BACKGROUND:Progress toward gender equality in the indoor residual spraying (IRS) workforce lags behind other areas of vector control implementation and research. One reason for this may be misconceptions about the cost of implementing IRS with a higher percentage of female staff. The assumption that employing more female spray operators increases costs may stem from the perception that women are less physically capable of performing the demanding work of IRS, resulting in lower productivity and requiring programmes to hire additional staff. The Tchau Tchau Malaria programme in southern Mozambique has achieved high levels of gender equality in its workforce and provides a valuable case study for analysing the impact of gender equality on spray operator salary costs during annual IRS campaigns. METHODS:This study examined data from the 2020/2021 campaign of the Tchau Tchau Malaria programme to understand how employing a high percentage of female spray operators affected the cost of salaries paid to spray operators during the training and implementation phases of the campaign. Salary cost estimates for the actual Tchau Tchau Malaria campaign were compared to a counterfactual scenario assuming a lower percentage of female SOs (30%), consistent with other IRS programmes in sub-Saharan Africa. RESULTS:Approximately 58.5% of the 2182 spray operators employed by the 2020/2021 Tchau Tchau Malaria campaign were female. Male spray operators were slightly more productive than female spray operators. However, female spray operators were more likely to have worked with previous campaigns; therefore, the average cost of training for female spray operators was lower than the average cost of training for male spray operators. The total salary cost paid to spray operators for the Tchau Tchau Malaria campaign compared with the counterfactual scenario differed by less than 1%. CONCLUSIONS:Analysis of the Tchau Tchau Malaria campaign in Mozambique, when compared to a counterfactual scenario with low gender equality, revealed that achieving a gender-integrated indoor residual spraying workforce had a minimal effect on spray operator salary costs, which represent a significant component of overall IRS programme costs.

Although ART has transformed HIV into a manageable chronic condition, significant cost and logistical challenges persist, threatening progress toward the UNAIDS 95-95-95 targets. Budget allocation to the health sector declined by over 30% in the last decade in Zimbabwe, attributed to donor fatigue and emergence of pandemics. The time-driven activity-based costing (TDABC) method was used to estimate the provider costs of ART and inform resource allocation for sustained ART programming. A descriptive cross-sectional study in 11 facilities across Zimbabwe's four levels of care collected data using standardized instruments, capturing over 2,500 provider-recipient observations. Process maps of HIV care pathways were developed with subject matter experts to document resource use and standard of care. Time taken to deliver ART services, cost of space and cost of equipment were used to calculate costs and validated by national level stakeholders. In 2022, annual provider costs for ART in totalled $168.66 million for 1.2 million patients. National costs are projected to $192.44 million by 2026, attributed to declining HIV-related mortality and incidence. Primary care facilities bore 75% of costs due to higher patient volume. Provider costs averaged $57.05 for adult ART initiation and $62.70 for paediatric initiation. First-year ART costs per client were $252.78 (adult) and $450.56 (paediatric). Annual maintenance costs were $138.93 for first-line and $174.93 for second-line ART. Laboratory services ($30.72) contributed more to adult ART costs than medicines ($27.98). ART costs exceeded prior estimates, driven by facility-level differences, laboratory expenses, and paediatric formulations. Task-shifting proved cost-efficient, but sustainability is threatened by funding gaps and low health worker compensation. Optimizing laboratory systems and decentralizing services remain critical. External funding withdrawal created an annual gap of more than $50 million. Sustaining ART to 2030, requires improving domestic resource mobilization, strengthening ART decentralization, and designing cost-efficient laboratory models that preserve treatment quality.

