Africa: Why Small Health Facilities Matter in Getting Treatment to HIV Patients
Mid-last month, I was invited by the Global Fund Country Coordinating Mechanism in Uganda to make a presentation on our three-year research examining the sustainability of HIV treatment programmes in health facilities in Uganda.
Immediately after my presentation, I was inundated with calls to disseminate the study findings to a broader audience. And here is why.
Over the past three years, there have been ‘game changers’ on the global scene regarding HIV treatment eligibility. In 2014, UNAIDS unveiled the ambitious 90-90-90 targets apart of which aim at enrolling 90 per cent of those with HIV on sustained antiretroviral treatment(ART) by 2020. In November 2015, The World Health Organization (WHO) announced new treatment guidelines recommending that all diagnosed with HIV be enrolled on ART regardless of disease stage.
Even prior to this ‘test and treat’ policy, Uganda had already dramatically increased ART coverage through expanding the network of facilities providing HIV treatment beyond large government hospitals with PEPFAR and Global Fund support. This expanded service delivery programme was also implemented in private-for-profit facilities. Our study findings drawn from a nationally-representative sample of 195 health facilities across Uganda which participated in the first phase of ART roll-out demonstrate that lower-level health facilities and small private clinics are relatively constrained in sustaining HIV treatment services. We found several smaller health facilities which have since discontinued HIV treatment services despite the availability of free antiretrovirals (ARVs), medical equipment support and health worker training.
We found that the current HIV treatment funding architecture in Uganda favors larger, well-established hospitals. Our findings published in BMC Health Services Research show that large hospitals have been able to attract multiple donor grants for HIV treatment while several smaller health facilities are hard-pressed to maintain even a single funder given the associated performance requirements.
Specifically, we found that smaller, rural and especially for-profit health facilities were constrained in sustaining HIV treatment services. The barriers identified were numerous but the major ones included shortage and attrition of ART-proficient personnel, inability to keep up with ART programme reporting mandates by funders and irregular and insufficient supply of ARVs.Our findings suggest that the organisational goals of for-profit facilities are not well-aligned with the public health goal of mass access to HIV treatment. We found evidence in some for-profit providers where donor-supported HIV treatment services attracted long patient queues and a broader socio-economic class of patients which was at odds with the goal of catering to high-end patients who sought privacy. A number of providers discontinued services based on this mismatch alone.
Demand factors were also at play. Patients often bypassed nearer smaller health facilities and sought care in larger hospitals because they had a broader ‘menu’ of HIV services, more staff and therefore shorter waiting times and less frequent ARV stock-outs. These findings suggest that unless interventions are devised, smaller, rural and for-profit providers are bound to fail and hence HIV treatment coverage is bound not to expand beyond well-established hospitals. This defeats the very essence of HIV treatment scale-up of increasing service delivery platforms including in small for-profit health facilities which constitute half of all health facilities in Uganda.
So, how do we grow smaller health facilities to ensure they ‘take-off’ and thrive?
Mentoring programmes involving the twinning of large hospitals and smaller health facilities could be helpful. Service purchase agreement between government and for-profit providers are worthy of consideration. Salary support to select for-profit facilities with large patient volumes or in hard-to-reach areas are worth a thought.
Our study reveals high levels of dependence on external donors for HIV services delivery in Uganda. An increased role of the Uganda government in this regard is warranted. Expanding the fiscal space for HIV treatment is critical as dependence on the current major donors is clearly unsustainable.
Henry Zakumumpa is a CARTA Cohort 4 PhD Fellow, Makerere University, School of Public Health.