The effect of facility-based antiretroviral therapy programs on outpatient services in Kenya and Uganda

HIV/AIDS has been a leading cause of death and disability in sub-Saharan Africa since the mid-1990s [1]. However, due to an unprecedented global response, the rate of new HIV infections has declined and an estimated 19·1 million life-years have been saved by interventions such as antiretroviral therapy (ART) [2]. Such gains have been driven by a rapid increase in HIV-specific development assistance for health (DAH), which rose in real terms from $1·4 billion in 2000 to $11 billion in 2015 [3]. Access to and enrollment in ART programs markedly increased in the last decade, [1, 4] providing life-saving treatment for people living with HIV throughout the world. Yet amid this success, considerable debate exists about how this massive scale-up of ART has affected the provision of non-HIV services [5‐7]. With HIV-targeted DAH stagnating since 2010 [3] and new treatment guidelines recommending universal access to ART, [8] understanding if and where the scale-up of ART services has had beneficial or detrimental health system effects is critical.

Previous studies provide conflicting evidence on how the scale-up of ART has affected health systems in sub-Saharan Africa. Many argue that the scale-up of ART strengthened overall health system capacity by increasing resource availability at health facilities, improving supply chains and bolstering support for human resources [9‐12]. By contrast, other studies have found that scarce resources were diverted away from other health needs and toward largely vertical HIV treatment programs [7, 13, 14]. Most commonly, these findings focused on human resources for health (HRH), [15‐17] documenting substantial employee shifts from public facilities to non-governmental organizations (NGOs) and HIV-focused treatment programs due to higher wages, greater prestige, and the opportunity to provide improved medical care [17‐20].

Mixed results from existing research suggest there may be a complex interplay between HIV and non-HIV services. For instance, volumes of maternal and reproductive health services such as family planning and antenatal care increased amid rising ART volumes in Zambia, but immunization services experienced fewer gains at facilities providing ART services [21]. Similarly, HIV funding was correlated with gains in maternal services such as prenatal blood testing, but decreases in immunization rates in sub-Saharan Africa [15]. Among rural health centers in Rwanda, the provision of HIV services appeared to have little effect on other patient services, [22] while one study in Uganda noted that facilities with funding from the US President’s Emergency Plan for AIDS Relief (PEPFAR) was associated with an increased number of deliveries [23]. Another recent paper analyzing the effect of PEPFAR investments on non-HIV services at the district-level in Uganda found that high PEPFAR investment was associated with small declines in several non-HIV outputs such as pediatric outpatient visits, TB tests, and inpatient deliveries [24].

In this study, we further examine the interaction between facility-based ART and non-ART outpatient department (OPD) services, filling an important information gap for key stakeholders as they develop policies aimed at reaching universal ART coverage. Drawing from unique, nationally-representative facility datasets in Kenya and Uganda, two countries with significant HIV epidemics, we assess trends in ART and non-ART OPD services at the country level and across facility types from 2007 to 2012. Specifically, we examine the impact of facility-based ART services on the utilization of non-ART OPD services, and investigate how various factors, such as facility location and ownership, influence this relationship.

To our knowledge, this is the first study to assess the effects of facility-based ART programs on trends in OPD services using nationally-representative facility datasets in sub-Saharan Africa. On average, we observed substantial increases for both ART and OPD volumes between 2007 to 2012 in both Kenya and Uganda. Furthermore, we found that the presence, scale-up, and size (overall and relative to the OPD clinic) of facility-based ART programs had no statistically significant effects on OPD visits over time. Overall, our study suggests that facility-based ART services were introduced and scaled up without having significantly negative effects on OPD volumes in Kenya and Uganda, a result that supports efforts to expand ART services in sub-Saharan Africa.

Sub-group analyses examining health centres and hospitals independently in both Kenya and Uganda generally revealed results consistent with the primary analysis across all health facilities. However, we found that the presence of ART services in Ugandan hospitals appeared to negatively affect OPD growth. The reason for this finding is unclear, but we do note some potentially important differences between hospitals in Uganda that provided ART and those that did not. First, the majority (55%) of hospitals offering ART services were public, while most non-ART hospitals were private (91%). This finding is not a surprise given the way in which ART services were initially rolled out at large public hospitals throughout Uganda and Kenya, before being offered in lower level facilities. However, private institutions may have had differential capacities or desire to expand services given more decentralized decision-making process [28] and different patient-mixes [29]. Second, non-ART hospitals were generally smaller than hospitals providing ART and had small provider to patient ratios (Table 2). It is possible that the smaller facilities simply had more capacity for growth, and were able to expand at a faster rate than the larger institutions. Lastly, it is important to consider that other contextual factors may significantly influence this finding, and the fact that this was noted in only one of the subgroup analyses suggest that further investigation is warranted.

