Articles tagged as "Health care delivery"

Traditional medicine and HIV

Kayombo EJ, Uiso FC, Mbwambo ZH, Mahunnah RL, Moshi MM, Mgonda YH. Experience of initiating collaboration of traditional healers in managing HIV and AIDS in Tanzania. J Ethnobiol Ethnomedicine 2007;3(1):6

Collaboration between traditional healers and biomedical practitioners is now being accepted by many African countries south of the Sahara because of the increasing problem of AIDS. The key problem, however, is how to initiate collaboration between two health systems which differ in theory of disease causation and management. Kayombo and colleagues present findings of the experience learned by initiation of collaboration between traditional healers and the Institute of Traditional Medicine in Arusha and Dar-es-Salaam Municipalities, Tanzania where 132 and 60 traditional healers respectively were interviewed. Of these healers, 110 traditional healers claimed to be treating HIV-related disease. The objective of the study was to initiate sustainable collaboration with traditional healers in managing HIV and AIDS. Consultative meetings with leaders of traditional healers associations and government officials were held, followed by surveys at respective traditional healers vilinge (traditional clinics). The findings were analysed using both qualitative and quantitative methods. The findings showed that influential people and leaders of traditional healers association appeared to be gatekeepers to access potential good healers in the two study areas. After consultative meetings these leaders showed to be willing to collaborate; and opened doors to other traditional healers, who too were willing to collaborate with the Institute of Traditional Medicine in managing AIDS patients. Seventy five percent of traditional healers who claimed to be treating AIDS knew some HIV-related symptoms; and some traditional healers attempted to manage these symptoms. Even though, they were willing to collaborate with the Institute of Traditional Medicine there were nevertheless some reservations based on questions surrounding sharing from collaboration. The reality of past experiences of mistreatment of traditional healers in the colonial period informed these reservations. The authors’ findings suggest that initiating collaboration is not as easy as it appears to be from the literature, if it is to be meaningful; and thus the authors conclude that there must be a call for appropriate strategies to access potential healers targeted for any study designed with sustainability in mind.

Editors’ note: For further guidance on this topic, we recommend the 2006 UNAIDS Best Practice publication: Collaborating with Traditional Healers for HIV Prevention and Care in sub-Saharan Africa: Suggestions for Programme Managers and Field Workers.

Health care delivery
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Human resources capacity

McCourt W, Awases M. Addressing the human resources crisis: a case study of the Namibian health service. Hum Resour Health 2007;5:1.                           http://www.human-resources-health.com/content/5/1/1

McCourt and Awases address an important practical challenge to staff management. In 2000 the United Nations committed themselves to the ambitious targets embodied in the Millennium Development Goals (MDGs). Only five years later, it was clear that poor countries were not on track to achieve them. It was also clear that achieving the three out of the eight MDGs that concern health would only be possible if the appropriate human resources were in place. The authors used a case study based on semi-structured interview data to explore the steps that Namibia, a country facing severe health problems that include an alarmingly high HIV infection rate, has taken to manage its health workers. In the 15 years since independence, Namibia has patiently built up a relatively good strategic framework for health policy in the context of government policy as a whole, including strong training arrangements at every level of health staffing, and it has brought HIV under the strategic umbrella through its National Strategic Plan for HIV and AIDS. Its major weakness is that it has not kept pace with the rise in HIV and TB infection: the community counselling service, still at the pilot stage at the time of this study, was the only specific response. That has created a tension between building long-term capacity in a strategic context and responding to the short-term demands of the AIDS and TB crisis, which in turn affects the ability of human resources to contribute to improving health outcomes. The authors conclude that it is suggested that countries like Namibia need a new paradigm for staffing their health services. Building on the existing strategic framework, it should target the training of 'mid-level cadres'. Higher-level cadres should take on the role of supporting and monitoring the mid-level cadres. To do that, they will need management training and a performance management framework for staff support and monitoring.

Health care delivery
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Dentist- Patient Concerns

Rohn EJ, Sankar A, Hoelscher DC, Luborsky M, Parise MH. How do social-psychological concerns impede the delivery of care to people with HIV? Issues for dental education. J Dent Educ 2006;70:1038-42.

