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

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.

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

PLoS ONE ◽

10.1371/journal.pone.0254214 ◽

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.

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

BMC Health Services Research ◽

10.1186/s12913-021-07105-9 ◽

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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Patient and Health worker experiences on Utilization of Community Client Led ART Delivery Model in South-Western Uganda: A Qualitative Study

10.21203/rs.3.rs-621867/v1 ◽

2021 ◽

Author(s):

Timothy Mwanje Kintu ◽

Anna Maria Ssewanyana ◽

Tonny Kyagambiddwa ◽

Pretty Mariam Nampijja ◽

Patience Kevin Apio ◽

...

Keyword(s):

Service Delivery ◽

Health System ◽

Health Worker ◽

Health Workers ◽

Full Range ◽

Health Centre ◽

Retention In Care ◽

Hiv Care ◽

Differentiated Service ◽

Art Delivery

Abstract BackgroundIn an effort to accommodate the growing number of stable 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 patient and health worker experiences on the utilization of CCLAD model at Bwizibwera Health Centre IV, south western Uganda.MethodsThis 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 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. ResultsPatient and health worker 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).ConclusionBased 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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Dispensing antiretrovirals during Covid-19 lockdown: re-discovering community-based ART delivery models in Uganda

BMC Health Services Research ◽

10.1186/s12913-021-06607-w ◽

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.

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Effects of transition on HIV and non-HIV services and health systems in Kenya: a mixed methods evaluation of donor transition

BMC Health Services Research ◽

10.1186/s12913-021-06451-y ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Daniela C. Rodríguez ◽

Diwakar Mohan ◽

Caroline Mackenzie ◽

Jess Wilhelm ◽

Ezinne Eze-Ajoku ◽

...

Keyword(s):

Mixed Methods ◽

Service Delivery ◽

Health Systems ◽

Local Level ◽

Health Facilities ◽

Government Support ◽

Hiv Care ◽

Local Context ◽

Mixed Methods Evaluation ◽

The Us

Abstract Background In 2015 the US President’s Emergency Plan for AIDS Relief (PEPFAR) initiated its Geographic Prioritization (GP) process whereby it prioritized high burden areas within countries, with the goal of more rapidly achieving the UNAIDS 90–90-90 targets. In Kenya, PEPFAR designated over 400 health facilities in Northeastern Kenya to be transitioned to government support (known as central support (CS)). Methods We conducted a mixed methods evaluation exploring the effect of GP on health systems, and HIV and non-HIV service delivery in CS facilities. Quantitative data from a facility survey and health service delivery data were gathered and combined with data from two rounds of interviews and focus group discussions (FGDs) conducted at national and sub-national level to document the design and implementation of GP. The survey included 230 health facilities across 10 counties, and 59 interviews and 22 FGDs were conducted with government officials, health facility providers, patients, and civil society. Results We found that PEPFAR moved quickly from announcing the GP to implementation. Despite extensive conversations between the US government and the Government of Kenya, there was little consultation with sub-national actors even though the country had recently undergone a major devolution process. Survey and qualitative data identified a number of effects from GP, including discontinuation of certain services, declines in quality and access to HIV care, loss of training and financial incentives for health workers, and disruption of laboratory testing. Despite these reports, service coverage had not been greatly affected; however, clinician strikes in the post-transition period were potential confounders. Conclusions This study found similar effects to earlier research on transition and provides additional insights about internal country transitions, particularly in decentralized contexts. Aside from a need for longer planning periods and better communication and coordination, we raise concerns about transitions driven by epidemiological criteria without adaptation to the local context and their implication for priority-setting and HIV investments at the local level.

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‘Oh, she is just a nurse’ Re-imagining the role of the nursing workforce in Uganda after a decade of ART scale-up (2004-2014)

10.21203/rs.3.rs-15525/v1 ◽

2020 ◽

Author(s):

Henry Zakumumpa

Keyword(s):

