Background: Despite policies and guidelines recommending integration of health services in South Africa, provision of maternal and child health services remains fragmented. This study evaluated a rapid, scaleable, quality improvement (QI) intervention to improve integration of maternal and child health and HIV services at a primary health level, in KwaZulu-Natal, South Africa. Methods: A three-month intervention comprised of six QI mentoring visits, learning sessions with clinic staff to share learnings, and a self-administered checklist aimed to assist health workers monitor and implement an integrated package of health services for mothers and children. The study evaluated 27 clinics in four sub-districts using a stepped-wedge design. Each sub-district received the intervention sequentially in a randomly selected order. Five waves of data collection were conducted in all participating clinics between December 2016-February 2017. A multi-level, mixed effects logistic regression was used to account for random cluster fixed time and group effects using Stata V13.1.

Background Public health practitioners have little guidance around how to plan for the sustainability of donor sponsored programs after the donor withdraws. The literature is broad and provides no consensus on a definition of sustainability. This study used a mixed-methods methodology to assess program sustainability factors to inform donor-funded programs. Methods This study examined 61 health facilities in the Western Cape, South Africa, supported by four PEPFAR-funded non-governmental organizations from 2007 to 2012. Retention in care (RIC) was used to determine health facility performance. Sustainability was measured by comparing RIC during PEPFAR direct service (20072012), to RIC in the post PEPFAR period (2013 to 2015). Forty-three semi-structured in-depth interviews were conducted with key informants. The qualitative data were used to examine how predictor variables were operationalized at a health facility and NGO level. Results Our qualitative results suggest the following lessons for the sustainability of future programs: Sufficient and stable resources (i.e., financial, human resources, technical expertise, equipment, physical space) Investment in organizations that understand the local context and have strong relationships with local government. Strong leadership at a health facility level Joint planning/coordination and formalized skill transfer Local positive perceived value of the program Partnerships Conclusion Sustainability is complex, context dependent, and is reliant on various processes and outcomes. This study suggests additional health facility and community level staff should be employed in the health system to ensure RIC sustainability. Sustainability requires joint donor coordination with experienced local organizations with strong managers before during and after program implementation. If the program is as large as the South African HIV effort some dedicated additional resources in the long term would be required.

Background: Research on the impact of the PEPFAR transition in South Africa (SA) in 2012 found varying results in retention in care (RIC) of people living with HIV (PLWH). Objectives: We investigated the factors that impacted RIC during the U.S. President's Emergency Plan for AIDS Relief (PEPFAR) transition in Western Cape, South Africa in 2012. Methods: We used aggregate data from 61 facilities supported by four non-governmental organizations from to 2007-2015. The main outcome was RIC at 12-months after antiretroviral therapy initiation for two time periods. We used quantile regression to estimate the effect of the PEPFAR pull-out and other predictors on RIC. The models were adjusted for various covariates. Results: Regression models (50th quantile) for 12-month RIC showed a 4.6% (95%CI: -8.4, -0.8%) decline in RIC post direct service. Facilities supported by Anova/Kheth'impilo fared worst post PEFPAR; a decline in RIC of (-5.8%; 95% CI: -9.7, -1.8%), while that'sit fared best (6.3% increase in RIC; 95% CI:2.5,10.1%). There was a decrease in RIC when comparing urban to rural areas (-5.8%; 95% CI: -10.1, -1.5%). City of Cape town combined with Western Cape Government Health facilities showed a substantial decrease (-9.1%; 95% CI: -12.3, -5.9%), while community health clinic (vs. primary health clinic) declined slightly (-4.4; 95% CI: -9.6, 0.9%) in RIC. We observed no RIC difference by facility size and a slight increase when two or more human resources transitioned from PEPFAR to the government. Conclusions: When PEPFAR funding decreased in 2012, there was a decrease in RIC. To ensure the continuity of HIV care when a major funder withdraws sufficient and stable transition resources, investment in organizations that understand the local context, joint planning, and coordination are required.

Longitudinal qualitative methodologies have gained increased attention in health and social science research as an appropriate methodology to explore participants’ experiences of change over time but is a challenging methodology to implement. We reflect on the methodological aspects of a novel longitudinal ‘mixed’ mixed-methods study using quantitative and qualitative methods with both individuals and groups, employing various participatory approaches. We focus on key learnings from our study including the use of a structured recruitment process to minimise loss to follow up, and issues of reflexivity when researchers and participants have a similar background. In addition, like many large mixed-methods longitudinal studies we experienced challenges determining sample size and managing and analysing a large dataset. There is a need for establishing clear guidelines for determining sample size, addressing reflexivity and managing large datasets. The lessons learned from this study will add rigour to the literature on conducting mixed-methods longitudinal studies.