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Doshmangir L, Mostafavi H, Behzadifar M, Yazdizadeh B, Sajadi HS, Hasanpoor E, Mahdavi M, Majdzadeh R. Individual and institutional capacity-building for evidence-informed health policy-making in Iran: a mix of local and global evidence. Health Res Policy Syst 2022; 20:18. [PMID: 35151312 PMCID: PMC8841080 DOI: 10.1186/s12961-022-00816-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 01/13/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Providing valid evidence to policy-makers is a key factor in the development of evidence-informed policy-making (EIPM). This study aims to review interventions used to promote researchers’ and knowledge-producing organizations’ knowledge and skills in the production and translation of evidence to policy-making and explore the interventions at the individual and institutional level in the Iranian health system to strengthen EIPM.
Methods
The study was conducted in two main phases: a systematic review and a qualitative study. First, to conduct the systematic review, the PubMed and Scopus databases were searched. Quality appraisal was done using the Joanna Briggs Institute checklists. Second, semi-structured interviews and document review were used to collect local data. Purposive sampling was used and continued until data saturation. A qualitative content analysis approach was used for data analysis.
Results
From a total of 11,514 retrieved articles, 18 papers were eligible for the analysis. Based on the global evidence, face-to-face training workshops for researchers was the most widely used intervention for strengthening researchers’ capacity regarding EIPM. Target audiences in almost all of the training programmes were researchers. Setting up joint training sessions that helped empower researchers in understanding the needs of health policy-makers had a considerable effect on strengthening EIPM. Based on the local collected evidence, the main interventions for individual and institutional capacity-building were educational and training programmes or courses related to the health system, policy-making and policy analysis, and research cycle management. To implement the individual and institutional interventions, health system planners and authorities and the community were found to have a key role as facilitating factors.
Conclusion
The use of evidence-based interventions for strengthening research centres, such as training health researchers on knowledge translation and tackling institutional barriers that can prevent well-trained researchers from translating their knowledge, as well as the use of mechanisms and networks for effective interactions among policy-makers at the macro and meso (organizational) level and the research centre, will be constructive for individual and institutional capacity-building. The health system needs to strengthen its strategic capacity to facilitate an educational and training culture in order to motivate researchers in producing appropriate evidence for policy-makers.
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Priority Activities in Child and Adolescent Tuberculosis to Close the Policy-Practice Gap in Low- and Middle-Income Countries. Pathogens 2022; 11:pathogens11020196. [PMID: 35215139 PMCID: PMC8878304 DOI: 10.3390/pathogens11020196] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 01/27/2022] [Accepted: 01/29/2022] [Indexed: 01/25/2023] Open
Abstract
Over the past 15 years, and despite many difficulties, significant progress has been made to advance child and adolescent tuberculosis (TB) care. Despite increasing availability of safe and effective treatment and prevention options, TB remains a global health priority as a major cause of child and adolescent morbidity and mortality—over one and a half million children and adolescents develop TB each year. A history of the global public health perspective on child and adolescent TB is followed by 12 narratives detailing challenges and progress in 19 TB endemic low and middle-income countries. Overarching challenges include: under-detection and under-reporting of child and adolescent TB; poor implementation and reporting of contact investigation and TB preventive treatment services; the need for health systems strengthening to deliver effective, decentralized services; and lack of integration between TB programs and child health services. The COVID-19 pandemic has had a significant negative impact on case detection and treatment outcomes. Child and adolescent TB working groups can address country-specific challenges to close the policy–practice gaps by developing and supporting decentral ized models of care, strengthening clinical and laboratory diagnosis, including of multidrug-resistant TB, providing recommended options for treatment of disease and infection, and forging strong collaborations across relevant health sectors.