Mixed Methods ◽

Disease Management ◽

Scale Up ◽

Task Shifting ◽

Health Facilities ◽

Hiv Care ◽

Scope Of Practice ◽

Nursing Workforce ◽

Hiv Disease

Abstract Background The expanding roles and increasing importance of the nursing workforce in health services delivery in resource-limited settings is not adequately documented and sufficiently recognized in the current literature. Drawing upon the theme of 2020 as the international year of the nurse and midwife, we set out to describe how the role of nurses had expanded tremendously in health facilities in Uganda during the era of anti-retroviral therapy (ART) scale-up between 2004 and 2014.Methods A mixed-methods study was conducted in two phases. Phase One entailed a cross-sectional health facility survey (n=195) to assess the extent to which human resource management strategies (such as task shifting) were common. Phase Two entailed qualitative case-studies of 16 (of the 195) health facilities for an in-depth understanding of the strategies adopted (e.g. nurse-centred HIV care). We adopted a qualitatively-led mixed methods approach whereby core thematic analyses were supported by descriptive statistics.Results We found that nurses were the most represented cadre of health workers involved in the overall leadership of HIV clinics across Uganda. Most of nurse-led HIV clinics were based in rural settings although this trend was fairly even across all settings (rural/urban/peri-urban). A number of health facilities in our sample (n=36) deliberately adopted nurse-led HIV care models. Nurses were empowered to be multi-skilled with a wide range of competencies across the HIV care continuum right from HIV testing to mainstream clinical HIV disease management. In several facilities, nursing cadre were the backbone of ART service delivery. A select number of facilities devised differentiated models of task shifting from physicians to doctors to nurses in which the latter handled patients who were stable on ART.Conclusion Overall, our study reveals a wide expansion in the scope-of-practice of nurses during the initial ART scale-up phase in Uganda. Nurses were thrust in roles of HIV disease management that were traditionally the preserve of medical doctors. Our study underscores the importance of reforming regulatory frameworks governing nursing workforce scope of practice in Uganda such as the need for evolving a policy on task shifting which is currently lacking in Uganda.

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A sustainable community based model of non-communicable disease risk factor surveillance: “SHRADDHA-JAGRITHI project” (Preprint)

10.2196/preprints.27299 ◽

2021 ◽

Author(s):

Jaideep Menon ◽

Mathews Numpeli ◽

Sajeev.P. Kunjan ◽

Beena.V. Karimbuvayilil ◽

Aswathy Sreedevi ◽

...

Keyword(s):

Public Health ◽

Health System ◽

Public Health System ◽

Health Workers ◽

Communicable Disease ◽

Community Based ◽

Frontline Health Workers ◽

The Individual ◽

Non Communicable Disease

UNSTRUCTURED Abstract: India has a massive non-communicable disease (NCD) burden at an enormous cost to the individual, family, society and health system at large, in spite of which prevention and surveillance is relatively neglected. Risk factors for atherosclerotic cardiovascular disease if diagnosed early and treated adequately would help decrease the mortality and morbidity burden. India is in a stage of rapid epidemiological transition with the state of Kerala being at the forefront, pointing us towards likely disease burden and outcomes for the rest of the country, in the future. A previous study done by the same investigators, in a population of >100,000, revealed poor awareness and treatment of NCDs and also poor adherence to medicines in individuals with CVD. The investigators are looking at a sustainable, community based model of surveillance for NCDs with corporate support wherein frontline health workers check all individuals in the target group ( > age 30 years) with further follow up and treatment planned in a “spoke and hub” model using the public health system of primary health centres (PHCs) as spokes to the hubs of Taluk or District hospitals. All data entry done by frontline health workers would be on a Tab PC ensuring rapid acquisition and transfer of participant health details to PHCs for further follow up and treatment. The model will be evaluated based on the utilisation rate of various services offered at all tier levels. The proportions of the target population screened, eligible individuals who reached the spoke or hub centres for risk stratification and care and community level control for hypertension and diabetes in annual surveys will be used as indicator variables. The model ensures diagnosis and follow up treatment at no cost to the individual entirely through the tiered public health system of the state and country.

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Barriers and facilitators associated with HIV testing uptake in South African health facilities offering HIV Counselling and Testing

Health SA Gesondheid ◽

10.4102/hsag.v21i0.938 ◽

2016 ◽

Vol 21 ◽

pp. 86-95 ◽

Cited By ~ 6

Author(s):

Neo Mohlabane ◽

Bomkazi Tutshana ◽

Karl Peltzer ◽

Aziza Mwisongo

Keyword(s):

Hiv Testing ◽

South African ◽

Health Workers ◽

Scale Up ◽

Health Facilities ◽

Barriers And Facilitators ◽

Hiv Care ◽

Treatment Needs ◽

Hiv Test ◽

Hiv Counselling And Testing

Background: The scale-up of HIV Counselling and Testing (HCT) in South Africa to 4500 public health facilities and the service's provision in mobile and non-medical sites was aimed at increasing HCT uptake. However, some people still have never had an HIV test.Objective: An HCT survey was carried out to ascertain barriers and facilitators for HIV testing in South Africa.Methods: A cross-sectional survey of 67 HCT-offering health facilities in 8 South African provinces was undertaken. Individuals (n = 489) who had not tested for HIV on the day of the site visit were interviewed on awareness of HCT services, HIV testing history and barriers to HIV testing. Frequencies were run to describe the sample characteristics, barriers and facilitators to HIV testing. Bivariate and multivariate logistic regression was usedt o identify the association between never tested for HIV with socio-demographics, awareness of HCT services and type of HCT facilities.Results: In all 18.1% participants never had an HIV test. Major barriers to HCT uptake comprise being scared of finding out one's HIV test result or what people may say, shyness or embarrassment, avoidance of divulging personal information to health workers and fear of death. In multivariate analysis the age group 55 years and older, and not being recommended to have an HIV test were associated with never had an HIV test. Potential facilitators for HIV testing include community or household HIV testing, providing incentives for those who test for HIV, mandatory HIV testing and disclosure of HIV status by those who test HIV positive.Conclusion: The benefits of HCT which include the reduction of HIV transmission, the availability of HIV care and treatment needs to be emphasized to enhance HCT uptake.