Background Prevention of Mother-to-Child Transmission of HIV (PMTCT) is central to maternal and child health in Zimbabwe. However, with the growing pressures on the health financing landscape, identifying opportunities for efficiency gains is critical. This study aimed to determine the provider costs of PMTCT services, identify key cost drivers, and inform resource allocation. Methods A cross-sectional Time-Driven Activity-Based Costing (TDABC) analysis was conducted across ten health facilities in Zimbabwe, from clinics up to central hospitals. Data were collected on personnel, medicines and consumables, space and equipment, laboratory, and overheads. Process maps for PMTCT pathways were developed, and time equations were used to calculate unit costs per patient. Cost analysis was used to estimate the lifetime cost implications were prevention fails. Results Guiding a mother-baby pair through the PMTCT cascade ($549) cost less than prevention failure. Paediatric ART ($450·56) cost over twice maternal ART ($209·30), with lifetime treatment costs reaching $5 210·78 for maternal seroconversion and $9 526·18 for infant infection. Every dollar invested in PMTCT avoided $17 in treatment costs. Key cost drivers were laboratory tests (42%), medicines (28%), and personnel (16%). Costs were lowest at primary clinics ($160·84). Monitoring HIV-negative mothers cost $48·78. Deviations from testing algorithm were common due to stockouts and workload. Conclusion PMTCT is a cost-saving intervention that requires Zimbabwe to prioritize decentralizing services, secure the supply chain for essential commodities and personnel, and formally reviewing its testing algorithm to improve outcomes. These findings offer an evidence-based roadmap to support continued investment in PMTCT.

Mutations have driven the evolution and development of new variants of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) with potential implications for increased transmissibility, disease severity and vaccine escape among others. Genome sequencing is a technique that allows scientists to read the genetic code of an organism and has become a powerful tool for studying emerging infectious diseases. Here, we conducted a cross-sectional study in selected districts of the Eastern Province of Zambia, from November 2021 to February 2022. We analyzed SARS-CoV-2 samples (n = 76) using high-throughput sequencing. A total of 4097 mutations were identified in 69 SARS-CoV-2 genomes with 47% (1925/4097) of the mutations occurring in the spike protein. We identified 83 unique amino acid mutations in the spike protein of the seven Omicron sublineages (BA.1, BA.1.1, BA.1.14, BA.1.18, BA.1.21, BA.2, BA.2.23 and XT). Of these, 43.4% (36/83) were present in the receptor binding domain, while 14.5% (12/83) were in the receptor binding motif. While we identified a potential recombinant XT strain, the highly transmissible BA.2 sublineage was more predominant (40.8%). We observed the substitution of other variants with the Omicron strain in the Eastern Province. This work shows the importance of pandemic preparedness and the need to monitor disease in the general population.

Antimicrobial resistance (AMR) is a public health problem exacerbated by the overuse and misuse of antibiotics and the inadequate capacity of laboratories to conduct AMR surveillance. This study assessed the capacity of laboratories in seven faith-based hospitals to conduct AMR testing and surveillance in Zambia. This multi-facility, cross-sectional exploratory study was conducted from February 2024 to April 2024. We collected and analysed data using the self-scoring Laboratory Assessment of Antibiotic Resistance Testing Capacity (LAARC) tool. This study found an average score of 39%, indicating a low capacity of laboratories to conduct AMR surveillance. The highest capacity score was 47%, while the lowest was 25%. Only one hospital had a full capacity (100%) to utilise a laboratory information system (LIS). Three hospitals had a satisfactory capacity to perform data management with scores of 83%, 85%, and 95%. Only one hospital had a full capacity (100%) to process specimens, and only one hospital had good safety requirements for a microbiology laboratory, with a score of 89%. This study demonstrates that all the assessed hospitals had a low capacity to conduct AMR surveillance, which could affect diagnostic stewardship. Therefore, there is an urgent need to strengthen the microbiology capacity of laboratories to enhance AMR surveillance in Zambia.

