TY - JOUR
T1 - Accounting for variations in ART program sustainability outcomes in health facilities in Uganda
T2 - A comparative case study analysis
AU - Zakumumpa, Henry
AU - Bennett, Sara
AU - Ssengooba, Freddie
N1 - Funding Information:
The nature of donor support to enable health facilities to commence ART delivery involved supply of free anti-retroviral (ARV) drugs, provision of diagnostic equipment such as CD4 machines, laboratory capacity support and ART standard-of-care training. In Uganda, donors finance over 80 percent of ART program costs [10]. This support was provided to health facilities under time-limited project grants. In the case of PEPFAR, the predominant donor, support was channeled through larger intermediary organizations known as ‘implementing partners’ on 5-year grant cycles [11]. Increasingly, the primary funders of HIV/AIDS services in Uganda are seeking to ensure the efficiency, sustainability and country of ownership of ART programs [4–7]. This brings the question of the sustainability of ART in countries like Uganda to the top of the policy agenda.
Funding Information:
This research was supported by the Consortium for Advanced Research Training in Africa (CARTA). CARTA is jointly led by the African Population and Health Research Center and the University of the Witwatersrand and funded by the Wellcome Trust (UK)(Grant No: 087547/Z/08/Z), the Department for International Development (DfID) under the Development Partnerships in Higher Education (DelPHE), the Carnegie Corporation of New York (Grant No: B 8606), the Ford Foundation (Grant No: 1100-0399),Google.Org (Grant No: 191994), Sida (Grant No: 54100029) and MacArthur Foundation Grant No: 10-95915-000-INP. The funders did not in any way contribute to the design of the study and collection, analysis, and interpretation of data.
Publisher Copyright:
© 2016 The Author(s).
PY - 2016/10/18
Y1 - 2016/10/18
N2 - Background: Uganda implemented a national ART scale-up program at public and private health facilities between 2004 and 2009. Little is known about how and why some health facilities have sustained ART programs and why others have not sustained these interventions. The objective of the study was to identify facilitators and barriers to the long-term sustainability of ART programs at six health facilities in Uganda which received donor support to commence ART between 2004 and 2009. Methods: A case-study approach was adopted. Six health facilities were purposively selected for in-depth study from a national sample of 195 health facilities across Uganda which participated in an earlier study phase. The six health facilities were placed in three categories of sustainability; High Sustainers (2), Low Sustainers (2) and Non- Sustainers (2). Semi-structured interviews with ART Clinic managers (N = 18) were conducted. Questionnaire data were analyzed (N = 12). Document review augmented respondent data. Based on the data generated, across-case comparative analyses were performed. Data were collected between February and June 2015. Results: Several distinguishing features were found between High Sustainers, and Low and Non-Sustainers' ART program characteristics. High Sustainers had larger ART programs with higher staffing and patient volumes, a broader 'menu' of ART services and more stable program leadership compared to the other cases. High Sustainers associated sustained ART programs with multiple funding streams, robust ART program evaluation systems and having internal and external program champions. Low and Non Sustainers reported similar barriers of shortage and attrition of ART-proficient staff, low capacity for ART program reporting, irregular and insufficient supply of ARV drugs and a lack of alignment between ART scale-up and their for-profit orientation in three of the cases. Conclusions: We found that ART program sustainability was embedded in a complex system involving dynamic interactions between internal (program champion, staffing strength, M &E systems, goal clarity) and external drivers (donors, ARVs supply chain, patient demand). ART program sustainability contexts were distinguished by the size of health facility and ownership-type. The study's implications for health systems strengthening in resource-limited countries are discussed.
AB - Background: Uganda implemented a national ART scale-up program at public and private health facilities between 2004 and 2009. Little is known about how and why some health facilities have sustained ART programs and why others have not sustained these interventions. The objective of the study was to identify facilitators and barriers to the long-term sustainability of ART programs at six health facilities in Uganda which received donor support to commence ART between 2004 and 2009. Methods: A case-study approach was adopted. Six health facilities were purposively selected for in-depth study from a national sample of 195 health facilities across Uganda which participated in an earlier study phase. The six health facilities were placed in three categories of sustainability; High Sustainers (2), Low Sustainers (2) and Non- Sustainers (2). Semi-structured interviews with ART Clinic managers (N = 18) were conducted. Questionnaire data were analyzed (N = 12). Document review augmented respondent data. Based on the data generated, across-case comparative analyses were performed. Data were collected between February and June 2015. Results: Several distinguishing features were found between High Sustainers, and Low and Non-Sustainers' ART program characteristics. High Sustainers had larger ART programs with higher staffing and patient volumes, a broader 'menu' of ART services and more stable program leadership compared to the other cases. High Sustainers associated sustained ART programs with multiple funding streams, robust ART program evaluation systems and having internal and external program champions. Low and Non Sustainers reported similar barriers of shortage and attrition of ART-proficient staff, low capacity for ART program reporting, irregular and insufficient supply of ARV drugs and a lack of alignment between ART scale-up and their for-profit orientation in three of the cases. Conclusions: We found that ART program sustainability was embedded in a complex system involving dynamic interactions between internal (program champion, staffing strength, M &E systems, goal clarity) and external drivers (donors, ARVs supply chain, patient demand). ART program sustainability contexts were distinguished by the size of health facility and ownership-type. The study's implications for health systems strengthening in resource-limited countries are discussed.
KW - ART scale-up
KW - Case-study
KW - HIV treatment
KW - Health systems
KW - Implementation
KW - Sustainability
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U2 - 10.1186/s12913-016-1833-4
DO - 10.1186/s12913-016-1833-4
M3 - Article
C2 - 27756359
AN - SCOPUS:84992187777
SN - 1472-6963
VL - 16
JO - BMC health services research
JF - BMC health services research
IS - 1
M1 - 584
ER -