The iDSI Reference Case is an aid to thought, not a substitute for it, and should not be followed slavishly without regard to context, culture, or history. This article presents the iDSI Reference Case and discusses the rationale, approach, components, and application in LMICs.

Formalized task shifting structures have been used to rapidly scale up antiretroviral service delivery to underserved populations in several countries, and may be a promising mechanism for accomplishing universal health coverage. However, studies evaluating the quality of service delivery through task shifting have largely ignored the patient perspective, focusing on health outcomes and acceptability to health care providers and regulatory bodies, despite studies worldwide that have shown the significance of patient satisfaction as an indicator of quality. This study aimed to measure patient satisfaction with task shifting of antiretroviral services in hospitals and health centres in four regions of Ethiopia. This cross-sectional study used data collected from a time–motion study of patient services paired with 665 patient exit interviews in a stratified random sample of antiretroviral therapy clinics in 21 hospitals and 40 health centres in 2012. Data were analyzed using f-tests across provider types, and multivariate logistic regression to identify determinants of patient satisfaction. Most (528 of 665) patients were satisfied or somewhat satisfied with the services received, but patients who received services from nurses and health officers were significantly more likely to report satisfaction than those who received services from doctors [odds ratio (OR) 0.26, P < 0.01]. Investments in the health facility were associated with higher satisfaction (OR 1.07, P < 0.01), while costs to patients of over 120 birr were associated with lower satisfaction (OR 0.14, P < 0.05). This study showed high levels of patient satisfaction with task shifting in Ethiopia. The evidence generated by this study complements previous biomedical and health care provider/regulatory acceptability studies to support the inclusion of task shifting as a mechanism for scaling-up health services to achieve universal health coverage, particularly for underserved areas facing severe health worker shortages.

BackgroundVoluntary medical male circumcision is an integral part of the South African government’s response to the HIV and AIDS epidemic. However, there remains a limited body of economic analysis on the cost of VMMC programming, and the demand creation activities used to mobilize males, especially among adolescent boys in school. This study addresses this gap by presenting the costs of a VMMC program which adopted two demand creation strategies targeting school-going males in South Africa.MethodsCost data was collected from a VMMC program in the KwaZulu-Natal province of South Africa. A retrospective, micro-costing ingredient approach was applied to identify, measure and value resources of two demand creation strategies targeting young males.ResultsThe program circumcised 4987 young males between May 2011 and February 2013, at a cost of $127.68 per circumcision. Demand creation activities accounted for 32% of the total cost, HCT contributing 10% with the medical circumcision procedure accounting for 58% of the total cost. Using the first demand creation strategy, 2168 circumcisions were performed at a cost of $149.57 per circumcision. Following this first strategy, a second demand creation strategy was adopted which saw the cost fall to $110.85 per circumcision. More young males were recruited following the second strategy with clinic services more efficiently utilized. Whilst the cost per circumcision of demand activities rose slightly between the first ($39.94) and second ($41.65) strategy, there was a substantial reduction in the cost of the circumcision procedure; $90.01 under the first strategy falling to $60.60 following the adoption of the second demand creation strategy.ConclusionEnsuring the optimal use of clinic facilities was the primary driver in reducing the cost per circumcision. This VMMC program has illustrated the value of evaluating progress and instituting changes to attain better cost efficiencies. This adjustment resulted in a substantial reduction in the cost per circumcision.

Shifting the handling of both severe drug reactions and antiretroviral drug regimen changes from physicians to other clinical officers is not associated with a significant change in the 2-year treatment success rate or the costs of ART care. As an observational study, these results are tentative, and more research is needed in determining the optimal patterns of task shifting.