Abstract Background The Global Fund partnered with the Zimbabwean government to provide end-to-end support to strengthen the procurement and supply chain within the health system. This was accomplished through a series of strategic investments that included infrastructure and fleet improvement, training of personnel, modern equipment acquisition and warehouse optimisation. This assessment sought to determine the effects of the project on the health system. Methods This study employed a mixed methods design combining quantitative and qualitative research methods. The quantitative part entailed a descriptive analysis of procurement and supply chain data from the Zimbabwe healthcare system covering 2018 – 2021. The qualitative part comprised key informant interviews using a structured interview guide. Informants included health system stakeholders privy to the Global Fund-supported initiatives in Zimbabwe. The data collected through the interviews were transcribed in full and subjected to thematic content analysis. Results Approximately 90% of public health facilities were covered by the procurement and distribution system. Timeliness of order fulfillment (within 90 days) at the facility level improved from an average of 42% to over 90% within the 4-year implementation period. Stockout rates for HIV drugs and test kits declined by 14% and 49% respectively. Population coverage for HIV treatment for both adults and children remained consistently high despite the increasing prevalence of people living with HIV. The value of expired commodities was reduced by 93% over the 4-year period. Majority of the system stakeholders interviewed agreed that support from Global Fund was instrumental in improving the country's procurement and supply chain capacity. Key areas include improved infrastructure and equipment, data and information systems, health workforce and financing. Many of the participants also cited the Global Fund-supported warehouse optimization as critical to improving inventory management practices. Conclusion It is imperative for governments and donors keen to strengthen health systems to pay close attention to the procurement and distribution of medicines and health commodities. There is need to collaborate through joint planning and implementation to optimize the available resources. Organizational autonomy and sharing of best practices in management while strengthening accountability systems are fundamentally important in the efforts to build institutional capacity.

Wastewater-based surveillance has emerged as an important method for monitoring the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2). This study investigated the presence of SARS-CoV-2 in wastewater in Zambia. We conducted a longitudinal study in the Copperbelt and Eastern provinces of Zambia from October 2023 to December 2023 during which 155 wastewater samples were collected. The samples were subjected to three different concentration methods, namely bag-mediated filtration, skimmed milk flocculation, and polythene glycol-based concentration assays. Molecular detection of SARS-CoV-2 nucleic acid was conducted using real-time Polymerase Chain Reaction (PCR). Whole genome sequencing was conducted using Illumina COVIDSEQ assay. Of the 155 wastewater samples, 62 (40%) tested positive for SARS-CoV-2. Of these, 13 sequences of sufficient length to determine SARS-CoV-2 lineages were obtained and 2 sequences were phylogenetically analyzed. Various Omicron subvariants were detected in wastewater including BA.5, XBB.1.45, BA.2.86, and JN.1. Some of these subvariants have been detected in clinical cases in Zambia. Interestingly, phylogenetic analysis positioned a sequence from the Copperbelt Province in the B.1.1.529 clade, suggesting that earlier Omicron variants detected in late 2021 could still be circulating and may not have been wholly replaced by newer subvariants. This study stresses the need for integrating wastewater surveillance of SARS-CoV-2 into mainstream strategies for monitoring SARS-CoV-2 circulation in Zambia.

Antimicrobial resistance (AMR) is a public health problem exacerbated by the overuse and misuse of antibiotics and an inadequate capacity of laboratories to conduct AMR surveillance. This study assessed the capacity of laboratories in seven faith-based hospitals to conduct bacteriology, AMR testing and surveillance in Zambia. This multi-facility, cross-sectional exploratory study was conducted from February 2024 to April 2024. We collected and analysed data using the self-scoring Laboratory Assessment of Antibiotic Resistance Testing Capacity (LAARC) tool. This study found an overall score of 39%, indicating a low capacity of laboratories to conduct AMR surveillance. The highest capacity score was 47%, while the lowest was 25%. Only one hospital had full capacity (100%) to utilise a Laboratory Information System (LIS). Three hospitals had good capacity to perform data management with scores of 83%, 85%, and 95%. Only one hospital had full capacity (100%) to process specimens, and only one hospital had good safety requirements for a microbiology laboratory, with a score of 89%. This study demonstrates that all the assessed hospitals have a low capacity to conduct AMR surveillance. Therefore, there is an urgent need to strengthen the microbiology capacity of laboratories to enhance surveillance in faith-based hospitals in Zambia.

