1
|
Neel AH, Rodríguez DC, Sikazwe I, Pillay Y, Barron P, Pereira SK, Makakole-Nene S, Bennett SC. HIV programme sustainability in Southern and Eastern Africa and the changing role of external assistance for health. Health Policy Plan 2024; 39:i107-i117. [PMID: 38253440 PMCID: PMC10803196 DOI: 10.1093/heapol/czad091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 09/13/2023] [Indexed: 01/24/2024] Open
Abstract
High human immunodeficiency virus (HIV)-prevalence countries in Southern and Eastern Africa continue to receive substantial external assistance (EA) for HIV programming, yet countries are at risk of transitioning out of HIV aid without achieving epidemic control. We sought to address two questions: (1) to what extent has HIV EA in the region been programmed and delivered in a way that supports long-term sustainability and (2) how should development agencies change operational approaches to support long-term, sustainable HIV control? We conducted 20 semi-structured key informant interviews with global and country-level respondents coupled with an analysis of Global Fund budget data for Malawi, Uganda, and Zambia (from 2017 until the present). We assessed EA practice along six dimensions of sustainability, namely financial, epidemiological, programmatic, rights-based, structural and political sustainability. Our respondents described HIV systems' vulnerability to donor departure, as well as how development partner priorities and practices have created challenges to promoting long-term HIV control. The challenges exacerbated by EA patterns include an emphasis on treatment over prevention, limiting effects on new infection rates; resistance to service integration driven in part by 'winners' under current EA patterns and challenges in ensuring coverage for marginalized populations; persistent structural barriers to effectively serving key populations and limited capacity among organizations best positioned to respond to community needs; and the need for advocacy given the erosion of political commitment by the long-term and substantive nature of HIV EA. Our recommendations include developing a robust investment case for primary prevention, providing operational support for integration processes, investing in local organizations and addressing issues of political will. While strategies must be locally crafted, our paper provides initial suggestions for how EA partners could change operational approaches to support long-term HIV control and the achievement of universal health coverage.
Collapse
Affiliation(s)
- Abigail H Neel
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD 21205, USA
| | - Daniela C Rodríguez
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD 21205, USA
| | - Izukanji Sikazwe
- Centre for Infectious Disease Research in Zambia (CIDRZ), 34620 Lukasu Road, Mass Media, Lusaka 10101, Zambia
| | - Yogan Pillay
- Department of Global Health, Stellenbosch University, Stellenbosch, South Africa
| | - Peter Barron
- School of Public Health, University of the Witwatersrand, Johannesburg 2193, South Africa
| | - Shreya K Pereira
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD 21205, USA
| | | | - Sara C Bennett
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD 21205, USA
| |
Collapse
|
2
|
Zakumumpa H, Paina L, Ssegujja E, Shroff ZC, Namakula J, Ssengooba F. The impact of shifts in PEPFAR funding policy on HIV services in Eastern Uganda (2015-21). Health Policy Plan 2024; 39:i21-i32. [PMID: 38253438 PMCID: PMC10803197 DOI: 10.1093/heapol/czad096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 09/19/2023] [Accepted: 10/20/2023] [Indexed: 01/24/2024] Open
Abstract
Although donor transitions from HIV programmes are increasingly common in low-and middle-income countries, there are limited analyses of long-term impacts on HIV services. We examined the impact of changes in President's Emergency Plan for AIDS Relief (PEPFAR) funding policy on HIV services in Eastern Uganda between 2015 and 2021.We conducted a qualitative case study of two districts in Eastern Uganda (Luuka and Bulambuli), which were affected by shifts in PEPFAR funding policy. In-depth interviews were conducted with PEPFAR officials at national and sub-national levels (n = 46) as well as with district health officers (n = 8). Data were collected between May and November 2017 (Round 1) and February and June 2022 (Round 2). We identified four significant donor policy transition milestones: (1) between 2015 and 2017, site-level support was withdrawn from 241 facilities following the categorization of case study districts as having a 'low HIV burden'. Following the implementation of this policy, participants perceived a decline in the quality of HIV services and more frequent commodity stock-outs. (2) From 2018 to 2020, HIV clinic managers in transitioned districts reported drastic drops in investments in HIV programming, resulting in increased patient attrition, declining viral load suppression rates and increased reports of patient deaths. (3) District officials reported a resumption of site-level PEPFAR support in October 2020 with stringent targets to reverse declines in HIV indicators. However, PEPFAR declared less HIV-specific funding. (4) In December 2021, district health officers reported shifts by PEPFAR of routing aid away from international to local implementing partner organizations. We found that, unlike districts that retained PEPFAR support, the transitioned districts (Luuka and Bulambuli) fell behind the rest of the country in implementing changes to the national HIV treatment guidelines adopted between 2017 and 2020. Our study highlights the heavy dependence on PEPFAR and the need for increasing domestic financial responsibility for the national HIV response.
