The impact of loss of PEPFAR support on HIV services at health facilities in low-burden districts in Uganda

Abstract

Background Although donor transitions from HIV programs are more frequent, little research exists seeking to understand the perceptions of patients and providers on this process. Between 2015 and 2017, PEPFAR implemented the ´geographic prioritization´ (GP) policy in Uganda whereby it shifted support from 734 ‘low-volume’ facilities and 10 districts with low HIV burden and intensified support in select facilities in high-burden districts. Our analysis intends to explore patient and provider perspectives on the impact of loss of PEPFAR support on HIV services in transitioned health facilities in Uganda. Methods We report qualitative findings from a larger mixed-methods evaluation. Six facilities were purposefully selected as case studies seeking to ensure diversity in facility ownership, size, and geographic location. Five out of the six selected facilities had experienced transition. A total of 62 in-depth interviews were conducted in June 2017 (round 1) and November 2017 (round 2) with facility in-charges (n = 13), ART clinic managers (n = 12), representatives of PEPFAR implementing organizations (n = 14), district health managers (n = 23) and 12 patient focus group discussions (n = 72) to elicit perceived effects of transition on HIV service delivery. Data were analyzed using thematic analysis. Results While core HIV services, such as testing and treatment, offered by case-study facilities prior to transition were sustained, patients and providers reported changes in the range of HIV services offered and a decline in the quality of HIV services offered post-transition. Specifically, in some facilities we found that specialized pediatric HIV services ceased, free HIV testing services stopped, nutrition support to HIV clients ended and the ‘mentor mother’ ART adherence support mechanism was discontinued. Patients at three ART-providing facilities reported that HIV service provision had become less patient-centred compared to the pre-transition period. Patients at some facilities perceived waiting times at clinics to have become longer, stock-outs of anti-retroviral medicines to have been more frequent and out-of-pocket expenditure to have increased post-transition. Conclusions Participants perceived transition to have had the effect of narrowing the scope and quality of HIV services offered by case-study facilities due to a reduction in HIV funding as well as the loss of the additional personnel previously hired by the PEPFAR implementing organizations for HIV programming. Replacing the HIV programming gap left by PEPFAR in transition districts with Uganda government services is critical to the attainment of 90–90-90 targets in Uganda.

Examining health facility financing in Kenya in the context of devolution

“…This is alarming as there is a plan for donors to progressively transition from supporting the Kenyan health sector generally, and primary healthcare facilities specifically. Donor transition is expected to put additional fiscal pressure to LMIC health systems, threatening service delivery, and thus requiring them to device ways replace diminishing donor support with domestic resources [21,22]. Third, consistent with previous findings [12,23], funds flow to public health facilities from prepaid sources (county and national government allocations, and NHIF disbursements), are characterized by delays in disbursements.…”

Examining Health Facility Financing in Kenya in the Context of Devolution

“…This is alarming as there is a plan for donors to progressively transition from supporting the Kenyan health sector generally, and primary healthcare facilities speci cally. Donor transition is expected to put additional scal pressure to LMIC health systems, threatening service delivery, and thus requiring them to device ways replace diminishing donor support with domestic resources (20,21).…”

Drivers of retention of the HIV workforce transitioned from PEPFAR support to the Uganda government payroll

“…A recent study found that between June 2015 and December 2017, of the PEPFAR-recruited HIV workforce, 694 were absorbed into mainstream GoU employment ( PEPFAR plans to transition all HWs it recruited under the intervention to the GoU payroll to support accelerated HIV service delivery across Uganda in line with UNAIDS's 95-95-95 targets [7]. However, there is little empirical understanding of the drivers of retention of HWs once they are absorbed into the Ugandan public service, given their prior private sector work experience.…”

“…Uganda is heavily dependent on global health initiatives (GHIs), notably President's Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund for AIDS, Tuberculosis, and Malaria (Global Fund) in its national HIV response [4]. Since 2004, PEPFAR has supported Uganda's national HIV response by rapidly expanding ART coverage and rolling out HIV prevention initiatives such as safe male circumcision (SMC) and pre-exposure prophylaxis (PrEP) [2]- [7].…”