The Single-Parent Paradox: Problematizing causes of vulnerability to HIV; Informing HIV prevention and Control Policies in Uganda

Background: 

Personal decisions; economic pressures; and lifestyle are responsible for increasing numbers of single-parents. These same issues are also risk factors linked to HIV disease in this category of population group. Personal decisions range from: abstinence following death of a spouse or partner; child-bearing to prove fecundity or as financial security from a more well to do partner; living independently as a self-supporting person. Economic pressures include: working so many miles away from home; situations when a female earns more than male partner; and relying on males with in polygamous relations. Lifestyle issues  include: fashion and trend of single-parenthood popular in urban settings; and pressures of living in urban settings as a single-parent. These characteristics should be linked to prevention and control interventions against HIV. 

Description:

 Anecdotal methods were used to generate responses on characteristics, prevention and control practices among groups of single-parents in Wakiso (20 males:30 females); Kampala (30 males:45 females); Mukono ( 20 males: 32 females); Busia (12 males:15 females); Masaka (10 males: 20 females); Bukomansimbi (50 males: 65 females); and Kyegegwa (10 males: 23 females). Anecdotal and literature review were also used to generate further information on HIV Services and demands made that target single-parents: counseling, sexual-reproductive health, post-test practices, prevention, prophylaxis, staying negative, avoiding transmission and economic empowerment. Stigma and discrimination; pressures of bearing children; daily survival; care for children and  caring for people living with AIDS still remain single-parents related issues also linked to HIV.

Lessons learned:

For the time period January 2014 to December 2015, we reached 382 single-parents. 152 are males: 230 are females; 182 were < 45 years; 200 were > 45 years; 300 were HIV-exposed; 10 were living in discordant relations; 120 had had an STI treated in past 12 months. All 382 had engaged in unprotected sexual intercourse with a partner other than their first debut. All 382 expressed need for economic empowerment as means of looking after themselves and their families. 200 females said they had children as a means of getting support from male partners or relatives as well as a desire to bear a child/children. 75 males responded that they had a child or children with female who are not long-term partners. 100 females had lost a male partner to HIV but they bore children as a way of staying with subsequent male partners or spouses.

Conclusions/Next steps:

Single-parents are persons who have made a conscious decision to remain without formal partners. The need to bear children also means engaging in sex without condoms. Planned pregnancies may also mean unwanted STIs and HIV. HIV prevention and Control should incorporate messaging targeting unique needs of single-parents. The messaging should show merits of long-term relation, monogamous fidelity, integrate economic empowerment, discourage widow-inheritance and provide motivation to forming post-test clubs where single-parents as a cohesive force advocate for safe and healthy outcomes.

A Stimulus to Characterize Social, Political, Anthropological, Clinical and Economical Aspects of Pro HIV-Cure Strategies: Africa’s Mississippi Baby, The French Visconti cohort and Berlin Patient on the Horizons.

Institutionalizing HIV-Cure advocacy, implementation and vigorous longitudinal research in African countries will not only popularize the science and trials uptake by subjects but help reproduce results such as the ‘Berlin Patient.’ Africa needs to use many strategies to bring down the escalating HIV Prevalence.  From South Africa's bold  anti-HIV innovations (http://www.sahivsoc.org/(1) to Uganda's robust treatment and prevention initiatives, Africa has all it takes to act as an HIV-Cure force (http://www.avert.org (2).

HIV persists in spite of potent ART through the establishment of HIV latency, when integrated viral DNA is silenced by host mechanisms and the virus cannot be accessed by current ART or by host clearance mechanisms. The primary cellular target for HIV infection is the CD4+T cell. Most infected cells die rapidly but a small proportion become stably infected with integrated HIV-originated DNA and revert to a long-lived resting phenotype [3]. Additional barriers to HIV cure include the existence of non-T cell reservoirs, such as macrophages, ongoing cycles of HIV replication even in the presence of ART, persistent blood/tissue HIV-RNA and an immune system that is permanently affected by HIV that cannot adequately clear the virus [4]. Eradication of HIV in Africa is still held back by resources and policy. HIV cure to grow in momentum needs the combined effort of scientists, governments, development partners, leaders, policy makers,civil society, traditional healers and health advocates. HIV-cure can be institutionalized by leveraging an enabling environment that will in turn galvanize pro HIV-cure funding, human resource, legislation and an enduring culture of efficacy, documentation, ethics and nurturing (EDEN) of research work. The terminology, biomedical interventions and health informatics need to be understood, applicable and agreed upon by academics, policy-makers, leaders, professionals and African traditional healers in the field. To get there, seven aspects  will make HIV cure robust and these are:

(i) Build on existing HIV Prevention and Control Initiatives as iterate opportunities for Pro HIV-Cure Strategies in Africa

(ii) Character of  Social Aspects of Pro HIV-Cure Strategies in Africa

(iii) Character of  Political Aspects of Pro HIV-Cure Strategies in Africa

(iv) Character of  Anthropological Aspects of Pro HIV-Cure Strategies in Africa

(v) Character of  Clinical Aspects of Pro HIV-Cure Strategies

(vi) Character of Economical Aspects of Pro HIV-Cure Strategies

(vii) Outcomes and reproduction of HIV-Cure Strategies in Africa

CONCLUSION:

Africa has the structures to produce large numbers of post-treatment controllers as well as move towards zero infection (saafrica.org (6). Prioritizing resources and embracing global health trends are two major strategies that will ensure this outcome.

