scholarly journals Dispensing antiretrovirals during Covid-19 lockdown: re-discovering community-based ART delivery models in Uganda

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Henry Zakumumpa ◽  
Christopher Tumwine ◽  
Kiconco Milliam ◽  
Neil Spicer
Keyword(s):  
Health System ◽  
National Level ◽  
Hiv Care ◽  
District Health ◽  
Community Based ◽  
Community Based Art ◽  
System Resilience ◽  
Delivery Models ◽  
Art Delivery

Abstract Background The notion of health-system resilience has received little empirical attention in the current literature on the Covid-19 response. We set out to explore health-system resilience at the sub-national level in Uganda with regard to strategies for dispensing antiretrovirals during Covid-19 lockdown. Methods We conducted a qualitative case-study of eight districts purposively selected from Eastern and Western Uganda. Between June and September 2020, we conducted qualitative interviews with district health team leaders (n = 9), ART clinic managers (n = 36), representatives of PEPFAR implementing organizations (n = 6).In addition, six focus group discussions were held with recipients of HIV care (48 participants). Qualitative data were analyzed using thematic approach. Results Five broad strategies for distributing antiretrovirals during ‘lockdown’ emerged in our analysis: accelerating home-based delivery of antiretrovirals,; extending multi-month dispensing from three to six months for stable patients; leveraging the Community Drug Distribution Points (CDDPs) model for ART refill pick-ups at outreach sites in the community; increasing reliance on health information systems, including geospatial technologies, to support ART refill distribution in unmapped rural settings. District health teams reported leveraging Covid-19 outbreak response funding to deliver ART refills to homesteads in rural communities. Conclusion While Covid-19 ‘lockdown’ restrictions undoubtedly impeded access to facility-based HIV services, they revived interest by providers and demand by patients for community-based ART delivery models in case-study districts in Uganda.

scholarly journals Dispensing Antiretrovirals During Covid-19 Lockdown: Pathways to Health System Resilience in Uganda

2021 ◽  
Author(s):  
Henry Zakumumpa ◽  
Christopher Tumwine ◽  
Kiconco Milliam ◽  
Neil Spicer
Keyword(s):  
Health System ◽  
National Level ◽  
Access To Health Services ◽  
District Health ◽  
Home Based ◽  
Related Notion ◽  
Rural Settings ◽  
System Resilience ◽  
The Impact

Abstract INTRODUCTIONAlthough there is an emerging evidence base on the impact of Covid-19 pandemic on access to health services in low-and middle-income countries, the related notion of health system resilience has received little empirical attention. The objective of this study was to explore health system resilience at the sub-national level in Uganda with regard to strategies for dispensing of antiretrovirals during Covid-19 lockdown restrictions.METHODSWe conducted a qualitative case-study of eight districts from Eastern Uganda (Mbale, Sironko, Manafwa, Bulambuli, Bududa) and Western Uganda (Kabarole, Kyegegwa, Kyenjonjo) purposively selected due to having a relatively high HIV burden. Between June and September 2020, we conducted key informant interviews with district health team leaders (n=9), with ART clinic managers (n=36), representatives of PEPFAR implementing organizations (n=6) and six focus group discussions with recipients of HIV/AIDS care (48 participants). Qualitative data were analyzed using thematic approach.RESULTSFive broad strategies for distributing antiretrovirals during ‘lockdown’ emerged in our analysis: accelerating home-based antiretroviral therapy (ART) deliveries,; extending multi-month dispensing from three to six months for stable patients; leveraging the Community Drug Distribution Points (CDDPs) model for ART refill pick-ups at outreach sites in the community; an increased reliance on health information systems, including geospatial technologies, to support ART refill distribution in unmapped rural settings. District health teams reported benefiting from the Covid-19 outbreak response funding to deliver ART refills to homesteads in rural communities.CONCLUSIONAlthough Covid-19 ‘lockdown’ undoubtedly impeded access to facility-based HIV services, it unraveled new possibilities and innovations in the distribution of antiretrovirals in the predominantly rural settings of our case-study districts. Further research is recommended to evaluate the potential of home-based deliveries as an alternative differentiated ART delivery model in Uganda and other countries with a high HIV burden.

scholarly journals A mixed-methods evaluation of the uptake of novel differentiated ART delivery models in a national sample of health facilities in Uganda

