Are They Really Lost? "True" Status and Reasons for Treatment Discontinuation among HIV Infected Patients on Antiretroviral Therapy Considered Lost to Follow Up in Urban Malawi

INTRODUCTION Patients who are lost to follow-up (LTFU) while on antiretroviral therapy (ART) pose challenges to the long-term success of ART programs. We describe the extent to which patients considered LTFU are misclassified as true disengagement from care when they are still alive on ART and explain reasons for ART discontinuation using our active tracing program to further improve ART retention programs and policies. METHODS We identified adult ART patients who missed clinic appointment by more than 3 weeks between January 2006 and December 2010, assuming that such patients would miss their doses of antiretroviral drugs. Patients considered LTFU who consented during ART registration were traced by phone or home visits; true ART status after tracing was documented. Reasons for ART discontinuation were also recorded for those who stopped ART. RESULTS Of the 4,560 suspected LTFU cases, 1,384 (30%) could not be traced. Of the 3,176 successfully traced patients, 952 (30%) were dead and 2,224 (70%) were alive, of which 2,183 (99.5%) started ART according to phone-based self-reports or physical verification during in-person interviews. Of those who started ART, 957 (44%) stopped ART and 1,226 (56%) reported still taking ART at the time of interview by sourcing drugs from another clinic, using alternative ART sources or making brief ART interruptions. Among 940 cases with reasons for ART discontinuations, failure to remember (17%), too weak/sick (12%), travel (46%), and lack of transport to the clinic (16%) were frequently cited; reasons differed by gender. CONCLUSION The LTFU category comprises sizeable proportions of patients still taking ART that may potentially bias retention estimates and misdirect resources at the clinic and national levels if not properly accounted for. Clinics should consider further decentralization efforts, increasing drug allocations for frequent travels, and improving communication on patient transfers between clinics to increase retention and adherence.

Outcomes of antiretroviral treatment programmes in rural Lesotho: health centres and hospitals compared

Introduction: Lesotho 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. Methods: The 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. Results: Of 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). Conclusions: In 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.

Rapport final d'intervention, production et diffusion d'une série de dix émissions sur la décentralisation à Menabe

Final project report: Production of radio broadcasting based on the ALS module on decentralization

Matching Social and Ecological Systems in Complex Ocean Fisheries

This paper considers ocean fisheries as complex adaptive systems and addresses the question of how human institutions might be best matched to their structure and function. Ocean ecosystems operate at multiple scales, but the management of fisheries tends to be aimed at a single species considered at a single broad scale. The paper argues that this mismatch of ecological and management scale makes it difficult to address the fine-scale aspects of ocean ecosystems, and leads to fishing rights and strategies that tend to erode the underlying structure of populations and the system itself. A successful transition to ecosystem-based management will require institutions better able to economize on the acquisition of feedback about the impact of human activities. This is likely to be achieved by multiscale institutions whose organization mirrors the spatial organization of the ecosystem and whose communications occur through a polycentric network. Better feedback will allow the exploration of fine-scale science and the employment of fine-scale fishing restraints, better adapted to the behavior of fish and habitat. The scale and scope of individual fishing rights also needs to be congruent with the spatial structure of the ecosystem. Place-based rights can be expected to create a longer private planning horizon as well as stronger incentives for the private and public acquisition of system relevant knowledge.

Economic Rights, Human Development Effort and Institutions

This paper focuses on the link between economic rights and institutions. Simple analysis of data is used to demonstrate countries' human development effort in advancing economics rights of the citizens. A country's human development effort is evaluated on the basis of the well-being of the poorest members of the society. An analysis of data reveals that there is a wide variation in countries' pro-poor stance. While it is accepted that positive rights are pro-poor, this paper argues that so too are negative economic rights and in fact the two are complements rather than substitutes. Classifying countries into human development income deficit and human development effort deficit, it is demonstrated that a large number of countries could achieve higher welfare levels for the poor if they improved on bother positive and negative economic rights. The paper attempts to explain variations in the observed commitment to economic rights by focusing on pro-poor institutions. The basic thesis advanced in the paper is that pro-poor policies are more likely to be implemented and sustained in those institutions where power is sufficiently diffused such that even the poor have leverage over policy outcomes. The paper focuses on how institutions impact on power diffusion and therefore the adoption of pro-poor growth and policies. The failure of countries to adopt pro-poor growth and policies is attributed to institutional failures manifested in concentration of power. The policy recommendations emanating from the analysis focus on institutional reforms to enhance power diffusion. These policies include enlarging the political space through democratization, strengthening institutions and capacity to fight corruption and improve transparency, and bringing the government closer to the people through appropriate design and implementation of decentralization schemes. Some recent examples of improvements in economic rights following power diffusion are provided.