REFERENCES:

1. http://www.sahivsoc.org. Retrieved on January 18th 2016.

2. http://www.avert.org/professionals/hiv-around-world/sub-saharan-africa. Retrieved on January 18th 2016.

3. Siliciano JD, Kajdas J, Finzi D et al. Long-term follow-up studies confirm the stability of the latent reservoir for HIV-1 in resting CD4+ T cells. Nat Med 2003; 9: 727–728. 

4. Siliciano RF, Greene WC. HIV latency. Cold Spring Harb Perspect Med 2011; 1: a00709.

5. Buzon MJ, Sun H, Li C et al. HIV-1 persistence in CD4(+) T cells with stem cell-like properties. Nat Med 2014; 20: 139–142.

6. http://saafrica.org. Retrieved on January 18th 2016.

Comparison of USA and Republic of South Africa (RSA) Health Indicators

In Physical health status  is often interpreted  through morbidity ( disease and disability) and mortality (death) rates (Shi & Singh, 2015). The following indicators: population size; total expenditure on health as a % of GDP; infant mortality; and life expectancy are used for this short write up.

The total population (2013) of USA is 320,051,000; Life expectancy at birth m/f (2013) is 76/80; and total expenditure on health as % of GDP (2013) is 17.1 (WHO, 2013). The infant mortality rate per 1,000 live births for 2011 was 6.05 (Child Health USA, 2013).

Food is important as a good and a product.

The Republic of South Africa total expenditure on health as % of GDP (2013) is 8.9; life expectancy at birth m/f (2013) is 57/64; and total population (2013) is 52,776,000 ( WHO, 2013). The infant mortality rate per 1,000 live births (2013) is 32.8 (OECD)

The population size of USA is larger than that of RSA, this is because the United States is a larger country. A larger population engages in a variety of production modes. This brings in income and countries are able to get taxes to use to invest in services such as health.

Both countries, USA and RSA has mechanisms in place that promote good health, good healthy outcomes and migration of people. However, the USA has policies that tie the health of people to enjoyment of life.  A proxy of good health outcomes as far as population goes is longevity. Longevity in turn can be measured through life expectancy. Life expectancy is “prediction of how long a person will live” (Page 56).  The table shows that USA has higher life expectancy figures than RSA. The two common measures are life expectancy at birth and life at age 65. Life expectancy at birth is how long a newborn can expect to live and  life expectancy at age 65 is the expected remaining years of life for someone at age 65.

The number of females in USA are more than those in RSA. This means that the pool from which females aged 15-44 is larger in USA than RSA. Fertility or capacity of a population  to reproduce is higher in USA.

Equitable  distribution of healthcare in USA and RSA can be seen through how their populations live. from the table populations live longer in USA than in RSA.  USA has organized structures that produce health services in relation to all categories of population groups i.e., from prenatal, postnatal, infancy, adolescence, adulthood and seniors. USA produces and it also distributes more health care.

Both countries have mechanisms in place that promote health outcomes. The following can make different countries appear to be doing more; investment in health; population sizes; initiatives to promote health according to various populations that demand for the services; and balancing health vis-a-vis other priorities such as: politics; production of food; establishment of infrastructure; and other goods and services.

REFERENCES:

1. Child Health USA. 2013. http://mchb.hrsa.gov/chusa13/perinatal-health-status-indicators/p/infant-mortality.html. Retrieved on December 27 2015.

2. OECD. 2013. https://data.oecd.org/healthstat/infant-mortality-rates.htm#indicator-chart. retrieved on December 27 2015.

3. Shi, L., & Singh, D. A. (2015). Delivering healthcare in America: A systems approach (6th ed.). Burlington, MA: Jones & Bartlett.

Comparison of the United States of America (USA) and the Republic Of South Africa (RSA) Health Care Delivery Systems

Introduction

The term health care delivery means the major components (characteristics) of the system and processes that enable people to be provided or receive health care or services. In this paper, one will read about two countries and how they have organized their health care delivery; statistics that inform policy and programming; measures to improve on health care; a glimpse into culture of provision and demand;the challenges unique to each country; and summaries unique to the two countries.

The United States of America, commonly referred to as the United States or America, is a federal republic composed of 50 states, a federal district, five major territories and various possessions. At 3.8 million square miles and with over 320 million people, the country is the world's third or fourth-largest by total area and the third most populous. It is one of the world's most ethnically diverse and multicultural nations, the product of large-scale immigration from many countries. South Africa, officially the Republic of South Africa, is the southernmost country in Africa. It is the 25th-largest country in the world by land area occupying 470,693 square miles and with close to 53 million people, is the world's 24th-most populous nation (bing.com). USA is almost 9 times the size of  Republic of South Africa (RSA).

Dr. Aaron Motsoaledi (in black suit) during World AIDS Day Event in South Africa. Photo courtesy of National Health Department of RSA.

