BackgroundCounselling is considered a prerequisite for the proper handling of testing and for ensuring effective HIV preventive efforts. HIV testing services have recently been scaled up substantially with a particular focus on provider-initiated models. Increasing HIV test rates have been attributed to the rapid scale-up of the provider-initiated testing model, but there is limited documentation of experiences with this new service model. The aim of this study was to determine the use of different types of HIV testing services and to investigate perceptions and experiences of these services with a particular emphasis on the provider initiated testing in three selected districts in Kenya, Tanzania, and, Zambia.MethodsA concurrent triangulation mixed methods design was applied using quantitative and qualitative approaches. A population-based survey was conducted among adults in the three study districts, and qualitative data were obtained from 34 focus group discussions and 18 in-depth interviews. The data originates from the ongoing EU funded research project "REsponse to ACountable Priority Setting for Trust in Health Systems" (REACT) implemented in the three countries which has a research component linked to HIV and testing, and from an additional study focusing on HIV testing, counselling perceptions and experiences in Kenya.ResultsProportions of the population formerly tested for HIV differed sharply between the study districts and particularly among women (54% Malindi, 34% Kapiri Mposhi and 27% Mbarali) (p < 0.001). Women were much more likely to be tested than men in the districts that had scaled-up programmes for preventing mother to child transmission of HIV (PMTCT). Only minor gender differences appeared for voluntary counselling and testing. In places where, the provider-initiated model in PMTCT programmes had been rolled out extensively testing was accompanied by very limited pre- and post-test counselling and by a related neglect of preventative measures. Informants expressed frustration related to their experienced inability to 'opt-out' or decline from the provider-initiated HIV testing services.ConclusionCounselling emerged as a highly valued process during HIV testing. However, counselling efforts were limited in the implementation of the provider-initiated opt-out HIV testing model. The approach was moreover not perceived as voluntary. This raises serious ethical concerns and implies missed preventive opportunities inherent in the counselling concept. Moreover, implementation of the new testing approach seem to add a burden to pregnant women as disproportionate numbers of women get to know their HIV status, reveal their HIV status to their spouse and recruit their spouses to go for a test. We argue that there is an urgent need to reconsider the manner in which the provider initiated HIV testing model is implemented in order to protect the client's autonomy and to maximise access to HIV prevention.
BackgroundHealth, fair financing and responsiveness to the user's needs and expectations are seen as the essential objectives of health systems. Efforts have been made to conceptualise and measure responsiveness as a basis for evaluating the non-health aspects of health systems performance. This study assesses the applicability of the responsiveness tool developed by WHO when applied in the context of voluntary HIV counselling and testing services (VCT) at a district level in Kenya.MethodsA mixed method study was conducted employing a combination of quantitative and qualitative research methods concurrently. The questionnaire proposed by WHO was administered to 328 VCT users and 36 VCT counsellors (health providers). In addition to the questionnaire, qualitative interviews were carried out among a total of 300 participants. Observational field notes were also written.ResultsA majority of the health providers and users indicated that the responsiveness elements were very important, e.g. confidentiality and autonomy were regarded by most users and health providers as very important and were also reported as being highly observed in the VCT room. However, the qualitative findings revealed other important aspects related to confidentiality, autonomy and other responsiveness elements that were not captured by the WHO tool. Striking examples were inappropriate location of the VCT centre, limited information provided, language problems, and concern about the quality of counselling.ConclusionThe results indicate that the WHO developed responsiveness elements are relevant and important in measuring the performance of voluntary HIV counselling and testing. However, the tool needs substantial revision in order to capture other important dimensions or perspectives. The findings also confirm the importance of careful assessment and recognition of locally specific aspects when conducting comparative studies on responsiveness of HIV testing services.
Health care forms a large economic sector in all countries, and procurement of medicines and other essential commodities necessarily creates economic linkages between a country's health sector and local and international industrial development. These procurement processes may be positive or negative in their effects on populations' access to appropriate treatment and on local industrial development, yet procurement in low and middle income countries (LMICs) remains under-studied: generally analysed, when addressed at all, as a public sector technical and organisational challenge rather than a social and economic element of health system governance shaping its links to the wider economy. This article uses fieldwork in Tanzania and Kenya in 2012-15 to analyse procurement of essential medicines and supplies as a governance process for the health system and its industrial links, drawing on aspects of global value chain theory. We describe procurement work processes as experienced by front line staff in public, faith-based and private sectors, linking these experiences to wholesale funding sources and purchasing practices, and examining their implications for medicines access and for local industrial development within these East African countries. We show that in a context of poor access to reliable medicines, extensive reliance on private medicines purchase, and increasing globalisation of procurement systems, domestic linkages between health and industrial sectors have been weakened, especially in Tanzania. We argue in consequence for a more developmental perspective on health sector procurement design, including closer policy attention to strengthening vertical and horizontal relational working within local health-industry value chains, in the interests of both wider access to treatment and improved industrial development in Africa.
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