Abstract

BackgroundIn 2011, a decision was made to scale up a pilot innovation involving ‘adherence clubs’ as a form of differentiated care for HIV positive people in the public sector antiretroviral therapy programme in the Western Cape Province of South Africa. In 2016 we were involved in the qualitative aspect of an evaluation of the adherence club model, the overall objective of which was to assess the health outcomes for patients accessing clubs through epidemiological analysis, and to conduct a health systems analysis to evaluate how the model of care performed at scale. In this paper we adopt a complex adaptive systems lens to analyse planned organisational change through intervention in a state health system. We explore the challenges associated with taking to scale a pilot that began as a relatively simple innovation by a non-governmental organisation.ResultsOur analysis reveals how a programme initially representing a simple, unitary system in terms of management and clinical governance had evolved into a complex, differentiated care system. An innovation that was assessed as an excellent idea and received political backing, worked well whilst supported on a small scale. However, as scaling up progressed, challenges have emerged at the same time as support has waned. We identified a ‘tipping point’ at which the system was more likely to fail, as vulnerabilities magnified and the capacity for adaptation was exceeded. Yet the study also revealed the impressive capacity that a health system can have for catalysing novel approaches.ConclusionsWe argue that innovation in largescale, complex programmes in health systems is a continuous process that requires ongoing support and attention to new innovation as challenges emerge. Rapid scaling up is also likely to require recourse to further resources, and a culture of iterative learning to address emerging challenges and mitigate complex system errors. These are necessary steps to the future success of adherence clubs as a cornerstone of differentiated care. Further research is needed to assess the equity and quality outcomes of a differentiated care model and to ensure the inclusive distribution of the benefits to all categories of people living with HIV.

Highlights

  • In 2011, a decision was made to scale up a pilot innovation involving ‘adherence clubs’ as a form of differentiated care for Human Immunodeficiency Virus (HIV) positive people in the public sector antiretroviral therapy programme in the Western Cape Province of South Africa

  • The original Médecins Sans Frontières (MSF) idea of a club in Khayelitsha was reported by MSF staff to have come from the concept of an airline loyalty club, in that the model incorporated the principle that membership required certain criteria to be met in an ongoing way

  • We have argued that innovation in largescale, complex programmes in health systems is a continuous process that requires ongoing support and ongoing attention to new innovation as challenges emerge

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Summary

Introduction

In 2011, a decision was made to scale up a pilot innovation involving ‘adherence clubs’ as a form of differentiated care for HIV positive people in the public sector antiretroviral therapy programme in the Western Cape Province of South Africa. We explore the challenges associated with taking to scale a pilot that began as a relatively simple innovation by a non-governmental organisation. An innovation: The ART adherence club model The South African public sector antiretroviral therapy (ART) programme, for people infected by Human Immunodeficiency Virus (HIV), has received earmarked funds and dedicated staffing. Our interest is in analysing planned organisational change through intervention in a state health system, and in exploring the challenges associated with taking to scale a pilot that began as a relatively simple innovation by a non-governmental organisation (NGO). How do different stakeholders initially frame the need for innovation and what are the implications? What is the broader political, social and health systems context in which an innovation becomes policy, and what factors might enable or inhibit the change required for scaling up? These questions are posed for a scenario where change was introduced in the context of an existing large-scale national ART programme, a vertical service that by 2016 was assessed by many to be remarkable and to have successfully scaled up medication delivery in the country to millions of people, against considerable odds [6]

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