Both the Republic of South Africa and United States of America value their populations. Healthy populations are an asset to any given country; vast and complex networks of government, private institutions, non-governmental organizations (NGO’s) and community initiatives create structures through which healthy outcomes are achieved; public health is structured according to existing social-political-cultural structures; the authority granted to health professionals; funding provided for social services and programmatic emphasis; and manipulating factors that influence health and illness play an important role on delivery and accessibility of health services. The information garnered can be used to assess population and community health status and develop effective health interventions and public policy (Turnock, 2015). The relevance of these factors “resides in their focus on causes or influence of particular health outcomes” (Page 22).  Data on mortality, morbidity, medical records and population assessments are utilized as measures to gauge health outcomes. Information on health status of a population can be collected and compared to study differences between one country and another. This can offer valuable information about the comparative state of health of a population or about disease trends (American Medical Association, 1989). Crude mortality rates count deaths within the entire populations; age-adjusted mortality rates show age-related factors that influence health (e.g., stroke, heart disease, HIV infections, infant deaths, tuberculosis, influenza, pneumonia, malaria, URTIs, UTIs, syphilis, cancer);  age-specific mortality rates relate the number of deaths to the number of persons in a specific age group ( e.g., infant-mortality rate describes number of deaths of live-born infants occurring in the first year of life per 1,000 live births and maternal-mortality describes number of death by mothers during or after delivery); age-adjusted rates are calculated by applying age-specific rates to a standard population ( the year 2000 is used in USA). “This adjustment permits more meaningful comparisons of mortality experience between populations with different age distribution patterns” (Page 26); Life expectancy, is a computation of the number of years between any given age (e.g., birth or age 75) and the average age of death for that population; and Years of Potential Life Lost (YPLL) is a mortality-based indicator that places greater weight on deaths that occur at younger ages. An arbitrary or given age is used as a threshold e.g., 65. Together  with infant mortality rates, life expectancies are commonly used in comparisons of health  status among nations. These two mortality-based indicators are often considered to be general indicators of the overall health status of a population.  Comparisons between the two different countries for causes of death for say, cancer, heart disease, unintentional injuries, suicide, homicide, cerebrovascular diseases, chronic obstructive lung disease, diabetes mellitus, HIV infections and chronic liver disease and cirrhosis, offer insight into magnitude and impact of problems. This in turn will inform policy, investments and interventions needed. But before one collects the information, it would do to understand the  characteristics or structures that influence particular health outcomes.

Integrated Care for Mothers and Children is an important health approach. Photo courtesy of World Bank.

Characteristics of US Health Care System: 

The total population (2013) of USA is 320,051,000; Life expectancy at birth m/f (2013) is 76/80; and total expenditure on health as % of GDP (2013) is 17.1 (WHO, 2013). The infant mortality rate per 1,000 live births for 2011 was 6.05 (Child Health USA, 2013). The health system in USA is complex and decentralized, having a combination of national, state and local public health services.  The private sector is responsible for the delivery and production of most care in USA. The department of health and human services is similar to a ministry of health. An individual can gain access to needed services, including specialized care through hospitals and organizations that supply health services, medical equipments, pharmaceuticals, supplies, health insurance and training work force. Healthcare services are paid for through insurance and out-of-pocket. The U.S has a national health system with tax-funded coverage, a health insurance system with a single payer and a health insurance system with multiple insurers. There are different hospitals, health centers, government insurance programs such as Medicare, Medicaid, State Children’s Health Insurance Program (SCHIP) and these provide vulnerable populations with access to health care services. These are benefits that people in this country experience because of the health system’s characteristics. People are guaranteed access to healthcare services. Medicare is one of the largest sources of health insurance in U.S. serving nearly 39 million people who are either 65 years old or older and who are suffering from certain disabilities or are diagnosed with end-stage renal disease. This is managed by Health Care Financing Administration (HCFA). Medicare has four parts (A, B, C & D). Medicaid is the third largest health insurance in U.S. providing coverage for low-income women, children, elderly people and individuals with disabilities covering 12% of U.S. population. The program provides outpatient care and prescription drugs for vulnerable populations. The SCHIP covers children who are uninsured and those in families with low-income. SCHIP pays for child’s physician visit, immunization, hospitalization and emergency room visits. Insured patients receive well-coordinated care under the Managed Care Organization (MCOs) and Accountable Care Organizations (ACOs). Health information is readily available to providers through an integrated technology system. Not only is there a great deal of choice when selecting physicians but there are other providers along the continuum of care chain. Uninsured people face challenges in accessing basic, well-directed, coordinated, continuous and routine health care. This may translate into typically a long wait to see a specialist. It may cause  many people to encounter adverse effects because medical supplies are not readily available. Because of lack of insurance healthcare services can be prohibitively expensive for most people (Shi & Singh 2015). “In the U.S., public health can be affected by disruptions of physical, biological, and ecological systems. The health effects of these disruptions include increased respiratory and cardiovascular disease, injuries and premature deaths related to extreme weather events, changes in the prevalence and geographical distribution of food- and water-borne illnesses and other infectious diseases, and threats to mental health” (National Center for Environmental Health, 2015). Factoring in environmental health, safeguards the health of populations that are particularly vulnerable to certain environmental hazards e.g., children, the elderly, people with disabilities and persons new to places.

