Impact of health system inputs on health outcome: A multilevel longitudinal analysis of Botswana national antiretroviral program (2002-2013)

Mansoor Farahani, Natalie Price, Shenaaz El-Halabi, Naledi Mlaudzi, Koona Keapoletswe, Refeletswe Lebelonyane, Ernest Benny FetogangR, Tony Chebani, Poloko Kebaabetswe, Tiny Masupe, Keba Gabaake, Andrew F. Auld, Oathokwa Nkomazana, Richard Marlink

Publication Date: 08/01/2016

Objective To measure the association between the number of doctors, nurses and hospital beds per 10,000 people and individual HIV-infected patient outcomes in Botswana. Design Analysis of routinely collected longitudinal data from 97,627 patients who received ART through the Botswana National HIV/AIDS Treatment Program across all 24 health districts from 2002 to 2013. Doctors, nurses, and hospital bed density data at district-level were collected from various sources. Methods A multilevel, longitudinal analysis method was used to analyze the data at both patient- and district-level simultaneously to measure the impact of the health system input at districtlevel on probability of death or loss-to-follow-up (LTFU) at the individual level. A marginal structural model was used to account for LTFU over time. Results Increasing doctor density from one doctor to two doctors per 10,000 population decreased the predicted probability of death for each patient by 27%. Nurse density changes from 20 nurses to 25 nurses decreased the predicted probability of death by 28%. Nine percent decrease was noted in predicted mortality of an individual in the Masa program for every five hospital bed density increase.