Organisational capacity of public sector ART provision in Gauteng Province and its impact on patient adherence : Case studies of two facilities
Date
2008-10-23T09:41:52Z
Authors
Naidoo, Nicolette Prea
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Abstract
In November 2003, the Department of Health launched the Operational Plan for Comprehensive
Care, Management and Treatment (CCMT) for South Africa. This policy has as its central goal
universal access to antiretroviral therapy to 1 million people living with HIV by the end of 2007.
National implementation of the operational plan began in April 2004 and as at the end of October
2006, South Africa had initiated 213 828 people onto ART through the Plan, making it the biggest
programme in the world. Of these, 55 580 people had been placed on treatment in Gauteng
Province.
Despite these early achievements, there are concerns as to whether the South African public
health sector can rise to the challenge of universal access while achieving good clinical outcomes
and programme performance. As Venter (2006: 298) states, “the health sector is buckling under the
current load, and currently does not have the capacity to do anymore than dent the numbers
needed to treat, unless a radical restructuring of health services occurs.” A crucial factor in
providing a comprehensive approach to HIV/AIDS is the reorientation of service delivery from
acute to chronic disease care. In addition to the shift in focus to chronic disease management of
HIV/AIDS, health system constraints need to be addressed. These include inadequate health
system infrastructure and human resources.
This study aimed to comprehensively assess organisational capacity to provide antiretroviral
therapy (ART) in two public sector CCMT sites in Gauteng Province and the influence of these
organisational factors on follow-up and adherence to ART, with the view to understanding whether
public sector CCMT sites are able to deal with new challenges posed by the Plan. The objectives
were to assess: (1) levels of follow-up and adherence in patients registered at the CCMT site, (2)
dimensions of organisational capacity, drawing on internationally recognised chronic disease care
frameworks, namely the Wagner Chronic Care Model (CCM) and Innovative Care for Chronic Conditions (ICCC). These dimensions were: presence of motivated and adequately staffed teams;
delivery systems design; the quality of support systems; and facility information systems. 3) the
similarities and differences between the two sites with respect to organisational capacity, follow-up
and adherence.
The two sites were selected through a stratified (CHC and hospital) random sample of
CCMT sites in Region A of the province, excluding the long–standing and well-established
academic hospital CCMT sites in the sampling frame. The two sites, located in a District Hospital
in the West Rand and a Community Health Centre (CHC) in Central Witwatersrand, were visited
between May and July 2006. They had initiated 540 and 1001 patients on ART respectively since
October 2004. A multi-method health service evaluation of capacity in the HIV related services
(ART/Wellness, VCT, PMTCT, and TB) was conducted. This consisted of 11 semi-structured
interviews with facility and programme managers; review of registers and routine facility data; an
observation checklist and mapping to assess the physical infrastructure of the facility, presence of
management and health information systems; 35 self administered questionnaires to assess the
levels of motivation of nursing staff at each site. Data on self-reported adherence and viral loads
were obtained from a separate study involving exit interviews with 356 patients who had been
attending the services for at least four months in the two sites.1
Of the 540 and 1001 patients enrolled in the two services, 69.8% and 69.3% were still in the
service after 18 months at the hospital and CHC, respectively. The monthly drop-out rate at the
hospital had risen fairly sharply towards the end of the 18 month period, attributed by the staff to
growing difficulties in access to the site by new enrolments. Nevertheless, based on self-reports (3-
day recall period), viral load measures, and loss to follow-up, adherence levels at both sites appeared
to be in line with national and international best practice. The percentage of patients with undetectable virus was 76.2% and 74.4% at the hospital and CHC, respectively.
Staffing of the CCMT sites matched the pre-requisites outlined by the National Department
of Health for a ‘core’ health care team treating 500 patients. The CHC CCMT site, however, had
more than 500 patients on ART and moreover was providing two services within one unit, i.e.