Characteristics of South African Health Care System:

The Republic of South Africa total expenditure on health as % of GDP (2013) is 8.9; life expectancy at birth m/f (2013) is 57/64; and total population (2013) is 52,776,000 ( WHO, 2013). The infant mortality rate per 1,000 live births (2013) is 32.8 (OECD). In the Republic Of South Africa, health care has the following characteristics:  a) Pharmaceuticals, consumables and supplies; public health sector; private health sector; curative hospi-centric focus; human resources; fragmented funding pools; out-of-pocket payments and financing systems (South Africa Gazette, 2015). The National Health Insurance (NHI) of the Republic Of South Africa is a centralized health financing system that is designed to pool funds to provide access to quality, affordable personal health services for all South Africans based on their health needs, irrespective of their socioeconomic status. NHI is intended to ensure that the use of health services does not result in financial hardships for individuals and their families (South Africa Gazette, 2015). An individual can gain access to needed services, including specialized care. Healthcare services are paid for by government and out of pocket. Population coverage under NHI ensures that all South Africans have access to comprehensive quality health care services. This means that people will be able to access health care services closest to where they live. The health care services will be accessed at the appropriate level of care and will be delivered through certified and accredited public and private providers using the NHI Card. NHI creates a unified health system by improving equity in financing, reducing fragmentation in funding pools, and by making health care delivery more affordable and accessible for the population. NHI will eliminate out-of-pocket payments when the population needs to access health care services. In the long run, households will also benefit from increased disposable income as a result of a significantly lower mandatory prepayment ( Page 12). Primary Health Care (PHC) is being reengineered through four streams to improve timely access and to promote health and prevent disease. These streams are Municipal Ward-based Primary Health Care Outreach Teams (WBPHCOTs); Integrated School Health Programme (ISHP); District Clinical Specialist Teams (DCSTs); and Contracting of nonspecialist Health Professionals. This system has its benefits such as: Phakisa Ideal Clinic Realization Programme aimed at improving the performance and quality of health services in the PHC facilities. As well as quality public health infrastructure complete with bulk services such as provision of electricity, water supply, sanitation and waste management supported by effective transport and communication systems. South Africa has had a history of improvements that guaranteed access to healthcare services. Several proposals and attempts to implement health financing reforms namely: the 1928 Commission of Old Age Pension and NHI; 1941 Collie’s Committee of Inquiry into NHI; the 1943 African Claims that proposed equal treatment in the scheme of Social Security; the Dr Henry Gluckman National Health Services Commission of 1943 to 1944 that proposed NHI; The Freedom Charter as adopted by the Congress of the People, 1955; the 1994 Ministerial Committee on Health Care Financing; the 1995 Ministerial Committee of Inquiry into NHI (Broomberg and Shisana Report); the 1997 Social Health Insurance Working Group; Professor Taylor’s 2002 Committee of Inquiry into a Comprehensive Social Security System; Ministerial Task Team on Social Health Insurance and the 2009-2014 Ministerial Advisory Committee on NHI (Government Printing Works, 2015). Patients receive well-coordinated care through an established network of clinics e.g., from 2009 to 2013, the number of nurses trained on Nurse Initiated Management of Anti-Retroviral Therapy (NIMART) increased from 250 to 23,000. This increase contributed to the massive roll out of Anti-Retroviral Therapy (ART) “resulting in the largest ART programme in the world” (South Africa Gazette, Page 17).  People make choices of which clinics to go to as well as selecting physicians. The challenges that people in this country encounter include: “high costs in the private health sector due largely to a fee- for-service model” ( South Africa Gazette Page 22 & 23); High HIV prevalence, e.g., for 15-49 year old is 18.9 (World Bank); controls in place to access HIV medication such as PrEP still serve as a hurdle to prevention (MCC, 2015); “the main cost drivers (other than human resources) in the public health sector are: pharmaceuticals; laboratory services; blood and blood products; equipment; and surgical consumables” (South African Gazette, Page 23); the lack of peer review or regulation of traditional healers who make claims for many cures including that for HIV; congestion at health facilities; and impact of weather changes that cause water shortages e.g., at Stanger Hospital in Ilembe, Kwazulu Natal, South Africa (Kaveel Singh, 2015).

Comparison of USA Health Care System to RSA:

The US health care system is not centralized, serves a population of  320,051,000; Life expectancy at birth m/f is 76/80; and total expenditure on health as % of GDP (2013) is 17.1. The infant mortality rate per 1,000 live births for 2011 is 6.05. Whereas for Republic of South Africa total expenditure on health as % of GDP is 8.9; life expectancy at birth m/f is 57/64; and total population 52,776,000. The infant mortality rate per 1,000 live births is 32.8.

Potential benefits for people in USA and RSA:

In USA, an individual can gain access to needed services, including specialized care through hospitals and organizations that supply health services, medical equipments, pharmaceuticals, supplies, health insurance and training work force. A national health system with tax-funded coverage and a health insurance system with multiple insurers exists. Access to different hospitals, health centers, government insurance programs such as Medicare, Medicaid, State Children’s Health Insurance Program (SCHIP) provide vulnerable populations with affordability to health care services. These are benefits that people in this country experience because of the health system’s characteristics. People are guaranteed access to healthcare services. 