Oral health is an essential aspect of the overall medical care for patients with HIV. However, fear of status disclosure is a significant barrier to access to care. Preparing future oral health care providers to maintain all aspects of confidentiality and to understand the role stigma plays in the lives of people living with HIV are critical issues that must be addressed by dental education. Rhon and colleagues provide important perspectives regarding HIV-related stigma and confidentiality by presenting data from a longitudinal qualitative study of adherence to antiretroviral therapy among African Americans and reviewing current literature regarding HIV patient confidentiality and student attitudes regarding HIV. Findings suggest that dental student attitudes may be improved by providing more comprehensive experiences and information and that procedures in place in dental clinics should be continuously monitored to ensure that patient confidentiality is maintained. Strategies for addressing these important issues in dental education are presented. The authors conclude that ensuring that dental school graduates are well prepared to maintain confidentiality with sensitivity to the role stigma plays in HIV disease has the potential to enhance access to health care.

Health care delivery
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Patient- Provider Communication

Fehringer J, Bastos FI, Massard E, Maia L, Pilotto JH, Kerrigan D. Supporting adherence to highly active antiretroviral therapy and protected sex among people living with HIV/AIDS: The role of patient-provider communication in Rio De Janeiro, Brazil. AIDS Patient Care STDS 2006;20:637-48.

Photo credit: WHO/A.Waak
Photo credit: WHO/A.Waak
Fehringer and colleagues examined patient-provider communication dynamics regarding adherence to HAART and protective sexual behaviour among people living with HIV. The authors conducted 20 direct observations of routine consultations between people living with HIV and care providers in two large public health clinics providing free HIV medications and clinical care to people living with HIV in the greater Rio de Janeiro area of Brazil. Immediately after these observations, 20 semi-structured in-depth interviews were conducted with observation participants regarding their communication with providers, overall clinic experience, and questions and concerns about adherence to HAART and safer sex. Findings from observations showed that patient-provider communication focused almost exclusively on biomedical aspects of HIV-related treatment such as symptom management. In most observations, adherence to HAART was addressed. However, questions posed by providers regarding adherence were generally close-ended and leading, discouraging an open exchange regarding potential difficulties related to adherence. HIV/STI- related protective behaviours were seldom addressed except when the patient displayed STI symptoms or was thought to be pregnant. In qualitative interviews, patients generally reported satisfaction with their providers, but also reported a variety of concerns and challenges related to adherence to HAART and protective sexual behaviour that were not expressed in patient-provider interactions. The authors conclude that one way in which adherence to HAART and protective sexual behaviour among people living with HIV could be facilitated is by improving patient-provider communication on these topics, including increasing the frequency of open-ended, non-judgmental dialogue initiated by care providers.


Pathela P, Hajat A, Schillinger J, Blank S, Sell R, Mostashari F. Discordance between sexual behavior and self-reported sexual identity: a population-based survey of New York City men. Ann Intern Med 2006;145:416-25.Pathela and colleagues described discordance between self-described sexual identity and behaviour among men who have sex with men and associations between identity-behaviour and risk behaviours. They used a cross-sectional, random digit-dialled telephone survey of health status and risk behaviours in a population-based sample of 4193 men in New York City. Of the men reporting a sexual identity, 12% reported sex with other men. Men who had sex with men exclusively but self-identified as heterosexual were more likely than their gay-identified counterparts to belong to minority racial or ethnic groups, be foreign-born, have lower education and income levels, and be married. These men were more likely than gay-identified men who have sex with men to report having only 1 sexual partner in the previous year. However, they were less likely to have been tested for HIV during that time (OR 0.6, 95%CI 0.4-0.9) and less likely to have used condoms during their last sexual encounter (OR 0.5, 95%CI 0.3-1.0). The survey did not sample groups that cannot be reached by using residential telephone services. The authors conclude that many New York City men who have sex with men do not identify as gay. Medical providers cannot rely on patients' self-reported identities to appropriately assess risk for HIV infection and sexually transmitted diseases; they must inquire about behaviour. Public health prevention messages should target risky sexual activities rather than a person's sexual identity.

Health care delivery
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Health Workforce Strengthening

Drager S, Gedik G et al. Health workforce issues and the Global Fund to fight AIDS, Tuberculosis and Malaria: an analytical review. Hum Resour Health 2006;4:23.http://www.human-resources-health.com/content/4/1/23