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Osman M, Karat AS, Khan M, Meehan SA, von Delft A, Brey Z, Charalambous S, Hesseling AC, Naidoo P, Loveday M. Health system determinants of tuberculosis mortality in South Africa: a causal loop model. BMC Health Serv Res 2021; 21:388. [PMID: 33902565 PMCID: PMC8074279 DOI: 10.1186/s12913-021-06398-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 04/09/2021] [Indexed: 12/14/2022] Open
Abstract
Background Tuberculosis (TB) is a major public health concern in South Africa and TB-related mortality remains unacceptably high. Numerous clinical studies have examined the direct causes of TB-related mortality, but its wider, systemic drivers are less well understood. Applying systems thinking, we aimed to identify factors underlying TB mortality in South Africa and describe their relationships. At a meeting organised by the ‘Optimising TB Treatment Outcomes’ task team of the National TB Think Tank, we drew on the wide expertise of attendees to identify factors underlying TB mortality in South Africa. We generated a causal loop diagram to illustrate how these factors relate to each other. Results Meeting attendees identified nine key variables: three ‘drivers’ (adequacy & availability of tools, implementation of guidelines, and the burden of bureaucracy); three ‘links’ (integration of health services, integration of data systems, and utilisation of prevention strategies); and three ‘outcomes’ (accessibility of services, patient empowerment, and socio-economic status). Through the development and refinement of the causal loop diagram, additional explanatory and linking variables were added and three important reinforcing loops identified. Loop 1, ‘Leadership and management for outcomes’ illustrated that poor leadership led to increased bureaucracy and reduced the accessibility of TB services, which increased TB-related mortality and reinforced poor leadership through patient empowerment. Loop 2, ‘Prevention and structural determinants’ describes the complex reinforcing loop between socio-economic status, patient empowerment, the poor uptake of TB and HIV prevention strategies and increasing TB mortality. Loop 3, ‘System capacity’ describes how fragmented leadership and limited resources compromise the workforce and the performance and accessibility of TB services, and how this negatively affects the demand for higher levels of stewardship. Conclusions Strengthening leadership, reducing bureaucracy, improving integration across all levels of the system, increasing health care worker support, and using windows of opportunity to target points of leverage within the South African health system are needed to both strengthen the system and reduce TB mortality. Further refinement of this model may allow for the identification of additional areas of intervention.
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Affiliation(s)
- Muhammad Osman
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.
| | - Aaron S Karat
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK.,The Institute for Global Health and Development, Queen Margaret University, Edinburgh, UK
| | - Munira Khan
- Tuberculosis and HIV Investigative Network (THINK), Durban, South Africa
| | - Sue-Ann Meehan
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Arne von Delft
- School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.,TB Proof, Cape Town, South Africa
| | - Zameer Brey
- Bill and Melinda Gates Foundation, Johannesburg, South Africa
| | - Salome Charalambous
- The Aurum Institute, Parktown, South Africa.,School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Anneke C Hesseling
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Pren Naidoo
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Marian Loveday
- HIV Prevention Research Unit, South African Medical Research Council, KwaZulu-Natal, Pietermaritzburg, South Africa.,South African Medical Research Council-CAPRISA-HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
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Chandra DK, Moll AP, Altice FL, Didomizio E, Andrews L, Shenoi SV. Structural barriers to implementing recommended tuberculosis preventive treatment in primary care clinics in rural South Africa. Glob Public Health 2021; 17:555-568. [PMID: 33650939 DOI: 10.1080/17441692.2021.1892793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
The World Health Organization (WHO) recommends tuberculosis preventive treatment (TPT) in people with HIV (PWH), yet implementation remains poor, especially in rural communities. We examined factors influencing TPT initiation in PWH on antiretroviral therapy (ART) in rural South Africa using the Promoting Action on Research Implementation in Health Services (PARiHS) framework to identify contextual factors and facilitation strategies to successfully implement TPT. Patient and clinical factors were extracted from medical records at two primary healthcare clinics (PHCs). Among 455 TPT eligible indivdiuals, only 263 (57.8%) initiated TPT. Patient-level characteristics (older age and symptoms of fever or weight loss) were significantly associated with TPT initiation in bivariate analysis, but PHC was the only independent correlate of TPT initiation (aOR: 2.24; 95% CI: 1.49-3.38). Clinic-level factors are crucial targets for implementing TPT to reduce the burden of HIV-associated TB. Gaps in knowledge of HCW, staff shortages, and non-integrated HIV/TB services were identified barriers to TPT implementation. Evidence-based strategies for facilitating TPT implementation that might be under-prioritized include ongoing reprioritization, expanding training for primary care providers, and quality improvement strategies (organisational changes, multidisciplinary teams, and monitoring and feedback). Addressing contextual barriers through these facilitation strategies may improve future TPT implementation in this setting.