Improving medicines regulation can lead to better population health, but how this process works in low- and middle-income countries remains underexplored. Tanzania's pharmaceutical sector is often cited as a successful example of a well-functioning regulatory system in a developing country, attributed to the work of the Tanzania Food and Drugs Authority (TFDA), now the Tanzania Medicines and Medical Devices Authority (TMDA). This raises the question: how was this regulatory capacity developed, and what lessons can other countries learn from Tanzania's experience? This paper analyzes changes in Tanzania's pharmaceutical regulation over three periods of significant sectoral reform. A desk review was conducted of Tanzania's policies, laws, regulations, guidelines, procedures, and institutional reports. The study reveals that Tanzania's regulatory capacity improved significantly through targeted reforms that addressed challenges in key regulatory areas. The three key periods examined are: 1) The separation of medicines regulation from food safety (1978-2003), 2) The expansion of regulatory domains and the establishment of a semi-autonomous regulatory agency (2003-2011), and 3) The expanded role of the Pharmacy Council to include premises regulation (2011-2020). The development of a well-functioning regulatory system in Tanzania resulted from advancements in four key areas: 1) The evolution of a legal regulatory framework, 2) Strong stakeholder engagement, 3) Continuous capacity building, and 4) Effective organizational leadership. Tanzania's regulatory system has evolved from being relatively ineffective to leading regional harmonization efforts in East Africa. This progress was not linear, requiring sustained effort, collaboration, and support from key development partners such as the Global Fund, WHO, and UNDP. Future efforts to enhance regulatory effectiveness should focus on creating adaptive systems that respond to changing needs, rather than solely prescriptive functions.

Objective The Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund) partnered with the Ethiopian Pharmaceutical Supply Agency (EPSA) in 2018–2019 to reform procurement and supply chain management (PSCM) procedures within the Ethiopian healthcare system. This assessment sought to determine the impact of the reforms and document the lessons learnt.Design Mixed-methods study incorporating qualitative and quantitative analysis. Purposive and snowballing sampling techniques were applied for the qualitative methods, and the data collected was transcribed in full and subjected to thematic content analysis. Descriptive analysis was applied to quantitative data.Setting The study was based in Ethiopia and focused on the EPSA operations nationally between 2017 and 2021.Participants Twenty-five Ethiopian healthcare decision-makers and health workers.Intervention Global Fund training programme for health workers and infrastructural improvementsOutcomes Operational and financial measures for healthcare PSCM.Results The availability of antiretrovirals, tuberculosis and malaria medicines, and other related commodities, remained consistently high. Line fill rate and forecast accuracy were average. Between 2018 and 2021, procurement lead times for HIV and malaria-related orders reduced by 43.0% relative to other commodities that reported an increase. Many interview respondents recognised the important role of the Global Fund support in improving the performance of EPSA and provided specific attributions to the observed successes. However, they were also clear that more needs to be done in specific critical areas such as financing, strategic reorganisation, data and information management systems.Conclusion The Global Fund-supported initiatives led to improvements in the EPSA performance, despite several persistent challenges. To sustain and secure the gains achieved so far through Global Fund support and make progress, it is important that various stakeholders, including the government and the donor community, work together to support EPSA in delivering on its core mandate within the Ethiopian health system.

Leishmaniasis is a vector-borne disease against which there are no approved vaccines, and the treatment is based on highly toxic drugs. The alkaloids consist of a chemical class of natural nitrogen-containing substances with a long history of antileishmanial activity. The present study aimed [...] Read more.

