Diffusion and Adoption of Policies for the Prevention of Mother-to-Child Transmission of HIV (PMTCT) and their Effect on the Delivery of Key PMTCT Services in Eastern and Southern Africa Open Access
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With the goal of eliminating mother-to-child transmission by 2015, a wide range of governmental and other efforts within low- and middle-income countries have sought to provide services for the prevention of mother-to-child transmission of HIV (PMTCT) to the estimated 1.2 million pregnant women in need. In support of this goal, the World Health Organization (WHO), as the leading normative international body in the area of evidence-based clinical guidelines, issued policy recommendations on the use of antiretroviral drugs for PMTCT. Through various mechanisms, including guidance notes and dissemination workshops, WHO supports countries to adopt and adapt the guidelines within their national policy frameworks. Through three analyses, this dissertation examines the diffusion of WHO PMTCT guidelines in five Eastern and Southern African countries over a 16-year period (1998-2013) and estimates the effect of PMTCT policy adoption on delivery of key services. The first analysis of the adoption of specific PMTCT guideline updates between 1998 and 2013 seeks to ascertain which internal factors may explain why and when countries decided to adopt new technical guidance. The policy analysis shows that the five countries adopted a majority of the key international PMTCT technical guidance updates. It can be concluded that international to national policy diffusion was taking place and that national policies converged to be more similar and more in line with international guidelines over the time period studied. Variation in adoption and in the internal determinants at play in each country was minimal, making it difficult to assess the influence of determinants qualitatively. The three internal determinants that appeared to most influence adoption of key PMTCT updates were: 1) the severity of the MTCT problem 2) governance effectiveness, and 3) prior PMTCT policy adoption. The lag between adoption and implementation in these countries is discussed. The findings indicate that in the countries studied, policies promoted by WHO and other international bodies can play a critical role in supporting national policy adoption for program advancement in the area of PMTCT.The second and third analyses investigate whether the completeness of a country’s body of PMTCT-supporting policies was associated with the delivery of two key PMTCT services – the offer of an HIV test and the receipt of HIV counseling as a part of antenatal care (ANC) – in four of the five countries included in the first analysis. Two nationally representative surveys per country were used to conduct a quasi-experimental fixed-effects analysis of the role of policy in predicting a woman’s probability of being offered an HIV test or receiving HIV counseling in ANC, controlling for other key individual- and country-level covariates. According to the ‘testing’ model, a one-unit increase in policy score was associated with a 0.042 (p<0.000) increase in the probability that a woman was offered an HIV test as a part of antenatal care. According to the ‘counseling’ model, a one-unit increase in policy score was associated with a 0.014 (p<0.001) increase in the probability that a woman received HIV counseling as a part of antenatal care. In both the testing and counseling models, the policy/education interaction was statistically significant in the final model, with a greater policy effect estimated at among those with higher education levels. Time statistically significantly influenced the probability of the outcome, as did government health spending, governance effectiveness, and donor health spending. Further study is needed to identify the policy elements that have the most impact on improving service delivery. The three analyses presented here support the premise that international health policies influence national-level policy adoption, and that national-level policy adoption in turn influences national service outputs. As countries and their development partners mobilize for the Sustainable Development Goal era, policy adoption at the international level will continue to be an important influence in national policy adoption in the area of PMTCT. This research has described a number of potential internal and external determinants that will influence national adoption in this next round of global health policy advocacy. Looking forward, this study shows that countries and their development partners should continue to invest in the work of policy adoption to complement other efforts to reach health goals, including increased government health spending.