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Affiliation(s)
- Divya K Chandra
- Department of Medicine, Section of Infectious Diseases, AIDS Program, Yale School of Medicine, New Haven, CT, USA.,University of Connecticut School of Medicine, Farmington, CT, USA
| | | | - Frederick L Altice
- Department of Medicine, Section of Infectious Diseases, AIDS Program, Yale School of Medicine, New Haven, CT, USA
| | - Elizabeth Didomizio
- Department of Medicine, Section of Infectious Diseases, AIDS Program, Yale School of Medicine, New Haven, CT, USA
| | - Laurie Andrews
- Department of Medicine, Section of Infectious Diseases, AIDS Program, Yale School of Medicine, New Haven, CT, USA
| | - Sheela V Shenoi
- Department of Medicine, Section of Infectious Diseases, AIDS Program, Yale School of Medicine, New Haven, CT, USA
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Adu PA, Spiegel JM, Yassi A. Towards TB elimination: how are macro-level factors perceived and addressed in policy initiatives in a high burden country? Global Health 2021; 17:11. [PMID: 33430902 PMCID: PMC7802197 DOI: 10.1186/s12992-020-00657-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2019] [Accepted: 12/17/2020] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Notwithstanding extensive general discussion of the effects of upstream forces on health, there has been limited empirical examination, let alone systematic evidence documenting policy responses to such pathways in the area of tuberculosis (TB) management and control. Our study aimed to gain insight into how macro level drivers of TB are perceived by key stakeholders involved in TB management and control in a high-endemic country, and to assess how such concerns are being addressed in policy initiatives in this setting. South Africa was chosen for this case study due to our team's long-standing collaborations there, its very high burden of TB, and its introduction of a strategic plan to combat this disease. METHOD Semi-structured interviews were conducted with 20 key informants who were purposively selected for their knowledge and expertise of TB in South Africa. South Africa's National Strategic Plan for HIV, TB and STIs 2017-2022 was then reviewed to examine how identified themes from the interviews were reflected in this policy document. RESULTS A history of colonization, the migrant labour system, economic inequality, poor shelter, health system challenges including TB governance, the HIV epidemic, and pertinent socio-cultural factors were all perceived to be major drivers of the epidemic. Although South Africa's current National Strategic Plan makes a firm discursive commitment to addressing the structural or macro-level drivers of TB, our analysis revealed that this commitment was not clearly reflected in projected budgetary allocations. CONCLUSION As in many other high burden settings, macro-level drivers of TB are widely recognized. Nonetheless, while micro-level (biomedical and clinical) measures, such as improving diagnostic procedures and investment in more efficacious drugs, are being (and well should be) implemented, our findings showed that macro-level drivers of TB are underrepresented in budgeting allocations for initiatives to combat this disease. Although it could be argued that structural drivers that undermine health-promoting actions are beyond the purview of the health sector itself, we argue that strategic plans to combat TB in high burden settings need more attention to directly considering such drivers to prompt the necessary changes and reduce the burden of this and other such diseases.
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Affiliation(s)
- Prince A. Adu
- School of Population and Public Health, University of British Columbia, 2206 E Mall, Vancouver, BC V6T 1ZE Canada
- British Columbia Centre for Disease Control, 655 W 12th Ave, Vancouver, BC V5Z 4R4 Canada
| | - Jerry M. Spiegel
- School of Population and Public Health, University of British Columbia, 2206 E Mall, Vancouver, BC V6T 1ZE Canada
| | - Annalee Yassi
- School of Population and Public Health, University of British Columbia, 2206 E Mall, Vancouver, BC V6T 1ZE Canada
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Bozzani FM, Sumner T, Mudzengi D, Gomez GB, White R, Vassall A. Informing Balanced Investment in Services and Health Systems: A Case Study of Priority Setting for Tuberculosis Interventions in South Africa. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2020; 23:1462-1469. [PMID: 33127017 PMCID: PMC7640941 DOI: 10.1016/j.jval.2020.05.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 04/27/2020] [Accepted: 05/10/2020] [Indexed: 05/08/2023]
Abstract
OBJECTIVES Health systems face nonfinancial constraints that can influence the opportunity cost of interventions. Empirical methods to explore their impact, however, are underdeveloped. We develop a conceptual framework for defining health system constraints and empirical estimation methods that rely on routine data. We then present an empirical approach for incorporating nonfinancial constraints in cost-effectiveness models of health benefit packages for the health sector. METHODS We illustrate the application of this approach through a case study of defining a package of services for tuberculosis case-finding in South Africa. An economic model combining transmission model outputs with unit costs was developed to examine the cost-effectiveness of alternative screening and diagnostic algorithms. Constraints were operationalized as restrictions on achievable coverage based on: (1) financial resources; (2) human resources; and (3) policy constraints around diagnostics purchasing. Cost-effectiveness of the interventions was assessed under one "unconstrained" and several "constrained" scenarios. For the unconstrained scenario, incremental cost-effectiveness ratios were estimated with and without the costs of "relaxing" constraints. RESULTS We find substantial differences in incremental cost-effectiveness ratios across scenarios, leading to variations in the decision rules for prioritizing interventions. In constrained scenarios, the limiting factor for most interventions was not financial, but rather the availability of human resources. CONCLUSIONS We find that optimal prioritization among different tuberculosis control strategies in South Africa is influenced by whether and how constraints are taken into consideration. We thus demonstrate both the importance and feasibility of considering nonfinancial constraints in health sector resource allocation models.
