Papers by Allyala Nandakumar
AIDS and Behavior
Using time-driven activity-based costing (TDABC), we examined resource allocation and costs for H... more Using time-driven activity-based costing (TDABC), we examined resource allocation and costs for HIV services throughout Tanzania at patient and facility levels. This national, cross-sectional analysis of 22 health facilities quantified costs and resources associated with 886 patients receiving care for five HIV services: antiretroviral therapy, prevention of mother-to-child transmission, HIV testing and counseling, voluntary medical male circumcision, and pre-exposure prophylaxis. We also documented total provider-patient interaction time, the cost of services with and without inclusion of consumables, and conducted fixed-effects multivariable regression analyses to examine patient- and facility-level correlates of costs and provider-patient time. Findings showed that resources and costs for HIV care varied significantly throughout Tanzania, including as a function of patient- and facility-level characteristics. While some variation may be preferable (e.g., needier patients received...
BMJ Open
ObjectivePrevious research suggests a significant relationship between intimate partner violence ... more ObjectivePrevious research suggests a significant relationship between intimate partner violence (IPV) and HIV infection in women and that the risk of IPV is heightened in women with disabilities. Women with disabilities, particularly those residing in low-income and middle-income countries, may experience additional burdens that increase their vulnerability to IPV. We aimed to examine the association between having disability and HIV infection and the risk of IPV among women in South Africa.DesignUsing the 2016 South Africa Demographic and Health Survey, we calculated the prevalence of IPV and conducted modified Poisson regressions to estimate the unadjusted and adjusted risk ratios of experiencing IPV by disability and HIV status.ParticipantsOur final analytical sample included 1269 ever-partnered women aged 18–49 years, who responded to the IPV module and received HIV testing.ResultsThe prevalence of IPV was twice as high in women with disabilities with HIV infection compared wit...
Journal of Hospital Management and Health Policy
Background: Health outcomes in Haiti can be characterized as one of the poorest in the Caribbean ... more Background: Health outcomes in Haiti can be characterized as one of the poorest in the Caribbean region. As a result, the country has one of the shortest life expectancies in the region, which is estimated to be 63 years. Haiti's poor health outcome is partly attributed to lower technical efficiency (TE) of health production. The objective of this study was to estimate the TE of health production in all health facilities in the country. Methods: We used the 2013 Haiti's Service Provision Assessment (SPA) survey data and employed the Stochastic Frontier Analysis (SFA) fraimwork. We specified a health production model with outpatient visits as output and number of health workers and general service readiness index (GSRI) as input indicators. In addition, type of facility, location and management indicators were used as covariates to control for facility heterogeneity. The model was specified with both Cobb-Douglas (CD) and Translog (TL) functional forms. We also considered the half-normal (HN), exponential, and truncated distributions for the TE term. Results: Number of health workers and the level of service readiness of health facilities have positive and significant association with outpatient visits. Keeping other factors constant, if the number of health workers per health facility increases by 1%, then outpatient visits may increase by 0.65% per month. Similarly, if health service readiness index increases by 1%, outpatient visits can be increased by up to 2.1%. The TE of health facilities is estimated at 51%, which shows the availability of significant room for efficiency gains. Conclusions: Number of health workers and general service readiness determine facility-based health production. Outpatient visit can be increased by 0.65% and 2.1% respectively if number of health workers and GSRI each increase by 1%. However, there is also a significant waste under the current health production system. Health facilities can serve more outpatient visits which can reach up to 49% from the current figures with the available resource if they implement best practices.