PLoS ONE ◽  
2021 ◽  
Vol 16 (7) ◽  
pp. e0254214
Author(s):  
Henry Zakumumpa ◽  
Kimani Makobu ◽  
Wilbrod Ntawiha ◽  
Everd Maniple
Keyword(s):  
Mixed Methods ◽  
Fast Track ◽  
Drug Distribution ◽  
Health Facilities ◽  
Hiv Care ◽  
Adult Males ◽  
Community Based ◽  
For Profit ◽  
Delivery Models ◽  
Art Delivery

Introduction Since 2017, Uganda has been implementing five differentiated antiretroviral therapy (ART) delivery models to improve the quality of HIV care and to achieve health-system efficiencies. Community-based models include Community Client-Led ART Delivery and Community Drug Distribution Points. Facility-based models include Fast Track Drug Refill, Facility Based Group and Facility Based Individual Management. We set out to assess the extent of uptake of these ART delivery models and to describe barriers to uptake of either facility-based or community-based models. Methods Between December 2019 and February 2020, we conducted a mixed-methods study entailing a cross-sectional health facility survey (n = 116) and in-depth interviews (n = 16) with ART clinic managers in ten case-study facilities as well as six focus group discussions (56 participants) with patients enrolled in differentiated ART models. Facilities were selected based on the 10 geographic sub-regions of Uganda. Statistical analyses were performed in STATA (v13) while qualitative data were analysed by thematic approach. Results Most facilities 63 (57%) commenced implementation of differentiated ART delivery in 2018. Fast Track Drug Delivery was the most common facility-based model (implemented in 100 or 86% of health facilities). Community Client-Led ART Delivery was the most popular community model (63/116 or 54%). Community Drug Distribution Points had the lowest uptake with only 33 (24.88%) facilities implementing them. By ownership-type, for-profit facilities reported the lowest uptake of differentiated ART models. Barriers to enrolment in community-based models include HIV-related stigma and low enrolment of adult males in community models. Conclusion To the best of our knowledge this is the first study reporting national coverage of differentiated ART delivery models in Uganda. Overall, there has been a higher uptake of facility-based models. Interventions for enhancing the uptake of differentiated ART models in for-profit facilities are recommended.

scholarly journals A mixed-methods evaluation of the uptake of novel differentiated ART delivery models in a national sample of health facilities in Uganda

2021 ◽  
Author(s):  
Henry Zakumumpa ◽  
Kimani Makobu ◽  
Ntawiha Wilbrod ◽  
Everd Maniple
Keyword(s):  
Mixed Methods ◽  
Health System ◽  
Fast Track ◽  
Health Workers ◽  
Drug Distribution ◽  
Health Facilities ◽  
Hiv Care ◽  
Adult Males ◽  
Community Based ◽  
Art Delivery

Abstract INTRODUCTIONSince 2017, Uganda has been implementing differentiated antiretroviral therapy services (DARTS) to improve the quality of HIV care and health-system efficiencies. The Ministry of Health endorsed five models. The community-based models include Community Client-Led Drug Delivery (CCLAD) and Community Drug Distribution Points (CDDPs), with facility-based models being either Fast Track Drug Refill (FTDR), Facility Based Group (FBG) or Facility-Based Individual Management (FBIM). It is unclear what the uptake of DARTS is since roll-out in 2017. We set out to assess the extent of uptake of DARTS models and to describe barriers to uptake of either facility-based or community-based models.METHODSBetween August and December 2019, we conducted a mixed-methods study entailing a cross-sectional health facility survey (n=116) and in-depth interviews (n=18) with ART clinic managers in ten case-study facilities as well as six focus group discussions (56 participants) with patients enrolled in DARTS models. Facilities were selected based on the 10 geographic sub-regions of Uganda. Statistical analyses were performed in STATA (v13) while qualitative data were analyzed by thematic approach. The qualitative arm of our study was dominant.RESULTSMost facilities 63 (57%) commenced implementation of DARTS in 2018. The most implemented facility-based model was Fast Track Drug Refill (FTDR) implemented in 100 (86%) of health facilities. Community Client-Led ART Delivery (CCLAD) was the most popular community model implemented in more than a half of facilities (63/116 or 54%). Community Drug Distribution Points (CDDP) model had the lowest uptake and was implemented in only 33 (24.88%) facilities. Overall, there has been a higher uptake of facility-based models. Barriers to enrollment in community-based models include; HIV-related stigma and a fear of breach of confidentiality of HIV status, low enrollment of adult males in community models. Health-system constraints include insufficient training of health workers in DARTS and inadequate funding to facilities for implementing community-based models.CONCLUSIONTo the best of our knowledge this is the first study reporting national DARTS coverage in Uganda. There is need to devise stigma-reduction interventions to enhance uptake of community models and increased donor and government funding for community models to maximize DARTS potential for achieving health-system efficiencies.

