Policy change and micro-politics in global health aid: HIV in South Africa

Kavanagh, Matthew M.; Dubula-Majola, Vuyiseka

doi:10.1093/heapol/czy103

Cited by 4 publications

(4 citation statements)

References 16 publications

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“…Adequate health resources are known to be critical components in ensuring quality health services and positive patient outcomes [28,[38][39][40][41]. While NGO partners have been instrumental in supporting policy implementation in South Africa and Sub-Saharan Africa [42,43], they often cannot improve long-term infrastructural needs [42,[44][45][46]. In South Africa, government-led initiatives such as the Ideal Clinic Realisation and Maintenance (ICRM) programs and the Integrated Chronic Disease Management (ICDM) model are attempts to correct resource and infrastructure deficiencies and improve the quality of primary health care services [36,47].…”

Section: Discussionmentioning

confidence: 99%

Health provider perspectives on the implementation of the same-day-ART initiation policy in the Gauteng province of South Africa

Onoya

Mokhele

Sineke

et al. 2021

Health Res Policy Sys

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Background In September 2016, South Africa (SA) began implementing the universal-test-and-treat (UTT) policy in hopes of attaining the UNAIDS 90-90-90 targets by 2020. The SA National Department of Health provided a further directive to initiate antiretroviral therapy (ART) on the day of HIV diagnosis in September 2017. We conducted a qualitative study to determine the progress in implementing UTT and examine health providers' perspectives on the implementation of the same-day initiation (SDI) policy, six months after the policy change. Methods We conducted in-depth interviews with three professional nurses, and four HIV lay counsellors of five primary health clinics in the Gauteng province, between October and December 2017. In September 2018, we also conducted a focus group discussion with ten professional nurses/clinic managers from ten clinic facilities. The interviews and focus groups covered the adoption and implementation of UTT and SDI policies. Interviews were conducted in English, Sotho or Zulu and audio-recorded with participant consent. Audio-recordings were transcribed verbatim, translated to English and analysed thematically using NVivo 11. Results The data indicates inconsistencies across facilities and incongruities between counsellor and nursing provider perspectives regarding the SDI policy implementation. While nurses highlighted the clinical benefits of early ART initiation, they expressed concerns that immediate ART may be overwhelming for some patients, who may be unprepared and likely to disengage from care soon after the initial acceptance of ART. Accordingly, the SDI implementation was slow due to limited patient demand, provider ambivalence to the policy implementations, as well as challenges with infrastructure and human resources. The process for assessing patient readiness was poorly defined by health providers across facilities, inconsistent and counsellor dependent. Providers were also unclear on how to ensure that patients who defer treatment return for ongoing counselling. Conclusions Our results highlight important gaps in the drive to achieve the ART initiation target and demonstrate the need for further engagement with health care providers around the implementation of same-day ART initiation, particularly with regards to infrastructural/capacity needs and the management of patient readiness for lifelong ART on the day of HIV diagnosis. Additionally, there is a need for improved promotion of the SDI provision both in health care settings and in media communications to increase patient demand for early and lifelong ART.

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Section: Discussionmentioning

confidence: 99%

Health provider perspectives on the implementation of the same-day-ART initiation policy in the Gauteng province of South Africa

Onoya

Mokhele

Sineke

et al. 2021

Health Res Policy Sys

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“…Success of these HRH interventions, then, can be linked to national and regional health policies, and HRH effectiveness can be more of an enabler than a constraint of epidemic control [40]. This can only enhance HRH e cacy and intervention sustainability [41].…”

Section: Discussionmentioning

confidence: 99%

Strengthening Human Resources for Health to Achieve Epidemic Control: A Case Study of Democratic Republic of the Congo