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Affiliation(s)
- Fiammetta M Bozzani
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, England, UK.
| | - Tom Sumner
- TB Modelling Group, Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, England, UK
| | | | - Gabriela B Gomez
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, England, UK
| | - Richard White
- TB Modelling Group, Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, England, UK
| | - Anna Vassall
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, England, UK; Sanofi Pasteur SA, Vaccine Epidemiology and Modelling, Lyon, France
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Onwujekwe O, Mbachu C, Etiaba E, Ezumah N, Ezenwaka U, Arize I, Okeke C, Nwankwor C, Uzochukwu B. Impact of capacity building interventions on individual and organizational competency for HPSR in endemic disease control in Nigeria: a qualitative study. Implement Sci 2020; 15:22. [PMID: 32299484 PMCID: PMC7164165 DOI: 10.1186/s13012-020-00987-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Accepted: 04/03/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The need to build capacity for health policy and systems research (HPSR) in low- and middle-income countries has been underscored as this encompasses the processes of decision-making at all levels of the health system. This implementation research project was undertaken in Southeast Nigeria to evaluate whether the capacity-building intervention improves the capacity to produce and use research evidence for decision making in endemic disease control. METHODS Three training workshops were organized for purposively selected participants comprising "producers of evidence" such as health research scientists in three universities and "users of evidence" such as policy makers, program managers, and implementers in the public health sector. Participants also held step-down workshops in their organizations. The last workshop was used to facilitate the formation of knowledge networks comprising of both producers and users, which is a critical step for getting research into policy and practice (GRIPP). Three months after the workshops, a subset, 40, of workshop participants was selected for in-depth interviews. Information was collected on (i) perceptions of usefulness of capacity-building workshops, (ii) progress with proposed research and research uptake activities, (iii) effects of these activities on evidence-informed decision making, and (iv) constraints and enablers to implementation of proposed activities. RESULTS Most participants felt the workshops provided them with new competencies and skills in one or more of research priority setting, evidence generation, communication, and use for the control of endemic diseases. Participants were at different stages of planning and implementing their proposed research and research uptake activities, and were engaging across professional and disciplinary boundaries to ensure relevance and usefulness of outputs for decision making. Key enablers of successful implementation of activities were positive team dynamics, good balance of competencies, effective communication and engagement within teams, team leader's capacity to innovate, and personal interests such as career progress. Lack of funding, limited decision space, organizational bureaucracies, and poor infrastructure were the key constraints to the implementation of proposed activities. Lack of mentorship and continuous support from trainers delayed progress with implementing proposed activities. CONCLUSIONS The capacity-building interventions contributed to the development of a critical mass of research scientists, policy makers, and practitioners who have varying levels of competencies in HPSR for endemic disease control and would require further support in carrying out their medium and long-term goals.
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Affiliation(s)
- Obinna Onwujekwe
- Department of Health Administration and Management, University of Nigeria Enugu campus, Nsukka, Nigeria
- Health Policy Research Group, University of Nigeria Nsukka, Nsukka, Nigeria
| | - Chinyere Mbachu
- Department of Health Administration and Management, University of Nigeria Enugu campus, Nsukka, Nigeria.
- Department of Community Medicine, University of Nigeria Enugu campus, Nsukka, Nigeria.
| | - Enyi Etiaba
- Department of Health Administration and Management, University of Nigeria Enugu campus, Nsukka, Nigeria
- Health Policy Research Group, University of Nigeria Nsukka, Nsukka, Nigeria
| | - Nkoli Ezumah
- Health Policy Research Group, University of Nigeria Nsukka, Nsukka, Nigeria
| | - Uchenna Ezenwaka
- Health Policy Research Group, University of Nigeria Nsukka, Nsukka, Nigeria
| | - Ifeyinwa Arize
- Department of Health Administration and Management, University of Nigeria Enugu campus, Nsukka, Nigeria
- Health Policy Research Group, University of Nigeria Nsukka, Nsukka, Nigeria
| | - Chinyere Okeke
- Department of Health Administration and Management, University of Nigeria Enugu campus, Nsukka, Nigeria
- Department of Community Medicine, University of Nigeria Enugu campus, Nsukka, Nigeria
| | - Chikezie Nwankwor
- Department of Health Administration and Management, University of Nigeria Enugu campus, Nsukka, Nigeria
- Health Policy Research Group, University of Nigeria Nsukka, Nsukka, Nigeria
| | - Benjamin Uzochukwu
- Department of Health Administration and Management, University of Nigeria Enugu campus, Nsukka, Nigeria
- Department of Community Medicine, University of Nigeria Enugu campus, Nsukka, Nigeria
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8