Collapse
Affiliation(s)
- Henry Zakumumpa
- Department of Health Policy, Planning and Management, School of Public Health, Makerere University, P O Box 7061, Kampala, Uganda
| | - Ligia Paina
- Bloomberg School of Public Health, Johns Hopkins University, P O Box 7062, Kampala, Uganda
| | - Eric Ssegujja
- Department of Health Policy, Planning and Management, School of Public Health, Makerere University, P O Box 7061, Kampala, Uganda
| | - Zubin Cyrus Shroff
- Alliance for Health Policy and Systems, World Health Organization, 20 Avenue Appia, Geneva 1211, Switzerland
| | - Justin Namakula
- Department of Health Policy, Planning and Management, School of Public Health, Makerere University, P O Box 7061, Kampala, Uganda
| | - Freddie Ssengooba
- Department of Health Policy, Planning and Management, School of Public Health, Makerere University, P O Box 7061, Kampala, Uganda
| |
Collapse
|
3
|
Zakumumpa H, Rujumba J, Kyomuhendo M, Stempler L, Amde W. Drivers of retention of the HIV workforce transitioned from PEPFAR support to the Uganda government payroll. HUMAN RESOURCES FOR HEALTH 2023; 21:38. [PMID: 37161486 PMCID: PMC10170838 DOI: 10.1186/s12960-023-00824-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 05/02/2023] [Indexed: 05/11/2023]
Abstract
BACKGROUND Health worker (HW) retention in the public health sector in Uganda is an enduring health system constraint. Although previous studies have examined the retention of in-service HWs, there is little research focusing on donor-recruited HWs. The objective of this study was to explore drivers of retention of the HIV workforce transitioned from PEPFAR support to the Uganda government payroll between 2015 and 2017. METHODS We conducted ten focus group discussions with HWs (n = 87) transitioned from PEPFAR support to the public sector payroll in 10 purposively selected districts across Uganda. In-depth interviews were conducted with national-level stakeholders (n = 17), district health and personnel officers (n = 15) and facility in-charges (n = 22). Data were analyzed by a hybrid approach of inductive and deductive thematic development based on the analytical framework by Schaefer and Moos regarding individual-level and organizational-context drivers. RESULTS At the individual level, job security in the public sector was the most compelling driver of health worker retention. Community embeddedness of HWs in the study districts, opportunities for professional development and career growth and the ability to secure salary loans due to 'permanent and pensionable' terms of employment and the opportunity to work in 'home districts', where they could serve their 'kinsmen' were identified as enablers. HWs with prior private sector backgrounds perceived public facilities as offering more desirable challenging professional work. Organizational context enablers identified include perceptions that public facilities had relaxed supervision regimes and more flexible work environments. Work environment barriers to long-term retention include frequent stock-out of essential commodities, heavy workloads, low pay and scarcity of rental accommodation, particularly in rural Northern Uganda. Compared to mid-cadres (such as nurses and midwives), higher calibre cadres, such as physicians, pharmacists and laboratory technologists, expressed a higher affinity for seeking alternative employment in the private sector in the immediate future. CONCLUSIONS Overall, job security was the most compelling driver of retention in public service for the health workforce transitioned from PEPFAR support to the Uganda government payroll. Monetary and non-monetary policy strategies are needed to enhance the retention of upper cadre HWs, particularly physicians, pharmacists and laboratory technologists in rural districts of Uganda.
