SPH: Global Health Datasets
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Item MAHMAZ maternity waiting home: setup cost datasetJuntunen, Allison; Scott, Nancy A.; Kaiser, Jeanette L.; Vian, Taryn; Ngoma, Thandiwe; Mataka, Kaluba K.; Bwalya, Misheck; Sakanga, Viviane; Kalaba, David; Biemba, Godfrey; Rockers, Peter C.; Hamer, Davidson H.; Long, Lawrence C.These datasets detail 1) the setup costs expended to set up 10 maternity waiting homes in rural Zambia and 2) the monthly occupancy of the maternity waiting homes. The former includes the date of purchase, cost category, and the purchase amount in Kwacha. The latter describes how many patients visited the maternity waiting home in the last year of our project. We utilized this data to create a manuscript describing the setup costs of these homes, and the cost per admission to the homes, to serve as a guide for future implementors.Item Dataset: observational study of the clinical performance of a Public-Private Partnership national referral hospital network in Lesotho: Do improvements last over time?Scott, Nancy A.; Kaiser, Jeanette L.; Jack, Brian W.; Nkabane-Nkholongo, Elizabeth L.; Juntunen, Allison; Nash, Tshema; Alade, Mayowa Oluwatosin; Vian, TarynPublic-private partnerships (PPP) may increase healthcare quality but lack longitudinal evidence for success. The Queen ‘Mamohato Memorial Hospital (QMMH) in Lesotho is one of Africa's first healthcare PPPs. We compare data from 2012 and 2018 on capacity, utilization, quality, and outcomes to understand if early documented successes have been sustained using the same measures over time. In this observational study using administrative and clinical data, we assessed beds, admissions, average length of stay (ALOS), outpatient visits, and patient outcomes. We measured triage time and crash cart stock through direct observation in 2013 and 2020. Operational hospital beds increased from 390 to 410. Admissions decreased (-5.3%) while outpatient visits increased (3.8%). ALOS increased from 5.1 to 6.5 days. Occupancy increased from 82% to 99%; half of the wards had occupancy rates ≥90%, and Neonatal ward occupancy was 209%. The proportion of crash cart stock present (82.9% to 73.8%) and timely triage (84.0% to 27.6%) decreased. While overall mortality decreased (8.0% to 6.5%) and neonatal mortality overall decreased (18.0% to 16.3%), mortality among very low birth weight neonates increased (30.2% to 36.8%). Declines in overall hospital mortality are promising. Yet, continued high occupancy could compromise infection control and impede response to infections, such as COVID-19. High occupancy in the Neonatal ward suggests that the population need for neonatal care outpaces QMMH capacity; improvements should be addressed at the hospital and systemic levels. The increase in ALOS is acceptable for a hospital meant to take the most critical cases. The decline in crash cart stock completeness and timely triage may affect access to emergency treatment. While the partnership itself ended earlier than anticipated, our evaluation suggests that generally the hospital under the PPP was operational, providing high-level, critically needed services, and continued to improve patient outcomes. Quality at QMMH remained substantially higher than at the former Queen Elizabeth II hospital.Item Simplified clinical algorithm for identifying patints eligible for immediate initiation of antiretroviral therapy for HIV (SLATE): protocol for a randomised evaluation(Boston University, 2017-05) Rosen, Sydney; Fox, Matthew P.; Larson, Bruce A.; Brennan, Alana Teresa; Maskew, Mhairi; Tsikhutsu, Isaac; Ehrenkranz, Peter D.; Venter, Wd FrancoisINTRODUCTION: African countries are rapidly adopting guidelines to offer antiretroviral therapy (ART) to all HIV-infected individuals, regardless of CD4 count. For this policy of 'treat all' to succeed, millions of new patients must be initiated on ART as efficiently as possible. Studies have documented high losses of treatment-eligible patients from care before they receive their first dose of antiretrovirals (ARVs), due in part to a cumbersome, resource-intensive process for treatment initiation, requiring multiple clinic visits over a several-week period. METHODS AND ANALYSIS: The Simplified Algorithm for Treatment Eligibility (SLATE) study is an individually randomised evaluation of a simplified clinical algorithm for clinicians to reliably determine a patient's eligibility for immediate ART initiation without waiting for laboratory results or additional clinic