Recent studies have shown evidence of a direct and positive causal link between the number of health workers and health outcomes. Several studies have identified an adequate health workforce as one of the key ingredients to achieving improved health outcomes. Global health initiatives are faced with human resources issues as a major, system-wide constraint. This article explores how the Global Fund addresses the challenges of a health workforce bottleneck to the successful implementation of priority disease programmes. Possibilities for investment in human resources in the Global Fund's policy documents and guidelines are reviewed. This is followed by an in-depth study of 35 Global Fund proposals from five African countries: Ethiopia, Ghana, Kenya, Malawi and Tanzania. The discussion presents specific human resources interventions that can be found in proposals. Finally, the comments on human resources interventions in the Global Fund's Technical Review Panel and the budget allocation for human resources for health were examined. Policy documents and guidelines of the Global Fund foster taking account of human resources constraints in recipient countries and interventions to address them. However, the review of actual proposals clearly shows that countries do not often take advantage of their opportunities and focus mainly on short-term, in-service training in their human resources components. The comments of the Technical Review Panel on proposed health system-strengthening interventions reveal a struggle between the Global Fund's goal to fight the three targeted diseases, on the one hand, and the need to strengthen health systems as a prerequisite for success, on the other. The authors conclude that in realizing the opportunities the Global Fund provides for human resources interventions, countries should go beyond short-term objectives and link their activities to a long-term development of their human resources for health.

Editors’ note: This analysis should receive attention at the Global Fund board and is a definite heads-up for countries preparing for the next round.

Health care delivery
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Traditional Medicine

Bodeker G, Carter G, et al. HIV/AIDS: Traditional systems of health care in the management of a global epidemic. J Altern Complement Med 2006;12:563-76.

Cultural preference and the high cost and unavailability of anti-HIV drugs for people living with HIV in the developing world lead many to turn to traditional (indigenous) medicine to manage HIV-related illness. Traditional health practitioners can play an important role in delivering an HIV prevention message and some may be able to offer treatment for opportunistic infections. In industrialized countries, approximately half or more of those with HIV-related disease use complementary medicines in conjunction with their antiretroviral therapy. A growing body of research highlights the immunomodulatory and antiviral potential of plant-based medicines. There are also concerns about unsafe practices and a growth in claims of traditional cures for AIDS. Partnerships between the modern and traditional/complementary health sectors in research, policy, and practice are essential in building comprehensive HIV control strategies.

Editors’ note: an upcoming UNAIDS best practice publication focuses on principles for effectively engaging traditional health practitioners in the response to the epidemic.

Health care delivery
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Treatment: Implementation Research

McCarthy EA, O'Brien ME, Rodriguez WR. Training and HIV-Treatment Scale-Up: Establishing an Implementation Research Agenda. PLoS Med 2006;3:e304. http://medicine.plosjournals.org/perlserv/?request=get-document&doi=10.1371/journal.pmed.0030304

 

The provision of HIV treatment and care in resource-limited settings is expanding rapidly. Health-worker training is one of many factors critical to the rapid scale-up of high-quality care. Large numbers of health workers require HIV training; yet, few countries have a comprehensive training plan, a clear assessment of ongoing training needs, a plan to operationalise training on a large scale, or adequate funds budgeted for training. McCarthy and colleagues gathered information on global HIV training through a thorough review of the published peer-reviewed literature, internet sites, programme reports related to training for HIV treatment in resource-limited countries, a survey of HIV training efforts in high-burden countries, and discussions with appropriate professionals in selected countries. They review challenges and approaches to clinical HIV training, and suggest that the care delivery model, the roles played by different health workers, the number of workers needing training, resources available for training, and the phase of programme development should affect training design. Evidence to support these decisions must come from implementation research (operational research into how proven interventions are implemented and can be improved to accelerate high-quality HIV-treatment scale-up) to answer the overarching question: what is the optimal approach to training the health workforce for an expanding HIV-treatment programme in a resource-limited setting?

 

Health care delivery
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Traditional and Alternative Medicine

Mills E, Singh S, et al. The challenges of involving traditional healers in HIV/AIDS care. Int J STD AIDS 2006;17(6):360-3.

 http://www.ingentaconnect.com/content/rsm/std/2006/00000017/00000006

In sub-Saharan Africa, traditional healers play a major role in providing for the needs of people, particularly in rural areas where western health care is unavailable. Despite a paucity of reliable figures to determine the prevalence of traditional medicine usage, it is estimated that some 70% of sub-Saharan Africans access traditional healers. There is now mounting evidence of the importance of involving traditional healers in the management of the HIV epidemic - both for their potential benefits, although poorly researched and understood, and to reduce the impact that some traditional healing interventions may play on the spread of HIV and unsafe treatment of infected patients. While there are few collaborative projects between traditional healers and biomedical health providers, there is an enthusiasm on the part of traditional healers to collaborate and learn from their western-trained counterparts. Collaboration is essential, given the changing epidemic of HIV and the dynamic relationship between the two health sectors.

Health care delivery
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