scholarly journals Market-Based Conservation for Better Livelihoods? The Promises and Fallacies of REDD+ in Tanzania

Land ◽  
2018 ◽  
Vol 7 (4) ◽  
pp. 119 ◽  
Author(s):  
Andreas Scheba
Keyword(s):  
Sustainable Development ◽  
Nature Conservation ◽  
Ecosystem Services ◽  
Forest Management ◽  
National Level ◽  
Policy Reforms ◽  
Community Based ◽  
Alternative Livelihood ◽  
Governance Institutions

Governments, multilateral organisations, and international conservation NGOs increasingly frame nature conservation in terms that emphasise the importance of technically managing and economically valuing nature, and introducing markets for ecosystem services. New mechanisms, such as REDD+, have been incorporated in national-level policy reforms, and have been piloted and implemented in rural project settings across the Global South. By reflecting on my research on REDD+ implementation in two case study villages in Tanzania, the paper argues that the emergence and nature of market-based conservation are multi-faceted, complex, and more profoundly shaped by structural challenges than is commonly acknowledged. The paper identifies three particularly important challenges: the politics surrounding the establishment of community-based forest management; the mismatch between formal governance institutions and actual practices on the ground; and the fickleness of income from carbon sales and alternative livelihood opportunities. I argue that these challenges are not merely teething troubles, but they question fundamental assumptions of market-based conservation, more generally. I end with reference to better ideas for achieving sustainable development.

scholarly journals How might improved estimates of HIV programme outcomes influence practice? A formative study of evidence, dissemination and response

2020 ◽  
Vol 18 (1) ◽  
Author(s):  
Njekwa Mukamba ◽  
Laura K. Beres ◽  
Chanda Mwamba ◽  
Jeanna Wallenta Law ◽  
Stephanie M. Topp ◽  
...  
Keyword(s):  
Health System ◽  
Data Management ◽  
Patient Outcomes ◽  
National Level ◽  
Routine Data ◽  
Decision Makers ◽  
Hiv Care ◽  
Research Translation ◽  
Term Survival ◽  
Health Decision

Abstract Background While HIV programmes have started millions of persons on life-saving antiretroviral therapy in Africa, longitudinal health information systems are frail and, therefore, data about long-term survival is often inaccurate or unknown to HIV programmes. The ‘Better Information for Health in Zambia’ (BetterInfo) Study – a regional sampling-based survey to assess retention and mortality in HIV programmes in Zambia – found both retention and mortality to be higher than prevailing estimates from national surveillance systems. We sought to understand how Zambian health decision-makers at different health system levels would respond to these new data, with a view to informing research translation. Methods We interviewed 25 purposefully sampled health decision-makers from community, facility, district, provincial and national levels. During the interviews, we shared retention and mortality estimates from both routine programme surveillance and those generated by the study. Transcripts were analysed for inductive and deductive themes, the latter drawing on Weiss’s framework that policy-makers interpret and apply evidence as ‘warning’, ‘guidance’, ‘reconceptualisation’ or ‘mobilisation of support’. Findings All decision-makers found study findings relevant and important. Decision-makers viewed the underestimates of mortality to be a warning about the veracity and informativeness of routine data systems. Decision-makers felt guided by the findings to improve data monitoring and, acknowledging limitations of routine data, utilised episodic patient tracing to support improved data accuracy. Findings catalysed renewed motivation and mobilisation by national level decision-makers for differentiated models of HIV care to improve patient outcomes and also improved data management systems to better capture patient outcomes. Inductive analysis highlighted a programmatic application data interpretation, in which study findings can influence facility and patient-level decision-making, quality of care and routine data management. Conclusions New epidemiological data on patient outcomes were widely seen as informative and relevant and can potentially catalyse health system action such as using evaluations to supplement electronic medical record data to improve HIV programmes. Formative evidence suggests that targeting research dissemination at different levels of the health system will elicit different responses. Researchers supporting the translation of evidence to action should leverage all relevant levels of the health system to facilitate both policy and programmatic action.