In RSA, an individual can gain access to needed services, including specialized care. Healthcare services are paid for by government and out of pocket. Population coverage under NHI ensures that all South Africans have access to comprehensive quality health care services. People access health care services closest to where they live through certified and accredited public and private providers using the NHI Card or  pay out-of-Pocket.

Built areas contribute to good health. Photo courtesy of Tom Mukasa

Potential challenges for people in USA and RSA:

In USA, uninsured people face challenges in accessing basic, well-directed, coordinated, continuous and routine health care. Because of lack of insurance healthcare services can be prohibitively expensive for most people. Public health can be affected by disruptions of physical, biological, and ecological systems. The health effects include exposure to elements, increased respiratory and cardiovascular disease, injuries and premature deaths related to extreme weather events, changes in the prevalence and geographical distribution of food- and water-borne illnesses and other infectious diseases, and threats to mental health. 

In RSA, challenges that people encounter include:high costs in the private health sector due largely to a fee- for-service model; High HIV prevalence, e.g., for 15-49 year old it is 18.9; the controls in place to access HIV medication such as PrEP can be a hindrance for prevention; high costs for: pharmaceuticals; laboratory services; blood and blood products; equipment; and surgical consumables; the lack of peer review or regulation of traditional healers who make claims for many cures including that for HIV; congestion at health facilities; and impact of weather changes that cause, say,  water shortages in hospitals.

REFERENCES:

American Medical Association. 1989. Encyclopedia of Medicine.New York, NY: Random House.

2. bing.com. http://www.bing.com/land size. Retrieved on December 27 2015.


3. Child Health USA. 2013. http://mchb.hrsa.gov/chusa13/perinatal-health-status-indicators/p/infant-mortality.html. Retrieved on December 27 2015.

4. Government Printing Works. 2015. http://www.gpwonline.co.za/Pages/default.aspx. Retrieved on December 27 2015.

5. Kaveel Singh. December 15 2015. News24. http://allafrica.com/stories/201512160832.html. Retrieved on December 27 2015.

6. Medical Control Council. 2015. http://www.mccza.com/. Retrieved on December 27 2015.

7. National Center for Environmental Health. 2015. http://www.cdc.gov/climateandhealth/effects/default.htm. Retrieved on December 28 2015.

8. OECD. 2013. https://data.oecd.org/healthstat/infant-mortality-rates.htm#indicator-chart. retrieved on December 27 2015.

9. Shi, L., & Singh, D. A. (2015). Delivering health care in America: A systems approach (6th ed.). Burlington, MA: Jones & Bartlett.

10. South Africa Gazette. 2015. http://www.gov.za/sites/www.gov.za/files/39506_gon1230.pdf. Retrieved on December 27 2015.

11. Turnock, B. J. (2015). Essentials of public health (3rd ed.). Burlington, MA: Jones & Bartlett.

12. World Bank Data. 2015. http://data.worldbank.org/indicator/SH.DYN.AIDS.ZS/countries?display=map. Retrieved on December 27 2015.

13. World Health Organization. 2013. http://www.who.int/countries/. Retrieved on December 27 2015.

Comparing Integrated Management of Child Illnesses at Kawempe Health Center (IV) in Uganda, Vertically Integrated Health System and a Horizontally Integrated Health System at two centers in San Francisco County California USA

Comparing Integrated Management of Child Illnesses at Kawempe Health Center (IV) in Uganda, Vertically Integrated Health System and a Horizontally Integrated Health System at two centers in San Francisco County California USA

Muyunga-Mukasa, T.R.

                       Kawempe National Referral Hospital. Source: Google

                                                 INTRODUCTION

In Uganda, a country in East Africa, collaboration with International teaching Hospitals has helped create opportunities for transfer of knowledge, best-practices and skills that would otherwise not be available at lower level health facilities. The Liverpool-Mulago Collaboration is one such example. This resulted in the integrated management of childhood illnesses where: identifying families with expecting mothers; immunization drives; neonatal care; postnatal care; involving men in caring for expectant mothers; voluntary medical male circumcision; HIV/STIs checking; Partner counselling; and home-based nutrition plans are performed as packaged health services. In USA, the San Francisco Bay Area’s San Francisco County has various health delivery services that are combined as a single package. In this discussion, one will read briefly about Kawempe Health Center (IV),  Kaiser Permanente (KP) and Mercy Housing.

Access is a proxy measure for patient experience around which health delivery is built. Access can be initiated in form of collaboration, vertical integration or horizontal integration. These three strategies make the initiatives provide better health outcomes such as: collaboration, integration and service expansion accessible to the people who need them.  Collaboration creates space for transfer of  health delivery skills, human resource,  capital and logistics (LMP, 2014). Integration is as a result of acquisition, merger, alliance networks and joint ventures. Service integration includes extension of core product or service and this is known as horizontal integration. 

The kind that involves entry into a new type of service along the continuum of care provides diversified services is called vertical integration. Vertical integration provides proximity to different services, specialties, research, clinic trials and availability of different health professionals (Memorial Hermann, 2015).  For the sake of this discussion, access is the ability of a person to obtain health care services when needed (Shi, 2015).