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Health system readiness for innovation scale-up: the experience of community-based distribution of injectable contraceptives in Nigeria

BMC Health Services Research ◽

10.1186/s12913-019-4786-6 ◽

2019 ◽

Vol 19 (1) ◽

Cited By ~ 1

Author(s):

Oluwaseun Akinyemi ◽

Bronwyn Harris ◽

Mary Kawonga

Keyword(s):

Health System ◽

Community Health ◽

Health Workers ◽

Scale Up ◽

Task Shifting ◽

Policy Framework ◽

Framework Analysis ◽

Community Based ◽

System Readiness ◽

Injectable Contraceptives

Abstract Background Following the successful pilot of the community-based distribution of injectable contraceptives (CBDIC) by community health extension workers (CHEWs) in Gombe, northern Nigeria in 2010, there was a policy decision to scale-up the innovation to other parts of the country. However, there is limited understanding of health system factors that may facilitate or impede the successful scale-up of this innovation beyond the pilot site. Thus, this study assessed the health system readiness to deliver CBDIC in Nigeria and how this may influence the scale-up process. Methods This study was conducted in two Local Government Areas in Gombe State in September 2016. Seven key informant interviews were held with purposively sampled senior officials of the ministries of health at the federal and state levels as well as NGO program managers. Also, 10 in-depth interviews were carried out with health workers. All transcripts were analyzed using the thematic framework analysis approach. Result The availability of a policy framework that supports task-shifting and task-sharing, as well as application of evidence from the pilot programme and capacity building programmes for health workers provided a favourable environment for scale-up. Health system challenges for the scale-up process included insufficient community health workers, resistance to the task-shifting policy from professional health groups (who should support the CHEWs), limited funding and poor logistics management which affected commodity distribution and availability. However, there were also a number of health worker innovations which kept the scale-up going. Health workers sometimes used personal resources to make up for logistics failures and poor funding. They often modify the process in order to adapt to the realities on the ground. Conclusion This study shows health system weaknesses that may undermine scale-up of CBDIC. The study also highlights what happens when scale-up is narrowly focused on the intervention without considering system context, capacity and readiness. However, agency and discretionary decision-making among frontline health workers facilitated the process of scaling up, although the sustainability of this is questionable. Benefits observed during the pilot may not be realised on a larger scale if health system challenges are not addressed.

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RE-ASSESSING COMMUNITY-DIRECTED TREATMENT: EVIDENCE FROM MAZABUKA DISTRICT, ZAMBIA

Journal of Biosocial Science ◽

10.1017/s0021932014000170 ◽

2014 ◽

Vol 47 (1) ◽

pp. 28-44 ◽

Cited By ~ 3

Author(s):

H. HALWINDI ◽

P. MAGNUSSEN ◽

S. SIZIYA ◽

D. W. MEYROWITSCH ◽

A. OLSEN

Keyword(s):

Health Workers ◽

Health Centre ◽

Drug Distribution ◽

Implementation Process ◽

Community Members ◽

Community Based ◽

Cross Sectional ◽

Child Treatment ◽

Helminth Infections ◽

Significant Health

SummaryCross-sectional surveys with carers, health workers, community drug distributors (CDDs) and neighbourhood health committees were conducted to identify factors associated with utilization of community-directed treatment (ComDT) of soil-transmitted helminths in children aged 12–59 months in Mazabuka district, Zambia. The surveys took place in December 2006 and December 2007. In addition child treatment records were reviewed. The factors that were found to be significantly associated (p<0.05) with treatment of children by the CDDs were: (1) the perception of soil-transmitted helminth infections as having significant health importance, (2) the community-based decision to launch and subsequently implement ComDT, (3) the use of the door-to-door method of drug distribution, (4) CDDs being visited by a supervisor, (5) CDDs receiving assistance in mobilizing community members for treatment, (6) CDDs having access to a bicycle and (7) CDDs having received assistance in collecting drugs from the health centre. Despite the effectiveness of ComDT in raising treatment coverage there are factors in the implementation process that will still affect whether children and their carers utilize the ComDT approach. Identification and understanding of these factors is paramount to achieving the desired levels of utilization of such interventions.

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