This is the first systematic review of childhood/adolescent vaccine-related discrete choice experiments. In future, special attention should be paid to ensuring that choice context and discrete choice experiment design are compatible to generate reliable estimates of uptake.
ObjectiveTo quantify the impact of service provider characteristics on young people’s choice of family planning (FP) service provider in rural Malawi in order to identify strategies for increasing access and uptake of FP among youth.Methods and Findings A discrete choice experiment was developed to assess the relative impact of service characteristics on preferences for FP service providers among young people (aged 15–24). Four alternative providers were included (government facility, private facility, outreach and community based distribution of FP) and described by six attributes (the distance between participants’ home and the service delivery point, frequency of service delivery, waiting time at the facility, service providers’ attitude, availability of FP commodities and price). A random parameters logit model was used to estimate preferences for service providers and the likely uptake of services following the expansion of outreach and community based distribution (CBDA) services. In the choice experiment young people were twice as likely to choose a friendly provider (government service odds ratio [OR] = 2.45, p<0.01; private service OR = 1.99, p<0.01; CBDA OR = 1.88, p<0.01) and more than two to three times more likely to choose a provider with an adequate supply of FP commodities (government service OR = 2.48, p<0.01; private service OR = 2.33, p<0.01; CBDA = 3.85, p<0.01). Uptake of community based services was greater than facility based services across a variety of simulated service scenarios indicating that such services may be an effective means of expanding access for youth in rural areas and an important tool for increasing service uptake among youth.ConclusionsEnsuring that services are acceptable to young people may require additional training for service providers in order to ensure that all providers are friendly and non-judgemental when dealing with younger clients and to ensure that supplies are consistently available.
BackgroundThere is growing interest in integration of HIV and sexual and reproductive health (SRH) services as a way to improve the efficiency of human resources (HR) for health in low- and middle-income countries. Although this is supported by a wealth of evidence on the acceptability and clinical effectiveness of service integration, there is little evidence on whether staff in general health services can easily absorb HIV services.MethodsWe conducted a descriptive analysis of HR integration through task shifting/sharing and staff workload in the context of the Integra Initiative - a large-scale five-year evaluation of HIV/SRH integration. We describe the level, characteristics and changes in HR integration in the context of wider efforts to integrate HIV/SRH, and explore the impact of HR integration on staff workload.ResultsImprovements in the range of services provided by staff (HR integration) were more likely to be achieved in facilities which also improved other elements of integration. While there was no overall relationship between integration and workload at the facility level, HIV/SRH integration may be most influential on staff workload for provider-initiated HIV testing and counselling (PITC) and postnatal care (PNC) services, particularly where HIV care and treatment services are being supported with extra SRH/HIV staffing. Our findings therefore suggest that there may be potential for further efficiency gains through integration, but overall the pace of improvement is slow.ConclusionsThis descriptive analysis explores the effect of HIV/SRH integration on staff workload through economies of scale and scope in high- and medium-HIV prevalence settings. We find some evidence to suggest that there is potential to improve productivity through integration, but, at the same time, significant challenges are being faced, with the pace of productivity gain slow. We recommend that efforts to implement integration are assessed in the broader context of HR planning to ensure that neither staff nor patients are negatively impacted by integration policy.
ObjectiveTo present evidence on the total costs and unit costs of delivering six integrated sexual reproductive health and HIV services in a high and medium HIV prevalence setting, in order to support policy makers and planners scaling up these essential services.DesignA retrospective facility based costing study conducted in 40 non-government organization and public health facilities in Kenya and Swaziland.MethodsEconomic and financial costs were collected retrospectively for the year 2010/11, from each study site with an aim to estimate the cost per visit of six integrated HIV and SRH services. A full cost analysis using a combination of bottom-up and step-down costing methods was conducted from the health provider’s perspective. The main unit of analysis is the economic unit cost per visit for each service. Costs are converted to 2013 International dollars.ResultsThe mean cost per visit for the HIV/SRH services ranged from $Int 14.23 (PNC visit) to $Int 74.21 (HIV treatment visit). We found considerable variation in the unit costs per visit across settings with family planning services exhibiting the least variation ($Int 6.71-52.24) and STI treatment and HIV treatment visits exhibiting the highest variation in unit cost ranging from ($Int 5.44-281.85) and ($Int 0.83-314.95), respectively. Unit costs of visits were driven by fixed costs while variability in visit costs across facilities was explained mainly by technology used and service maturity.ConclusionFor all services, variability in unit costs and cost components suggest that potential exists to reduce costs through better use of both human and capital resources, despite the high proportion of expenditure on drugs and medical supplies. Further work is required to explore the key drivers of efficiency and interventions that may facilitate efficiency improvements.
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