                             Kawempe Health Center (IV), Kampala Uganda

Kawempe Health Centre (IV) is about 5-6 miles away from the National Referral Hospital, Mulago. The health facility is used as a primary health unit that offsets the congestion or referrals at Mulago. This ensured such activities that led to  over 6,000 deliveries per year (LMP, 2014). Funds to pay for resident doctors, a functioning operating theatre, blood transfusion facilities and Uganda government commitment to improve the functionality of Kawempe Health Centre have seen a fresh start there. Currently such services like caesarean sections and Voluntary Medical Male Circumcision are conducted there. This in turn is reducing the number of referrals to Mulago Hospital. Other services include: Mother and Child health services; Youth Friendly Services; HIV and STI counseling services; Laboratory Services;health Management Information Services; primary care;and a Health Centre (III) with a fully functional maternity unit. The long-term volunteers continue to offer support and training to the local midwives in areas such as neonatal resuscitation, patient monitoring and emergency obstetric skills. The form of collaboration has elements of vertical integration and is known for its cost-effective care with quality services to its enrollees. It is a yellow-star awardee providing quality services and access to healthcare services for a wide ranging population in Kawempe Division (a division of Kampala Capital City Authority-KCCA). 

The implications of  collaboration and integration for the management of the organization is that it has brought about facilitation that promotes healthy outcomes for the urban/sub-urban communities.

                        Kaiser Permanente, San Francisco Bay Area California USA

Kaiser Permanente is a vertically integrated health system that links services at different stages in the production process of health care, e.g., organization of primary care, acute care, post acute services and a hospital (Kaiser Permanente. (2014). The vertically integrated health system provides an environment in which an important element of health delivery or provision called access is possible. As one of America’s leading health care providers and not-for-profit health plans, founded in 1945, Kaiser Permanente has a mission to provide high-quality, affordable health care services and to improve the health of members and the communities. Kaiser Permenente serves more than 10 million members in eight states and the District of Columbia. Care for members and patients is focused on their total health and guided by their personal physicians, specialists and team of caregivers. Our expert and caring medical teams are empowered and supported by industry-leading technology advances and tools for health promotion, disease prevention, state-of-the-art care delivery and world-class chronic disease management. Kaiser Permanente is dedicated to care innovations, clinical research, health education and the support of community health (kp.org/share). Kaiser Permenente provides employment, care, coverage, a list of doctors to choose from, get lab tests, and pick up medications all in one place. Under the same arrangement one is able to purchase individual or family health pan; Medicaid/Medical; Medicare; Employer-sponsored plans; as well as explore employment opportunities. Kaiser Permanente health plans ware expended to include breast cancer screenings and early detection (kp.org/healthy). The form of integration exhibited by Kaiser Permenente is known for its cost-effective care with quality services to its enrollees (Shi, 2015). It is a top-notch provider of quality services and it continues to provide access to healthcare services for a wide ranging population in Northern California. 

The implications of integration for the management of the organization is that scattered  entities are under one mutually cooperative arrangement. This has significant influence on patient well being as well as the patient/consumer experience along the continuum of care. Being under one roof the following six features, i.e., safety, effectiveness, patient-centeredness, timeliness, efficiency and equitable services that close the gap for minorities or underserved population groups are achievable.

                    Mercy Housing  San Francisco Bay Area California USA

Mercy Housing is in 41 states of US and is an example of horizontal integration that I chose to share with you. Mercy Housing, a national nonprofit organization, is working to build a more humane world where poverty is alleviated, communities are healthy and all people can develop to their full potential. Affordable housing and supportive programs improve the economic status of residents, revitalize neighborhoods and stabilize lives. Mercy Housing one of the nation’s largest affordable housing organizations participates in the development, preservation, management and/or financing of affordable, program-enriched housing across the country. It serves a variety of populations with housing projects for low-income families, seniors and people with special needs. It acquires and renovates existing housing, as well as develop new affordable rental properties. Mercy Housing created a stable foundation where residents can explore their full potential, supported by practical resident programs such as health classes, financial education, employment initiatives, parenting and after-school programs for children. Residents are supported with the resources they need to be good neighbors and members of a greater community. Mercy Housing begins with housing, but goes far beyond to strengthen the lives of the people who call Mercy Housing home. Whether it's educational support, a financial literacy program or health care education, Mercy Housing is always trying to provide services for local low-income community. Mercy Housing provides Resident Services that fall into four program areas: Economic Development, Education, Community and Health & Wellness. In an effort to assist the millions of people in need of stable affordable housing, Mercy Housing provides a wide range of affordable, low-income apartment rental opportunities across the United States.  The housing services are available for families, seniors and people with special needs, including those with developmental disabilities, HIV/AIDS, formerly homeless individuals and Veterans. 70% of  all residents are families;21% of our residents are seniors; 9% of residents are people with special needs (people with HIV/AIDS, formerly homeless individuals, veterans and people with physical and mental impairments). 

The implications of integration for the management of the organization is that the scattered housing are earmarked to serve different population groups geographically and health-wise. Mercy Housing can also go into mutual cooperative arrangement with other service providers. This has significant influence on resident well being as well as experience. Being that they are grounded in non-discrimination, Mercy Housing provides homes for vulnerable population groups. Other service providers are able to bring care to the home-bound and bed-ridden. Under such an arrangement, minorities or underserved population groups are able to access services that improve of their welfare (Mercy Housing Publications, 2015).

