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Abstract
OBJECTIVE To measure the readiness of health facilities in Papua New Guinea (PNG) to provide obstetric care and other maternal health services. DESIGN Cross-sectional study involving random sample of health centres, district/rural hospitals (levels 3 and 4 facilities) and all upper-level hospitals operational at the time of survey. Structured questionnaires were used to collect data from health facilities. SETTING Health facilities in PNG. Facility administrators and other facility personnel were interviewed. Number of facility personnel interviewed was usually one for health centres and two or more for hospitals. PARTICIPANTS 19 upper-level facilities (levels 5-7, provincial, regional and national hospitals) and 60 lower-level facilities (levels 3 and 4, health centres and district/rural hospitals). OUTCOME MEASURES Four service-types were used to understand readiness of surveyed health facilities in the provision of maternity care including obstetric care services: (1) facility readiness to provide clinical services; (2) availability of family planning items; (3) availability of maternal and neonatal equipment and materials; and (4) ability to provide emergency obstetric care (EmOC). RESULTS 56% of lower-level facilities were not able to provide basic emergency obstetric care (BEmOC). Even among higher-level facilities, 16% were not able to perform one or more of the functions required to be considered a BEmOC provider. 11% of level 3 and 4 health facilities were able to provide comprehensive emergency obstetric care (CEmOC) as compared with 83% of higher-level facilities. CONCLUSION Given the high fertility rate and maternal mortality ratio (MMR) in PNG, lack of BEmOC at the first level inpatient service providers is a major concern. To improve access to EmOC, level 3 and 4 facilities should be upgraded to at least BEmOC providers. Significant reduction in MMR will require improved access to CEmOC and optimal geographic location approach can identify facilities to be upgraded.
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Affiliation(s)
- Xiaohui Hou
- Health, Nutrition and Population Global Practice, World Bank Group, Washington, District of Columbia, USA
| | - M Mahmud Khan
- Health Policy and Management, University of Georgia College of Public Health, Athens, Georgia, USA
| | - Justin Pulford
- International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
- Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea
| | - Olga P M Saweri
- Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea
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Adawiyah RA, Saweri OPM, Boettiger DC, Applegate TL, Probandari A, Guy R, Guinness L, Wiseman V. The costs of scaling up HIV and syphilis testing in low- and middle-income countries: a systematic review. Health Policy Plan 2021; 36:939-954. [PMID: 33693731 PMCID: PMC8227996 DOI: 10.1093/heapol/czab030] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/24/2021] [Indexed: 12/18/2022] Open
Abstract
Around two-thirds of all new HIV infections and 90% of syphilis cases occur in low- and middle-income countries (LMICs). Testing is a key strategy for the prevention and treatment of HIV and syphilis. Decision-makers in LMICs face considerable uncertainties about the costs of scaling up HIV and syphilis testing. This paper synthesizes economic evidence on the costs of scaling up HIV and syphilis testing interventions in LMICs and evidence on how costs change with the scale of delivery. We systematically searched multiple databases (Medline, Econlit, Embase, EMCARE, CINAHL, Global Health and the NHS Economic Evaluation Database) for peer-reviewed studies examining the costs of scaling up HIV and syphilis testing in LMICs. Thirty-five eligible studies were identified from 4869 unique citations. Most studies were conducted in Sub-Saharan Africa (N = 17) and most explored the costs of rapid HIV in facilities targeted the general population (N = 19). Only two studies focused on syphilis testing. Seventeen studies were cost analyses, 17 were cost-effectiveness analyses and 1 was cost-benefit analysis of HIV or syphilis testing. Most studies took a modelling approach (N = 25) and assumed costs increased linearly with scale. Ten studies examined cost efficiencies associated with scale, most reporting short-run economies of scale. Important drivers of the costs of scaling up included testing uptake and the price of test kits. The 'true' cost of scaling up testing is likely to be masked by the use of short-term decision frameworks, linear unit-cost projections (i.e. multiplying an average cost by a factor reflecting activity at a larger scale) and availability of health system capacity and infrastructure to supervise and support scale up. Cost data need to be routinely collected alongside other monitoring indicators as HIV and syphilis testing continues to be scaled up in LMICs.