HOUSE-TO-HOUSE SURVEY OF ACCESS TO AND USE OF PUBLIC HEALTH FACILITIES IN METROPOLITAN LAGOS, NIGERIA

One of the broad objectives of the Nigerian health service, vigorously being pursued at all levels of government, is to make comprehensive health care available and accessible to the population at the lowest possible cost, within available resources. Some state governments in the federation have already introduced free medical service as a practical way to remove financial barriers to access and in turn to encourage greater utilization of publicly funded care facilities.^ To aid health planners and decision makers in identifying a shorter corridor through which urban dwellers can gain access to comprehensive health care, a health interview survey of the metropolitan Lagos was undertaken. The primary purpose was to ascertain the magnitude of access problems which urban households face in seeking care from existing public facilities at the time of need. Six categories of illness chosen from the 1975 edition of the International Classification of Disease were used as indicators of health need.^ Choice of treatment facilities in response to illness episode was examined in relation to distance, travel time, time of use and transportation experiences. These were graphically described. The overall picture indicated that distance and travel time coexist with transportation problems in preventing a significant segment of those in need of health care from benefitting in the free medical service offered in public health facilities. Within this milieu, traditional medicine and its practitioners became the most preferred alternative. Recommendations were offered for action with regard to decentralization of general practitioner (GP) consultations in general hospitals and integration of traditional medicine and its practitioners into public health service. ^

Los nuevos desafíos para la gestión del desarrollo local

Este trabajo tiene como objetivo el análisis, la investigación y la propuesta de Tecnologías de Gestión, Nuevas formas de Articulación y Medidas Innovativas que se implementan o pueden ser implementadas en diferentes Gobiernos Locales, en orden a proveer los principios y requerimientos básicos para lograr un cambio del Modelo de Gestión de los Municipios. Entendemos al Desarrollo Local como la estrategia adecuada y necesaria, pero no suficiente, para lograr satisfacer las demandas crecientes de una Sociedad Local que se complejiza y para hacer frente a los desafíos emergentes del Proceso Globalizador y las Políticas de Descentralización con eficiencia.

Municipalización y descentralización del Estado : ¿autonomía vacía o fortalecimiento de la capacidad de gestión?

Los cambios operados en la Argentina de la última década van desde la Reforma del Estado a una desocupación que supera los índices históricos. La llamada Municipalización del Estado, como uno de los cambios relevantes, será nuestro objeto de estudio. La pregunta que nos guía es si la descentralización operada fortalece la capacidad de gestión de los municipios o si sólo implica transferencia de responsabilidades sin autonomía ni recursos. Promover un desarrollo local mediante programas dirigidos a dualizar las regiones urbanas, creando islotes de modernidad exportadora en océanos de pobreza, produce altas tasas de desocupación, pauperización y desintegración social.

Redes para las nuevas formas de clientelismo político

La descentralización de políticas sociales hacia los municipios es planteada como una alternativa de desarrollo a partir de las relaciones micro sociales. Los municipios deben asumir una nueva responsabilidad y plantearse una nueva función: definir y ejecutar políticas sociales locales o regionales. Esta nueva relación del municipio con su población ha sido uno de los elementos, en un proceso que tiene múltiples explicaciones, que ha favorecido nuevas prácticas clientelares denominadas Clientelismo fino o institucional. Este clientelismo favorece una situación de sometimiento y de asistencialismo, dificultando nuevas formas de relación que permitan el desarrollo humano y el ejercicio de derechos.

La vida cultural de las políticas públicas : un análisis de los conflictos por el uso del agua en el contexto neoliberal

La descentralización en el marco de las políticas neoliberales se concibió como una reforma política-administrativa para minimizar el rol del Estado postulando como bastión clave "La participación local". Sin embargo ésta sólo se queda en los ámbitos formales. El caso particular de las políticas de descentralización del riego en la provincia de Mendoza no es una excepción. Lo que nos lleva a analizar su microcosmos y las redes sociales informales que dan cuenca de la desigual participación de los distintos usuarios del agua de riego en las decisiones en torno a este recurso, según sus trayectorias y sus capitales sociales, económicos y culturales.

