Abstract
BackgroundDespite increasing recognition that health-systems constraints are the fundamental barrier to attaining anti-retroviral therapy (ART) scale-up targets in Sub-Saharan Africa, current discourses are dominated by a focus on financial sustainability. Utilizing the health system dynamics framework, this study aimed to explore the interactions in health system components and their influence on the sustainability of ART scale-up implementation in Uganda.MethodsThis study entailed qualitative organizational case-studies within a two-phased mixed-methods sequential explanatory research design. In Phase One, a survey of 195 health facilities across Uganda which commenced ART services between 2004 and 2009 was conducted. In Phase Two, six health facilities were purposively selected for in-depth examination involving i) In-depth interviews (n = 44) ii) and semi-structured interviews (n = 35). Qualitative data was analyzed by coding and thematic analysis. Descriptive statistics were managed in STATA (v 13).ResultsFive dynamic interactions in ART program sustainability drivers were identified; i) Failure to update basic ART program records contributed to chronic ART medicines stock-outs ii) Health workforce shortages and escalating patient volumes prompted adaptations in ART service delivery models iii) Broader governance issues manifested in poor road networks undermined ART medicines supply chains iv) Sustained financing for ART programs was influenced by external donors v) The values associated with the ownership-type of a health facility affected ART service delivery and coverage.ConclusionThe sustainability of ART programs at the facility-level in Uganda is a function of a complex interaction in elements of the health system and must be understood beyond sustaining international funding for ART scale-up.
Highlights
Despite increasing recognition that health-systems constraints are the fundamental barrier to attaining anti-retroviral therapy (ART) scale-up targets in Sub-Saharan Africa, current discourses are dominated by a focus on financial sustainability
88 (45%) of the health facilities were located in peri -urban settings or urbanized parts of rural areas, this was followed by those located in urban settings 78 (40%) and those based in rural areas 29 (15%)
Five principal dynamic interactions emerged in our study; i) inability to update basic ART program records contributed to chronic ART medicines stock-outs ii) Health workforce shortages and escalating patient volumes prompted adaptations in ART service delivery models iii) Broader national governance challenges manifested in poor road networks undermined ART medicines supply chains iv) The financing of ART programs was influenced by external donor contexts and v) The values espoused by the ownership-type of a health facility affected ART service delivery and coverage
Summary
Despite increasing recognition that health-systems constraints are the fundamental barrier to attaining anti-retroviral therapy (ART) scale-up targets in Sub-Saharan Africa, current discourses are dominated by a focus on financial sustainability. After years of sustained increases in global health aid for ART scale up implementation in SSA, recent indications point to a decline in international funding flows for ART scale-up [4, 5] This decline in funding comes amidst the escalating demand for ART arising from adoption of the ‘universal test and treat’ policy which recommends that all Zakumumpa et al Global Health Research and Policy (2018) 3:23 diagnosed as HIV positive be enrolled on sustained ART regardless of disease stage [6, 7]. Studies have been done modeling future HIV treatment needs based on unit cost analyses [14,15,16,17]
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