R4D Zambia

Health workforce responses to global health initiatives funding: a comparison of Malawi and Zambia

Wed, 16 May 2012 07:22 GMT

Document Type: Journal Article
Creator: Brugha, R.; Kadzndira, J.; Simbaya, J.; Dicker, P.; Mwapasa, V.; Walsh, A.

Production Year: 2010

Citation: Brugha, R.; Kadzndira, J.; Simbaya, J.; Dicker, P.; Mwapasa, V.; Walsh, A. Health workforce responses to global health initiatives funding: a comparison of Malawi and Zambia. Human Resources for Health (2010) 8 (1) 19. [DOI: 10.1186/1478-4491-8-19]

Summary: Background
Shortages of health workers are obstacles to utilising global health initiative (GHI) funds effectively in Africa. This paper reports and analyses two countries' health workforce responses during a period of large increases in GHI funds.
Methods
Health facility record reviews were conducted in 52 facilities in Malawi and 39 facilities in Zambia in 2006/07 and 2008; quarterly totals from the last quarter of 2005 to the first quarter of 2008 inclusive in Malawi; and annual totals for 2004 to 2007 inclusive in Zambia. Topic-guided interviews were conducted with facility and district managers in both countries, and with health workers in Malawi.
Results
Facility data confirm significant scale-up in HIV/AIDS service delivery in both countries. In Malawi, this was supported by a large increase in lower trained cadres and only a modest increase in clinical staff numbers. Routine outpatient workload fell in urban facilities, in rural health centres and in facilities not providing antiretroviral treatment (ART), while it increased at district hospitals and in facilities providing ART. In Zambia, total staff and clinical staff numbers stagnated between 2004 and 2007. In rural areas, outpatient workload, which was higher than at urban facilities, increased further. Key informants described the effects of increased workloads in both countries and attributed staff migration from public health facilities to non-government facilities in Zambia to PEPFAR.
Conclusions
Malawi, which received large levels of GHI funding from only the Global Fund, managed to increase facility staff across all levels of the health system: urban, district and rural health facilities, supported by task-shifting to lower trained staff. The more complex GHI arena in Zambia, where both Global Fund and PEPFAR provided large levels of support, may have undermined a coordinated national workforce response to addressing health worker shortages, leading to a less effective response in rural areas.

Demand for Maize Hybrids, Seed Subsidies, and Seed Decisionmakers in Zambia. HarvestPlus Working Paper No. 8.

Tue, 15 May 2012 05:00 GMT

Document Type: Working Paper
Creator: Smale, M.; Mason, N.

Production Year: 2012

Citation: Smale, M.; Mason, N. Demand for Maize Hybrids, Seed Subsidies, and Seed Decisionmakers in Zambia. HarvestPlus Working Paper No. 8. (2012) 21 pp.

Summary: The successful development and diffusion of improved maize seed in Zambia during the 1970s–80s was a major achievement of African agriculture but was predicated on a government commitment to parastatal grain and seed marketing, the provision of services to maize growers, and a pan-territorial pricing scheme that was fiscally unsustainable. Declining maize output when this system was dismantled contributed to the reinstatement in 2002 of subsidies for maize seed and fertilizer through the Fertilizer and Farmer Input Support Programs (FISP). In the meantime, seed liberalization has led to an array of new, improved maize varieties, most of which are hybrids. This analysis explores the determinants of demand for first-generation (F1) hybrid maize seed in Zambia based on a survey of maize growers during the 2010/11 cropping season. We estimate the determinants of demand with a control function approach to handle the potential endogeneity of the binary variable measuring subsidy receipt and compare determinants of demand between female and male seed decisionmakers. We find that hybrid seed use in Zambia is still very much an “affair of state” in that farmers’ use of F1 hybrids is explained largely by inclusion in FISP. The quality (literacy) of the labor supply, the ratio of active labor to dependents in the household, sources of information, and length of residence in the village are predictors of maize seed subsidy receipt. Overall, we find that male and female seed decisionmakers may represent distinct demand segments. The fact that the percentage of seed decisionmakers who are women is much higher than the percentage of women who are de jure or de facto household heads has implications for the design of extension strategies and variety promotion.

