Background In 2010, Israel intensified its adoption of Procedure-Related Group (PRG) based hospital payments, a local version of DRG (Diagnosis-related group). PRGs were created for certain procedures by clinical fields such as urology, orthopedics, and ophthalmology. Non-procedural hospitalizations and other specific procedures continued to be paid for as per-diems (PD). Whether this payment reform affected inpatient activities, measured by the number of discharges and average length of stay (ALoS), is unclear. Methods We analyzed inpatient data provided by the Ministry of Health from all 29 public hospitals in Israel. Our observations were hospital wards for the years 2008–2015, as proxies to clinical fields. We investigated the impact of this reform at the ward level using difference-in-differences analyses among procedural wards. Those for which PRG codes were created were treatment wards, other procedural wards served as controls. We further refined the analysis of effects on each ward separately. Results Discharges increased more in the wards that were part of the control group than in the treatment wards as a group. However, a refined analysis of each treated ward separately reveals that discharges increased in some, but decreased in other wards. ALoS decreased more in treatment wards. Difference-in-differences results could not suggest causality between the PRG payment reform and changes in inpatient activity. Conclusions Factors that may have hampered the effects of the reform are inadequate pricing of procedures, conflicting incentives created by other co-existing hospital-payment components, such as caps and retrospective subsidies, and the lack of resources to increase productivity. Payment reforms for health providers such as hospitals need to take into consideration the entire provider market, available resources, other – potentially conflicting – payment components, and the various parties involved and their interests.
BackgroundWhile poor countries have made progress attaining the The Joint United Nations Programme on HIV/AIDS (UNAIDS) goals for 2025, continued progress depends on continued accessibility of program services, as well as continued improvements in compliant behavior by HIV positive populations. This paper examines household survey data in four African countries pertaining to those critical behaviors and identifies the key population barriers for attaining UNAIDS goals. MethodsThis study used Population-based HIV Impact Assessment (PHIA) survey data for Zambia, Malawi, Eswatini, and Tanzania to examine household and other influences associated with effectively managing HIV-infected adults using three key outcomes: (i) self-awareness of HIV status, (ii) antiretroviral therapy adherence, and (iii) rate of viral load suppression (VLS). ResultsFactors found to increase HIV risk also posed barriers to awareness and viral suppression, such as being young, having multiple partners, and having a job outside the home. Additional barriers to awareness and viral suppression were low education, low wealth, low knowledge of HIV, and the HIV status and gender of the household head. The most consistent factor influencing awareness and viral load suppression was the gender of the individual. Women were much more likely to be aware of their HIV status and more likely to be virally suppressed at rates almost twice as high as comparable men. Our analysis shows that the gender differential for awareness seems primarily due the testing and other services provided for women giving birth. We also found that the VLS gender gap was not related birthing-related services. ConclusionsThe most substantial barrier to achieving UNAIDS goals appears to be poorer compliance by men regarding testing and sustained VLS. Routinely providing HIV testing and other HIV information during antenatal care (ANC) may have contributed to improved rates of HIV-status awareness of birthing-age women. New programs to routinely integrate HIV testing into men's health care in workplaces or other settings could improve men's awareness and compliance with treatment. Also needed are more effective interventions to target sectors of the population that are less likely to adhere to treatment regimens, such as persons with low-education levels, low wealth, and/or low knowledge of HIV.This study examines Population-based HIV Impact Assessment (PHIA) household survey data in four sub-Saharan African (SSA) countries to understand the personal, household and community factors that are associated with awareness of human immunodeficiency virus (HIV) status and continued viral load suppression (VLS) among HIV-positive individuals. The Joint United Nations Programme on HIV/ AIDS (UNAIDS) 95-95-95 cascade goals for 2025 depend critically on both accessibility of program activities as well as compliant behavior of households. 1 Specifically, current UNAIDS targets are the following:1. 95% of HIV positive persons should be aware of their positive status. This requires testing and ...