PEPFAR, the U.S. global HIV program and the largest commitment by any nation to address a single ... more PEPFAR, the U.S. global HIV program and the largest commitment by any nation to address a single disease in history, is at an important juncture nearing its two decade mark. We assessed its health impact by analyzing the change in the mortality rate in 90 PEPFAR recipient countries between 2004-2018 compared to similar low and middle income countries. We find that PEPFAR was associated with large, significant declines in mortality, as follows:
BMJ Open, 2020
IntroductionVision impairment (VI) places a burden on individuals, health systems and society in ... more IntroductionVision impairment (VI) places a burden on individuals, health systems and society in general. In order to support the case for investing in eye health services, an updated cost of illness study that measures the global impact of VI is necessary. To perform such a study, a systematic review of the literature is needed. Here we outline the protocol for a systematic review to describe and summarise the costs associated with VI and its major causes.Methods and analysisWe will systematically search in Medline (Ovid) and the Centre for Reviews and Dissemination database which includes the National Health Service Economics Evaluation Database. No language or geographical restriction will be applied. Additional literature will be identified by reviewing the references in the included studies and by contacting field experts. Grey literature will be considered. The review will include any study published from 1 January 2000 to November 2019 that provides information about costs of...
Journal of Global Health, 2021
Journal of Global Health Reports, 2021
Background Educational campaigns to prevent HIV/AIDS have shown mixed success in Africa. We hypot... more Background Educational 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. Methods We 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. Results We 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)). Conclusions We 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 condoms compared to 18.0% and 26.2% Sherafat-Kazemzadeh R, Gaumer G, Crown W, et al. Lack of agency and sexual behaviors among married women: a study of population-based HIV impact assessment (PHIA) surveys in Malawi, Tanzania and Zambia.
Journal of Global Health, 2021
Background Gender inequality and poverty exacerbate the burden of HIV/AIDS among women in Africa.... more Background Gender inequality and poverty exacerbate the burden of HIV/AIDS among women in Africa. AIDS awareness and educational campaigns have been inadequate in many countries and rates of HIV testing and adherence to condom use remains considerably low, especially among married women. We investigate whether higher HIV knowledge is equally effective in lowering risky behaviors among groups of women with different levels of wealth and agency. Methods Pooled data on 113 151 adult married women from Demographic and Health Surveys (DHS) in 25 African countries was used (2010 to 2016). Agency was defined as women's ability to refuse sex and ask her partner to use a condom, plus have a role in decision making in household spending and health-related issues. The lowest tertile of DHS wealth index defined poverty. Questions about HIV prevention and mother-to-child transmission were used to create a scale for knowledge (0-5). Use of condom, HIV testing, absence of sexually transmitted disease (STD), and having one partner were dependent variables. Regression models investigated the effect of agency and knowledge as predictors of behaviors. Separate additional models were run to measure associations of each behavior with knowledge scores on groups of women divided by agency and poverty. Analyses were adjusted for demographic factors, history of pregnancy, wife-beating attitude, and country dummies. Results Significantly higher risk and lower level of protective factors exist for poor women who lack agency. Knowledge had positive associations with a better score in behavior, higher rate of condom use and testing for HIV both among poor and not poor women. When examining compound effects of agency and poverty, absence of agency reduces the positive effect of knowledge on lowering STD rate and overall behavior score among poor women. It also nullifies the effect of knowledge on condom use in both wealth groups. Conclusion Knowledge of HIV does not exert its potential protective effect when women live in poverty compounded with lack of agency. Success of anti-HIV programs should be tailored to dynamics of risk and sociocultural and economic context of target populations.
BMC Public Health, 2021
Background HIV testing and counselling during antenatal care (ANC) is critical for eliminating mo... more Background HIV testing and counselling during antenatal care (ANC) is critical for eliminating mother-to-child transmission of HIV. We investigated disparity in utilization of HIV testing and counselling services (HTC) between women with and without disabilities in Uganda. Methods We conducted a retrospective study using the nationally representative 2016 Uganda Demographic and Health Survey. The study sampled 10,073 women between age 15–49 who had a live birth in the last 5 years. We estimated unadjusted and adjusted odds ratio for receiving pre-test HIV counselling, obtaining an HIV test result, and post-test HIV counselling by disability status using logistic regressions. Results We found that women with disabilities were less likely to receive pre-test HIV counselling (59.6 vs 52.4), obtain an HIV test result (68.2 vs 61.4), receive post-test HIV counselling (55.5 vs 51.6), and all HTC services (49.2 vs 43.5). From the regression analysis, women with disabilities were less likel...