Hacia una escuela inclusiva : un aporte desde las estrategias de la gestión

Ante un contexto signado por reformas educativas, demandas de pluralismo y atención a la diversidad, nos enfrentamos al cambio paradigmático de lo organizacional, lo que implica una revisión profunda del modo de gestión de las instituciones en los distintos niveles educativos. La escuela, inmersa en un contexto de cambios acelerados tanto científicos como tecnológicos, y continuamente demandada por una sociedad cada vez más heterogénea y pluralista, debe adaptarse a estos cambios y dar una respuesta efectiva. La escuela inclusiva es una alternativa válida tanto desde sus principios como en sus procedimientos, hacia la apertura a la diversidad de la población en edad escolar. En tal sentido, el desarrollo de una gestión educativa basada en la descentralización; la sustitución de la programación de detalle por la orientación estratégica; el “achatamiento" de la jerarquía; la desburocratización; el trabajo en equipo y la democratización en la toma de decisiones. Desde tal perspectiva, en este trabajo se plantean una serie de consideraciones a tener en cuenta en todo proyecto de inclusión escolar desde la gestión, que podrían contribuir al análisis de la capacidad de inclusión de la escuela actual, en sus diversas dimensiones: pedagógica, administrativa, organizativa y comunitaria, y para la puesta en práctica de un modelo Curricular, desde una gestión participativa.

Organizaciones vecinales en municipios de Mendoza : Potencialidad para generar prácticas sociales con inteligencia territorial

The idea of Territorial Intelligence emphasizes the participation of different types from actors in the decisions that concern to the local territory. Between the communitarian actors, the ocal organizations are fundamental because they have an existential knowledge of the geographic space who share the neighbors. That knowledge, is focused generally in the deficiencies of the district or of the district and it is constituted in its reason of being, like average for the defense as opposed to the authority of the local government. This so shared in common function is left lamentably to a quite traditional relation like intermediary between municipality and community annotated. A special case constitutes the cooperative calls of rural services or vicinal organizations that are in charge to administer the service of potable water, those that are generally led by people greater or small proprietors of traditional agriculture. A strong territorial identity can be observed that, as opposed to the transformations and modernization of the field, subsists exactly by that feeling of root. In the province of Mendoza, the importance of the ocal organizations was increased during the decade of the' 90 with the decentralization processes, to canalize house policies, some public works and services in the districts. From a perspective of associated management, projects of economic, cultural, environmental development would have to revitalize their function like organizations able to also agglutinate not only demands but that they promote to the local territory from other dimensions. With these motivations and the purpose of proposing strategies to induce practices of ocal work with territorial intelligence, a set of reflections that allow to compare the space distribution and the characteristics of these organizations between 90 years' and the present time, in some departments of the province of Mendoza appears. The most important result is expressed in a tipología of ocal unions, with a cartography that ties feasible territory and social actors to collaborate to generate transformations social, specially in rural areas

Descentralización municipal, intendentes y 'fuerzas vivas' durante el Proceso (1976- 1983)

En este artículo analizaremos el diseño y la implementación de tres medidas que tuvieron diferentes repercusiones en el tiempo : la 'municipalización' (1976-1980); la selección de intendentes en 1981 y el recorte del gasto público hacia 1982. En primer lugar, veremos que la política de municipalización se inscribió en un programa más general de reducción del aparato estatal sostenido por el ministro de Economía, José Martínez de Hoz (1976-1981). Observaremos que, en algunos distritos, dicha municipalización careció del impacto que los propios funcionarios le atribuían. En segundo término, presentaremos las derivaciones que tuvo la política de selección de intendentes en 1981. Clausurados los mecanismos electorales, los gobernadores tenían la autoridad exclusiva para nombrar y remover intendentes. Esta práctica comenzó a ser denunciada públicamente por los grupos que se sentían perjudicados. Sin elecciones ala vista, el gobernador y sus ministros respondieron a los reclamos de distintas maneras, lo que acentuó la arbitrariedad. En algunos casos atendieron a las protestas y en otros las ignoraron abiertamente. En tercer lugar, estudiaremos los efectos de las medidas económicas de ajuste que debieron aplicar los intendentes al final del Proceso. Por un lado, aparecieron movimientos de 'amas de casa' que presionaban para que bajaran los precios; y por el otro, los intendentes en persona admitían que la política económica los estaba afectando directamente

Descentralización, autogestión, gestión local. Estudio de caso de un municipio en La Pampa, Argentina

Los municipios, en los últimos veinticinco años, han cambiado sus roles. En la actualidad, los gobernantes locales asumen formas de gestionar que atienden a las crecientes demandas sociales de sus vecinos, redefiniendo las políticas públicas municipales. Parte de la tarea de gestión es el ordenamiento territorial como estrategia para orientar la distribución espacial del desarrollo, de acuerdo con los recursos disponibles, con el mejor uso que a los mismos se da en términos sociales, económicos y ambientales. Concretarlo implica cambios cualitativos importantes, adecuaciones en la gestión político-administrativa. En Victorica, La Pampa, la autogestión se perfila como una de las características más sobresalientes. La dinámica gestión de su territorio es ejemplo para otros municipios que intentan imitar el estilo. Los actores sociales son la clave del cambio.