BackgroundEducational campaigns to prevent HIV/AIDS have shown mixed success in Africa. We hypothesized that women's lack of agency in decision-making and taking discernible actions reduces the beneficial impact of HIV-related knowledge. MethodsWe used data from Population-based HIV Impact Assessment (PHIA) surveys in Malawi, Tanzania and Zambia. A subsample of surveys that were completed by married adult women were selected for the HIV knowledge module which included responses for household decision-making questions. We created a binary variable for agency (ability to participate in decision-making about household matters, health, and sex), and scalar variables for HIV-related knowledge and sexual behaviors. We used regression analysis using survey weights with the behaviors as dependent variables. ResultsWe pooled survey results from 16,822 women (63% from Tanzania, 19% from Malawi and 18% from Zambia). Altogether, 13.5% of women (17% of those 15-24 years old) exhibited poor agency. Those with a higher degree of agency had higher education, were working, and were wealthier. Women lacking agency were significantly less likely to use condoms (4.7% vs. 6.2%, P=0.022). Approximately 95% reported having a single partner over past 12 months, while Zambian women with no agency showed significantly lower rate of 92% (odds ratio, OR=0.66, 95% confidence interval, CI=0.45-0.95, P=0.027). The rate of HIV testing across the three countries was 83%-92%. In Tanzania, presence of good knowledge and agency together increased the odds of HIV testing by 60% (interaction term). However, among those with good knowledge yet reporting poor agency, the likelihood of HIV testing decreased by 65%, nullifying knowledge impact. We did not observe similar associations in Malawi. Among women with poor knowledge, lack of agency reduced the odds of condom use by 50% compared to those with agency. Alternatively, for women who exhibited good knowledge without agency, the odds of condom use was more than double compared to women with some agency (OR=2.14, 95% CI=1.07-4.27, P=0.032)). ConclusionsWe detected a moderating effect for agency on knowledge-driven behavior. Results on different behaviors and across individual countries are mixed and suggest caution to derive definitive conclusions. Despite limitations, these findings indicate that policies that increase women's agency may help anti-HIV programs' success.Women have fallen victim to the HIV/AIDS epidemic at disproportionally higher rates than men, especially in African countries. 1 This fact has created a sense of priority to promote improved safe sex practices that could protect women against the infection. In this effort, educationbased interventions have been successful in providing greater access to healthcare services and other resources in low-income countries, though the uptake of disease preventative behaviors has been generally low. 2,3 Women, in particular married women, have very low rates of condom use. For instance, in Kenya, 1.8% and in Zambia 4.7%, of married women use con...
Background HIV/AIDS continues to persist as a major global public health issue in Africa. Within the younger adult population, adolescent girls and younger women aged 15 to 29 years have been identified as having a heightened risk of contracting HIV. Risky sexual behaviors are important drivers behind the HIV prevalence gender gap among younger adults in sub-Saharan Africa. Methods We used nationally representative survey data from three sub-Saharan African countries, Malawi, Tanzania and Zambia, to explain the relationship between HIV prevalence and having an older partner and/or having multiple partners using a logit model. We then proceeded to conduct a Blinder-Oaxaca decomposition analysis to better understand the gap drivers. Results We found that while the gender gap is driven largely by women having higher levels of risk for sexual behaviors and other risk factors in two of the study countries, this was not found in the third. We also found that different sexual behaviors vary in their riskiness across countries. Having multiple partners and having an older partner carried a similar risk with regard to younger adults contracting HIV in Malawi; in Tanzania and Zambia the risk associated with having multiple partners was greater than the risk associated with having an older partner. In all three countries the risk of being a younger adult female was higher than men, other risk factors the same. Conclusions Risky sexual behavior contributed to increased prevalence of HIV in the study countries. Policies aiming to encourage younger women to form relationships with men among their cohort would be most impactful in Malawi, where currently many younger women have partners who are more than five years their senior compared to younger men. Other policies can attempt to reduce non-monogamous relationships among younger adults, wherein multiple partners are a key driver of the HIV gender gap.
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