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Runge M, Molteni F, Mandike R, Snow RW, Lengeler C, Mohamed A, Pothin E. Applied mathematical modelling to inform national malaria policies, strategies and operations in Tanzania. Malar J 2020; 19:101. [PMID: 32122342 PMCID: PMC7053121 DOI: 10.1186/s12936-020-03173-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Accepted: 02/20/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND More than ever, it is crucial to make the best use of existing country data, and analytical tools for developing malaria control strategies as the heterogeneity in malaria risk within countries is increasing, and the available malaria control tools are expanding while large funding gaps exist. Global and local policymakers, as well as funders, increasingly recognize the value of mathematical modelling as a strategic tool to support decision making. This case study article describes the long-term use of modelling in close collaboration with the National Malaria Control Programme (NMCP) in Tanzania, the challenges encountered and lessons learned. CASE DESCRIPTION In Tanzania, a recent rebound in prevalence led to the revision of the national malaria strategic plan with interventions targeted to the malaria risk at the sub-regional level. As part of the revision, a mathematical malaria modelling framework for setting specific predictions was developed and used between 2016 and 2019 to (1) reproduce setting specific historical malaria trends, and (2) to simulate in silico the impact of future interventions. Throughout the project, multiple stakeholder workshops were attended and the use of mathematical modelling interactively discussed. EVALUATION In Tanzania, the model application created an interdisciplinary and multisectoral dialogue platform between modellers, NMCP and partners and contributed to the revision of the national malaria strategic plan by simulating strategies suggested by the NMCP. The uptake of the modelling outputs and sustained interest by the NMCP were critically associated with following factors: (1) effective sensitization to the NMCP, (2) regular and intense communication, (3) invitation for the modellers to participate in the strategic plan process, and (4) model application tailored to the local context. CONCLUSION Empirical data analysis and its use for strategic thinking remain the cornerstone for evidence-based decision-making. Mathematical impact modelling can support the process both by unifying all stakeholders in one strategic process and by adding new key evidence required for optimized decision-making. However, without a long-standing partnership, it will be much more challenging to sensibilize programmes to the usefulness and sustained use of modelling and local resources within the programme or collaborating research institutions need to be mobilized.
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Affiliation(s)
- Manuela Runge
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Fabrizio Molteni
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
- National Malaria Control Programme, Ministry of Health Community Development Gender Elderly and Children, Dodoma, Tanzania
| | - Renata Mandike
- National Malaria Control Programme, Ministry of Health Community Development Gender Elderly and Children, Dodoma, Tanzania
| | - Robert W Snow
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, OX3 7LJ, UK
- Population Health Unit, Kenya Medical Research Institute-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Christian Lengeler
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Ally Mohamed
- National Malaria Control Programme, Ministry of Health Community Development Gender Elderly and Children, Dodoma, Tanzania
| | - Emilie Pothin
- Swiss Tropical and Public Health Institute, Basel, Switzerland.
- University of Basel, Basel, Switzerland.
- CHAI, Clinton Health Access Initative, Boston, USA.
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Sumner T, Bozzani F, Mudzengi D, Hippner P, Houben RM, Cardenas V, Vassall A, White RG. Estimating the Impact of Tuberculosis Case Detection in Constrained Health Systems: An Example of Case-Finding in South Africa. Am J Epidemiol 2019; 188:1155-1164. [PMID: 30824911 PMCID: PMC6545281 DOI: 10.1093/aje/kwz038] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Revised: 02/05/2019] [Accepted: 02/06/2019] [Indexed: 11/13/2022] Open
Abstract
Mathematical models are increasingly being used to compare strategies for tuberculosis (TB) control and inform policy decisions. Models often do not consider financial and other constraints on implementation and may overestimate the impact that can be achieved. We developed a pragmatic approach for incorporating resource constraints into mathematical models of TB. Using a TB transmission model calibrated for South Africa, we estimated the epidemiologic impact and resource requirements (financial, human resource (HR), and diagnostic) of 9 case-finding interventions. We compared the model-estimated resources with scenarios of future resource availability and estimated the impact of interventions under these constraints. Without constraints, symptom screening in public health clinics and among persons receiving care for human immunodeficiency virus infection was predicted to lead to larger reductions in TB incidence (9.5% (2.5th–97.5th percentile range (PR), 8.6–12.2) and 14.5% (2.5th–97.5th PR, 12.2–16.3), respectively) than improved adherence to diagnostic guidelines (2.7%; 2.5th–97.5th PR, 1.6–4.1). However, symptom screening required large increases in resources, exceeding future HR capacity. Even under our most optimistic HR scenario, the reduction in TB incidence from clinic symptom screening was 0.2%–0.9%—less than that of improved adherence to diagnostic guidelines. Ignoring resource constraints may result in incorrect conclusions about an intervention’s impact and may lead to suboptimal policy decisions. Models used for decision-making should consider resource constraints.