BACKGROUND:Tanzania is 1 of the 30 high TB burden countries and 1 of the 13 countries in which 75% of people with TB are unaccounted for and that is prioritized for the Global Fund Catalytic investment and Strategic Initiative support. Tanzania decided to strengthen its National TB Programme to find these people with TB who are unaccounted for by identifying evidence-driven innovations to deliver high-quality services and to improve the efficiency of TB case-finding. A quality improvement (QI) initiative was implemented by the National Tuberculosis and Leprosy Programme to enhance TB case-finding. The initiative involved identifying gaps in the quality of services, introducing new tools, improving the work capacity of health care workers through training and mentorship sessions, strengthening laboratory and referral services, and implementing mandatory TB screening of all patients attending health facilities. We aimed to assess the effectiveness of QI initiative to enhance TB case-findings at the health facility level.METHOD:A cross-sectional design, and intervention and control facilities randomly selected for an evaluation of the QI initiative were used. Twenty facilities from the Dodoma region across all health care system levels (dispensaries, health centres, and hospitals) were involved in this evaluation. The facilities were randomly divided into either the intervention or control groups at a 1:1 ratio (10 intervention and 10 control facilities). Data routinely collected from program registers from January 2016 to June 2017 were used.RESULT:The evaluation registered a 52% increase in TB case notification in Q1 of 2017 compared with in Q1 of 2016 and, similarly, a 52% increase in Q2 of 2017 compared with in Q2 of 2016, with 9 out of 10 intervention sites reporting increases in their quarterly TB case notifications. There were no positive changes in the 'control facilities' where routine services were provided, with half of the facilities showing a decrease in TB case notification from baseline.CONCLUSION:This QI initiative has the potential to support a long-term comprehensive approach to ending TB and to improve the quality of the foundations of the health care system. This initiative sets a reliable pace for health facilities to efficiently respond to and manage TB case-finding interventions put into action. Tanzania's experience with implementing QI interventions could serve as a model for improving TB case notifications in other settings.

Globally, more than US$20 billion are spent each year on HIV prevention and treatment.1Global Burden of Disease Collaborative NetworkGlobal HIV/AIDS Spending 2000–2017. Institute for Health Metrics and Evaluation, Seattle, WA2020Google Scholar This includes expenditures from country ministries, as well as bilateral and multilateral investments. However, it is notoriously difficult to know how resources are actually being expended at health-care facilities.2Global Burden of Disease Health Financing Collaborator NetworkHealth sector spending and spending on HIV/AIDS, tuberculosis, and malaria, and development assistance for health: progress towards Sustainable Development Goal 3.Lancet. 2020; 396: 693-724Summary Full Text Full Text PDF PubMed Scopus (42) Google Scholar In the long run, this information should shape sustainable financing of HIV epidemic control. A new initiative known as activity-based costing/management (ABC/M)—coordinated by the Office of the Global AIDS Coordinator, The US Agency for International Development, The Global Fund to Fight AIDS, Tuberculosis and Malaria, and UNAIDS—is seeking to transform the status quo.3Institute for Global Health and DevelopmentActivity-based costing and management. A global management system for tracking healthcare costs.https://heller.brandeis.edu/abcDate: 2022Date accessed: April 12, 2022Google Scholar These institutions have aligned behind a novel framework to gather resource allocation information on services for thousands of patients receiving HIV/AIDS care throughout sub-Saharan Africa. The initiative will use time-driven activity-based costing (TDABC) to directly observe the resource consumption patterns of individual patients as they move through health-care facilities.4McBain RK Jerome G Warsh J et al.Rethinking the cost of healthcare in low-resource settings: the value of time-driven activity-based costing.BMJ Glob Health. 2016; 1e000134Crossref PubMed Scopus (20) Google Scholar By distilling HIV service delivery to a series of process maps (appendix), TDABC will yield insights into where patients go, what services they receive, how long and how often they interface with providers, what types of medicines they receive, and what laboratory tests are ordered. This information should allow policy makers to determine whether facilities are implementing service delivery protocols that correspond to best practices, or if there are departures that could compromise patients’ health outcomes. Perhaps the most unique feature of TDABC is that it quantifies resource consumption in terms of the minutes that the patient uses a resource, whether that resource is a provider, a physical space, or medical equipment.5Kaplan RS Anderson SR Time-driven activity-based costing.https://hbr.org/2004/11/time-driven-activity-based-costingDate accessed: April 12, 2022Google Scholar This allows researchers to examine the main factors that account for variation in resource consumption across patients, including whether those factors match expectations (eg, sicker patients receive more resources) or else indicate inequities (eg, wealthier patients receive more resources). The overarching objective of ABC/M is to empower country governments and global health institutions to align and optimise investments to improve population health. Participating ministries, which so far include those of Kenya, Mozambique, Namibia, Tanzania, Uganda, and Zambia, will regularly convene through a secretariat to share findings and exchange ideas on how to strengthen clinical care. Each country level effort will also feature a steering committee that safeguards country ownership of the ABC/M process by developing implementation strategies, providing oversight of local partners, and internally deliberating results. In time, ABC/M will expand to include an even larger cohort of participant countries. Cost estimates will be re-estimated and process maps redrawn at routine intervals to track progress. Ultimately, ABC/M holds the potential to fine tune clinical operations that could benefit millions of individuals affected by HIV/AIDS. Findings from early implementers, including Tanzania and Uganda, will be shared later this year. The views expressed are those of the authors and do not necessarily represent the views of their employers and institutional affiliates. We would like to thank all members of the ABC/M Coordination Committee: AK Nandakumar, Carlyn Mann, Susanna Baker, Kalipso Chalkidou, Shufang Zhang, Fern Terris-Prestholt, Steven Forsythe, Bryant Lee, Sarah Byakika, Joshua Musinguzi, and Robert S Kaplan. We declare no competing interests. Download .pdf (.39 MB) Help with pdf files Supplementary appendix