Several past studies support our broader findings, offering a number of explanations as to how ART services expanded without crowding out OPD services. First, many facilities may have had the slack capacity to accommodate more patients prior to the introduction and scale-up of ART, allowing for an influx of additional patients without substantially straining facility resources [30, 31]. Facility managers also may have instituted mechanisms for reallocation of resources within facilities, such as task-shifting among medical staff [5, 32, 33]. Further, the largely vertical funding and implementation of ART programs may have shielded other facility resources from being used for ART [5, 34]. Lastly, HIV-targeted funds may have increased facility supplies and employed additional medical staff specifically for ART services, thus preventing a crowd-out of other types of non-HIV services [9].

Although there has been a large debate on the effect of ART scale-up and vertical programming on the larger health system, the majority of published literature assessing the effects of ART services at the facility level supports our results. Most studies found no significant deleterious effects on the utilization of non-ART services with the introduction of ART services, [22, 35] and some have even shown a positive effect of ART on non-ART services [23]. Much of the research suggesting a negative impact of ART programs on the larger health system focuses on qualitative assessments of health worker migration from the public to private sector, and analyses of how funding allocation changed with the increased focus on HIV/AIDS [8, 16, 18, 20]. However, the impact of ART services may also vary by the service of interest (i.e. inpatient, immunization, antenatal care etc.) [15, 21]. Furthermore, different types of HIV services may have differential effects on non-HIV services, [36] and as we found here, the impact may also vary by facility-type. Finally, we should be wary of a possible non-linear relationship between ART and ODP visits. Currently, many health facilities in Kenya and Uganda are operating with low technical efficiency, indicating some slack capacity that can accommodate ART patients without affecting the volume of other services [30]. Yet both Uganda and Kenya recently updated their guidelines to extend ART eligibility to all people living with HIV, which may substantially increase the strain on the health system and begin affecting other types of services [37, 38].

In an era of stagnating DAH for HIV/AIDS, there is sizeable interest in identifying way for further scaling up HIV services while continuing to provide and expand non-HIV services in a complementary manner [30]. This issue will likely continue to attract attention given the recent update of WHO HIV treatment guidelines, which expand ART eligibility to all people living with HIV [8]. Experiences in Kenya and Zambia show that integrating ART with other health services may be one strategy for supporting continued growth in patient volumes without a corresponding increase in medical staff [39‐41]. However, these experiences also show that integration alone cannot overcome existing human resource and infrastructure shortages; instead such integration can lead to greater occupational stress due to increased workload for providers and reduced time with patients [41]. Increased efficiency through improved use of space and staff time, better teamwork and accountability, task-shifting, expanded training, and improved patient satisfaction are all strategies that may support continued ART expansion without negatively impacting existing programs [20, 39‐41]. Going forward, it will be important to monitor how new models of care alter the relationship between ART and other services, to both avoid potential strains on resources and maximize synergies.

The findings of this study should be viewed in light of some limitations. First, we could not account for potential shifts in quality of services provided during the introduction and scale-up of ART. The potential exists that in order to meet increased patient loads, less time was spent with patients, and quality of care suffered [16, 41]. On the other hand, prior studies demonstrate that service quality can improve amid investments in laboratories, provider trainings, supply chains, and facility infrastructure, all of which occurred in Kenya and Uganda during their scale-ups of ART [16, 42]. Second, record-keeping and data quality varied substantially by facility, and it is possible that facilities with ART have benefited from investments in improved health information systems [43]. However, in comparing rates of data missingness and entry errors across facilities, we did not find evidence of systematic differences between facilities with and without ART. Finally, we do not truly know what would have happened to OPD services in the absence of ART at facilities that provided both services. Without this counterfactual, we sought to compare facilities with ART to those without ART. However, it is possible that facilities without ART fundamentally differed from facilities with ART. We sought to control for these differences by including several facility characteristics in our analyses, but we could not account for every possible factor, such as task shifting and changes in the catchment population of each facility. Therefore, some unobserved confounding factors may remain.

Drawing from a nationally-representative facility data set in Kenya and Uganda, we found that the presence, scale-up, overall, and relative size of facility-based ART programs had no statistically significant impact on OPD visits. At the national level, we did not observe a “crowding-out” of OPD services as ART expanded both within facilities and to new facilities. Recent changes in ART recommendations may result in an additional influx of patients seeking ART services, and our study suggests that this may be possible without negatively affecting OPD services. Nonetheless, ongoing monitoring of facility-specific needs and resource use will be critical to both improving service provision and minimising strains to health systems.