Background
Globally, there is growing critical interest attached to the goal of universal access to HIV treatment. In September 2014, UNAIDS unveiled the 90-90-90 global targets, part of which aim at enrolling 90 % of those with HIV infection on sustained antiretroviral therapy (ART) by 2020 [
1]. The Sustainable Development Goals (SDGs) announced in September 2015 re-affirmed universal access to HIV treatment in the new international development agenda [
2]. In November 2015, WHO released treatment guidelines requiring that all diagnosed as HIV positive be initiated on ART regardless of disease stage [
3].
Attaining these global targets and treatment guidelines in the developing world, particularly in Sub Saharan Africa, will depend substantially on the capacity of health systems to sustain and expand ART scale-up [
4,
5]. Global Health Initiatives such as PEPFAR and The Global Fund, which supported the rapid expansion in ART coverage in Sub Saharan Africa, have increasingly recognized the importance of health systems strengthening in the attainment of ART scale-up goals [
6,
7].
Uganda started implementing a national ART scale-up program in June 2004 with reliance on external donor support. HIV service delivery was scaled-up from tertiary to primary care facilities and from public to non-public facilities [
8,
9]. The national ART scale-up program was also implemented in private-for-profit health facilities [
40].
The nature of donor support to enable health facilities to commence ART delivery involved supply of free antiretroviral (ARV) drugs, provision of diagnostic equipment such as CD4 machines, laboratory capacity support and ART standard-of-care training. In Uganda, donors finance over 80 percent of ART program costs [
10]. This support was provided to health facilities under time-limited project grants. In the case of PEPFAR, the predominant donor, support was channeled through larger intermediary organizations known as ‘implementing partners’ on 5-year grant cycles [
11]. Increasingly, the primary funders of HIV/AIDS services in Uganda are seeking to ensure the efficiency, sustainability and country of ownership of ART programs [
4‐
7]. This brings the question of the sustainability of ART in countries like Uganda to the top of the policy agenda.
There are numerous studies reporting on initial implementation of ART scale-up [
12‐
15] and associated clinical outcomes [
16‐
18]. However, little is known about
how and
why some health facilities have sustained ART and why some have not sustained these interventions over the past 12 years. What conditions, contexts or processes are conducive for the long-term sustainability of ART at the organizational level of ART providers? [
19]. The objective of the study was to identify facilitators and barriers to the long-term sustainability of ART delivery at health facilities in Uganda which received initial grant funding for ART start-up between 2004 and 2009.
The term ‘sustainability’ is defined in varied ways in different content fields [
21,
22,
25]. Within the literature on health program sustainability, there are two dominant strands in the way sustainability is defined. On one hand, it has been defined as program continuation of a newly introduced intervention within an organization after initial implementation efforts have ended [
20‐
22]. On the other hand, sustainability has been defined as ‘institutionalization’ or the extent to which a new intervention is integrated in the organizational routines of the host implementing agency [
22‐
24]. We adopted Proctor et al. [
25] s’ definition which unifies these two dimensions. They define sustainability as ‘the extent to which a newly implemented treatment is
maintained or
institutionalized within a service setting’s ongoing, stable operations’ (emphasis ours) [
25]. This study aligns with the literature suggesting that sustainability is not an either/or phenomenon but one assessed along a continuum or levels of sustainability [
20,
26,
28].
There is a paucity of research analyzing the long-term sustainability of ART provision in Uganda. However, comparative case studies examining intervention sustainability outcomes other than ART have been conducted in other fields. Savaya et al. (2009) conducted a comparative case study of six projects in Israel which operated between 1980 and 2000 to assess why some projects were sustained while others were not. They found that the human factor in terms of the leadership of the host organization compared to factors such as availability of donor funding explained the difference [
26]. Wright [
27] investigated the reasons why four rural primary care programs in the United States survived 30 years after implementation and found that having program champions, organization flexibility and community integration were key. LaPelle et al. [
28] examined 77 tobacco treatment programs in the United States after termination of funding following a state recession and found that re-defining the scope of services and adopting alternative financing strategies distinguished between sustained and non-sustained programs. Stolldorf DP (2013) conducted a comparative case study of four hospitals with the highest and lowest scores for sustaining a nursing intervention and concluded that certain contexts and processes facilitated program sustainability in hospitals in the United States [
29]. Like most of the above studies, this study is situated within the framework by Shediac-Rizkallah and Bone [
20] which posits that health program sustainability is potentially influenced at the (i) programmatic, (ii) organizational and (iii) broader environment levels.
