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1.  Assessing the technical efficiency of health posts in rural Guatemala: a data envelopment analysis 
Global Health Action  2014;7:10.3402/gha.v7.23190.
Strengthening health service delivery to the rural poor is an important means of redressing inequities. Meso-level managers can help enhance efficiency in the utilization of existing resources through the application of practical tools to analyze routinely collected data reflecting inputs and outputs. This study aimed to assess the efficiency and change in productivity of health posts over two years in a rural department of Guatemala.
Data envelopment analysis was used to measure health posts’ technical efficiency and productivity change for 2008 and 2009. Input/output data were collected from the regional health office of Alta Verapaz for 34 health posts from the 19 districts comprising the health region.
Technical efficiency varied widely across health posts, with mean scores of 0.78 (SD=0.24) and 0.75 (SD=0.21) in 2008 and 2009, respectively. Overall, productivity increased by 4%, though 47% of health posts experienced a decline in productivity. Results were combined on a bivariate plot to identify health posts at the high and low extremes of efficiency, which should be followed up to determine how and why their production processes are operating differently.
Assessing efficiency using the data that are available at the meso-level can serve as a first step in strengthening performance. Further work is required to support managers in the routine application of efficiency analysis and putting the results to use in guiding efforts to improve service delivery and increase utilization.
PMCID: PMC3901389  PMID: 24461356
data envelopment analysis; efficiency; Malmquist; primary health care; health services management; Guatemala
2.  Determinants of survival in adult HIV patients on antiretroviral therapy in Oromiyaa, Ethiopia 
Global Health Action  2010;3:10.3402/gha.v3i0.5398.
The antiretroviral treatment (ART) scale-up service has been a recent development in Ethiopia, but its impact on mortality has not been well investigated. The aim of this study was to assess the early survival outcome of the scale-up service by utilizing routine hospital data.
All adult HIV/AIDS patients who started on antiretroviral treatment in Shashemene and Assela hospitals from January 1, 2006 to May 31, 2006 were included and followed up for 2 years. Data were extracted from standard patient medical registrations. Kaplan–Meier curves were used to estimate survival probability and the Cox proportional hazard model was applied to determine predictors of mortality. Two alterative assumptions (real case and worst case) were made in determining predictors of mortality.
The median age of patients was 33 years and 57% were female. Eighty-five percent had CD4 <200 cells/µL with a median CD4 count of 103 cells/µL. The median survival time was 104.4 weeks. A total of 28 (10.3%) deaths were observed during the 2-year period and 48 patients (18%) were lost to follow up. The majority of deaths occurred in the first 4 months of treatment. In multivariate analysis, 2-year survival was significantly associated with the clinical stage of the disease, baseline hemoglobin, and cotrimoxazole prophylaxis therapy (CPT) at or before ART initiation in both assumptions. The median CD4 count and body weight showed a marked improvement during the first 6 months of treatment, followed by stagnation thereafter.
The study has shown an overall low mortality but a high loss to follow-up rate of the cohort. Advanced clinical stage, anemia, low body weight, and lack of CPT initiation were independent predictors of mortality – but not gender. CPT initiation should be encouraged in routine HIV care services, and patient retention mechanisms have to be strengthened. Stagnation in immunological and weight recovery after the first 6 months should be further investigated. The utilization of routine data should be encouraged in order to facilitate appropriate decision making.
PMCID: PMC2967337  PMID: 21042435
antiretroviral therapy; CD4; HIV/AIDS; survival analysis; Ethiopia
3.  Performance evaluation of the essential dimensions of the primary health care services in six localities of Bogota–Colombia: a cross-sectional study 
The high segmentation and fragmentation in the provision of services are some of the main problems of the Colombian health system. In 2004 the district government of Bogota decided to implement a Primary Health Care (PHC) strategy through the Home Health program. PHC was conceived as a model for transforming health care delivery within the network of the first-level public health care facilities. This study aims to evaluate the performance of the essential dimensions of the PHC strategy in six localities geographically distributed throughout Bogotá city.