Acceptability of Vaginal Film, Soft-Gel Capsule, and Tablet as Potential Microbicide Delivery Methods Among African Women

Fri, 04 May 2012 08:00 GMT

Document Type: Journal Article
Creator: Nel, A.M.; Mitchnick, L.B.; Risha, P.; Muungo, L.T.M.; Norick, P.M.

Production Year: 2011

Citation: Nel, A.M.; Mitchnick, L.B.; Risha, P.; Muungo, L.T.M.; Norick, P.M. Acceptability of Vaginal Film, Soft-Gel Capsule, and Tablet as Potential Microbicide Delivery Methods Among African Women. Journal of Women's Health (2011) 20 (8) 1207-1214. [DOI: 10.1089/jwh.2010.2476]

Summary: Background: Vaginal microbicides are in development for the prevention of HIV transmission to women via sexual intercourse. Acceptability of the microbicide delivery method in the targeted population is important to product adherence and, therefore, product effectiveness. It is anticipated that multiple delivery methods will be required to satisfy personal preferences among future microbicide users.

Methods: A total of 526 sexually active women aged 18–30 years participated in a consumer product preference study in Burkina Faso, Tanzania, and Zambia. Screened women who had given consent were instructed to use each of the three products (placebo formulations of a vaginal tablet, film, and soft-gel capsule) once daily for 7 consecutive days for a total of 21 days. Women were interviewed about their impressions of the product at the completion of each 7-day trial period.

Results: Over 80% of women reported they liked using each dosage form, and over 85% said they would definitely use it. The film and soft-gel capsule were chosen significantly more often than the tablet as the preferred dosage form (39% and 37% vs. 25%, respectively) mainly because of faster dissolving time and easier insertion. Women in Burkina Faso and Tanzania preferred the soft-gel capsule (42%–46%), whereas Zambian women preferred the film (51%). Age, socioeconomic status, and marital status did not significantly affect product preference.

Conclusions: All three dosage forms were acceptable to the women surveyed. Preferred dosage forms varied by country. These data suggest that the availability of microbicides in multiple dosage forms may increase acceptability, adherence, and, therefore, effectiveness.

Patient care seeking barriers and tuberculosis programme reform: a qualitative study

Mon, 23 Apr 2012 09:08 GMT

Document Type: Journal Article
Creator: Needham, D.M.; Bowman, D.; Foster, S.D.; Godfrey-Faussett, P.

Production Year: 2004

Citation: Needham, D.M.; Bowman, D.; Foster, S.D.; Godfrey-Faussett, P. Patient care seeking barriers and tuberculosis programme reform: a qualitative study. Health Policy (2004) 67 (1) 93-106. [DOI: 10.1016/S0168-8510(03)00065-4]

Summary: The patient's perspective, including his/her socio-economic and cultural environment, is an important consideration for tuberculosis control programmes. Through semi-structured interviews, this qualitative research studies the barriers to successful care seeking faced by 202 adult patients with pulmonary tuberculosis in urban Zambia. Three common, interdependent themes explain patient barriers to successful care seeking: (1) number of health care encounters and duration of illness prior to diagnosis; (2) existing financial constraints and additional unrecognized patient costs; and (3) travel distances. On average, patients have 6.7 health care encounters prior to being diagnosed with tuberculosis. Within a resource-poor setting, patients face financial constraints and unrecognized costs associated with their illness. Specifically, travel distances and related transportation costs create a significant burden on patients. In addition, ‘special food’ expenditures add to their financial constraints. The implications of these patient barriers from this study are then discussed in the context of three tuberculosis programme reforms occurring in sub-Saharan Africa: (1) decentralization of tuberculosis services; (2) integration of tuberculosis and other services; and (3) evaluation of diagnostic techniques. The patient's perspective and related care seeking barriers should be considered in reviewing existing tuberculosis programmes and policy, evaluating potential programme reform and assessing new tuberculosis interventions.

Development of a Bacteriophage Phage Replication Assay for Diagnosis of Pulmonary Tuberculosis

Mon, 23 Apr 2012 08:52 GMT

Document Type: Journal Article
Creator: McNerney, R.; Kambashi, B.S.; Kinkese, J.; Tembwe, R.; Godfrey-Faussett, P.