ART/Wellness and VCT thus increasing the patient load. Sites were reaching saturation and this
was due to the lack of sufficient space coupled with the high volumes of patients, shortage of
certain scarce skills (in particular pharmacy staff), and the multiple responsibilities of nursing staff.
In general, the staffing situation at the hospital appeared better. More staff had joined than left the
hospital over the year prior to March 2006, and clinical workloads both in the ambulatory services
and the CCMT site were less than at the CHC. Vacancy rates were low, at 13.8% and 4.8% for the
hospital and CHC, respectively.
Strong leadership of CCMT sites by motivated ART programme managers was displayed;
site managers were highly respected and revered by staff. Based on ratings in a self-administered
questionnaire, overall levels of motivation and organisational commitment at both sites appeared
good, although, worryingly, a sizeable proportion of respondents in both sites agreed with
statement “I intend to leave this hospital/clinic.” Lack of external support (from the HIV/AIDS,
STI, TB Programme) and debriefing systems for programme managers and nursing staff was
identified as weaknesses.
With some exceptions, both sites showed evidence of strong ‘horizontal’ mechanisms of
referral and coordination between HIV and AIDS related services within sites; however the
PMTCT programme at the hospital was less co-ordinated and networked with other services. In
addition, ART and PMTCT programme managers at the hospital indicated that the relationship
between hospital services and surrounding clinics was poor.
Apart from the lack of space at the CHC CCMT site, support systems were adequate. There
were no reported drug stock outs and supply of drugs and general supplies was good at both sites.
Both sites were able to offer a range of routine and HIV specific tests.
A combination of paper and electronic based information systems were used at both sites,
however, the hospital CCMT site used a mixture of standard and locally designed data collection
forms compared to the CHC which mainly used standard Department of Health forms. The
information systems were adequate in monitoring and evaluating patients and programme
performance; however, the study highlighted the absence of a clear patient register for individual
and programme monitoring and only cross sectional patient data was reported. There was also
considerable duplication at the hospital in collecting and compiling patient information.
The findings of the study suggest that the two sites, located in the ‘routine’ public sector
environment of Gauteng Province have demonstrated ability to build organisational capacity for
ART provision, through a degree of systems integration and design, decision support systems,
generation and local use of information and motivated local champions. Through these elements of
organisational capacity, both sites have achieved good adherence rates. The key factors to achieving
this good programme performance were motivated local champions who drove programmes
forward and good working relationships between the CCMT and other players.
In light of the weaknesses identified, the following key recommendations are proposed:
Review sites to identify the reasons for the high-drop out rate and address these issues
Due to evidence of early saturation at the CHC, it is suggested that additional roll-out sites
be established, or alternatively increase staffing and space at the CHC to meet the needs of the
high patient load. In addition, well patients should be decanted to lower level services e.g.
community based care organisations, thus reducing the burden on the site Pay attention to the physical infrastructure needs of clinic based sites, especially as they
become saturated
Foremost, the current Employee Assistance Programme (EAP) implemented in Gauteng
Province should be strengthened and marketed so that staff members are more aware of the
service and make use of it accordingly. Alternatively, a culture of “caring for the caregivers”
should be cultivated, through for example, specialist assistance, debriefing sessions, and better
external programme support from HIV/AIDS, STI, TB (HAST) managers
Improve support and supervision of ART programmes by facilitating greater
communication and feedback between sites and district, national and provincial levels of
government.
Adopt a strategy of “task shifting”, through better use of lay workers, counsellors, and mid
level workers such as pharmacy assistants.
Facilitate greater integration and coordination between the PMTCT programmes and other
services, including the provision of VCT and training of staff. In addition, it is imperative that
there is good integration between services provided by local and provincial Departments of
Health
Simplify and standardise information systems, particularly the development of clear patient
registers to allow for cohort analysis.
Description
Keywords
antiretroviral therapy, Gauteng Province, ART provision