The results reported here form part of a larger study investigating the sustainability of ART programs in Uganda with regard to the determinants of sustainability, institutionalization outcomes and an exploration of ART provider contexts [
30,
31].
Methods
Research design
A case-study design was adopted. This involved both qualitative and quantitative approaches to data collection and analysis.
Cases selection
The cases were identified through a 2-stage process. In the first phase, a sample of 195 (out of 394) health facilities accredited to deliver ART between 2004 and 2009 were enrolled into a survey that assessed ART institutionalization using Level of Institutionalization Scales (LoIn) scales (Goodman, 1993) [
23]. A 45-item questionnaire measured institutionalization based on four ‘sub- systems’ theorized to make up an organization (Production, Maintenance, Supportive, Managerial) assessed against two levels of institutionalization; routines (lower) and niche saturation (higher) A summative score was determined for each of the 195 health facilities [
30]. In the second phase, six health facilities were purposively selected for in-depth study. The selected health facilities were grouped into three categories; two facilities with highest scores (High Sustainers), two facilities with lowest scores (Low Sustainers) and two facilities that stopped providing ART (Non-Sustainers) [
32,
33].
The outcome of the selection of the cases based on those with the highest and lowest ART institutionalization scores, allowed us to explore ART program sustainability at different levels of care of the Ugandan health system [
34,
35]. The results from the first study phase showed variations in institutionalization scores by level of care. On average, hospitals had higher institutionalization scores than health centers. HS-001 and HS-002 represent hospital-level providers compared to LS-001 and LS-002 which are mid-size health centers. NS-001 and NS-002 were smaller health centers. (Table
1).
Table 1
Art program characteristics of selected health facilities
High sustainers | HS-001 | PUBLIC | 26.8 | 9,540 | 24,408 | 53 | URBAN |
HS-002 | PNFP | 26 | 2,556 | 4,337 | 63 | URBAN |
Low sustainers | LS-002 | PFP | 3.9 | 84 | 19 | 1 | URBAN |
LS-001 | PUBLIC | 2.7 | 146 | 458 | 2 | PERI-URBAN |
Non-sustainers | NS-001 | PFP | ART Discontinued April 2013 | 11 | 0 | ART Discontinued April 2013 | RURAL |
NS-002 | PFP | ART Discontinued January 2014 | 324 | 0 | ART Discontinued January 2014 | RURAL |
The six cases reflect the three major health facility ownership categories in Uganda namely; Public (LS-001), Private for Profit (LS-002, NS-001 and NS-001) and Private Not for Profit (HS-002). The selected cases had an appropriate urban/rural mix. Three of the cases were based in urban towns of Uganda compared to the other three that were based in rural areas. All selected cases were accredited ART sites suggesting a minimum level of service delivery and infrastructural capacity at the time of accreditation.
Data collection methods
Case-study designs rely on multiple sources of data to gain richness, in depth analysis and data triangulation [
36,
37]. To this end, (1) Semi-structured interviews were conducted with at least three respondents per case (
N = 18) (2) The quantitative data collection included two instruments
. One was a survey that generated quantitative data on ART program characteristics for each of the cases (
N = 6). The second tool was the Level of Institutionalization (LoIn) scales which measured the extent of institutionalization of ART programs (
N = 6) [
30]. (3) On-site observation notes of program characteristics and processes at each of the cases were examined (4) Documentary analyses of grey literature in respect to the cases, such as ART program evaluation reports and websites were scrutinized to augment respondent data. Data were collected between February and May 2015 by two authors and four research assistants who were experienced in data collection in ART-providing organizations.
Interview procedure
An interview guide was constructed based on factors identified in the literature as potentially influential on health program sustainability. The selected factors were most consistent with those identified in the review article by Scheirer MA and Dearing JW [
22]. The open-ended nature of the interview guide allowed us to elicit responses from interviewees regarding the facilitators and barriers to ART program sustainment at their sites from the interviewees’ perspectives. When sustainability factors or attributes contained in the interview guide were not spontaneously raised by interviewees, probing was done to cover the remaining attributes.
We sought interviewees who had the longest ART program experience at their sites, particularly those who had been in service during the pilot phase of ART delivery at their sites. As a first step, the ART Clinic heads were contacted and requested to have their health facilities voluntarily participate in the study. All six cases agreed to participate in the study.
The ART clinic heads were then asked to nominate interviewees who met the criteria. Voluntary consent to participate of the nominated interviewees was sought. They then signed a written consent form agreeing to be interviewed for the study. Interviews were typically conducted in the respondents’ offices at the respective health facilities and lasted between 30 and 45 min. The interviews were conducted in the English language, between February and June 2015. At least three interviewees, per case, were recruited (n = 18).