HIV/AIDS care systems and structures can learn from the USA and vice versa. Shared lessons and themes are opportunities for transfer of knowledge, best-practices and skills across health facilities. Diversifying care and prevention norms include the integrated management of childhood illnesses; identifying families with expecting mothers; immunization drives; neonatal care; postnatal care; involving men in caring for expectant mothers; voluntary medical male circumcision; HIV/STIs checking; Partner counselling; and home-based nutrition plans being part  of the comprehensive package of health services. This contributes the strengthened prevention, support and mitigation continuum necessary for ending HIV. 

Source: LMP

Source: LMP

Source: LMP

Source: LMP

REFERENCES:

1). Being the Best Saves Lives: Kaiser Permanente Leads the Nation in 21 Quality Measures. October 22 2015. http://share.kaiserpermanente.org/article/being-the-best-saves-lives-kaiser-permanente-leads-the-nation-in-21-quality-measures. Retrieved on December 22 2015. 

2). Kaiser Permanente. (2014). Kaiser Permanente. Retrieved from http://kp.kaiserpermanente.org. Retrieved on December 22 2015.

3). Mercy Housing Publications. (2015). http://www.mercyhousing.org/Publications. Retrieved on December 22 2015.

4). Memorial Hermann. (2015). Memorial Hermann. Retrieved from http://www.memorialhermann.org. Retrieved on December 22 2015.

5) Liverpool-Mulago Partnership For Women's and Children's Health. 2014. http://lmpcharity.org/index.php/lmpprojects/hciv/kawempehciv. Retrieved on December 23 2015.

6). Shi, L., & Singh, D. A. (2015). Delivering health care in America: A systems approach (6th ed.). Burlington, MA: Jones & Bartlett.

The "Insurancization" Culture: What America can teach Africa: From a Public Health Perspective

The 2010 Patient Protection and Affordable Care Act (PPACA) and its modifier The 2010 Health Care and Education Reconciliation Act are also called the Affordable Care Act. They are good examples to emulate by African countries engaged in implementing sweeping health care delivery Laws, initiatives and systems if they want to be relevant in this post globalization era. In essence, they enable government to generate and direct funding means for a universal coverage initiative.

The United States of America is increasingly investing in global health. It is imperative that say, African countries, study what has made the US stand at par with older developed countries of Europe. One way to do this is by identifying historical events or circumstances that brought about the need for impacting legislation and examining the positive and/or negative consequences that followed the implementation of the acts.

Health delivery in the US is complex and fragmented into functional components: financing, insurance, delivery and payment.

Health delivery is changing to accommodate concerns of educational and research institutes, medical suppliers, insurers, payers, claims processors, healthcare providers and many integrated networks providing a continuum of care and covering many of the service components. The changes are mainly in response to concerns regarding costs, access and quality (Shi, L. & Singh, D. A., 2015).

How much have African countries empowered their communities to look at health as a commodity of value? 

Health is an outcome of individual behavior, inclination, opportunity to participate in healthy behavior in relation to  family, community, environment and social conventions on a backdrop of systems through which health services can be provided (Turnock, 2016). Three institutions: government (e.g., legislature, judiciary, executive, federal and state); private sector (e.g, foundations, research institutes and lobby groups) and businesses (e.g., military, media, law, finance, manufacturing, industry and non-governmental organizations) influence the delivery of health, allocate values and shape the lives of all Americans (Dye and Ziegler, (2006). US government is distinct from the private sector and business spheres. This was emphasized by many presidents, e.g., President Coolidge Calvin,1923-1929. This distinction is maintained further between Federal and State governments by court rulings too, e.g., the  US Supreme Court ruling of 2012.

The 2010 Patient Protection and Affordable Care Act (PPACA) is a comprehensive measure tying together comprehensive coverage, care and costs in order to deliver health services. PPACA is also tied to other acts such as the Sunshine Act (Sarah Freymann Fontenot, 2013) which mandates that any transaction between a physician (or teaching hospital) and the pharmaceutical or device industries more than $10 in value must be publicly disclosed. The government’s intention is to end what it labels covert activity, unnecessary drug prescription and potential conflicts of interest between physicians and the pharmaceutical and device manufacturing industries. PPACA also calls for comprehensive service provisions addressing the needs of elderly, disabled, women, men, youths, children, refugees, poor, special population groups and the uninsured. Enrollment is on-going. The PPACA has three features: expanded coverage; cost friendliness; and expanded care for different populations payable at different health provision facilities (e.g., local hospitals, dental clinics, and chosen network of Doctors within states and in some cases across states). It is  given different names in different states, e.g., Azcentral for Arizona, MassHealth in Massachusetts or Covered California in California.