Collapse
Affiliation(s)
- Henry Zakumumpa
- School of Public Health, Makerere University, Kampala, Uganda.
| | - Joseph Rujumba
- College of Health Sciences, Makerere University, Kampala, Uganda
| | - Marjorie Kyomuhendo
- College of Humanities and Social Sciences, Makerere University, Kampala, Uganda
| | - Llyse Stempler
- Open Development LLC, Washington, DC, United States of America
| | - Woldekidan Amde
- School of Public Health, University of the Western Cape, Cape Town, South Africa
| |
Collapse
|
4
|
Paina L, Rodriguez DC, Zakumumpa H, Mackenzie C, Ssengooba F, Bennett S. Geographic prioritisation in Kenya and Uganda: a power analysis of donor transition. BMJ Glob Health 2023; 8:bmjgh-2022-010499. [PMID: 37236658 DOI: 10.1136/bmjgh-2022-010499] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 04/21/2023] [Indexed: 05/28/2023] Open
Abstract
Introduction Donor transition for HIV/AIDS programmes remains sensitive, marking a significant shift away from the traditional investment model of large-scale, vertical investments to control the epidemic and achieve rapid scaling-up of services. In late 2015, the United States President's Emergency Plan for AIDS Relief (PEPFAR) headquarters instructed their country missions to implement 'geographic prioritisation' (GP), whereby PEPFAR investments would target geographic areas with high HIV burden and reduce or cease support in areas with low burden.Methods Using Gaventa's power cube framework, we compare how power is distributed and manifested using qualitative data collected in an evaluation of the GP's impact in Kenya and Uganda.Results We found that the GP was designed with little space for national and local actors to shape either the policy or its implementation. While decision-making processes limited the scope for national-level government actors to shape the GP, the national government in Kenya claimed such a space, proactively pressuring PEPFAR to change particular aspects of its GP plan. Subnational level actors were typically recipients of top-down decision-making with apparently limited scope to resist or change GP. While civil society had the potential to hold both PEPFAR and government actors accountable, the closed-door nature of policy-making and the lack of transparency about decisions made this difficult.Conclusion Donor agencies should exercise power responsibly, especially to ensure that transition processes meaningfully engage governments and others with a mandate for service delivery. Furthermore, subnational actors and civil society are often better positioned to understand the implications and changes arising from transition. Greater transparency and accountability would increase the success of global health programme transitions, especially in the context of greater decentralisation, requiring donors and country counterparts to be more aware and flexible of working within political systems that have implications for programmatic success.
Collapse
Affiliation(s)
- Ligia Paina
- International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | | | - Henry Zakumumpa
- Health Policy Planning & Management, Makerere University School of Public Health, Kampala, Uganda
| | | | - Freddie Ssengooba
- Health Policy Planning & Management, Makerere University School of Public Health, Kampala, Uganda
| | - Sara Bennett
- International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| |
Collapse
|
5
|
Ogbuabor D, Olwande C, Semini I, Onwujekwe O, Olaifa Y, Ukanwa C. Stakeholders’ Perspectives on the Financial Sustainability of the HIV Response in Nigeria: A Qualitative Study. GLOBAL HEALTH: SCIENCE AND PRACTICE 2023; 11:GHSP-D-22-00430. [PMID: 37116920 PMCID: PMC10141423 DOI: 10.9745/ghsp-d-22-00430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 03/01/2023] [Indexed: 03/31/2023]
Abstract
BACKGROUND Countries in sub-Saharan Africa, including Nigeria, continue to depend on donor funding to achieve their national HIV response goals. The Government of Nigeria has made limited progress in translating political commitment to reduce donor dependency into increased domestic investment to ensure the sustainable impact of the HIV response. We explored the context-specific factors affecting the financial sustainability of the HIV response in Nigeria. METHODS Between November 2021 and March 2022, we conducted document reviews (n=13) and semistructured interviews with purposively selected national and subnational stakeholders (n=35). Data were analyzed thematically using the framework of health financing functions comprising revenue generation, pooling, and purchasing. RESULTS Stakeholders reported that there is a low level of government funding for the HIV response, which has been compounded by the weak engagement of Ministry of Finance officials and the unpredictable and untimely release of budgeted funds. Opportunities for domestic funding include philanthropy and an HIV Trust Fund led by the private sector. Integration of HIV treatment services into social health insurance schemes has been slow. Commodity purchasing has been inefficient due to ineffective coordination. Government stakeholders have been reluctant to support one-stop-shop facilities that target key and priority populations. CONCLUSION Opportunities exist in the government and private sectors for improving domestic health financing to support transitioning from donor support and ensuring the financial sustainability of the HIV response in Nigeria. To ensure that domestic financing for the HIV response is stable and predictable, the amount of domestic funding needs to increase and a framework that incorporates donor transition milestones must be developed, implemented, and monitored.