During the interview, participants were asked to describe program characteristics such as the number of patients currently enrolled on ART and the range of HIV treatment services offered. Interviewees were then asked to describe how the ART program at their site had evolved since the initial phase of implementation. We deliberately began with an open-ended dialogue to elicit responses from interviewees regarding the facilitators and barriers to ART program sustainment at their sites from the interviewees’ perspectives. When sustainability attributes contained in the interview guide were not spontaneously raised by interviewees, probing of those attributes followed.
The interviews were recorded using an electronic recorder. The audio recordings were transcribed and stored on a password-protected computer. The authors listened to the audio recordings multiple times to ensure accuracy in transcription of the interviews.
Data analysis
Qualitative data
As a first step, two authors read through the interview transcripts separately to identify themes emerging from the interview responses under ART program sustainability barriers and facilitators with respect to each of the six cases and subsequently across the cases [
36,
38]. The authors sought convergence in the interpretation and the assignment of codes and themes with respect to facilitators or barriers to ART program sustainability.
In the second stage, the authors compared the themes emerging from the interviews against those in the initial coding scheme. The initial coding scheme was constructed based on factors identified in the review article by Scheirer MA and Dearing JW [
22]. The codes were then methodically grouped under the three over-arching themes of the study. For ease of comparison of the cases, themes emerging from each individual case and across the cases were summarized in a two-column table [
28,
39]. In the third stage, codes which were not adequately captured by the initial coding scheme or those which emerged inductively were grouped into categories to enable generation of new themes which were jointly agreed upon by the authors through consensus. Interviewee data were triangulated with other information sources such as questionnaire data and document review such as donor project evaluation reports involving the cases.
Case-study comparative analyses
A case description was constructed for each of the cases based on questionnaire data, provider interviews and documentary evidence to gain an understanding of the operational context of each of the cases. In the first instance, with-in case analyses was completed for each of the cases to assess facilitators and barriers of ART program sustainability based on the three principal sources of data which were processed into text data to facilitate thematic analyses. Across-case analyses were conducted for each of the three case categories to assess concurrence or divergence of the emerging facilitators and barriers to ART sustainability.
Quantitative data
Quantitative data were extracted from a self-administered questionnaire filled with respect to the cases. We compared closed-ended responses relating to ART program characteristics to explore distinguishing features within and across the cases (Table
1). The second questionnaire sought to measure the extent of institutionalization of ART programs at each of the cases. We compared the quantitative scores assigned to the cases computed from the descriptive statistics generated from each of the cases.
Mixed-methods integration
The study was conducted in two consecutive phases [
38]. The results of the questionnaire measuring the level of institutionalization of ART programs at 195 health facilities [
30] were used to purposively select six cases for in-depth study [
38]. In the results under Section A, a case description for each of the six cases was constructed based on quantitative data (questionnaire) and qualitative (interviewee) data. In the results, under Section B, the across-case comparisons of ART program characteristics are based on quantitative data in Table
1. We draw upon the qualitative data (in Section C) to explain the significance of the differences reflected in Table
1 in Section B of the results. Additionally, in our qualitative findings in Section C, we cite instances where there is triangulation of data sources with quantitative data in Section A. Full integration of qualitative and quantitative data was done in our overall interpretation of the findings in the Discussion.
Section A
Case descriptions
HS-001 is a public hospital located in an urban town of South-western Uganda. The ART clinic is a specialized unit within a large hospital complex. In 2004, the hospital implemented an ART scale-up program with donor support. HS-001 had the highest ART institutionalization score in a national sample of 195 health facilities.
HS-002 is an old mission hospital in Uganda located in Uganda’s capital. The ART clinic is a specialized unit within a large hospital complex. The hospital implemented an ART scale-up program in 2005 with donor funding. HS-002 had the second highest ART institutionalization score.
LS-001 is a public, Health Centre IV, located in a peri-urban setting of East Central Uganda. The Health Center serves a geographical area equivalent to a county or Health Sub-district. This health facility had the lowest ART institutionalization score in a national sample of 195 health facilities.
LS-002 is a mid-size, private clinic, in an urban town in Central Uganda. In 2009, the clinic benefited from a USAID-funded project to initiate ART delivery through site accreditation support, ART workforce training, and provision of laboratory infrastructure such as a chemistry analyzer and autoclave and on-site support supervision. This clinic has the second lowest ART institutionalization score
NS-001 is a private employee clinic located in a rural setting in Hoima district in Mid-western Uganda. The Clinic is equivalent in size to a Health Centre III. It caters to 800 families on a Tea Estate. In 2009, it benefited from USAID funding to enable it commence ART services through site accreditation support, ART workforce training and on-site support supervision. The Clinic discontinued ART delivery in January 2014.
