Development expenditures and the local financing constraint

Focusing on the local financing constraint sheds new light on issues of aid, fiscal reform, and the management of public spending. The fungibility of aid need not translate into resource flows to fill the local financing gap. Indeed, project aid can widen the local financing gap. To augment direct local financing of development, aid must be nonproject aid that can generate local currency. In the longer term, project aid's effect on local financing lies in its impact on growth and on expanding the base for tax revenues, seigniorage, and borrowing. When inadequate local financing limits project implementation and effective use of aid, local currency funds are more valuable than project aid, at the margin--and it becomes important to reallocate local funds, to leverage project aid, and to raise the quality of investment projects. A persistent gap in local financing complicates programs of fiscal reform. For such programs to be effective, the local financing gap has to be confronted directly by matching planned local fund expenditures against expected local fund receipts. This requires a transparent database to develop indicators and to monitor the allocation and use of local resources.Development Economics&Aid Effectiveness,Economic Theory&Research,Environmental Economics&Policies,Payment Systems&Infrastructure,Fiscal&Monetary Policy,Environmental Economics&Policies,Development Economics&Aid Effectiveness,National Governance,Fiscal&Monetary Policy,Economic Theory&Research

Addressing the mental health needs of children affected by HIV in Rwanda: validation of a rapid depression screening tool for children 7–14 years old

Background: Depression in children presents a significant health burden to society and often co-exists with chronic illnesses, such as human immunodeficiency virus (HIV). Research has demonstrated that 10–37% of children and adolescents living with HIV also suffer from depression. Low-and-middle income countries (LMICs) shoulder a disproportionate burden of HIV among other health challenges, but reliable estimates of co-morbid depression are lacking in these settings. Prior studies in Rwanda, a LMIC of 12 million people in East Africa, found that 25% of children living with HIV met criteria for depression. Though depression may negatively affect adherence to HIV treatment among children and adolescents, most LMICs fail to routinely screen children for mental health problems due to a shortage of trained health care providers. While some screening tools exist, they can be costly to implement in resource-constrained settings and are often lacking a contextual appropriateness. Methods: Relying on international guidelines for diagnosing depression, Rwandan health experts developed a freely available, open-access Child Depression Screening Tool (CDST). To validate this tool in Rwanda, a sample of 296 children with a known diagnosis of HIV between ages 7–14 years were recruited as study participants. In addition to completing the CDST, all participants were evaluated by a mental health professional using a structured clinical interview. The validity of the CDST was assessed in terms of sensitivity, specificity, and a receiver operating characteristic (ROC) curve. Results: This analysis found that depression continues to be a co-morbid condition among children living with HIV in Rwanda. For identifying these at-risk children, the CDST had a sensitivity of 88.1% and specificity of 96.5% in identifying risk for depression among children living with HIV at a cutoff score of 6 points. This corresponded with an area under the ROC curve of 92.3%. Conclusions: This study provides evidence that the CDST is a valid tool for screening depression among children affected by HIV in a resource-constrained setting. As an open-access and freely available tool in LMICs, the CDST can allow any health practitioner to identify children at risk of depression and refer them in a timely manner to more specialized mental health services. Future work can show if and how this tool has the potential to be useful in screening depression in children suffering from other chronic illnesses

Developing Human Rights-Based Strategies to Improve Health Among Female Sex Workers in Rwanda

How governments should address sex work is a topic of current debate in Rwanda and other countries. Some constituencies propose harsher punishment of sex workers as the cornerstone of an improved policy. We argue that an adequate policy response to sex work in the Rwandan context must prioritize public health and reflect current knowledge of the social determinants of health. This does not imply intensified repression, but a comprehensive agenda of medical and social support to improve sex workers' access to health care, reduce their social isolation, and expand their economic options. Evidence from social epidemiology converges with rights-based arguments in this approach. Recent field interviews with current and former sex workers strengthen the case, while highlighting the need for further social scientific and epidemiological analysis of sex work in Rwanda. Rwanda has implemented some measures that reflect a rights-based perspective in addressing sex work. For example, recent policies seek to expand access to education for girls and support sex workers in the transition to alternative livelihoods. These policies reinforce the model of solidarity-based public health action for which Rwanda has been recognized. Whether such measures can maintain traction in the face of economic austerity and ideological resistance remains to be seen

Determinants Of Adherence To Highly Active Antiretroviral Therapy Among Hiv-Infected Children In Rwanda