Background: Insufficient cost data and limited capacity constrains the understanding of the actual resources required for effective TB control. This study used process maps and time-driven activity-based costing to document TB service delivery processes. The analysis identified the resources required to sustain TB services in Zimbabwe, as well as several opportunities for more effective and efficient use of available resources. Methods: A multi-disciplinary team applied time-driven activity-based costing (TDABC) to develop process maps and measure the cost of clinical pathways used for Drug Susceptible TB (DS-TB) at urban polyclinics, rural district and provincial hospitals, and community based targeted screening for TB (Tas4TB). The team performed interviews and observations to collect data on the time taken by health care worker-patient pairs at every stage of the treatment pathway. The personnel's practical capacity and capacity cost rates were calculated on five cost domains. An MS Excel model calculated diagnostic and treatment costs. Findings: Twenty-five stages were identified in the TB care pathway across all health facilities except for community targeted screening for TB. Considerable variations were observed among the facilities in how health care professionals performed client registration, taking of vital signs, treatment follow-up, dispensing medicines and processing samples.The average cost per patient for the entire DS-TB care was USD324 with diagnosis costing USD69 and treatment costing USD255. The average cost for diagnosis and treatment was higher in clinics than in hospitals (USD392 versus USD256). Nurses in clinics were 1.6 time more expensive than in hospitals. The main cost components were personnel (USD130) and laboratory (USD119). Diagnostic cost in Tas4TB was twice that of health facility setting (USD153 vs USD69), with major cost drivers being demand creation (USD89) and sputum specimen transportation (USD5 vs USD3). Conclusion: TDABC is a feasible and effective costing and management tool in low-resource settings. The TDABC process maps and treatment costs revealed several opportunities for innovative improvements in the NTP under public health programme settings. Re-engineering laboratory testing processes and synchronising TB treatment follow-up with antiretroviral treatments could produce better and more uniform TB treatments at significantly lower cost in Zimbabwe.