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Affiliation(s)
- Thomas Sumner
- TB Modelling Group, TB Centre, Centre for the Mathematical Modelling of Infectious Disease, Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Fiammetta Bozzani
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | | | - Rein M Houben
- TB Modelling Group, TB Centre, Centre for the Mathematical Modelling of Infectious Disease, Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | - Anna Vassall
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Richard G White
- TB Modelling Group, TB Centre, Centre for the Mathematical Modelling of Infectious Disease, Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
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Menzies NA, McQuaid CF, Gomez GB, Siroka A, Glaziou P, Floyd K, White RG, Houben RMGJ. Improving the quality of modelling evidence used for tuberculosis policy evaluation. Int J Tuberc Lung Dis 2019; 23:387-395. [PMID: 31053179 PMCID: PMC6490058 DOI: 10.5588/ijtld.18.0660] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Accepted: 11/12/2018] [Indexed: 12/23/2022] Open
Abstract
Mathematical modelling is commonly used to evaluate policy options for tuberculosis (TB) control in high-burden countries. Although major policy and funding decisions are made based on these analyses, there is concern about the variability of results produced using modelled policy analyses. We discuss new guidance for country-level TB policy modelling. The guidance was developed by the TB Modelling and Analysis Consortium in collaboration with the World Health Organization Global TB Programme, with input from a range of TB stakeholders (funders, modelling groups, country TB programme staff and subject matter experts). The guidance describes principles for country-level TB modelling, as well as good practices for operationalising the principles. The principles cover technical concerns such as model design, parameterisation and validation, as well as approaches for incorporating modelling into country-led policy making and budgeting. For modellers, this guidance suggests approaches to improve the quality and relevance of modelling undertaken to support country-level planning. For non-modellers, this guidance describes considerations for engaging modelling technical assistance, contributing to a modelling exercise and reviewing the results of modelled analyses. If routinely adopted, this guidance should improve the reliability, transparency and usefulness of modelling for country-level TB policy making. However, this guidance will not address all challenges facing modelling, and ongoing work is needed to improve the empirical evidence base for TB policy evaluation and develop stronger mechanisms for validating models. Increasing country ownership of the modelling process remains a challenge, requiring sustained engagement and capacity building.
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Affiliation(s)
- N A Menzies
- Department of Global Health and Population , Center for Health Decision Science, Harvard T H Chan School of Public Health, Boston, Massachusetts, USA
| | - C F McQuaid
- Department of Infectious Disease Epidemiology, TB Modelling Group, TB Centre and Centre for Mathematical Modelling of Infectious Diseases
| | - G B Gomez
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
| | - A Siroka
- Global TB Programme, World Health Organization, Geneva, Switzerland
| | - P Glaziou
- Global TB Programme, World Health Organization, Geneva, Switzerland
| | - K Floyd
- Global TB Programme, World Health Organization, Geneva, Switzerland
| | - R G White
- Department of Infectious Disease Epidemiology, TB Modelling Group, TB Centre and Centre for Mathematical Modelling of Infectious Diseases
| | - R M G J Houben
- Department of Infectious Disease Epidemiology, TB Modelling Group, TB Centre and Centre for Mathematical Modelling of Infectious Diseases
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Hippner P, Sumner T, Houben RMGJ, Cardenas V, Vassall A, Bozzani F, Mudzengi D, Mvusi L, Churchyard G, White RG. Application of provincial data in mathematical modelling to inform sub-national tuberculosis program decision-making in South Africa. PLoS One 2019; 14:e0209320. [PMID: 30682028 PMCID: PMC6347133 DOI: 10.1371/journal.pone.0209320] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Accepted: 12/05/2018] [Indexed: 01/01/2023] Open
Abstract
South Africa has the highest tuberculosis (TB) disease incidence rate in the world, and TB is the leading infectious cause of death. Decisions on, and funding for, TB prevention and care policies are decentralised to the provincial governments and therefore, tools to inform policy need to operate at this level. We describe the use of a mathematical model planning tool at provincial level in a high HIV and TB burden country, to estimate the impact on TB burden of achieving the 90-(90)-90 targets of the Stop TB Partnership Global Plan to End TB. "TIME Impact" is a freely available, user-friendly TB modelling tool. In collaboration with provincial TB programme staff, and the South African National TB Programme, models for three (of nine) provinces were calibrated to TB notifications, incidence, and screening data. Reported levels of TB programme activities were used as baseline inputs into the models, which were used to estimate the impact of scale-up of interventions focusing on screening, linkage to care and treatment success. All baseline models predicted a trend of decreasing TB incidence and mortality, consistent with recent data from South Africa. The projected impacts of the interventions differed by province and were greatly influenced by assumed current coverage levels. The absence of provincial TB burden estimates and uncertainty in current activity coverage levels were key data gaps. A user-friendly modelling tool allows TB burden and intervention impact projection at the sub-national level. Key sub-national data gaps should be addressed to improve the quality of sub-national model predictions.