NS-002 is a private clinic located in a remote part of Kyenjonjo district in western Uganda. In 2009, it benefited from USAID funding to initiate ART provision through site accreditation support, ART workforce training and on-site support supervision. The clinic discontinued ART delivery in April 2013.
Discussion
We found several distinguishing features between health facilities which had the highest ART sustainability scores (High sustainers) and those with the lowest scores (low sustainers) and health facilities which didn’t sustain ART(Non sustainers). The most important distinguishing feature were factors in the internal organizational context of the cases. High Sustainers reported having an internal program champion, stable program leadership of at least 7 years, robust ART program reporting systems and long-standing external champions. The finding that the organizational culture and climate of the implementing provider differentiates between agencies which sustain interventions from those which don’t is widely supported in the literature [
41‐
43].
There was concurrence in the barriers cited across the Low and Non-Sustainer categories which included attrition of ART-proficient staff, irregular and insufficient supply of ART commodities and absence of internal and external program champions. The degree of similarity in sustainability barriers and attributes cited across the cases that made up the Low Sustainer and Non-sustainer categories was high. This may suggest a convergence around the factors that detract from ART program sustainability that transcends case categorizations.
The case studies suggest that ART program sustainability objectives for for-profit providers were distinguished from other types of health facilities in Uganda as they were reported to be dependent on these programs being able to generate a profit in relation to provider investment. The findings demonstrate that the availability of donor support, in form of free supplies of ARV drugs, laboratory equipment and staff training, did not guarantee long-term program sustainability in for-profit providers. This finding agrees with previous studies which found that alignment of the intervention and organization’s mission influence sustainability outcomes [
22,
44,
45]. In the six cases, we found that continued delivery of ART programs was donor-dependent and was influenced by factors external to the providers. Program continuation depended on meeting donor criteria and performance targets which were important drivers of sustained ART delivery. We observed a dependence by providers on time-limited funding to sustain their rapidly expanded ART programs. The study findings add to mounting calls for increasing local-ownership of HIV service delivery [
4,
5,
7]. The finding that organizations are affected by external constraints and dynamics is well supported in the literature [
46‐
48].
The dynamic interactions driving ART program sustainability
A major finding of this study is that although barriers to ART program sustainment were cited independently by providers, our analysis revealed a dynamic interaction in these drivers. For instance, for three of the cases where profit-making was the overriding organizational goal, it’s plausible this orientation could have influenced their human resource management choices such as length of tenure and salary scales for the ART workforce which in turn affected retention and staffing strength. It emerged that ARV drug stock outs were partly a result of low staffing capacity which hampered the updating of ART registers which are used as the basis for ART commodities forecasts and requisitions to Uganda’s national medicines supplier.
ART workforce inputs such as staffing numbers and motivation influenced the ability of providers to deliver on ART program reporting mandates which in turn affected successor-grant prospects with funders. Low and Non sustainers were relatively constrained in meeting donor criteria of growing and retaining patient loads due to having lower internal capacity which resulted in less satisfactory client experiences characterized by drug stock outs, long waiting times and low patient follow-up capacities. With regard to the High Sustainers, we found that maintaining robust internal ART monitoring and evaluation systems attracted additional funding from the external environment and that this was in turn dependent on the organizational climate and culture of the host agency. The role of internal program champions and leaders was highlighted as influential in fostering ART program continuation and could have interacted with other sustainability drivers. An interaction in the factors affecting long-term implementation of interventions has been observed in previous studies [
21,
55]. A dynamic interaction of ART program sustainability drivers emerged in the analyses involving diverse stakeholders namely; providers, patients, external funders and the local ARV drugs supply chain. A broader systems thinking has been called for in the literature on health service delivery in resource-constrained settings and our findings provide further empirical support for this approach [
19,
46].
Implications for Health Systems strengthening
The findings from the cases we examined suggest that ART program sustainability strategies and contexts in Uganda are distinguished by the size of the health facility. We found that over the last ten years, larger and established hospitals were able to attract multiple grants for ART delivery from funders compared to smaller and less-established health facilities. The prioritization of ART program evaluation by High sustainers, was a key distinguishing feature as it enabled them to demonstrate success to external funders. Smaller health facilities reported barriers in keeping up with their ART program evaluation mandates due to internal capacity constraints such as having inadequate staff and physical space. From a demand perspective, compared to large hospitals, patients were not attracted by a narrower ‘menu’ of HIV services, weaker patient follow-up capacity, longer waiting times due to fewer staff, more frequent drug stock-outs and unreliable electricity supply. This finding agrees with previous studies which have found that health facility characteristics affect patient retention rates on ART programs [
52‐
54]. Previous studies have found that ‘mature’ organizations have lower HIV treatment unit costs and enjoyed economies of scale accruing from large patient volumes compared to less established health facilities [
49].