The challenges of budgeting in a newly introduced district health system: A case study

2009 ◽  
Vol 5 (1) ◽  
pp. 87-101 ◽  
Author(s):  
G.A. Nnaji ◽  
C. Oguoma ◽  
L.I. Nnaji ◽  
E. Nwobodo
Keyword(s):  
Health System ◽  
District Health ◽  
District Health System ◽  
System A

scholarly journals ART initiations following community-based distribution of HIV self-tests: meta-analysis and meta-regression of STAR Initiative data

2021 ◽  
Vol 6 (Suppl 4) ◽  
pp. e004986
Author(s):  
Melissa Neuman ◽  
Katherine L Fielding ◽  
Helen Ayles ◽  
Frances M Cowan ◽  
Bernadette Hensen ◽  
...  
Keyword(s):  
Meta Analysis ◽  
National Level ◽  
Population Level ◽  
Hiv Care ◽  
People Living With Hiv ◽  
Community Based ◽  
Variable Effect ◽  
Standard Testing ◽  
Meta Regression ◽  
The Impact

IntroductionMeasuring linkage after community-based testing, particularly HIV self-testing (HIVST), is challenging. Here, we use data from studies of community-based HIVST distribution, conducted within the STAR Initiative, to assess initiation of antiretroviral therapy (ART) and factors driving differences in linkage rates.MethodsFive STAR studies evaluated HIVST implementation in Malawi, Zambia and Zimbabwe. New ART initiations during the months of intervention at clinics in HIVST and comparison areas were presented graphically, and study effects combined using meta-analysis. Meta-regression was used to estimate associations between the impact of community-based HIVST distribution and indicators of implementation context, intensity and reach. Effect size estimates used (1) prespecified trial definitions of ART timing and comparator facilities and (2) exploratory definitions accounting for unexpected diffusion of HIVST into comparison areas and periods with less distribution of HIVST than was expected.ResultsCompared with arms with standard testing only, ART initiations were higher in clinics in HIVST distribution areas in 4/5 studies. The prespecified meta-analysis found positive but variable effects of HIVST on facility ART initiations (RR: 1.14, 95% CI 0.93 to 1.40; p=0.21). The exploratory meta-analysis found a stronger impact of HIVST distribution on ART initiations (RR: 1.29, 95% CI 1.08 to 1.55, p=0.02).ART initiations were higher in studies with greater self-reported population-level intensity of HIVST use (RR: 1.12; 95% CI 1.04 to 1.21; p=0.02.), but did not differ by national-level indicators of ART use among people living with HIV, number of HIVST kits distributed per 1000 population, or self-reported knowledge of how to link to care after a reactive HIVST.ConclusionCommunity-based HIVST distribution has variable effect on ART initiations compared with standard testing service alone. Optimising both support for and approach to measurement of effective and timely linkage or relinkage to HIV care and prevention following HIVST is needed to maximise impact and guide implementation strategies.

scholarly journals Adapting a community-based ART delivery model to the patients’ needs: a mixed methods research in Tete, Mozambique

2014 ◽  
Vol 14 (1) ◽  
Author(s):  
Freya Rasschaert ◽  
Tom Decroo ◽  
Daniel Remartinez ◽  
Barbara Telfer ◽  
Faustino Lessitala ◽  
...  
Keyword(s):  
Mixed Methods ◽  
Mixed Methods Research ◽  
Community Based ◽  
Delivery Model ◽  
Community Based Art ◽  
Art Delivery

scholarly journals Stakeholders’ perspectives on training over the counter medicine sellers and Community-based Health Planning and Services facilities to dispense antibiotics in Ghana

2021 ◽  
Vol 14 (1) ◽  
Author(s):  
Samuel Afari-Asiedu ◽  
Marlies Hulscher ◽  
Martha Ali Abdulai ◽  
Ellen Boamah-Kaali ◽  
Heiman F. L. Wertheim ◽  
...  
Keyword(s):  
Health Services ◽  
Health Planning ◽  
National Level ◽  
Public Health Education ◽  
Antibiotic Use ◽  
District Health ◽  
Community Based ◽  
Over The Counter ◽  
Middle Income ◽  
Pharmacy Council