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Affiliation(s)
| | - Tom Sumner
- TB Modelling Group, TB Centre, The London School of Hygiene and Tropical Medicine, London, United Kingdom
- Department of Infectious Disease Epidemiology, The London School of Hygiene and Tropical Medicine, London, United Kingdom
- * E-mail:
| | - Rein MGJ Houben
- TB Modelling Group, TB Centre, The London School of Hygiene and Tropical Medicine, London, United Kingdom
- Department of Infectious Disease Epidemiology, The London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | - Anna Vassall
- Department of Global Health and Development, The London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Fiammetta Bozzani
- Department of Global Health and Development, The London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | - Lindiwe Mvusi
- TB Control and Management, National Department of Health, Pretoria, South Africa
| | - Gavin Churchyard
- The Aurum Institute, Johannesburg, South Africa
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
- Advancing Care & Treatment (ACT) for TB/HIV, South African Medical Research Council, Johannesburg, South Africa
| | - Richard G. White
- TB Modelling Group, TB Centre, The London School of Hygiene and Tropical Medicine, London, United Kingdom
- Department of Infectious Disease Epidemiology, The London School of Hygiene and Tropical Medicine, London, United Kingdom
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Meiring C, van Helden PD, Goosen WJ. TB Control in Humans and Animals in South Africa: A Perspective on Problems and Successes. Front Vet Sci 2018; 5:298. [PMID: 30542655 PMCID: PMC6277860 DOI: 10.3389/fvets.2018.00298] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Accepted: 11/06/2018] [Indexed: 01/24/2023] Open
Abstract
Mycobacterium tuberculosis (M. tb) remains one of the most globally serious infectious agents for human morbidity and mortality, but with significant differences in prevalence across the globe. In many countries, the incidence is now low and declining, but control and eradication remain a distant view. Similarly, the prevalence of bovine TB caused by Mycobacterium bovis (M. bovis), varies significantly across regions, although unlike for M. tuberculosis, data are sparse. The reduction in incidence and prevalence and control of both human and bovine TB is difficult and costly, yet some countries have managed to do this with some success. This perspective will consider some of the critical control steps we now know to be important for the control of TB from M. tuberculosis in humans living in South Africa, where the incidence of TB is the highest currently experienced. Despite the high incidence of human TB, South Africa has been able to reduce this incidence remarkably in the past few years, despite limited resources and high HIV prevalence. We draw from our experience to ascertain whether we may learn useful lessons from control efforts for both diseases in order to suggest effective control measures for bovine TB.
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Affiliation(s)
- Christina Meiring
- Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, DST-NRF Centre of Excellence for Biomedical Tuberculosis Research, South African Medical Research Council Centre for Tuberculosis Research, Stellenbosch University, Cape Town, South Africa
| | - Paul D van Helden
- Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, DST-NRF Centre of Excellence for Biomedical Tuberculosis Research, South African Medical Research Council Centre for Tuberculosis Research, Stellenbosch University, Cape Town, South Africa
| | - Wynand J Goosen
- Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, DST-NRF Centre of Excellence for Biomedical Tuberculosis Research, South African Medical Research Council Centre for Tuberculosis Research, Stellenbosch University, Cape Town, South Africa
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13
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Wu B, Du Y, Feng Y, Wang Q, Pang W, Qi Z, Wang J, Yang D, Liu Y, Cao Y. Oral administration of vitamin D and importance in prevention of cerebral malaria. Int Immunopharmacol 2018; 64:356-363. [PMID: 30243072 DOI: 10.1016/j.intimp.2018.08.041] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Revised: 08/24/2018] [Accepted: 08/24/2018] [Indexed: 12/18/2022]
Abstract
Cerebral malaria (CM) is a serious and fatal malaria-associated syndrome caused by the development of an overwhelming proinflammatory response. Vitamin D (Vit.D; cholecalciferol) has regulatory functions associated with both innate and adaptive immune responses. Prevention is better than cure, in this experiment, we evaluated prophylactic oral Vit.D as a means of preventing CM presentation before infection of C57BL/6 mice with Plasmodium berghei ANKA (PbA) by modulating the host proinflammatory response. Mice that were supplemented with oral Vit.D has reduce death rate and ameliorated the integrity of the blood brain barrier. Prophylactic oral vitamin D relieved the symptoms of brain malaria and avoided death, gained valuable time for the diagnosis and treatment post infection. The robust Th1 response was attenuated in the Vit.D + PbA group. Furthermore, T-cell trafficking to the brain was diminished before PbA infection using Vit.D. The results suggest that Vit.D supplementation mediates the development of an anti-inflammatory environment that improves CM severity. In summary, the use of Vit.D as a nutritional supplement in malaria-endemic regions may help reduce the severity and mortality of CM.