PPACA is a summation and culmination of all other piecemeal tried and tested Acts since 1912. To arrive at it, one has to trace it from the beginnings of America. However, according to History of Health Reform in The USA (www.kff.org) concerted effort towards the present PPACA is traced from developments that transpired between 1912 to 1932 when major events such the 1921 Sheppard-Towner Act, 1929 Baylor Hospital Pre-paid Insurance and the National Health Insurance/New Deal; then the outcomes of events between 1933-1953 e.g., Economic Security Commission to address old-age, unemployment, medical care and insurance and  the report on risks to economic  security arising out of illness; the events of 1954-1974 that included: Military medicare and Civil Rights Act; 1975-1940 events that addressed the high inflation, high costs for health care; and 1991-2011 events that saw the appearance of the National Committee on Quality Assurance (NCQA) Forms to accredit managed care health plans and the eventual passing of the 2010 Patient Protection And Affordable Care Act (P.L. 111-148). 

The positive side of PPACA according to the NCBW 100 brochure  are:

Ending arbitrary withdrawals of insurance coverage.

Guarantees right to appeal.

Ends Pre-existing condition exclusion

Keeps young adults covered.

Covers preventive care at no cost to patients.

Ends lifetime limits on coverage

low monthly premium

The negative side of PPCA are:

It was not sold well to scared undocumented immigrants who thought it was a ruse to identify and have them rounded up.

The PPACA has added to the already fragmented systems that are loosely held together. This makes it hard for overall planning, direction and coordination from a central agency. There is a likelihood of inconsistencies and waste. 

PPACA and the Sunshine Act are interpreted as instruments to deter the medical and pharmaceutical world from prescribing large numbers of dangerous, inappropriate or unnecessary drugs allegedly because of industry influences. This depicts these professions as irresponsible which is not the case.

However, the above three can be addressed through continued awareness drives, involving communities in health delivery and engaging in proactive equitable interventions. The take back home lesson for African countries is to consider establishing mechanisms to generate insurance funds, consolidate a health care delivery system and develop policies that ensure financing, insurance, payments and delivery of health. This will be one way of improving on the general welfare of the populations.

REFERENCES:

1. Dye and Ziegler, (2006). Irony of Democracy. Belmont, CA: Thomson Higher Education).

2. History of Health Reform in The USA. https://kaiserfamilyfoundation.files.wordpress.com/2011/03/5-02-13-history-of-health-reform.pdf. Retrieved on December 3rd 2015.

3. NCBW 100. National Coalition of 100 Black Women-San Francisco Chapter 

4. Turnock, B. J. (2016). Essentials of public health (3rd ed.). Burlington, MA: Jones & Bartlett

5. Shi, L., & Singh, D. A. (2015). Delivering health care in America: A systems approach (6th ed.). Burlington, MA: Jones & Bartlett.

6. President Coolidge Calvin (1823-1933): Washington D.C: The White House Historical Association. 

7.Sarah Freymann Fontenot, (2013).Understanding the Affordable Care Act Bit by Bit: Will Transparency and Sunshine Shrink Costs? ACPE.ORG

The Pontiffs and Africa!

Pope Francis you are welcome to Africa,

Everyone in Africa welcomes you,
yes, this is true, everyone,
Even the young one will be told about you,
In Africa the seasons will be named after you,
yes, 'my  child shall be named Francesca if she is a girl.'
'My child shall be named Francis if he is a boy.'
'We had a bumper harvest during the Papal visit.'
Some will say, 'I felt the Spirit of the Lord,'
Others will say 'I was there and saw the pope with my eyes,'
You are a blessing to Africa,
You are a blessing to Kenya,
And so many will say, Uganda is blessed,
We were blessed before time,
Central African Republic is blessed,
You came to many countries in Africa,
Even if you visited 3 countries this time around,
You were on the African continent,
A very promising continent,

Am sure you are aware of this,

The smile you bring to many faces,

The humility and purpose,

The meaning of living in the now,

The reason to bring God in our life,

The effort behind being responsible,

The mortar between humanity and nature,
Many people were brought together by your visit,
By this I don't mean mere getting together in one place,
many people joined in the occasions that made your visit to Uganda successful,
People from different walks of life,
You brought about peace among enemies,
You caused many to revisit their dreams about life,
We saw purpose dressed in clothes,
A child kissed,
A leper hugged,
a young girl welcomes the pope,
adolescents given hope,
You lit a fire in all of us,
A fire of love,
A fire of respect,
A fire of accountability,
A fire of resolve,
A fire of commitment,
Whether in Kenya, Uganda or Central African Republic,
We promise you: we shall keep the fire burning!

Pope Paul XI and Emmanuel Cardinal Nsubuga of Uganda

Pope Francis

Pope Francis going to work in Rome

Pope admirers

Pope in CAR, November 2015

Pope in CAR

Pope in CAR

Emeritus Pope Benedict and Pope Francis

Pope arrives in CAR

Pope Francis and Emeritus Pope Benedict

Pope Francis

Pope In Kenya,November 2015

Pope in Uganda, November 2015

Seeing off the Pope, November, 2015 at Entebbe International Airport Uganda

Pope in Uganda

Pope with Ugandan youth

Pope visiting the sick

The Vatican

Pope Francis

Pope Francis saying Mass

Pope Francis waving to crowds

Rubaga Cathedral, Uganda

Pope in Kenya

ACKNOWLEDGEMENT: All pictures are collected from different sources such as: New Vision, Daily Monitor, Google, Wikipedia and Vatican Archives. Copyright belongs to them. Here they are used for educational purposes. Thanks.