visits. SLATE will enroll and randomize (1:1) 960 adult, HIV-positive patients who present for HIV testing or care and are not yet on ART in South Africa and Kenya. Patients randomized to the standard arm will receive routine, standard of care ART initiation from clinic staff. Patients randomized to the intervention arm will be administered a symptom report, medical history, brief physical exam and readiness assessment. Patients who have positive (satisfactory) results for all four components of SLATE will be dispensed ARVs immediately, at the same clinic visit. Patients who have any negative results will be referred for further clinical investigation, counseling, tests or other services prior to being dispensed ARVs. After the initial visit, follow-up will be by passive medical record review. The primary outcomes will be ART initiation ≤28 days and retention in care 8 months after study enrollment. ETHICS AND DISSEMINATION: Ethics approval has been provided by the Boston University Institutional Review Board, the University of the Witwatersrand Human Research Ethics Committee (Medical) and the KEMRI Scientific and Ethics Review Unit. Results will be published in peer-reviewed journals and made widely available through presentations and briefing documents.Item Dataset for "Barriers and facilitators to facility-based delivery in rural Zambia: A qualitative study of women’s perceptions after implementation of an improved Maternity Waiting Homes intervention"Scott, Nancy A.; Fong, Rachel M.; Kaiser, Jeanette L.; Ngoma, Thandiwe; Vian, Taryn; Bwalya, Misheck; Sakanga, Viviane R.; Lori, Jody R.; Musonda, Gertrude; Munro-Kramer, Michelle L.; Rockers, Peter C.; Ahmed Mdluli, Eden; Biemba, Godfrey; Hamer, Davidson H.Objectives: Women in sub-Saharan Africa face well-documented barriers to facility-based deliveries. An improved maternity waiting homes (MWH) model was implemented in rural Zambia to bring pregnant women closer to facilities for delivery. We qualitatively assessed whether MWHs changed perceived barriers to facility delivery among remote-living women. Design: We administered in-depth interviews (IDIs) to a randomly-selected subsample of women in intervention (n=78) and control (n=80) groups who participated in the primary quasi-experimental evaluation of an improved MWH model. The IDIs explored perceptions and preferences of delivery location. We conducted content analysis to understand perceived barriers and facilitators to facility delivery. Setting and participants: Participants lived in villages 10+ kilometers from the health facility and had delivered a baby in the previous 12 months. Intervention: The improved MWH model was implemented at 20 rural health facilities. Results: Over 96% of participants in the intervention arm and 90% in the control arm delivered their last baby at a health facility. Key barriers to facility delivery were distance and transportation, and costs associated with delivery. Facilitators included no user fees, penalties for home delivery, desire for safe delivery, and availability of MWHs. Most themes were similar between study arms. Both discussed the role MWHs have in improving access to facility-based delivery. Intervention arm participants expressed that the improved MWH model encourages use and helps overcome the distance barrier. Control arm participants either expressed a desire for an improved MWH model or did not consider it in their decision-making. Conclusions: Even in areas with high facility-based delivery rates in rural Zambia, barriers to access persist. MWHs may be useful to address the distance challenge, but no single intervention is likely to address all barriers experienced by rural, low-resourced populations. MWHs should be considered in a broader systems approach to improving access in remote areas. Trial Registration: ClinicalTrials.gov Identifier: NCT02620436Item Components of clean delivery kits and newborn mortality in the Zambia Chlorhexidine Application Trial (ZamCAT): an observational study(2021) Park, Jason; Hamer, Davidson; Mbewe, Reuben; Scott, Nancy; Herlihy, Julie; Yeboah-Antwi, Kojo; Semrau, KatherineBACKGROUND: Infection, a leading cause of neonatal death in low- and middle-income countries, is often caused by pathogens acquired during childbirth. Clean delivery kits (CDKs) have shown efficacy in reducing infection-related perinatal and neonatal mortality. However, there remain gaps in our current knowledge, including the effect of individual components, timeline of protection, and benefit of CDKs in home and