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Affiliation(s)
- Rabiah Al Adawiyah
- The Kirby Institute, University New South Wales, High St, Kensington 2052, New South Wales, Australia
| | - Olga P M Saweri
- The Kirby Institute, University New South Wales, High St, Kensington 2052, New South Wales, Australia.,Population Health and Demography, Papua New Guinea Institute of Medical Research, PO Box 60 Homate Street, Goroka, Papua New Guinea
| | - David C Boettiger
- The Kirby Institute, University New South Wales, High St, Kensington 2052, New South Wales, Australia
| | - Tanya L Applegate
- The Kirby Institute, University New South Wales, High St, Kensington 2052, New South Wales, Australia
| | - Ari Probandari
- Department of Public Health, Faculty of Medicine, Universitas Sebelas Maret, Jl. Ir. Sutami 36A. Surakarta, 57126, Indonesia
| | - Rebecca Guy
- The Kirby Institute, University New South Wales, High St, Kensington 2052, New South Wales, Australia
| | - Lorna Guinness
- London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK.,Centre for Global DevelopmentEurope, Great Peter House, Great College St, London SW1P 3SE, UK
| | - Virginia Wiseman
- The Kirby Institute, University New South Wales, High St, Kensington 2052, New South Wales, Australia.,London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK
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Saweri OPM, Batura N, Al Adawiyah R, Causer LM, Pomat WS, Vallely AJ, Wiseman V. Economic evaluation of point-of-care testing and treatment for sexually transmitted and genital infections in pregnancy in low- and middle-income countries: A systematic review. PLoS One 2021; 16:e0253135. [PMID: 34138932 PMCID: PMC8211269 DOI: 10.1371/journal.pone.0253135] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 05/30/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Sexually transmitted and genital infections in pregnancy are associated with adverse pregnancy and birth outcomes. Point-of-care tests for these infections facilitate testing and treatment in a single antenatal clinic visit and may reduce the risk of adverse outcomes. Successful implementation and scale-up depends on understanding comparative effectiveness of such programmes and their comparative costs and cost effectiveness. This systematic review synthesises and appraises evidence from economic evaluations of point-of-care testing and treatment for sexually transmitted and genital infections among pregnant women in low- and middle-income countries. METHODS Medline, Embase and Web of Science databases were comprehensively searched using pre-determined criteria. Additional literature was identified by searching Google Scholar and the bibliographies of all included studies. Economic evaluations were eligible if they were set in low- and middle-income countries and assessed antenatal point-of-care testing and treatment for syphilis, chlamydia, gonorrhoea, trichomoniasis, and/or bacterial vaginosis. Studies were analysed using narrative synthesis. Methodological and reporting standards were assessed using two published checklists. RESULTS Sixteen economic evaluations were included in this review; ten based in Africa, three in Latin and South America and three were cross-continent comparisons. Fifteen studies assessed point-of-care testing and treatment for syphilis, while one evaluated chlamydia. Key drivers of cost and cost-effectiveness included disease prevalence; test, treatment, and staff costs; test sensitivity and specificity; and screening and treatment coverage. All studies met 75% or more of the criteria of the Drummond Checklist and 60% of the Consolidated Health Economics Evaluation Reporting Standards. CONCLUSIONS Generally, point-of-care testing and treatment was cost-effective compared to no screening, syndromic management, and laboratory-based testing. Future economic evaluations should consider other common infections, and their lifetime impact on mothers and babies. Complementary affordability and equity analyses would strengthen the case for greater investment in antenatal point-of-care testing and treatment for sexually transmitted and genital infections.