Abstract Background Dispensing of antibiotics by over the counter medicine sellers (OTCMS) is a major driver of inappropriate use and resistance in low and middle income countries. Recent studies in Ghana revealed the need to consider training OTCMS and Community-based Health Planning and Services (CHPS)/health posts to dispense some antibiotics. Feasibility of training OTCMS and CHPS to dispense some antibiotics was explored in this study. Methods This was an explorative study involving 10 in-depth interviews (IDIs) among staff of Ghana health services (GHS), pharmacy council and the association of OTCMS at the district and regional levels. Next, findings were presented to the Ghana Antimicrobial Resistance (AMR) platform for further discussions at the national level. Five IDIs were also performed among selected members of the AMR platform as a follow-up on emerging issues. Data were thematically analysed and presented as narratives with quotes to support the findings. Results Two opposing views were found in our study. Leadership of OTCMS and GHS staff at the district health directorate supported the suggestion that OTCMS and CHPS should be trained to dispense specific antibiotics because they are already dispensing them. The leadership of OTCMS explained that some of their members are experienced and could be trained to improve their practices. In contrast, participants from pharmacy council, GHS in the region and national AMR platform generally alluded that OTCMS and CHPS should not be trained to dispense antibiotics because their level of education is inadequate. GHS personnel from the region further explained that training OTCMS could further compromise inappropriate antibiotic use in the context of already weak regulation enforcement. GHS and pharmacy council in the region rather suggested that OTCMS and CHPS should focus on public health education on disease prevention and appropriate antibiotic use. Conclusions There is general lack of consensus among stakeholders on whether OTCMS and CHPS should be trained to dispense specific antibiotics. Further stakeholder engagement is required to carefully consider this suggestion as views on feasibility differ. Ministries of health and healthcare agencies in Ghana and LMIC should improve access to approved health services to improve antibiotic use in rural settings.

scholarly journals Exploring drivers and barriers to the utilization of community client-led ART delivery model in South-Western Uganda: patients’ and health workers’ experiences

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Timothy Mwanje Kintu ◽  
Anna Maria Ssewanyana ◽  
Tonny Kyagambiddwa ◽  
Pretty Mariam Nampijja ◽  
Patience Kevin Apio ◽  
...  
Keyword(s):  
Service Delivery ◽  
Health System ◽  
Health Workers ◽  
Full Range ◽  
Health Centre ◽  
Hiv Care ◽  
Differentiated Service ◽  
Western Uganda ◽  
Depth Interviews ◽  
Art Delivery

Abstract Background In an effort to accommodate the growing number of HIV clients, improve retention in care and reduce health care burden, the differentiated service delivery (DSD) models were introduced in 2014. One such model, Community Client-Led ART Delivery (CCLAD) was rolled out in Uganda in 2017. The extent of utilization of this model has not been fully studied. The aim of the study was to explore the patients’ and health workers’ experiences on the utilization of CCLAD model at Bwizibwera Health Centre IV, south western Uganda. Methods This was a descriptive study employing qualitative methods. The study had 68 purposively selected participants who participated in 10 focus group discussions with HIV clients enrolled in CCLAD; 10 in-depth interviews with HIV clients not enrolled in CCLAD and 6 in-depth interviews with the health workers. Key informant interviews were held with the 2 focal persons for DSD. The discussions and interviews were audio recorded, transcribed verbatim and then translated. Both deductive and inductive approaches were employed to analyse the data using in NVivo software. Results Patients’ and health workers’ experiences in this study were categorized as drivers and barriers to the utilization of the CCLAD model. The main drivers for utilization of this model at different levels were: individual (reduced costs, living positively with HIV, improved patient self-management), community (peer support and contextual factors) and health system (reduced patient congestion at the health centre, caring health workers as well as CCLAD sensitization by health workers). However, significant barriers to the utilization of this community-based model were: individual (personal values and preferences, lack of commitment of CCLAD group members), community (stigma, gender bias) and health system (frequent drug stockouts, certain implementation challenges, fluctuating implementing partner priorities, shortage of trained health workers and insufficient health education by health workers). Conclusion Based on our findings the CCLAD model is meeting the objectives set out by Differentiated Service Delivery for HIV care and treatment. Notwithstanding the benefits, challenges remain which call on the Ministry of Health and other implementing partners to address these hindrances to facilitate the scalability, sustainability and the realisation of the full-range of benefits that the model presents.

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