et al. 2020

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Background The United States President's Emergency Plan for AIDS Relief (PEPFAR) in Democratic Republic of the Congo (DRC) continues to fund a robust portfolio of programs aimed at achieving epidemic control in three provinces where 30 percent of people living with HIV/AIDS in the country reside.Challenges around human resources for health (HRH), including inadequate sta ng and limited capacity, impede the delivery of quality HIV/AIDS services in DRC.Methods In partnership with the United States Health Resources and Services Administration (HRSA), PEPFAR, and DRC Ministry of Health (MoH), ICAP at Columbia University worked with 16 PEPFARidenti ed high-priority health facilities (HFs) in DRC and developed HRH-speci c interventions to address challenges in achieving 95-95-95 targets. These potential interventions were then prioritized for implementation using a collaborative, criteria-driven approach considering factors such as feasibility, viability, and time-to-impact. Through interviews at all 16 HFs, the joint teams developed an intervention framework, determined short-term priorities, and prepared to implement short-term HRH improvements to reach 95-95-95 targets across all HFs. Interviews used an adapted version of the PEPFAR HRH Rapid Assessment tool to capture key HRH information including sta ng levels by type of clinical or administrative position, key barriers to achieving 95-95-95 targets, and perceptions of needed HRHspeci c improvements.Results Site-level interviews occurred in April 2019, and the in-country team created a list of possible interventions across six domains: sta ng, training, workplace environment, medical supplies and equipment, and monitoring and evaluation. Thirty-ve interventions were hypothesized and prioritized into short, medium, and long-term priorities using a framework focused on desirability, feasibility, viability, and time-to-impact. Some interventions were applicable to all HFs while others applied only to selected HFs, the national MoH, or to implementation partners. Twelve interventions were selected as highest priority, and budget allocations and task planning were developed for each of the high-priority interventions. These high-priority interventions were then launched for implementation and evaluation within six months.Conclusions The supply and quality of HRH are critical to achieving epidemic control. This assessment delineated necessary interventions to address site-speci c HRH barriers, HRH interventions focused on ensuring adequate sta ng, optimal utilization of health workers, and strengthening health workers' capacity to provide quality HIV/AIDS services to achieve epidemic control. Downstream tracking and reporting of key PEPFAR metrics, including key Monitoring, Evaluation, and Reporting (MER) indicators, will allow intervention teams to conduct program evaluations of key interventions and their impacts on PEPFAR targets.

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“…The relative importance of TA in HIV response in SA has been directly affected by shifts in PEPFAR policy. 1 The US President's Emergency Plan for AIDS Relief's initial support focussed on building treatment programmes and scaling up access to antiretroviral therapy (ART) through direct service provision. 2 In 2009 its focus changed to implementing TA that supported the eventual transition of ownership of PEPFAR's initiatives to the Government of SA.…”

Section: Introductionmentioning

confidence: 99%

“…In 2016 PEPFAR's strategy shifted further to focus on front-line services in districts with a high HIV prevalence, whilst maintaining targeted TA to support specific aspects of the HIV programme. 1 The implementation of TA is frequently understood in terms of two key concepts: market 'pull-TA' and 'push-TA'. 3,4,5 'Pull-TA' is based on reactive responses to requests for support, whereas 'push-TA' proactively integrates technical expertise, research findings or technology into the programme-level practice.…”

Section: Introductionmentioning

confidence: 99%

Indicator-focussed technical assistance in South Africa’s HIV programme: A stepped-wedge evaluation

Jobson

Railton

Ranoto

et al. 2021

Southern African Journal of HIV Medicine

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Background: There is a lack of research on technical assistance (TA) interventions in low- and middle-income countries. Variation in local contexts requires tailor-made approaches to TA that are structured and replicable across intervention sites whilst retaining the flexibility to adapt to local contexts. We developed a systematic process of TA using multidisciplinary roving teams to provide support across the various elements comprising local HIV services.Objectives: To examine the effectiveness of targeting specific HIV and TB programme indicators for improvement using roving teams.Method: We conducted a cluster-randomised stepped-wedge evaluation of a TA support package focussing on clinical, managerial and pharmacy services in the Mopani district of the Limpopo province, South Africa (SA). Three roving teams delivered the intervention. Seventeen primary and community healthcare centres that had 400–600 patients on antiretroviral therapy (ART) were selected for inclusion. The TA package was implemented for six consecutive months across facilities until all had received the same level of support. Data were collected from the relevant health management information systems for 11 routine indicators.Results: The mean proportion of PLWH screened for tuberculosis (TB) at ART initiation increased from 85.2% to 87.2% (P = 0.65). Rates of retention in care improved, with the mean proportion of patients retained in care at three months post-ART initiation increasing from 79.9% to 87.4% (P 0.001) and from 70.3% to 77.7% (P 0.01) after six months. Finally, the mean proportion of patients with TB who completed their treatment increased from 80.6% to 82.1% (P = 0.75).Conclusion: Tailored TA interventions in SA using a standardised structure and process led to a significant improvement in retention-in-care rates and to non-significant improvements in the proportion of PLWH screened for TB and of those who completed their treatment.

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Policy change and micro-politics in global health aid: HIV in South Africa

Cited by 4 publications

References 16 publications

Health provider perspectives on the implementation of the same-day-ART initiation policy in the Gauteng province of South Africa

Health provider perspectives on the implementation of the same-day-ART initiation policy in the Gauteng province of South Africa

Strengthening Human Resources for Health to Achieve Epidemic Control: A Case Study of Democratic Republic of the Congo

Indicator-focussed technical assistance in South Africa’s HIV programme: A stepped-wedge evaluation

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