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Affiliation(s)
- Olga P. M. Saweri
- The Kirby Institute, University of New South Wales, Sydney, Australia
- The Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea
- * E-mail:
| | - Neha Batura
- University College London, London, United Kingdom
| | | | - Louise M. Causer
- The Kirby Institute, University of New South Wales, Sydney, Australia
| | - William S. Pomat
- The Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea
| | - Andrew J. Vallely
- The Kirby Institute, University of New South Wales, Sydney, Australia
- The Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea
| | - Virginia Wiseman
- The Kirby Institute, University of New South Wales, Sydney, Australia
- London School of Hygiene and Tropical Medicine, London, United Kingdom
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Morgan CJ, Saweri OPM, Larme N, Peach E, Melepia P, Au L, Scoullar MJL, Reza MS, Vallely LM, McPake BI, Beeson JG. Strengthening routine immunization in Papua New Guinea: a cross-sectional provincial assessment of front-line services. BMC Public Health 2020; 20:100. [PMID: 31973691 PMCID: PMC6979348 DOI: 10.1186/s12889-020-8172-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2019] [Accepted: 01/07/2020] [Indexed: 12/03/2022] Open
Abstract
Background Routine immunization programs face many challenges in settings such as Papua New Guinea with dispersed rural populations, rugged geography and limited resources for transport and health. Low routine coverage contributes to disease outbreaks such as measles and the polio that re-appeared in 2018. We report on an in-depth local assessment that aimed to document immunization service provision so as to review a new national strategy, and consider how routine immunization could be better strengthened. Methods In East New Britain Province, over 2016 and 17, we carried out a cross-sectional assessment of 12 rural health facilities, staff and clients. The study was timed to follow implementation of a new national strategy for strengthening routine immunization. We used interview, structured observation, and records review, informed by theory-based evaluation, a World Health Organization quality checklist, and other health services research tools. Results We documented strengths and weaknesses across six categories of program performance relevant to national immunization strategy and global standards. We found an immunization service with an operational level of staff, equipment and procedures in place; but one that could reach only half to two thirds of its target population. Stronger routine services require improvement in: understanding of population catchments, tracking the unvaccinated, reach and efficiency of outreach visits, staff knowledge of vaccination at birth and beyond the first year of life, handling of multi-dose vials, and engagement of community members. Many local suggestions to enhance national plans, included more reliable on-demand services, integration of other family health services and increased involvement of men. Conclusions The national strategy addresses most local gaps, but implementation and resourcing requires greater commitment. Long-term strengthening requires a major increase in centrally-allocated resources, however there are immediate locally feasible steps within current resources that could boost coverage and quality of routine immunization especially through better population-based local planning, and stronger community engagement. Our results also suggest areas where vaccination campaigns in PNG can contribute to routine immunization services.
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Affiliation(s)
- Christopher J Morgan
- Burnet Institute, Melbourne, Australia. .,Melbourne School of Population and Global Health and Department of Medicine, University of Melbourne, Melbourne, Australia.
| | - Olga P M Saweri
- Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea
| | - Nicholas Larme
- East New Britain Provincial Government, Kokopo, Papua New Guinea
| | | | | | - Lucy Au
- Burnet Institute, Kokopo, Papua New Guinea
| | - Michelle J L Scoullar
- Burnet Institute, Melbourne, Australia.,Melbourne School of Population and Global Health and Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Mohammad Salim Reza
- World Health Organization, Country Office Port Moresby, Port Moresby, Papua New Guinea
| | - Lisa M Vallely
- Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea.,Kirby Institute, University of New South Wales, Sydney, Australia
| | - Barbara I McPake
- Nossal Institute of Global Health, University of Melbourne, Melbourne, Australia
| | - James G Beeson
- Burnet Institute, Melbourne, Australia.,Melbourne School of Population and Global Health and Department of Medicine, University of Melbourne, Melbourne, Australia.,Central Clinical School and Department of Microbiology, Monash University, Melbourne, Australia
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Pulford J, Saweri OPM, Jeffery C, Siba PM, Mueller I, Hetzel MW. Does test-based prescription of evidence-based treatment for malaria improve treatment seeking and satisfaction? Findings of repeated cross-sectional surveys in Papua New Guinea. BMJ Glob Health 2018; 3:e000915. [PMID: 30498587 PMCID: PMC6254749 DOI: 10.1136/bmjgh-2018-000915] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2018] [Revised: 10/01/2018] [Accepted: 10/06/2018] [Indexed: 11/23/2022] Open
Abstract
Introduction The presumptive treatment of febrile illness with antimalarial medication is becoming less common in low-income and middle-income countries as access to reliable diagnostic tests improves. We explore whether the shift towards test-based antimalarial prescription, and the introduction of highly efficacious artemisinin combination therapies (ACTs), reduces critical delays in seeking treatment for febrile illness or increases patient satisfaction. Methods We conducted countrywide repeat, cross-sectional surveys in 118 randomly selected primary healthcare services in Papua New Guinea. The clinical case management of 1765 consecutively presenting febrile patients was observed and exit interviews were completed at discharge. This was done prior to implementation of test-based ACT prescription (2011) and at 12 (2012) and 60 months (2016) postimplementation. We conducted multiple logistic regressions. Treatment response time was dichotomised as <24 hours from symptom onset vs 24+ hours. Satisfaction was dichotomised as a ‘high’ vs ‘low’ rating based on participant response to a visual, 7-point Likert-type scale. Results 62% (322/517) of febrile patients reported seeking treatment within 24 hours of symptom onset in 2011 compared with 53% (230/434) in 2012 and 42% (339/814) in 2016. Adjusted ORs for reporting a treatment response time <24 hours in the postimplementation surveys were 0.77 (95% CI 0.48 to 1.26) and 0.45 (95% CI 0.31 to 0.65), respectively when compared with the preimplementation period. 53% (230/533) of febrile patients reported ‘high’ satisfaction with the service received in 2011 compared with 32% (143/449) in 2012 and 35% (278/803) in 2016. Adjusted ORs for reporting high satisfaction in the postimplementation surveys were 0.52 (95% CI 0.32 to 0.85) and 0.65 (95% CI 0.39 to 1.10), respectively when compared with the preimplementation period. Conclusion Nationwide implementation of test-based ACT prescription in Papua New Guinea has increased the likelihood of critical treatment seeking delays and decreased patient satisfaction with the service received.