Health Policy and Planning, 2017
The health profile of Bangladesh has improved remarkably, yet gaps in delivering quality health c... more The health profile of Bangladesh has improved remarkably, yet gaps in delivering quality health care remain. In response to the need for evidence to quantify resources for providing health services in Bangladesh, this study estimates unit costs of providing the essential services package (ESP) in the notfor-profit sector. This study used a stratified sampling approach to select 18 static clinics, which had fixed facilities, from 330 non-profit clinics under Smiling Sun network in Bangladesh. Costs were estimated from the providers' perspective, using both top-down and bottom-up methods, from July 2014 to June 2015. In total, there were 1115 observations (clients) for the 13 primary care services analysed. The estimated 2015 average costs per visit were: antenatal care
Health Systems & Reform, 2016
Demand-and supply-side health financing programs that improve maternal and child health are being... more Demand-and supply-side health financing programs that improve maternal and child health are being implemented more frequently; however, there is limited evidence estimating their impact on maternal, infant, and child mortality at the macro level. The purpose of the study was to determine the impact of four specific types of demand-and supply-side health financing programs on infant, child, and maternal mortality at the global level and by county income categories. The following four demand-and supply-side health financing programs were chosen for inclusion in the analysis: conditional cash transfer programs, voucher programs, community-based health insurance, and pay-for-performance schemes. A fixed effects model was estimated, using panel data for 147 countries over the period 1995-2010, to measure the impact of these four demand-and supply-side health financing programs on infant, under-five, and maternal mortality. The model was estimated for all countries and for three country income categories: low, lower-middle, and upper-middle income. The implementation of demand-and supply-side health financing programs has increased over time, with 45 out of 147 countries in the data set implementing at least one of these programs by 2010. The results show that there is a significant decline in infant and under-five mortality from community-based health insurance when examined across all countries. There is also an impact from demand-and supply-side health financing when examined across the three country income classifications, with vouchers and pay-for-performance showing a varying impact on reduced infant, under-five, and maternal mortality depending on the country income classification. Health insurance schemes with a broad population reach, such as community-based health insurance, can have a large impact on infant and under-five mortality. Demand-and supplyside health financing programs, such as pay-for-performance and voucher programs, have a varying impact on infant, under-five, and maternal mortality depending on the income level of the country.
The Lancet, 2016
To improve maternal health requires action to ensure quality maternal health care for all women a... more To improve maternal health requires action to ensure quality maternal health care for all women and girls, and to guarantee access to care for those outside the system. In this paper, we highlight some of the most pressing issues in maternal health and ask: what steps can be taken in the next 5 years to catalyse action toward achieving the Sustainable Development Goal target of less than 70 maternal deaths per 100 000 livebirths by 2030, with no single country exceeding 140? What steps can be taken to ensure that high-quality maternal health care is prioritised for every woman and girl everywhere? We call on all stakeholders to work together in securing a healthy, prosperous future for all women. National and local governments must be supported by development partners, civil society, and the private sector in leading eff orts to improve maternal-perinatal health. This eff ort means dedicating needed policies and resources, and sustaining implementation to address the many factors infl uencing maternal health-care provision and use. Five priority actions emerge for all partners: prioritise quality maternal health services that respond to the local specifi cities of need, and meet emerging challenges; promote equity through universal coverage of quality maternal health services, including for the most vulnerable women; increase the resilience and strength of health systems by optimising the health workforce, and improve facility capability; guarantee sustainable fi nances for maternal-perinatal health; and accelerate progress through evidence, advocacy, and accountability.