Collapse
Affiliation(s)
- Daniel Ogbuabor
- Department of Health Administration and Management, Faculty of Health Sciences and Technology, University of Nigeria, Enugu Campus, Enugu, Nigeria
| | | | - Iris Semini
- Equitable Financing Practice, Joint United Nations Programme on HIV/AIDS, Geneva, Switzerland
| | - Obinna Onwujekwe
- Department of Health Administration and Management, Faculty of Health Sciences and Technology, University of Nigeria, Enugu Campus, Enugu, Nigeria
| | | | - Chioma Ukanwa
- National AIDS, Sexually Transmitted Infections, and Hepatitis Control Programme, Federal Ministry of Health, Abuja, Nigeria
| |
Collapse
|
6
|
Akugizibwe M, Zalwango F, Namulundu CM, Namakoola I, Birungi J, Okebe J, Bachmann M, Jamie M, Jaffar S, Van Hout MC. "After all, we are all sick": multi-stakeholder understanding of stigma associated with integrated management of HIV, diabetes and hypertension at selected government clinics in Uganda. BMC Health Serv Res 2023; 23:20. [PMID: 36624438 PMCID: PMC9827009 DOI: 10.1186/s12913-022-08959-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 12/12/2022] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Integrated care is increasingly used to manage chronic conditions. In Uganda, the integration of HIV, diabetes and hypertension care has been piloted, to leverage the advantages of well facilitated and established HIV health care provision structures. This qualitative study aimed to explore HIV stigma dynamics whilst investigating multi-stakeholder perceptions and experiences of providing and receiving integrated management of HIV, diabetes and hypertension at selected government clinics in Central Uganda. METHODS: We adopted a qualitative-observational design. Participants were purposively selected. In-depth interviews were conducted with patients and with health care providers, clinical researchers, policy makers, and representatives from international nongovernmental organizations (NGOs). Focus group discussions were conducted with community members and leaders. Clinical procedures in the integrated care clinic were observed. Data were managed using Nvivo 12 and analyzed thematically. RESULTS Triangulated findings revealed diverse multi-stakeholder perceptions around HIV related stigma. Integrated care reduced the frequency with which patients with combinations of HIV, diabetes, hypertension visited health facilities, reduced the associated treatment costs, increased interpersonal relationships among patients and healthcare providers, and increased the capacity of health care providers to manage multiple chronic conditions. Integration reduced stigma through creating opportunities for health education, which allayed patient fears and increased their resolve to enroll for and adhere to treatment. Patients also had an opportunity to offer and receive psycho-social support and coupled with the support they received from healthcare worker. This strengthened patient-patient and provider-patient relationships, which are building blocks of service integration and of HIV stigma reduction. Although the model significantly reduced stigma, it did not eradicate service level challenges and societal discrimination among HIV patients. CONCLUSION The study reveals that, in a low resource setting like Uganda, integration of HIV, diabetes and hypertension care can improve patient experiences of care for multiple chronic conditions, and that integrated clinics may reduce HIV related stigma.