Production Year: 2004

Citation: McNerney, R.; Kambashi, B.S.; Kinkese, J.; Tembwe, R.; Godfrey-Faussett, P. Development of a Bacteriophage Phage Replication Assay for Diagnosis of Pulmonary Tuberculosis. Journal of Clinical Microbiology (2004) 42 (5) 2115-2120. [DOI: 10.1128/JCM.42.5.2115-2120.2004]

Summary: Successful infection and replication of bacteriophages is indicative of the presence of viable bacteria. We describe here the development of a bacteriophage replication assay for the detection of Mycobacterium tuberculosis by using mycobacteriophage D29. Optimization of phage inoculate and incubation times allowed highly sensitive detection of M. bovis BCG. Fewer than 10 CFU (100 CFU/ml) were detected. No false-positive results were observed in negative samples. Application of the assay to 496 sputum specimens in the National Reference Laboratory of Zambia produced sensitivity, specificity, and positive and negative predictive values of 44.1, 92.6, 82.2, and 67.5%, respectively, compared to culture on Lowenstein-Jensen medium. The equivalent corresponding results for direct fluorescent smear microscopy were 42.3, 96.8, 91.2, and 67.6%. The small increase in sensitivity over that of direct microscopy does not justify the introduction of this technique for routine diagnosis of pulmonary tuberculosis at this time.

Comparison of two bacteriophage tests and nucleic acid amplification for the diagnosis of pulmonary tuberculosis in sub-Saharan Africa

Mon, 23 Apr 2012 08:45 GMT

Document Type: Journal Article
Creator: Mbulo, G.M.; Kambashi, B.S.; Kinkese, J.; Tembwe, R.; Shumba, B.; Godfrey-Faussett, P.; McNerney, R.

Production Year: 2004

Citation: Mbulo, G.M.; Kambashi, B.S.; Kinkese, J.; Tembwe, R.; Shumba, B.; Godfrey-Faussett, P.; McNerney, R. Comparison of two bacteriophage tests and nucleic acid amplification for the diagnosis of pulmonary tuberculosis in sub-Saharan Africa. International Journal of Tuberculosis and Lung Disease (2004) 8 (11) 1342-1347.

Summary: SETTING: National reference laboratory in Zambia, a high-incidence setting with a high prevalence of HIV infection.

OBJECTIVE: To compare the performance of a commercial bacteriophage kit with a nucleic acid amplification kit and an ‘in-house’ bacteriophage method for rapid diagnosis of pulmonary tuberculosis (TB).

METHODS: Sputum specimens from suspected pulmonary TB cases were examined by direct fluorescence microscopy and culture on Löwenstein Jensen (LJ). In a blinded study, remaining samples were tested by AMTD and FASTPlaqueTB™ or an in-house bacteriophage assay. Two specimen decontamination protocols were investigated.

RESULTS: Microbial contamination of 40.4% was observed when using the FASTPlaqueTB kit specimen preparation protocol. When compared to culture on LJ, the sensitivity of the FASTPlaqueTB test was 20.7%. Implementation of a modified Petroff's decontamination protocol reduced contamination to 5.8% and the FASTPlaqueTB test detected 8/25 (32%) of culture-positive specimens. The sensitivity of AMTD and smear microscopy for these specimens were 64% and 48%, respectively. In a separate experiment the sensitivity of an in-house bacteriophage assay was 45.3% compared to 64.2% for AMTD and 45.3% for direct smear microscopy.

CONCLUSIONS: Additional analysis of sputum specimens by bacteriophage assay provided no advantage in this setting. For the rapid diagnosis of TB, AMTD offered improved sensitivity over direct smear microscopy.

Removing financial barriers to access reproductive, maternal and newborn health services: the challenges and policy implications for Human Resources for Health (HRH)

Thu, 05 Apr 2012 07:48 GMT

Document Type: Case Study
Creator: McPake, B.; Witter, S.; Ensor, T.; Fustukian, S.; Newlands, D.; Martineau, T.

Production Year: 2011

Citation: McPake, B.; Witter, S.; Ensor, T.; Fustukian, S.; Newlands, D.; Martineau, T. Removing financial barriers to access reproductive, maternal and newborn health services: the challenges and policy implications for Human Resources for Health (HRH). Queen Margaret University, East Lothian, UK (2011) 196 pp.