Introduction: Adherence to antiretroviral therapy (ART) among HIV-infected children is influenced by numerous socio-economic, clinical, spiritual and psychological factors. Interrupted adherence can result in resistance to first-line ART. In such cases, patients may infect others with resistant virus strains and they may require a significantly more expensive second-line ART regimens, which are more difficult to procure and more difficult for patients to access. Thus, ART adherence influences not only individual and population outcomes, but also has significant implications for long-term healthcare financing. It is essential to determine and address the factors that impact a patient’s likelihood to adhere to ART. Objective: This study investigates factors that are associated with HIV-infected children’s adherence to highly active antiretroviral therapy (HAART) in Rwanda. Methods: Five health facilities were visited in August 2005. Each health facility was treating HIV-infected children who had been receiving HAART for at least 12 months. Participants included children under 15 years who were treated with HAART for at least 12 months at the selected health facilities. A standard questionnaire was employed for each caregiver participant and administered in his or her home. Non-adherence was defined as missing at least one dose of ART during a 12 month period of HAART treatment. Results: Among the study participants 59% were girls and 41% were boys. Thirty-four percent of children had missed at least one dose of HAART in the past 12 months; forgetfulness (38%) and change in treatment routine (27%) were the most common reasons for missing doses. Caregivers who were members of an association for people living with HIV or AIDS (PLWHA) were more likely to be adherent than those who were not (p=0.031). The more time it took for children to be served at health centers, the less likely they were to be adherent (p=0.043). Finally, caregivers who were satisfied with the health care their children were receiving had children who were more likely to be adherent, compared to those caregivers who were unsatisfied (p=0.001). Conclusion: In order for Rwanda to increase full pediatric adherence to HAART, it must review the national counseling protocol to provide caregivers and children with tools to combat forgetfulness; it must sensitize child caregivers to join associations of PLWHA; and it must promote improved “customer care” practices at health centers.Introduction: L’adhérence à la thérapie antirétrovirale hautement active (TARHA) chez les enfants infectés par le VIH est influencée par des facteurs socio-économiques, cliniques, spirituels et psychologiques. La non adhérence peut entraîner une résistance à la TARHA de première ligne. Dans de tels cas, les patients peuvent infecter les autres personnes avec des souches de virus résistantes et nécessiter la mise sous une TARHA de deuxième ligne, beaucoup plus coûteuse, plus difficiles à obtenir et plus difficile d’accès pour les patients. Ainsi, l’adhérence à la TARHA influence non seulement les résultats individuels, mais a également des implications importantes pour la santé publique et les financements des soins de santé à long terme. C’est pourquoi il est essentiel de déterminer et de trouver une solution aux facteurs qui influencent négativement l’adhérence d’un patient à la TARHA. Objectif: Cette étude examine les facteurs qui sont associés à l’adhérence des enfants infectés par le VIH à la TARHA au Rwanda. Méthodes: Cinq établissements de santé ont été visités en août 2005. Chacun des établissements de santé avait traité des enfants infectés par le VIH qui avaient reçu une TARHA pendant au moins 12 mois. Les participants a l’étude comprenaient des enfants de moins de 15 ans qui ont été traités par TARHA pendant au moins 12 mois dans les établissements de santé sélectionnés. Un questionnaire standard a été utilisée pour chaque gardien - parent participant et été administré a domicile. La définition de la non adhérence est d’avoir manqué au moins une dose du traitement antirétroviral durant 12 mois de traitement HAART. Résultats: Parmi les participants à l’étude 59% étaient des filles et 41% étaient des garçons. Trente-quatre pour cent des enfants avaient manqué au moins une dose de TARHA au cours des 12 derniers mois; oubli (38%) et le changement dans la routine de traitement (27%) sont les raisons les plus communes de non adhérence. Les enfants qui ont des gardiens - parents membres d’une association de personnes vivant avec le VIH ou le SIDA (PVVIH) sont plus susceptibles d’être adhérentes que ceux qui ne le sont pas (p = 0,031). Plus le temps d’attente de services à l’enfant dans les centres de santé était long, moins l’enfant était adhérant (p = 0,043). Enfin, l’adhérence des enfants était plus grande quand les gardiens - parents qui étaient satisfaits des soins de santé donnés à leurs enfants que lorsqu’ils n’étaient pas satisfaits (p = 0,001). Conclusion: Pour que le Rwanda puisse augmenter l’adhérence a la TARHA chez les enfants, il faut revoir le protocole de consultation nationale à fournir aux gardiens - parents et aux enfants des outils pour lutter contre l’oubli; il faut sensibiliser les gardiens - parents des enfants à s’affilier a une association de PVVIH; et il faut favoriser l’amélioration du “service à la clientèle” dans les centres de santé