Collapse
Affiliation(s)
| | | | | | - Ivan Namakoola
- MRC/UVRI and LSHTM, Uganda Research Unit, Entebbe, Uganda
| | | | - Joseph Okebe
- Liverpool School of Tropical Medicine, Liverpool, UK, England
| | | | | | - Shabbar Jaffar
- Liverpool School of Tropical Medicine, Liverpool, UK, England
| | | |
Collapse
|
7
|
Zakumumpa H, Kitutu FE, Ndagije HB, Diana NK, Ssanyu JN, Kiguba R. Provider perspectives on the acceptability and tolerability of dolutegravir-based anti-retroviral therapy after national roll-out in Uganda: a qualitative study. BMC Infect Dis 2021; 21:1222. [PMID: 34876050 PMCID: PMC8650263 DOI: 10.1186/s12879-021-06933-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 11/30/2021] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The World Health Organization recommends dolutegravir (DTG) as the for first-line and second-line antiretroviral therapy (ART) worldwide. However, little is known about the acceptability and tolerability of DTG-based ART at routine points-of-care in Uganda. We set out to explore the perceptions of clinicians in ART clinics regarding the acceptability and tolerability of DTG-based ART since national roll-out in March 2018 in Uganda. METHODS We adopted a qualitative exploratory design involving 49 participants. Between September 2020 and February 2021, we conducted 22 in-depth interviews with clinicians in the ART clinics of 12 purposively selected health facilities across Uganda. The selection of study sites ensured diversity in facility ownership-type (public/private), level of service delivery (tertiary/secondary/primary) and the four major geographic sub-regions of Uganda. We conducted three focus group discussions with 27 clinicians in the participating facilities. Data were analyzed by thematic approach. RESULTS Clinicians in ART clinics acknowledged that DTG-based ART is well tolerated by the majority of their patients who appreciate the reduced pill burden, perceived less side effects and superior viral load suppression. However, they reported that a number of their patients experience adverse drug reactions (ADRs) after being transitioned to DTG. Hyperglycemia is, by far, the most commonly reported suspected ADR associated with DTG-based regimens and was cited in all but two participating facilities. Insomnia, weight gain and reduced libido are among the other frequently cited suspected ADRs. In addition, clinicians in ART clinics perceived some of the suspected ADRs as resulting from drug interactions between dolutegravir and isoniazid. Weak diagnostic capacities and shortage of associated commodities (e.g. glucometers and test kits) were reported as impediments to understanding the full extent of ADRs associated DTG-based ART. CONCLUSION While DTG-based regimens were perceived by clinicians in ART clinics to be well tolerated by the majority of their patients, they also reported that a number of patients experience suspected ADRs key among which were hyperglycemia, insomnia and reduced libido. Based on the perspectives of clinicians, we recommend that future studies examine the prevalence of dolutegravir-induced hyperglycemia in patients in Uganda.
Collapse
Affiliation(s)
- Henry Zakumumpa
- School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda.
| | - Freddy Eric Kitutu
- Sustainable Pharmaceutical Systems (SPS) Unit, Pharmacy Department, School of Health Sciences, Makerere University, Kampala, Uganda
| | | | | | - Jacquellyn Nambi Ssanyu
- Sustainable Pharmaceutical Systems (SPS) Unit, Pharmacy Department, School of Health Sciences, Makerere University, Kampala, Uganda
| | - Ronald Kiguba
- Department of Pharmacology and Therapeutics, Makerere University College of Health Sciences, Kampala, Uganda
| |
Collapse
|
8
|
Kairu A, Orangi S, Mbuthia B, Ondera J, Ravishankar N, Barasa E. Examining health facility financing in Kenya in the context of devolution. BMC Health Serv Res 2021; 21:1086. [PMID: 34645443 PMCID: PMC8515645 DOI: 10.1186/s12913-021-07123-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 09/30/2021] [Indexed: 11/18/2022] Open
Abstract
Background How health facilities are financed affects their performance and health system goals. We examined how health facilities in the public sector are financed in Kenya, within the context of a devolved health system. Methods We carried out a cross-sectional study in five purposely selected counties in Kenya, using a mixed methods approach. We collected data using document reviews and in-depth interviews (no = 20). In each county, we interviewed county department of health managers and health facility managers from two and one purposely selected public hospitals and health center respectively. We analyzed qualitive data using thematic analysis and conducted descriptive analysis of quantitative data. Results Planning and budgeting: Planning and budgeting processes by hospitals and health centers were not standardized across counties. Budgets were not transparent and credible, but rather were regarded as “wish lists” since they did not translate to actual resources. Sources of funds: Public hospitals relied on user fees, while health centers relied on donor funds as their main sources of funding. Funding flows: Hospitals in four of the five study counties had no financial autonomy. Health centers in all study counties had financial autonomy. Flow of funds to hospitals and health centers in all study counties was characterized by unpredictability of amounts and timing. Health facility expenditure: Staff salaries accounted for over 80% of health facility expenditure. This crowded out other expenditure and led to frequent stock outs of essential health commodities. Conclusion The national and county government should consider improving health facility financing in Kenya by 1) standardizing budgeting and planning processes, 2) transitioning public facility financing away from a reliance on user fees and donor funding 3) reforming public finance management laws and carry out political engagement to facilitate direct facility financing and financial autonomy of public hospitals, and 4) assess health facility resource needs to guide appropriate levels resource allocation. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-07123-7.