Summary:

In the last decade a growing consensus has emerged that user fees are regressive and undermine equitable access to essential health services, and in particular, may negatively affect pregnant women and children under five. A policy shift removing or reducing fees has occurred with consequences for the health system, including the need for replacement revenue and to ensure quality in response to increased utilization. Both of these raise specific concerns for human resources for health (HRH) and suggest that careful planning of the supply side response to the demand stimulated by removal of fees has to take place.

This research responds to this concern. Its objective is to determine the associations and interrelationships between workforce characteristics (stock, distribution, competencies and motivational state) and equitable access to Reproductive, Maternal and Neonatal Health (RMNH) services resulting from the removal of, or exemption from user fees.

The study was conducted in five countries: Ghana, Nepal, Sierra Leone, Zambia and Zimbabwe, and consisted of literature review of international and local published and grey literature, desk based analysis of secondary data from the five countries and field work in two countries, including primary data collection in Zimbabwe.

This document comprises a 6-page policy brief, the main report, the literature review, the 5 case studies and references.

insights 82. Innovative approaches to gender and food security.

Wed, 04 Apr 2012 04:54 GMT

Document Type: Briefing
Creator: Susanne Turrall (Editor)

Production Year: 2012

Citation: Susanne Turrall (Editor). insights 82. Innovative approaches to gender and food security. Institute of Development Studies, University of Sussex, Brighton, UK (2012) 8 pp.

Summary:

This issue of insights is the result of a collaborative process involving experts working in policy, research and practice on gender and food security in four global regions. At the centre of the process was a dynamic online discussion, which raised many issues and questions around the gender power dynamics of food production, consumption and governance. Particularly interesting, was the extent to which participants identified transformative development pathways that promote food security and poverty reduction while also enabling shifts in gender power relations. Focusing on six projects in South Asia, Africa, Latin America and the Middle East, the articles in this issue illustrate some of these pathways:

Transforming gender relations in homestead food production in Bangladesh (Emily Hillenbrand)
Challenging cultural values that affect food security in India (Suniti Neogy)
Equal access for women to seeds and food security in Syria (Alessandra Galié)
Engaging the whole family in food security planning in Zambia (Cathy Rozel Farnworth)
Women's groups versus households. Approaches to achieve food security and gender equality (Agnes Quisumbing and Neha Kumar)
Food sovereignty and women’s rights in Latin America (Pamela Caro)

Priorities for Antiretroviral Therapy Research in Sub-Saharan Africa: A 2002 Consensus Conference in Zambia

Tue, 03 Apr 2012 04:55 GMT

Document Type: Journal Article
Creator: Zulu, I.; Schuman, P.; Musonda, R.; Chomba, E.; Mwinga, K.; Sinkala, M.; Chisembele, M.; Mwaba, P.; Kasonde, D.; Vermund, S.H.

Production Year: 2004

Citation: Zulu, I.; Schuman, P.; Musonda, R.; Chomba, E.; Mwinga, K.; Sinkala, M.; Chisembele, M.; Mwaba, P.; Kasonde, D.; Vermund, S.H. Priorities for Antiretroviral Therapy Research in Sub-Saharan Africa: A 2002 Consensus Conference in Zambia. JAIDS Journal of Acquired Immune Deficiency Syndromes (2004) 36 (3) 831-834.

Summary: Background: A consensus conference was held to discuss priorities for antiretroviral therapy (ART) research in Zambia, one of the world's most heavily HIV-afflicted nations. Zambia, like other resource-limited settings, has increasing access to highly active antiretroviral therapy (HAART) because of declining drug costs, use of government-purchased generic medications, and increased global donations. For sustained delivery of care with HAART in a resource-constrained medical and public health context, operational research is required and clinical trials are desirable. The priority areas for research are most relevant today given the increasing availability of HAART.

Methods: A conference was held in Lusaka, Zambia, in January 2002 to discuss priority areas for ART research in Zambia, with participants drawn from a broad cross section of Zambian society. State-of-the-art reviews and 6 intensive small group discussions helped to formulate a suggested research agenda.

