to fully understand the effects, context, challenges, and facilitators of data use, as well as how to scale up data use interventions. However, in the context of low resource settings, little is known about how implementation research can be employed to assess the implementation and impact of data use interventions. Methods: We will conduct a hybrid type 2 effectiveness-implementation study employing a mixed method controlled before and after design to measure the effects of data use interventions while simultaneously understanding the implementation of those initiatives. The controlled before and after entails measurement of the effects of the interventions at baseline and end line in a matched intervention and control health facilities using structured questionnaire to health workers (n = 440) and existing patients (n = 422) while also extracting selected health outcome variable from routine data in all participating health facilities (n = 80). The mixed methods component entails measuring the implementation outcomes (adoption, acceptability, fidelity and maintenance) and their moderators entails the integration of both quantitative and qualitative data collection, analysis, and interpretation (i.e. mixed methods) approach by using a structured questionnaire to implementers (health workers and managers) (n = 400). Experiential dimensions of implementation processes and moderators will be explored using qualitative interviews. Guided by implementation research theories and frameworks, a theory of change (TOC) is developed first to guide the evaluation of implementation processes and effects of the interventions. Descriptive and inferential statistics will be employed to analyze quantitative data whereas thematic analysis approach will be employed for qualitative data. Discussion: This study is one of the first to test the simultaneous measurement of effects and implementation processes of data use interventions in the primary health care settings. Findings will support efforts to improve quality of services by optimizing scale up and sustainability of the data use initiatives in primary health care settings. [ABSTRACT FROM AUTHOR]

Background: Access to essential health commodities is fundamental to healthcare system efficacy. These commodities are vital in delivering health services and form integral elements within the World Health Organization's strengthening framework, encompassing the six foundational building blocks. Regrettably, there has been a global increase in shortages and stockouts of essential health commodities in recent years. Objective: The study aimed to identify factors influencing the availability of essential health commodities throughout all levels of the supply chain in Tanzania. Methods: A cross-sectional convergent parallel mixed method study that employed both qualitative and quantitative data collection techniques was conducted. Quantitative data were analyzed using STATA version 16, while qualitative data were thematically analyzed. Results: Factors contributing to stockouts of essential commodities at the national level included increased demand, delayed shipments from donors, decreased funding commitments, delayed disbursement of funds, global shortages, inadequate governance, debt within the Medical Stores Department, donor dependency for vertical programme commodities, and long lead times by Medical Stores Department's suppliers. At the regional and district levels, such factors include a shortage of human resources, lack of electronic medical records, limited interoperability of information systems, poor quality of logistics data, inadequate use of data for decision-making, and poor inventory management. At the healthcare facility level, factors included; an overwhelming number of exempted clients, which reduces facility revenues. Conclusion: More efforts are still needed to address both the upstream and downstream challenges required to ensure sustainable access and availability of essential health commodities at service delivery points, as a pathway for improving health sector performance. [ABSTRACT FROM AUTHOR]

Organizational learning is critical for delivering safe, high-quality surgical care, especially in low- and middle-income countries (LMICs) where perioperative outcomes remain poor. While current investments in LMICs prioritize physical infrastructure, equipment, and staffing, investments in organizational learning are equally important to support innovation, creativity, and continuous improvement of surgical quality. This study aims to assess the extent to which health facilities in Tanzania's Lake Zone perform as learning organizations from the perspectives of surgical providers. The insights gained from this study can motivate future quality improvement initiatives and investments to improve surgical outcomes. We conducted a cross-sectional analysis using data from an adapted survey to explore the key components of organizational learning, including a supportive learning environment, effective learning processes, and encouraging leadership. Our sample included surgical team members and leaders at 20 facilities (health centers, district hospitals, and regional hospitals). We calculated the average of the responses at individual facilities. Responses that were 5+ on a 7-point scale or 4+ on a 5-point scale were considered positive. We examined the variation in responses by facility characteristics using a one-way ANOVA or Student's t -test. We used univariate and multiple regression to assess relationships between facility characteristics and perceptions of organizational learning. Ninety-eight surgical providers and leaders participated in the survey. The mean facility positive response rate was 95.1% (SD 6.1%). Time for reflection was the least favorable domain with a score of 62.5% (SD 35.8%). There was variation by facility characteristics including differences in time for reflection when comparing by level of care (P  = .02) and location (P  = .01), and differences in trying new approaches (P  = .008), capacity building (P  = .008), and information transfer (P  = .01) when comparing public versus faith-based facilities. In multivariable analysis, suburban centers had less time for reflection than urban facilities (adjusted difference = −0.48; 95% CI: −0.95, −0.01; P  = .046). Surgical team members reported more positive responses compared to surgical team leaders. We found a high overall positive response rate in characterizing organizational learning in surgery in 20 health facilities in Tanzania's Lake Zone. Our findings identify areas for improvement and provide a baseline for assessing the effectiveness of change initiatives. Future research should focus on validating the adapted survey and exploring the impact of strong learning environments on surgical outcomes in LMICs. Organizational learning is crucial in surgery and further research, funding, and policy work should be dedicated to improving learning cultures in health facilities. [ABSTRACT FROM AUTHOR]

Background: Strengthening health systems through planned safety and quality improvement initiatives is an imperative to achieve more equitable, resilient, and effective care. And yet, years of organizational behavior research demonstrate that change initiatives often fall short because managers fail to account for organizational readiness for change. This finding remains true especially among surgical safety and quality improvement initiatives in low-income countries and middle-income countries. In this study, our aim was to psychometrically assess the construct validity and internal consistency of the Safe Surgery Organizational Readiness Tool (SSORT), a short survey tool designed to provide change leaders with insight into facility infrastructure that supports learning and readiness to undertake change. Materials and methods: To demonstrate generalizability and achieve a large sample size (n=1706) to conduct exploratory factor analysis (EFA) and confirmatory factor analysis (CFA), a collaboration between seven surgical and anesthesia safety and quality improvement initiatives was formed. Collected survey data from health care workers were divided into pilot, exploration, and confirmation samples. The pilot sample was used to assess feasibility. The exploration sample was used to conduct EFA, while the confirmation sample was used to conduct CFA. Factor internal consistency was assessed using Cronbach's alpha coefficient. Results: Results of the EFA retained 9 of the 16 proposed factors associated with readiness to change. CFA results of the identified 9 factor model, measured by 28 survey items, demonstrated excellent fit to data. These factors (appropriateness, resistance to change, team efficacy, team learning orientation, team valence, communication about change, learning environment, vision for sustainability, and facility capacity) were also found to be internally consistent. Conclusion: Our findings suggest that communication, team learning, and supportive environment are components of change readiness that can be reliably measured prior to implementation of projects that promote surgical safety and quality improvement in low-income countries and middle-income countries. Future research can link performance on identified factors to outcomes that matter most to patients. [ABSTRACT FROM AUTHOR]