Our paper illuminates barriers to realizing the ART scale-up goals in Uganda. This is especially with regard to for-profit providers who are an important part of the service delivery infrastructure and alleviate the over-burdened public sector. We note that private–for-profit health facilities constitute half of all health facilities in Uganda [
50]. Part of the solution suggested by for-profit providers was that salary top-ups be provided to their ART workforce for the extra workload brought on by ART scale-up at their clinics - a proposal earlier suggested by Biesma et al. [
51].
Our findings reveal capacity constraints in routine ART program reporting among for-profit providers which is suggestive of a need for interventions to strengthen capacity in program reporting, a critical aspect that impacts on the ARV supply chain, patient outcomes and successor grants from funders. A study by Kyayise et al. (2008) found similar constraints in for-profit HIV service providers in Uganda [
50].
Our findings are suggestive of the kind of health facilities which are more likely to sustain ART programs and the organizational and environmental contexts that are conducive for the long-term sustainability of ART programs in Uganda. By describing the characteristics of health facilities which have been successful in sustaining ART, following a post-implementation phase in Uganda, our study contributes empirical evidence that is relevant to funders of ART programs in resource-limited settings.
Implications for country ownership of ART service delivery in Uganda
The study findings suggest a dependence by health facilities in Uganda on external donor support for ART service delivery. An increased role of the Uganda government in ART service delivery and long-term sustainability is imperative. A gradual and phased increase in domestic budget support to ART service delivery is called for. Increasing government contribution to the cost of procurement of ART commodities through domestic resource mobilization could be a good step in promoting country ownership of HIV programs in Uganda which is a topical subject in the literature [
4‐
7].
We found that for-profit providers were relatively constrained in sustaining ART programs. Policies and programs targeted at supporting PFPs are critical to continued ART scale-up in Uganda. Government service purchase agreements with for-profit providers or seconding government-salaried health workers to PFPs with high patient volumes, especially those located in rural settings, or during designated peak periods such as ART Clinic days, is worthy of consideration. In addition, training programs targeting ART Clinic mangers in the areas of human resources for health (HRH) and program reporting could enhance program sustainability outcomes. The Ministry of Health’s ART monitoring Unit needs to be strengthened to enable it deliver on its mandate of monitoring ART service delivery all over the country. Strengthening the program monitoring function of this unit through the development of early warning systems and research to identify health facilities that need interventions could go a long way in improving ART program sustainability outcomes.
Consideration of the program sustainability strategies elicited by the study and the barriers identified, by ART program managers and planners in Uganda and other resource-constrained settings could improve long-term sustainability outcomes of ART programs and contribute to efforts to realize the global health agenda of universal access to HIV treatment.
Limitations
Some limitations are important to acknowledge. Given that a significant amount of time had elapsed since ART was piloted at participating health facilities, recall bias could have been a shortcoming even when we relied on multiple respondents per case and the triangulation of data sources. Because of a complex dynamic interaction between organizational and environmental facilitators and barriers to ART program sustainability, the direction of causality was at times difficult to distinguish. For instance, maintaining robust monitoring and evaluation systems for ART programs was associated with attracting additional donor funding. Conversely, concerted donor policies over the study period could have influenced the prioritization of ART program evaluation by health facilities in their bid to ensure sustained external grants. In this study, we interrogated the sustainability of ART programs in health facilities in Uganda from the perspective of the providing organizations. Additional interviews with policy makers and the community could have enabled more diverse perspectives on the study findings.
Conclusion
We found that ART program sustainability was embedded in a complex system involving dynamic interactions between internal (program champion, staffing strength, program evaluation) and external (donors, ARVs supply chain, patient demand) drivers. In the cases we examined, ART program sustainability contexts and strategies were distinguished by the size of the health facility and having a private-for-profit orientation. Our study highlights the influence of the framework by Shediac-Rizkallah & Bone [
20] in illuminating the complex and multi-faced nature of health program sustainability.
The study has implications for health system strengthening for ART scale-up in Uganda and other resource-limited settings.
Acknowledgements
The authors would like to acknowledge and thank ART Clinic managers from all the participating health facilities who participated in this study despite their incredibly busy schedules.