Abstract
ABSTRACTBackground: In the context of declining international assistance for ART scale-up in Sub-Saharan Africa, the institutionalization of ART programs through integrating them in the organizational routines of health facilities is gaining importance as a program sustainability strategy.Objective: The aims of this study were; (i) to compare the level of institutionalization of ART programs in health facilities in Uganda and (ii) to explore reasons for variations in the degree of program institutionalization.Methods: In Phase One, we utilized Level of Institutionalization Scales developed by Goodman (1993) to measure the degree of institutionalization of ART interventions in 195 health facilities across Uganda. The 45-item questionnaire measured institutionalization based on four sub-systems (production, maintenance, supportive, managerial) theorized to make up an organization assessed against two levels of institutionalization; routines (lowest) niche saturation (highest). In Phase Two, four health facilities were purposively selected (2 with the highest and 2 with the lowest institutionalization scores) for a multiple case-study involving semi-structured interviews with ART clinic managers(n = 32), on-site observations and document review.Results: The two highest scoring health facilities had a longer HIV intervention implementation history of between 8 and 11 years. The highest scoring cases associated intervention institutionalization with sustained workforce trainings in ART management, the retention of ART-trained personnel and generating in-house ART manuals. The turnover of ART-proficient staff was identified as a barrier to intervention institutionalization in the lowest-ranked cases. Significant differences in organizational contexts were identified. The two highest-ranked health facilities were well-established, higher-tier hospitals while the lowest scoring health facilities were lower-level health facilities.Conclusions: The level of institutionalization of ART interventions appeared to be differentiated by level of care in the Ugandan health system. Interventions aimed at strengthening program institutionalization in lower-level health centers at the level of human resources for health could enhance ART scale-up sustainability.
Highlights
In the context of declining international assistance for anti-retroviral therapy (ART) scale-up in SubSaharan Africa, the institutionalization of ART programs through integrating them in the organizational routines of health facilities is gaining importance as a program sustainability strategy
Multiple on-site visits were spent engaging in informal discussions with clinicians and ART clinic managers, conducting formal, face-to-face interviews with multiple informants, filling out an on-site checklist based on observations and reading literature availed by health facilities relating to their ART programs such as annual reports and donor program evaluation reports
This study offers an in-depth, contextualized understanding of the factors impacting the institutionalization of externally supported ART programs at higher and lower levels of care of the Ugandan health system, the findings need to be interpreted within the context of the study’s limitations
Summary
In the context of declining international assistance for ART scale-up in SubSaharan Africa, the institutionalization of ART programs through integrating them in the organizational routines of health facilities is gaining importance as a program sustainability strategy. Objective: The aims of this study were; (i) to compare the level of institutionalization of ART programs in health facilities in Uganda and (ii) to explore reasons for variations in the degree of program institutionalization. Methods: In Phase One, we utilized Level of Institutionalization Scales developed by Goodman (1993) to measure the degree of institutionalization of ART interventions in 195 health facilities across Uganda. In Sub-Saharan Africa (SSA), the region with the highest HIV burden in the world [6], the accelerated expansion in ART coverage, has depended substantially on global health initiatives (GHIs) principally, The President’s Emergency Fund for AIDS Relief (PEPFAR) and The Global Fund [7]. In Uganda, an estimated 85% of the national HIV response is externally funded principally through PEPFAR and The Global Fund which have supported ART scale-up since June 2004 [9,10].
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