Modifications to ART service delivery models by health facilities in Uganda in promotion of intervention sustainability: a mixed methods study

Abstract

BackgroundIn November 2015, WHO released new treatment guidelines recommending that all diagnosed as HIV positive be enrolled on antiretroviral therapy (ART). Sustaining and expanding ART scale-up programs in resource-limited settings will require adaptations and modifications to traditional ART delivery models to meet the rapid increase in demand. We identify modifications to ART service delivery models by health facilities in Uganda to sustain ART interventions over a 10-year period (2004–2014).MethodsA mixed methods approach involving two study phases was adopted. In the first phase, a survey of a nationally representative sample of health facilities (n = 195) in Uganda which were accredited to provide ART between 2004 and 2009 was conducted. The second phase involved semi-structured interviews (n = 18) with ART clinic managers of 6 of the 195 health facilities purposively selected from the first study phase. We adopted a thematic framework consisting of four categories of modifications (format, setting, personnel, and population).ResultsThe majority of health facilities 185 (95%) reported making modifications to ART interventions between 2004 and 2014. Of the 195 health facilities, 157 (81%) rated the modifications made to ART as “major.” Modifications to ART were reported under all the four themes. The quantitative and qualitative findings are integrated and presented under four themes. Format: Reducing the frequency of clinic appointments and pharmacy-only refill programs was identified as important strategies for decongesting ART clinics. Setting: Home-based care programs were introduced to reduce provider ART delivery costs. Personnel: Task shifting to non-physician cadre was reported in 181 (93%) of the health facilities. Population: Visits to the ART clinic were rationalized in favor of the sub-population deemed to have more clinical need. Two health facilities focused on patients living nearer the health facilities to align with targets set by external donors.ConclusionsOver the study period, health facilities made several modifications ART interventions to improve fit with their resource-constrained settings thereby promoting long-term sustainability. Further research evaluating the effect of these modifications on patient outcomes and ART delivery costs is recommended. Our findings have implications for the sustainability of ART scale-up programs in Uganda and other resource-limited settings.

Assessing the level of institutionalization of donor-funded anti-retroviral therapy (ART) programs in health facilities in Uganda: implications for program sustainability

“…In 2014, UNAIDS unveiled the ambitious 90-90-90 targets a part of which aims at enrolling 90% of those with HIV on sustained ART by 2020 [2]. In November 2015, WHO released new global ART treatment guidelines recommending that all diagnosed with HIV be enrolled on sustained ART regardless of disease stage [3,4]. …”

“…In Uganda, an estimated 85% of the national HIV response is externally funded principally through PEPFAR and The Global Fund which have supported ART scale-up since June 2004 [9,10]. National ART roll-out commenced at a relatively higher-level of care starting at major tertiary hospitals in Uganda [4]. ART services were subsequently decentralized to lower-level health facilities including in small for-profit clinics [4].…”

“…National ART roll-out commenced at a relatively higher-level of care starting at major tertiary hospitals in Uganda [4]. ART services were subsequently decentralized to lower-level health facilities including in small for-profit clinics [4]. The goal of ART scale-up was to expand coverage through commissioning multiple sites with the aim of extending service delivery beyond large tertiary hospitals [9].…”

“…Against this background, the sustainability of the implementation of ART scale-up in SSA has come into critical focus [1,4,9–11]. The institutionalization or integration of interventions in the organizational routines of health service organizations is considered an important indicator of long-term program sustainability [12–16].…”

“…The institutionalization or integration of interventions in the organizational routines of health service organizations is considered an important indicator of long-term program sustainability [12–16]. Although there have been numerous studies documenting the initial phase of ART scale-up in SSA [4,7], there is a dearth of systematic analysis of level of institutionalization of ART programs in externally supported health facilities in Uganda and the broader Sub-Saharan Africa region.…”