Collapse
Affiliation(s)
- Angela Kairu
- Health Economics Research Unit (HERU), KEMRI-Wellcome Trust Research Program, P.O. Box 43640, - 00100, Lenana Road, Nairobi, Kenya.
| | - Stacey Orangi
- Health Economics Research Unit (HERU), KEMRI-Wellcome Trust Research Program, P.O. Box 43640, - 00100, Lenana Road, Nairobi, Kenya
| | | | - Joanne Ondera
- Independent Consultant, P.O. Box 102370-00101, Nairobi, Kenya
| | | | - Edwine Barasa
- Health Economics Research Unit (HERU), KEMRI-Wellcome Trust Research Program, P.O. Box 43640, - 00100, Lenana Road, Nairobi, Kenya.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Peter Medawar Building for Pathogen Research, South Parks Road, Oxford, OX1 3SY, UK
| |
Collapse
|
9
|
Rodríguez DC, Mohan D, Mackenzie C, Wilhelm J, Eze-Ajoku E, Omondi E, Qiu M, Bennett S. Effects of transition on HIV and non-HIV services and health systems in Kenya: a mixed methods evaluation of donor transition. BMC Health Serv Res 2021; 21:457. [PMID: 33985482 PMCID: PMC8117613 DOI: 10.1186/s12913-021-06451-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 04/28/2021] [Indexed: 12/18/2022] Open
Abstract
Background In 2015 the US President’s Emergency Plan for AIDS Relief (PEPFAR) initiated its Geographic Prioritization (GP) process whereby it prioritized high burden areas within countries, with the goal of more rapidly achieving the UNAIDS 90–90-90 targets. In Kenya, PEPFAR designated over 400 health facilities in Northeastern Kenya to be transitioned to government support (known as central support (CS)). Methods We conducted a mixed methods evaluation exploring the effect of GP on health systems, and HIV and non-HIV service delivery in CS facilities. Quantitative data from a facility survey and health service delivery data were gathered and combined with data from two rounds of interviews and focus group discussions (FGDs) conducted at national and sub-national level to document the design and implementation of GP. The survey included 230 health facilities across 10 counties, and 59 interviews and 22 FGDs were conducted with government officials, health facility providers, patients, and civil society. Results We found that PEPFAR moved quickly from announcing the GP to implementation. Despite extensive conversations between the US government and the Government of Kenya, there was little consultation with sub-national actors even though the country had recently undergone a major devolution process. Survey and qualitative data identified a number of effects from GP, including discontinuation of certain services, declines in quality and access to HIV care, loss of training and financial incentives for health workers, and disruption of laboratory testing. Despite these reports, service coverage had not been greatly affected; however, clinician strikes in the post-transition period were potential confounders. Conclusions This study found similar effects to earlier research on transition and provides additional insights about internal country transitions, particularly in decentralized contexts. Aside from a need for longer planning periods and better communication and coordination, we raise concerns about transitions driven by epidemiological criteria without adaptation to the local context and their implication for priority-setting and HIV investments at the local level. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-06451-y.
Collapse
Affiliation(s)
- Daniela C Rodríguez
- Department of International Health, Johns Hopkins School of Public Health, 615 Wolfe Street, 8th Floor, Baltimore, MD, 21205, USA.
| | - Diwakar Mohan
- Department of International Health, Johns Hopkins School of Public Health, 615 Wolfe Street, 8th Floor, Baltimore, MD, 21205, USA
| | | | - Jess Wilhelm
- Department of International Health, Johns Hopkins School of Public Health, 615 Wolfe Street, 8th Floor, Baltimore, MD, 21205, USA
| | - Ezinne Eze-Ajoku
- Department of International Health, Johns Hopkins School of Public Health, 615 Wolfe Street, 8th Floor, Baltimore, MD, 21205, USA
| | | | - Mary Qiu
- Department of International Health, Johns Hopkins School of Public Health, 615 Wolfe Street, 8th Floor, Baltimore, MD, 21205, USA
| | - Sara Bennett
- Department of International Health, Johns Hopkins School of Public Health, 615 Wolfe Street, 8th Floor, Baltimore, MD, 21205, USA
| |
Collapse
|