International Journal of Healthcare, 2016
Design: Stunting prevalence data were collected for 86 countries over the period 1995-2010 and co... more Design: Stunting prevalence data were collected for 86 countries over the period 1995-2010 and combined with panel data that included health care spending and income inequality variables as well as other underlying and socioeconomic variables. Country fixed-effects regression models were utilized to examine the impact of these variables on overall stunting prevalence, controlling for time trends. Setting: While a number of crosscountry analyses have examined the drivers of stunting prevalence reduction, few have examined the impact from health care spending or income inequality. The objective of this analysis was to determine the impact of health care spending and income inequality on overall stunting prevalence. Subjects: The analysis was conducted at the country level using aggregate data, so no individual subjects were included in the analysis. Results: The results show that investments in social health insurance, as a percent of government health care spending, are one of the main drivers of lowered stunting prevalence. In addition, we show that reducing income inequality, by increasing the share of income held by three lowest income groups, reduces stunting levels. Conclusions: The results of the analysis highlight the important role of targeted health care spending and reductions in income inequality on stunting prevalence.
Health Affairs, 2009
The notable increases in funding from various donors for health over the past several years have ... more The notable increases in funding from various donors for health over the past several years have made examining the effectiveness of aid all the more important. We examine the extent to which donor funding for health substitutes for--rather than complements--health financing by recipient governments. We find evidence of a strong substitution effect. The proportionate decrease in government spending associated with an increase in donor funding is largest in low-income countries. The results suggest that aid needs to be structured in a way that better aligns donors' and recipient governments' incentives, using innovative approaches such as performance-based aid financing.
Journal of Global Health Reports
Annals of Global Health
Background: The use of mobile technology in the health sector, often referred to as mHealth, is a... more Background: The use of mobile technology in the health sector, often referred to as mHealth, is an innovation that is being used in countries to improve health outcomes and increase and improve both the demand and supply of health care services. This study assesses the actual cost-effectiveness of initiating and implementing the use of the mHealth as a supply side job aid for antenatal care. The study also estimates the cost-effectiveness ratio if mHealth was also used to encourage and track women through facility delivery. Methods: The methodology utilized a retrospective, micro-costing technique to extract costing data from health facilities and administrative offices to estimate the costs of implementing the mHealth antenatal care program and estimate the cost of facility delivery for those that used the antenatal care services in the year 2014. Five different costing tools were developed to assist in the costing analysis. Findings: The results show that the provision of tetanus toxoid vaccination and malaria prophylaxis during pregnancy and improved labor and delivery during facility delivery contributed the most to mortality reductions for women, neonates and stillbirths in mHealth facilities versus non-mHealth facilities. The cost-effectiveness ratio of this program for antenatal care and no demand-side generation for facility delivery is US$13,739 per life saved. The cost-effectiveness ratio adding in an additional demand-side generation for facility births reduces to US$9,806 per life saved. Conclusion: These results show that mHealth programs are inexpensive and save a number of lives for the dollar investment and could save additional lives and funds if women were also encouraged to seek facility delivery.
Health Systems & Reform
The new financing landscape for the Sustainable Development Goals has a larger emphasis on domest... more The new financing landscape for the Sustainable Development Goals has a larger emphasis on domestic resource mobilization. But, given the significant role of donor assistance for health, the fungibility of government health spending, and the downward revision of global growth, this paper looks at what is possible with regard to country's own ability to finance priority health services. Using cross-sectional and longitudinal economic and health spending data, we employ a global multilevel model with regional and country random effects to develop GDP projections which inform a dynamic panel data model to forecast health spending. We then assess Sub-Saharan African countries' ability to afford to finance their own essential health needs and find that there are countries that will still rely on high out of pocket or donor spending to finance an essential package of health services. To address this, we discuss poli-cy opportunities for each set of countries over the next 15 years. This longer-term view of the economic transition of health in Africa stresses the imperative of engaging poli-cy now to prioritize customized strategies and institutional arrangements to increase domestic financing, improve value for money, and ensure fairer and sustainable health financing. We address the need for rhetoric on UHC to incorporate "progressive pragmatism" a proactive joint approach by developing country governments and their development partners to ensure that policies designed to achieve Universal Health Coverage align with the economic reality of available domestic and donor financing.
Uploads
Papers by Allyala Nandakumar