title: What does high and low have to do with it? Performance classification to identify health system factors associated with effective prevention of mother-to-child transmission of HIV delivery in Mozambique.
abstract: BACKGROUND
  Efforts to implement and take to scale highly efficacious, low-cost interventions to prevent mother-to-child HIV transmission (pMTCT) have been a cornerstone of reproductive health services in sub-Saharan Africa for over a decade. Yet efforts to increase access and utilization of these services remain far from optimal. This study developed and applied an approach to systematically classify pMTCT performance to identify modifiable health system factors associated with pMTCT performance which may be replicated in other pMTCT systems.
  
  
  METHODS
  Facility-level performance measures were collected at 30 sites over a 12-month period and reviewed for consistency. Five combinations of three indicators (1. HIV testing; 2. CD4 testing; 3. antiretroviral prophylaxis and combined antiretroviral therapy initiation) were compared including a composite of all three, a combination of 1. and 3., and each individually. Approaches were visually assessed to describe facility performance, focusing on rank order consistency across high, medium and low categories. Modifiable and non-modifiable factors were ascertained at each site and ranking process was reviewed to estimate association with facility performance through unadjusted Chi-square tests and logistic regression. After describing factors associated with high versus low performing pMTCT clinics, the effect of inclusion of the 10 middle performers was assessed.
  
  
  RESULTS
  The indicator most consistently associated with the reference composite indicator (HIV testing, antiretroviral prophylaxis and combined antiretroviral therapy) was the single measure of antiretroviral prophylaxis and combined antiretroviral therapy. Lower performing pMTCT clinics ranked consistently low across measurement strategies; high and middle performing clinics demonstrated more variability. Association between clinic characteristics and high pMTCT performance varied markedly across ranking strategies. Using the reference composite indicator, larger catchment area, higher number of institutional deliveries, onsite CD4 point-of-care capacity, and higher numbers of nurses and doctors were associated with high clinic performance while clinic location, NGO support, women's support group, community linkages patient-tracking systems and stock-outs were not associated with high performance.
  
  
  CONCLUSIONS
  Classifying high and low performance provided consistent results across ranking measures, though granularity was improved by aggregating middle performers with either high or low performers. Human resources, catchment size and utilization were positively associated with effective pMTCT service delivery.
authors.affiliation: Department of Family and Child Nursing, University of Washington, Seattle, WA, USA; Department of Global Health, University of Washington, Seattle, WA, USA; Health Alliance International, Seattle, WA, USA; sgimbel@uw.edu.
authors.forename: Sarah
authors.initials: S
authors.lastname: Gimbel
authors.affiliation: Department of Global Health, University of Washington, Seattle, WA, USA; Department of Biobehavioral Nursing and Health Systems, University of Washington, Seattle, WA, USA.
authors.forename: Joachim
authors.initials: J
authors.lastname: Voss
authors.affiliation: Department of Global Health, University of Washington, Seattle, WA, USA.
authors.forename: Alison
authors.initials: A
authors.lastname: Rustagi
authors.affiliation: Department of Global Health, University of Washington, Seattle, WA, USA.
authors.forename: Mary Anne
authors.initials: MA
authors.lastname: Mercer
authors.affiliation: Department of Biobehavioral Nursing and Health Systems, University of Washington, Seattle, WA, USA.
authors.forename: Brenda
authors.initials: B
authors.lastname: Zierler
authors.affiliation: Department of Global Health, University of Washington, Seattle, WA, USA; Health Alliance International, Seattle, WA, USA.
authors.forename: Stephen
authors.initials: S
authors.lastname: Gloyd
authors.affiliation: Health Alliance International, Beira, Mozambique.
authors.forename: Maria de Joana
authors.initials: Mde J
authors.lastname: Coutinho
authors.affiliation: Department of Community Health, University of Eduardo Mondlane, Maputo, Mozambique.
authors.forename: Maria de Fatima
authors.initials: Mde F
authors.lastname: Cuembelo
authors.affiliation: Department of Global Health, University of Washington, Seattle, WA, USA; Health Alliance International, Seattle, WA, USA.
authors.forename: Kenneth
authors.initials: K
authors.lastname: Sherr
mesh_terms: D015492:AIDS Serodiagnosis / Q000592:standards / Q000706:statistics & numerical data; D019380:Anti-HIV Agents / Q000627:therapeutic use; D019072:Antibiotic Prophylaxis / Q000592:standards / Q000706:statistics & numerical data; D018791:CD4 Lymphocyte Count / Q000592:standards / Q000706:statistics & numerical data; D005260:Female; D015658:HIV Infections / Q000517:prevention & control*; D006296:Health Services / Q000592:standards / Q000706:statistics & numerical data*; D006801:Humans; D018445:Infectious Disease Transmission, Vertical / Q000517:prevention & control*; D009073:Mozambique / Q000453:epidemiology; D011247:Pregnancy; D015397:Program Evaluation; D019984:Quality Indicators, Health Care / Q000592:standards / Q000706:statistics & numerical data
chemical_list: D019380:Anti-HIV Agents
keywords: Mozambique; PMTCT; health systems strengthening; implementation science; performance classification; performance measures