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Affiliation(s)
- Justin Pulford
- International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Olga P M Saweri
- Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea
| | - Caroline Jeffery
- International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Peter M Siba
- Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea
| | - Ivo Mueller
- Walter and Eliza Hall Institute of Medical Research, Melbourne, Australia.,University of Melbourne, Melbourne, Australia.,Institut Pasteur, Paris, France
| | - Manuel W Hetzel
- Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland
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Saweri OPM, Hetzel MW, Mueller I, Siba PM, Pulford J. The treatment of non-malarial febrile illness in Papua New Guinea: findings from cross sectional and longitudinal studies of health worker practice. BMC Health Serv Res 2017; 17:10. [PMID: 28056949 PMCID: PMC5217620 DOI: 10.1186/s12913-016-1965-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2015] [Accepted: 12/20/2016] [Indexed: 11/17/2022] Open
Abstract
Background The Papua New Guinea Department of Health recently shifted from a presumptive to a ‘test and treat’ malaria case management policy. This shift was supported by the widespread introduction of malaria rapid diagnostic tests in health facilities across the country. Health workers received training and job-aids detailing how to conduct and interpret a malaria rapid diagnostic test and how to treat test positive cases; however, little instruction on treating non-malaria febrile cases was provided. Accordingly, this study examined health worker case management of non-malarial febrile patients in the 12-month period immediately following the introduction of the revised malaria case management policy. Methods Data were collected from a country-wide cross-sectional survey of febrile case management at randomly selected health facilities and from longitudinal surveillance at sentinel health facilities. Analysis was restricted to febrile patients who tested negative for malaria infection by rapid diagnostic test (N=303 and 5705 outpatients, respectively). Results and Discussion 96.8% of non-malarial febrile patients received a diagnosis in the longitudinal sample, compared to 52.4% of the cross-sectional sample. Respiratory tract infections were the most commonly reported diagnoses. Over 90% of patients in both samples were prescribed one or more medications, most commonly an analgesic (71.3 & 72.9% of the longitudinal and cross-sectional samples, respectively), some form of antibiotic (72.7 & 73.4%, respectively) and/or an anthelminthic (17.9 & 16.5%, respectively). Prescribing behaviour was adherent with the recommendations in the standard treatment guidelines in fewer than 20% of cases (longitudinal sample only). Conclusion Many non-malarial febrile patients are not provided with a diagnosis. When diagnoses are provided they are typically some form of respiratory tract infection. Antibiotics and analgesics are widely prescribed, although medications prescribed rarely adhere to the Papua New Guinea standard treatment guidelines. These findings indicate that Papua New Guinea health workers require support for non-malarial febrile illness case management. Electronic supplementary material The online version of this article (doi:10.1186/s12913-016-1965-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Olga P M Saweri
- Papua New Guinea Institute of Medical Research (PNGIMR), PO Box 60, Goroka, EHP 441, Papua New Guinea
| | - Manuel W Hetzel
- Swiss Tropical and Public Health Institute, PO Box, 4002, Basel, Switzerland.,University of Basel, Petersplatz 1, 4003, Basel, Switzerland
| | - Ivo Mueller
- Barcelona Centre for International Health Research (CRESIB, Hospital Clínic-Universitat de Barcelona), Barcelona, Spain.,Walter and Eliza Hall Institute of Medical Research, Melbourne, Australia
| | - Peter M Siba
- Papua New Guinea Institute of Medical Research (PNGIMR), PO Box 60, Goroka, EHP 441, Papua New Guinea
| | - Justin Pulford
- Papua New Guinea Institute of Medical Research (PNGIMR), PO Box 60, Goroka, EHP 441, Papua New Guinea. .,Liverpool School of Tropical Medicine, Liverpool, UK.
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