The rapid assessment tool to measure PHC performance, validated in Brazil, was applied. The perception of participants (users, professionals, health managers) in public health facilities where the Home Health program was implemented was compared with the perception of participants in private health facilities not implementing the program. A global performance index and specific indices for each primary care dimension were calculated. A multivariate logistic regression analysis was conducted to determine possible associations between the performance of the PHC dimensions and the self-perceived health status of users.
The global performance index was rated as good for all participants interviewed. In general, with the exception of professionals, the differences in most of the essential dimensions seemed to favor public health care facilities where the Home Health program was implemented. The weakest dimensions were the family focus and community orientation—rated as critical by users; the distribution of financial resources—rated as critical by health managers; and, accessibility—rated as intermediate by users.
The overall findings suggest that the Home Health program could be improving the performance of the network of the first-level public health care facilities in some PHC essential dimensions, but significant efforts to achieve its objectives and raise its visibility in the community are required.
PMCID: PMC3844402  PMID: 23947574
Primary health care; Health services evaluation; Bogota
4.  Primary health care contribution to improve health outcomes in Bogota-Colombia: a longitudinal ecological analysis 
BMC Family Practice  2012;13:84.
Colombia has a highly segmented and fragmented national health system that contributes to inequitable health outcomes. In 2004 the district government of Bogota initiated a Primary Health Care (PHC) strategy to improve health care access and population health status. This study aims to analyse the contribution of the PHC strategy to the improvement of health outcomes controlling for socioeconomic variables.
A longitudinal ecological analysis using data from secondary sources was carried out. The analysis used data from 2003 and 2007 (one year before and 3 years after the PHC implementation). A Primary Health Care Index (PHCI) of coverage intensity was constructed. According to the PHCI, localities were classified into two groups: high and low coverage. A multivariate analysis using a Poisson regression model for each year separately and a Panel Poisson regression model to assess changes between the groups over the years was developed. Dependent variables were infant mortality rate, under-5 mortality rate, infant mortality rate due to acute diarrheal disease and pneumonia, prevalence of acute malnutrition, vaccination coverage for diphtheria, pertussis, tetanus (DPT) and prevalence of exclusive breastfeeding. The independent variable was the PHCI. Control variables were sewerage coverage, health system insurance coverage and quality of life index.
The high PHCI localities as compared with the low PHCI localities showed significant risk reductions of under-5 mortality (13.8%) and infant mortality due to pneumonia (37.5%) between 2003 and 2007. The probability of being vaccinated for DPT also showed a significant increase of 4.9%. The risk of infant mortality and of acute malnutrition in children under-5 years was lesser in the high coverage group than in the low one; however relative changes were not statistically significant.
Despite the adverse contextual conditions and the limitations imposed by the Colombian health system itself, Bogota’s initiative of a PHC strategy has successfully contributed to the improvement of some health outcomes.
PMCID: PMC3556055  PMID: 22898368
Primary health care; Health outcomes; Population Health; Outcomes Assessment; Multivariate analysis; Bogota
5.  ‘It’s the sense of responsibility that keeps you going’: stories and experiences of participation from rural community health workers in Guatemala 
Archives of Public Health  2012;70(1):18.
In 1978, the Alma-Ata declaration on primary health care (PHC) recognized that the world’s health issues required more than just hospital-based and physician-centered policies. The declaration called for a paradigm change that would allow governments to provide essential care to their population in a universally acceptable manner. The figure of the community health worker (CHW) remains a central feature of participation within the PHC approach, and being a CHW is still considered to be an important way of participation within the health system.
This study explores how the values and personal motivation of community health workers influences their experience with this primary health care strategy in in the municipality of Palencia, Guatemala. To do this, we used an ethnographic approach and collected data in January-March of 2009 and 2010 by using participant observation and in-depth interviews.
We found that the CHWs in the municipality had a close working relationship with the mobile health team and with the community, and that their positions allowed them to develop leadership and teamwork skills that may prove useful in other community participation processes. The CHWs are motivated in their work and volunteerism is a key value in Palencia, but there is a lack of infrastructure and growth opportunities.
Attention should be paid to keeping the high levels of commitment and integration within the health team as well as keeping up supervision and economic funds for the program.