Results: Conference participants believed that the most urgent research priorities were to assess how therapeutic resources could be applied for the greatest overall benefit and to minimize the impact of nonadherence and viral resistance. Identified research priorities were as follows:

1. To determine when to initiate HAART in relation to CD4+ cell count

2. To assess whether HIV/AIDS can be managed well without the use of costly frequent viral load measurements and CD4+ cell count monitoring

3. To assess whether HIV/AIDS can be managed in the same fashion in patients coinfected with opportunistic infections such as tuberculosis and HIV-related chronic diarrhea, taking into consideration complications that may occur in tuberculosis such as immune reconstitution syndrome and medication malabsorption in the presence of diarrhea

4. To carefully assess and characterize toxicities, adverse effects, and viral resistance patterns in Zambia, including studies of mothers exposed to prepartum single-dose nevirapine

5. To conduct operational research to assess clinical and field-based strategies to maximize adherence for better outcomes of ART in Zambia

6. To assess ART approaches most valuable for pediatric and adolescent patients in Zambia

Conference participants recommended that HIV-related clinical care and research be integrated within home-based care services and operated within the existing health delivery structures to ensure sustainability, reduce costs, and strengthen the structures.

Conclusion: Our consensus was that antiretroviral clinical trials and operational research are essential for Zambia to address the new challenges arising from increasing ART availability. There is global consensus that antiretroviral clinical trials in resource-constrained countries are possible, and the capacity for such trials should be developed further in Africa.

Co-trimoxazole as prophylaxis against opportunistic infections in HIV-infected Zambian children (CHAP): a double-blind randomised placebo-controlled trial

Mon, 02 Apr 2012 07:22 GMT

Document Type: Journal Article
Creator: Chintu, C.; Bhat, G.J.; Walker, A.S.; Mulenga, V.; Sinyinza, F.; Lishimpi, K.; Farrelly, L.; Kangason, N.; Zumla, A.; Gillespie, S.H.; Nunn, A.J.; Gibb, D.M.

Production Year: 2004

Citation: Chintu, C.; Bhat, G.J.; Walker, A.S.; Mulenga, V.; Sinyinza, F.; Lishimpi, K.; Farrelly, L.; Kangason, N.; Zumla, A.; Gillespie, S.H.; Nunn, A.J.; Gibb, D.M. Co-trimoxazole as prophylaxis against opportunistic infections in HIV-infected Zambian children (CHAP): a double-blind randomised placebo-controlled trial. Lancet (2004) 364 (9448) 1865-1871. [DOI: 10.1016/S0140-6736(04)17442-4]

Summary: Background No trials of co-trimoxazole (trimethoprim-sulfamethoxazole) prophylaxis for HIV-infected adults or children have been done in areas with high levels of bacterial resistance to this antibiotic. We aimed to assess the efficacy of daily co-trimoxazole in such an area.

Methods We did a double-blind randomised placebo-controlled trial in children aged 1—14 years with clinical features of HIV infection in Zambia. Primary outcomes were mortality and adverse events possibly related to treatment. Analysis was by intention to treat.

Findings In October, 2003, the data and safety monitoring committee recommended early stopping of the trial. 541 children had been randomly assigned; seven were subsequently identified as HIV negative and excluded. After median follow-up of 19 months, 74 (28%) children in the co-trimoxazole group and 112 (42%) in the placebo group had died (hazard ratio [HR] 0·57 [95% CI 0·43—0·77], p=0·0002). This benefit applied in children followed up beyond 12 months (n=320, HR 0·48 [0·27—0·84], test for heterogeneity p=0·60) and across all ages (test for heterogeneity p=0·82) and baseline CD4 counts (test for heterogeneity p=0·36). 16 (6%) children in the co-trimoxazole group had grade 3 or 4 adverse events compared with 18 (7%) in the placebo group. These events included rash (one placebo), and a neutrophil count on one occasion less than 0·5×109/L (16 [6%] co-trimoxazole vs seven [3%] placebo, p=0·06). Pneumocystis carinii was identified by immunofluorescence in only one (placebo) of 73 nasopharyngeal aspirates from children with pneumonia.

Interpretation Our results suggest that children of all ages with clinical features of HIV infection should receive co-trimoxazole prophylaxis in resource-poor settings, irrespective of local resistance to this drug.