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Affiliation(s)
- Bo Wu
- Department of Immunology, Basic Medicine College of China Medical University, Shenyang 110122, Liaoning, China; Department of Anus & Intestine Surgery, The First Hospital of China Medical University, Shenyang 110001, Liaoning, China
| | - Yunting Du
- Department of Immunology, Basic Medicine College of China Medical University, Shenyang 110122, Liaoning, China
| | - Yonghui Feng
- Department of Immunology, Basic Medicine College of China Medical University, Shenyang 110122, Liaoning, China; Department of Laboratory Medicine, The First Hospital of China Medical University, Shenyang 110001, Liaoning, China
| | - Qinghui Wang
- Department of Immunology, Basic Medicine College of China Medical University, Shenyang 110122, Liaoning, China
| | - Wei Pang
- Department of Immunology, Basic Medicine College of China Medical University, Shenyang 110122, Liaoning, China
| | - Zanmei Qi
- Department of Immunology, Basic Medicine College of China Medical University, Shenyang 110122, Liaoning, China
| | - Jichun Wang
- Department of Microbiology and Parasitology, Basic Medicine College of China Medical University, Shenyang 110122, Liaoning, China
| | - Dan Yang
- Department of Environmental and Health, School of Public Health, China Medical University, Shenyang 110122, Liaoning, China
| | - Yang Liu
- Department of Environmental and Health, School of Public Health, China Medical University, Shenyang 110122, Liaoning, China
| | - Yaming Cao
- Department of Immunology, Basic Medicine College of China Medical University, Shenyang 110122, Liaoning, China.
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Reuter A, Furin J. Bedaquiline use in South Africa reveals a lifesaving policy in action. THE LANCET RESPIRATORY MEDICINE 2018; 6:653-655. [DOI: 10.1016/s2213-2600(18)30280-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Accepted: 06/18/2018] [Indexed: 10/28/2022]
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Bozzani FM, Mudzengi D, Sumner T, Gomez GB, Hippner P, Cardenas V, Charalambous S, White R, Vassall A. Empirical estimation of resource constraints for use in model-based economic evaluation: an example of TB services in South Africa. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2018; 16:27. [PMID: 30069166 PMCID: PMC6065151 DOI: 10.1186/s12962-018-0113-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Accepted: 07/23/2018] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Evidence on the relative costs and effects of interventions that do not consider 'real-world' constraints on implementation may be misleading. However, in many low- and middle-income countries, time and data scarcity mean that incorporating health system constraints in priority setting can be challenging. METHODS We developed a 'proof of concept' method to empirically estimate health system constraints for inclusion in model-based economic evaluations, using intensified case-finding strategies (ICF) for tuberculosis (TB) in South Africa as an example. As part of a strategic planning process, we quantified the resources (fiscal and human) needed to scale up different ICF strategies (cough triage and WHO symptom screening). We identified and characterised three constraints through discussions with local stakeholders: (1) financial constraint: potential maximum increase in public TB financing available for new TB interventions; (2) human resource constraint: maximum current and future capacity among public sector nurses that could be dedicated to TB services; and (3) diagnostic supplies constraint: maximum ratio of Xpert MTB/RIF tests to TB notifications. We assessed the impact of these constraints on the costs of different ICF strategies. RESULTS It would not be possible to reach the target coverage of ICF (as defined by policy makers) without addressing financial, human resource and diagnostic supplies constraints. The costs of addressing human resource constraints is substantial, increasing total TB programme costs during the period 2016-2035 by between 7% and 37% compared to assuming the expansion of ICF is unconstrained, depending on the ICF strategy chosen. CONCLUSIONS Failure to include the costs of relaxing constraints may provide misleading estimates of costs, and therefore cost-effectiveness. In turn, these could impact the local relevance and credibility of analyses, thereby increasing the risk of sub-optimal investments.
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Affiliation(s)
- Fiammetta M. Bozzani
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH UK
| | | | - Tom Sumner
- TB Modelling Group, TB Centre, CMMID, London School of Hygiene & Tropical Medicine, London, UK
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Gabriela B. Gomez
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH UK
| | | | | | - Salome Charalambous
- TB Modelling Group, TB Centre, CMMID, London School of Hygiene & Tropical Medicine, London, UK
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Richard White
- TB Modelling Group, TB Centre, CMMID, London School of Hygiene & Tropical Medicine, London, UK
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Anna Vassall
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH UK
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