PMCID: PMC3464661  PMID: 22958409
Community health workers; Community participation; Guatemala; Primary Health Care; Alma-Ata declaration
6.  Voices from the frontline: counsellors' perspectives on TB/HIV collaborative activities in the Northwest Region, Cameroon 
The overlapping epidemiology of tuberculosis (TB) and human immunodeficiency virus (HIV) infections prompted the World Health Organisation in 2004 to recommend collaboration between national TB and HIV programmes. The goal of this collaboration is to decrease the burden of both infections in the population. This policy was subsequently adopted by the national TB and HIV programmes in Cameroon with TB and HIV nurses/counsellors acting as frontline implementers of the collaborative activities in the 10 regions of the country.
Qualitative research interviews were conducted with 30 nurses/counsellors in four approved treatment centres providing comprehensive TB and HIV/AIDS services in the Northwest region of Cameroon. The aim was to explore their experiences in counselling, in delivering joint TB and HIV services, and the constraints to effective collaboration between TB and HIV services. To complement the findings from the counsellors' interviews, as part of an emergent design, further interviews with 2 traditional healers and non-participant observations in two HIV support group meetings were conducted.
According to the respondents, counselling was regarded as a call to serve humanity irrespective of the reasons for choosing the profession. In addition, the counselling training and supervision received, and the skills acquired, have altogether contributed to build patients' trust in the healthcare system. Teamwork among healthcare workers and other key stakeholders in the community involved in TB/HIV prevention and control was used as a strategy to improve joint service delivery and patients' uptake of services. Several constraints to effective collaboration between TB and HIV services were identified, including shortage of human resources, infrastructure and drug supplies, poor patients' adherence to treatment and the influence of traditional healers who relentlessly dissuade patients from seeking mainstream medical care.
In order to achieve a sustainable collaboration between TB and HIV services, adequate planning, investment and strengthening of the health system including human resources, infrastructure and ensuring uninterrupted supplies of medicines are essential. A multidisciplinary approach to service delivery particularly focusing on harnessing the enormous potentials of traditional healers in TB/HIV prevention and control would also be indispensible.
PMCID: PMC3248870  PMID: 22129222
7.  "If the patients decide not to tell what can we do?"- TB/HIV counsellors' dilemma on partner notification for HIV 
There is a global consensus towards universal access to human immunodeficiency virus (HIV) services consequent to the increasing availability of antiretroviral therapy. However, to benefit from these services, knowledge of one's HIV status is critical. Partner notification for HIV is an important component of HIV counselling because it is an effective strategy to prevent secondary transmission, and promote early diagnosis and prompt treatment of HIV patients' sexual partners. However, counsellors are often frustrated by the reluctance of HIV-positive patients to voluntarily notify their sexual partners. This study aimed to explore tuberculosis (TB)/HIV counsellors' perspectives regarding confidentiality and partner notification.
Qualitative research interviews were conducted in the Northwest Region of Cameroon with 30 TB/HIV counsellors in 4 treatment centres, and 2 legal professionals between September and December 2009. Situational Analysis (positional map) was used for data analysis.
Confidentiality issues were perceived to be handled properly despite concerns about patients' reluctance to report cases of violation due to apprehension of reprisals from health care staffs. All the respondents encouraged voluntary partner notification, and held four varying positions when confronted with patients who refused to voluntarily notify their partners. Position one focused on absolute respect of patients' autonomy; position two balanced between the respect of patients' autonomy and their partners' safety; position three wished for protection of sexual partners at risk of HIV infection and legal protection for counsellors; and position four requested making HIV testing and partner notification routine processes.
Counsellors regularly encounter ethical, legal and moral dilemmas between respecting patients' confidentiality and autonomy, and protecting patients' sexual partners at risk of HIV infection.
This reflects the complexity of partner notification and demonstrates that no single approach is optimal, but instead certain contextual factors and a combination of different approaches should be considered. Meanwhile, adopting a human rights perspective in HIV programmes will balance the interests of both patients and their partners, and ultimately enhance universal access to HIV services.
PMCID: PMC3119031  PMID: 21639894

Results 1-7 (7)