facility-based deliveries. METHODS AND FINDINGS: A post-hoc, secondary analysis was performed using non-randomized data from the Zambia Chlorhexidine Application Trial (ZamCAT), a community-based, cluster-randomized controlled trial of chlorhexidine umbilical cord care in Southern Province of Zambia from February 2011 to January 2013. CDKs, containing soap, gloves, cord clamp, plastic sheet, razor blade, matches, and candles, were provided to all participants. Field monitors made home-based visit to each participant 4 days post-partum, during which CDK use and newborn outcomes were ascertained. Logistic regression was used to study the association between different CDK components and newborn mortality rate (NMR).Of 38,579 deliveries recorded during the study, 36,996 newborns were analyzed after excluding stillbirths and missing information. Gloves, cord clamp, and plastic sheets were the most frequently used CDK item combinations in both home and facility deliveries. Each of the 7 CDK components was associated with lower NMR in users versus non-users. Adjusted logistic regression showed that use of gloves (OR: 0.33, CI: 0.24-0.46), cord clamp (OR: 0.51, CI: 0.38-0.68), plastic sheets (OR: 0.46, CI: 0.34-0.63), and razor blades (OR: 0.69, CI: 0.53-0.89) were associated with lower risk of newborn mortality. Use of gloves and cord clamp was associated with reduced risk of immediate newborn death (<24 hours). Reduction in risk of early newborn death (1-7 days) was associated with use of gloves, cord clamp, plastic sheets, and razor blades. In examining perinatal mortality, similar patterns were observed. There was no significant reduction in risk of late newborn mortality (7-28 days) with CDK use. Study limitations included potential for potential recall bias of CDK use and inability to establish causality as a secondary observational study. CONCLUSIONS: CDK use was associated with reductions in early newborn mortality at both home and facility deliveries, especially when certain kit components were used. While causality could not be established in this non-randomized secondary analysis, given these beneficial associations, scaling up the use of CDKs in rural areas of sub-Saharan Africa may improve neonatal outcomes.Item An Excel-based template for estimating induction-phase treatment costs for cryptococcal meningitis in high HIV-burden African countries(2021-01) Larson, Bruce; Shroufi, Amir; Muthoga, Charles; Oladele, Rita; Rajasingham, Radha; Jordan, Alexander; Jarvis, Joe; Chiller, Tom; Govender, NeleshItem Changing the South African national antiretroviral therapy guidelines: The role of cost modellingMeyer-Rath, Gesine; Johnson, Leigh F.; Pillay, Yogan; Blecher, Mark; Brennan, Alana Teresa; Long, Lawrence; Moultrie, Harry; Sanne, Ian; Fox, Matthew P.; Rosen, SydneyBackground We were tasked by the South African Department of Health to assess the cost implications to the largest ART programme in the world of adopting sets of ART guidelines issued by the World Health Organization between 2010 to 2016. Methods Using data from large South African ART clinics (n = 24,244 patients), projections of patients in need of ART, and cost data from bottom-up cost analyses, we constructed a population-level health-state transition model with 6-monthly transitions between health states depending on patients’ age, CD4 cell count/ percentage, and, for adult first-line ART, time on treatment. Findings For each set of guidelines, the modelled increase in patient numbers as a result of prevalence and uptake was substantially more than the increase resulting from additional eligibility. Under each set of guidelines, the number of people on ART was projected to increase by 31-133% over the next seven years, and cost by 84-175%, while increased eligibility led to 1-26% more patients, and 1-17% higher cost. The projected increases in treatment cost due to the 2010 and the 2015 WHO guidelines could be offset in their entirety by the introduction of cost-saving measures such as opening the drug tenders for international competition and task-shifting. Under universal treatment, annual costs of the treatment programme will decrease for the first time from 2024 onwards. Conclusions Annual budgetary requirements for ART will continue to increase in South Africa until universal treatment is taken to full scale. Model results were instrumental in changing South African ART guidelines, more than tripling the population on treatment between 2009 and 2017, and reducing the per-patient cost of treatment by 64%.