Abstract
BackgroundIn October 2012 Uganda extended its prevention of mother to child HIV transmission (PMTCT) policy to Option B+, providing lifelong antiretroviral treatment for HIV positive pregnant and breastfeeding women. The rapid changes and adoptions of new PMTCT policies have not been accompanied by health systems research to explore health system preparedness to implement such programmes. The implementation of Option B+ provides many lessons which can inform the shift to ‘Universal Test and Treat’, a policy which many sub-Saharan African countries are preparing to adopt, despite fragile health systems.MethodsThis qualitative study of PMTCT Option B+ implementation in Uganda three years following the policy adoption, uses the health system dynamics framework to explore the impacts of this programme on ten elements of the health system. Qualitative data were gathered through rapid appraisal during in-country field work. Key informant interviews and focus group discussions (FGDs) were undertaken with the Ministry of Health, implementing partners, multilateral agencies, district management teams, facility-based health workers and community cadres. A total of 82 individual interviews and 16 focus group discussions were completed. We conducted a simple manifest analysis, using the ten elements of a health system for grouping data into categories and themes.ResultsOf the ten elements in the health system dynamics framework, context and resources (finances, infrastructure & supplies, and human resources) were the most influential in the implementation of Option B+ in Uganda. Support from international actors and implementing partners attempted to strengthen resources at district level, but had unintended consequences of creating dependence and uncertainty regarding sustainability.ConclusionsThe health system dynamics framework offers a novel approach to analysis of the effects of implementation of a new policy on critical elements of the health system. Its emphasis on relationships between system elements, population and context is helpful in unpacking impacts of and reactions to pressures on the system, which adds value beyond some previous frameworks.
Highlights
IntroductionIntroduction of OptionB+ created additional data reporting requirements. Challenges included lack of computer equipment for data-entry within facilities, requiring either district biostatisticians to travel monthly to collect forms or facility managers to bring the data to the district office
Introduction of OptionB+ created additional data reporting requirements
In Uganda, the Optimizing HIV Treatment Access (OHTA) initiative aimed to optimize implementation of Option B+, with particular focus on strengthening community-facility linkages and supporting routine monitoring to enhance retention in care. This descriptive qualitative study [23] used rapid appraisal methodology [24] to explore the impact of prevention of mother to child HIV transmission (PMTCT) Option B+ implementation on the Uganda health system
Summary
Introduction of OptionB+ created additional data reporting requirements. Challenges included lack of computer equipment for data-entry within facilities, requiring either district biostatisticians to travel monthly to collect forms or facility managers to bring the data to the district office. Strategies to prevent mother to child HIV transmission (PMTCT) evolved progressively from single dose nevirapine prophylaxis in 2000 to the current recommendation that all pregnant and breastfeeding women, irrespective of CD4 count, should receive lifelong antiretroviral treatment (ART), known as Option B+ [4]. Modelled estimates predict this approach to have substantial clinical and programmatic advantages, including simplification of regimen, harmonisation with ART programmes, protection of future pregnancies from transmission and prevention of HIV transmission to serodiscordant partners [4]. Insufficient consideration has been given to health systems’ readiness to absorb a new service requiring regular followup on a large section of the population for lifelong chronic treatment [5]
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