BACKGROUND:The Tanzania government sought support from The Global Fund to Fight AIDs, Tuberculosis and Malaria to reform its Medical Stores Department, with the aim of improving performance. The study sought to assess the impact of the reforms and document the lessons learnt.METHODS:Quantitative and qualitative research methods were applied to assess the impact of the reforms. The quantitative part entailed a review of operational and financial data covering the period before and after the implementation of the reforms. Interrupted time series analysis was used to determine the change in average availability of essential health commodities at health zones. Qualitative data were collected through 41 key informant interviews. Participants were identified through stakeholder mapping, purposive and snowballing sampling techniques and responses were analysed through thematic content analysis.RESULTS:Availability of essential health commodities increased significantly by 12.6% (95% CI 9.6% to 15.6%) after the reforms and continued to increase on a monthly basis by 0.2% (95%CI 0.0% to 0.3%) relative to the preintervention trend. Sales increased by 56.6% while the cost of goods sold increased by 88.6% between 2014/2015 and 2017/2018. Surplus income increased by 56.4% between 2014/2015 and 2017/2018 with reductions in rent and fuel expenditure. There was consensus among study participants that the reforms were instrumental in improving performance of the Medical Stores Department.CONCLUSION:Positive results were realised through the reforms. However, despite the progress, there were risks such as the increasing government receivable that could jeopardise the sustainability of the gains. Therefore, multistakeholder efforts are necessary to make progress and expand public health.

Background The Tanzania government sought support from The Global Fund to Fight AIDs, Tuberculosis and Malaria (Global Fund) to reform its Medical Stores Department (MSD), with the aim of improving performance. Our study aimed to assess the impact of the reforms and document the lessons learned. Methods We applied quantitative and qualitative research methods to assess the impact of the reforms. The quantitative part entailed a review of operational and financial data covering the period before and after the implementation of the reforms. We applied interrupted time series analysis to determine the change in average availability of essential health commodities at health zones. Qualitative data was collected through 41 key informant interviews. Participants were identified through stakeholder mapping, purposive and snowballing sampling techniques, and responses were analyzed through thematic content analysis. Results Availability of essential health commodities increased significantly by 12.6% (95%CI, 9.6-15.6), after the reforms and continued to increase on a monthly basis by 0.2% (95%CI, 0.0-0.3) relative to the preintervention trend. Sales increased by 56.6% while the cost of goods sold increased by 88.6% between 2014/15 and 2017/18. Surplus income increased by 56.4% between 2014/15 and 2017/18, with reductions in rent and fuel expenditure. There was consensus among participants that the reforms, were instrumental in improving performance of MSD. Conclusion Many positive results were realized through the reforms at MSD. However, despite the progress, there were risks such as the increasing government receivable that could jeopardize the gains. Multi-stakeholder efforts are necessary, to sustain the progress and expand public health.

BACKGROUND:With the scale-up of antiretroviral treatment, many health facilities in low- and middle-income countries have implemented innovative practices targeted at overcoming operational challenges and delivering efficient quality HIV services. However, many of these practices remain largely unexplored as a means to better reach the global 90-90-90 targets.SETTING:A study was conducted on selected facilities in districts of country programs supported by The Global Fund to Fight AIDS, Tuberculosis, and Malaria. The aims of the study were to understand how facilities seek to improve the delivery and uptake of HIV services and to examine what innovative practices might be contributing to their success.METHODS:The study used a qualitative approach through observations, document reviews, and semistructured interviews with site management and clinical staff to identify service delivery innovations in 30 health facilities in Kenya and Uganda.RESULTS:Eleven innovative practices were observed along the HIV care cascade. These practices led to improvements in the quality of testing, treatment, and retention across the facilities. Effective human resource and data management processes also enabled the implementation of these innovative practices.CONCLUSIONS:Many facilities use innovative practices along the HIV care cascade to address bottlenecks and challenges. These have the potential to improve the quality and efficiency of service delivery and support the attainment of the 90-90-90 treatment targets. Replicating these practices would require further implementation research and a mind shift of donors, governments, and implementers from a metric of coverage to a stronger focus on efficiency and impact.