Browsing by Subject "decentralization"

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    Open Access
    Outcomes of antiretroviral treatment programmes in rural Lesotho: health centres and hospitals compared
    (2013) Labhardt, Niklaus Daniel; Keiser, Olivia; Sello, Motlalepula; Lejone, Thabo Ishmael; Pfeiffer, Karolin; Davies, Mary-Ann; Egger, Matthias; Ehmer, Jochen; Wandeler, Gilles
    IntroductionLesotho was among the first countries to adopt decentralization of care from hospitals to nurse-led health centres (HCs) to scale up the provision of antiretroviral therapy (ART). We compared outcomes between patients who started ART at HCs and hospitals in two rural catchment areas in Lesotho.MethodsThe two catchment areas comprise two hospitals and 12 HCs. Patients ≥16 years starting ART at a hospital or HC between 2008 and 2011 were included. Loss to follow-up (LTFU) was defined as not returning to the facility for ≥180 days after the last visit, no follow-up (no FUP) as not returning after starting ART, and retention in care as alive and on ART at the facility. The data were analysed using logistic regression, competing risk regression and Kaplan-Meier methods. Multivariable analyses were adjusted for sex, age, CD4 cell count, World Health Organization stage, catchment area and type of ART. All analyses were stratified by gender.ResultsOf 3747 patients, 2042 (54.5%) started ART at HCs. Both women and men at hospitals had more advanced clinical and immunological stages of disease than those at HCs. Over 5445 patient-years, 420 died and 475 were LTFU. Kaplan-Meier estimates for three-year retention were 68.7 and 69.7% at HCs and hospitals, respectively, among women (p=0.81) and 68.8% at HCs versus 54.7% at hospitals among men (p<0.001). These findings persisted in adjusted analyses, with similar retention at HCs and hospitals among women (odds ratio (OR): 0.89, 95% confidence interval (CI): 0.73–1.09) and higher retention at HCs among men (OR: 1.53, 95% CI: 1.20–1.96). The latter result was mainly driven by a lower proportion of patients LTFU at HCs (OR: 0.68, 95% CI: 0.51–0.93).ConclusionsIn rural Lesotho, overall retention in care did not differ significantly between nurse-led HCs and hospitals. However, men seemed to benefit most from starting ART at HCs, as they were more likely to remain in care in these facilities compared to hospitals.
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    Open Access
    The Conservation Costs of Game Ranching
    (2016) Pitman, Ross T; Fattebert, Julien; Williams, Samual T; Williams, Kathryn S; Hill, Russell A; Hunter, Luke T B; Slotow, Rob; Balme, Guy A
    The devolution of user rights of wildlife in southern Africa has led to a widespread land-use shift from livestock farming to game ranching. The economic advantages of game ranching over livestock farming are significant, but so too are the risks associated with breeding financially valuable game where free-ranging wildlife pose a credible threat. Here, we assessed whether the conservation potential of game ranching, and a decentralized approach to conservation more generally, may be undermined by an increase in human-wildlife conflict. We demonstrate that game rancher tolerance towards free-ranging wildlife has significantly decreased as the game ranching industry has evolved. Our findings reveal a conflict of interest between wealth and wildlife conservation resulting from local decision-making in the absence of adequate centralized governance and evidence-based best practice. As a fundamental pillar of devolution-based natural resource management, game ranching proves an important mechanism for economic growth, albeit at a significant cost to conservation.
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    Transforming Health Systems: Case studies of critical health system analyses to support reform
    (2014-08-21) McIntyre, Diane; Gilson, Lucy
    A set of case studies to enhance critical analysis for health system reform. Over the years, the Health Economics Unit (University of Cape Town) and Centre for Health Policy (University of the Witwatersrand) have developed a range of training materials to strengthen critical analysis skills that can support health system reform. One of the case studies considers how national health accounts data can contribute to critically assessing existing health systems to identify key challenges that could potentially be addressed through reforms. The two key areas of health system reform focused on in these training materials are health care financing and decentralisation. These are complemented by case studies on resource allocation between and within health districts. While technical skills are important for health system reform, so are skills to understand and manage key policy actors or stakeholders. The set of materials, therefore, concludes with case studies to develop stakeholder analysis skills.