ACCESS GAINS AND LOSSES OF ‘DOWN-REFERRAL’
Decentralisation of patients taking ART from hospitals to PHC centres in rural
South AfricaMosa Moshabela, Helen Schneider, Susan Cleary, Paul Pronyk and John Eyles
6TH IAS Conference 20TH July 2011, Rome, ITALY
Background
Centralized ART Delivery Systems
• Introduction of ART through major hospitals down the hierarchy of the SA health system (NDOH):
Also, Boyer et al. 2010, Bemelmans et al. 2010
Tertiary
Secondary
District
Why Down-referral?• Supply-side factors:– Hospitals have reached capacity, Human resource
shortages Strengthening the nurse-driven Primary Health
Care System• Demand-side factors:– Loss to follow up attributed to distances, costs ART access “reaching those at the margins of the
health system”Bedelu et al. 2007, Decroo et al. 2009, Chan et al. 2010
METHODS
In 2008, REACH• 5-year project Researching Equity and ACcess to Health
care • A-Framework of access: availability, affordability and
acceptability (Knowledge and interaction)• 1266 participants across 4 diverse provinces, 2 rural
and 2 urban sub-districts selected• Included +18 years and minimum of 2 weeks since ART
initiation• Exit-interviews conducted and reviewed clinical records• Also, in-depth interviews, quality of care inventories,
quality of care observations
RESULTS
HospitalUsers
Down-Referred
Users
Bivariate Regression Model
Variable Category N=220 (%) N=109 (%) Odds Ratio
95% Confidence Interval
P-value
Socio-demographicAge (Years) 50 or older 39 (17.7) 29 (26.6) 1.68 0.92-3.06 0.089Sex Female 168 (76.4) 80 (73.4) 0.85 0.63-1.16 0.317Marital Status Widowed/
Separated96 (43.6) 52 (47.7) 1.18 0.82-1.69 0.376
Formal Education
None 35 (15.9) 32 (29.4) 2.20 1.09-4.44 0.028
Employment None 180 (81.8) 86 (78.9) 0.83 0.32-2.18 0.707Socio-economic Status
Poorer (Lowest 40%)
108 (49.1) 48 (44.0) 0.86 0.56-1.20 0.296
Disability Grant Yes 111 (50.5) 34 (31.2) 0.45 0.18-1.13 0.089
AVAILABILITY AFFORDABILITY ACCEPTABILITY Closest to home (Yes)
↑ ART Visit Costs-Transport & Meals (Mean)
↔ Waiting Queues (Too long)
↓
Mode of travel (Walking)
↑ Costs of Additional Health Care (Mean)
↔ Provider Attitude (Respectful)
↑
Home visits for HIV (Yes)
↔ Having to Incur Health Care Costs (Easy)
↔ Provider Preference (Dr over Nurse)
↑
ART Collection Frequency (2-monthly or more)
↔ Perceived Community Stigma (Yes)
↓
Travel Time (Mean Hours)
↓
CLINICAL CHARACTERISTICS CATEGORY
Short-term ART Adherence Previous 3 Days >95% ↔
Long-term ART Adherence No Missed Doses Since Initiation
↑
CD4 Count Knowledge Yes (Most recent CD4 value) ↓
Duration on ART Mean Months ↑
CD4 Count at ART Initiation Mean Cells/ul ↔
Most Recent CD4 Count Mean Cells/ul (Sub-sample) ↔
Viral Load Suppression <400 copies/ml (Sub-sample) ↓
ADDITIONAL HEALTH CARE-SEEKING
Odds Ratio
95% Confidence
Interval
P-value
Tuberculosis Clinic ↑ 3.63 1.09-12.01 0.035
Private Chemist ↔ - - -
Private Doctor ↑ 7.09 3.86-13.04 <0.001
Traditional Healer ↔ - - -
Self-Care Practice ↑ 4.91 2.37-10.17 <0.001
Undesired Effects of Down-Referral in Rural South Africa
Skilled Care
Prefer Doctor than a Nurse
Consult Private Doctors
Practice Self-Care
Knowledge Poor CD4 count Knowledge
Catastrophic Health Care Expenditure
Lack of Formal Education
Factors associated with Down-referral
Is health care adequate?
Conclusions
• Down-referred patients save time and may save money • Down-referred patients also perceive less stigma and feel
more respected• However, complementary health care increased; ‘better
skilled’ staff and self-care behaviour• Associated increased catastrophic health care
expenditure• Need to ensure use of trained nurses, good quality of
care and equivalent packages of care• Otherwise, economic gains of down-referral remain
under threat
Acknowledgements• Global Health Research Initiative (GHRI), a collaborative
research funding partnership of the Canadian Institutes of Health Research, the Canadian International Development Agency, Health Canada, the International Development Research Centre, and the Public Health Agency of Canada.
• Participants, REACH team, Department of Health in South Africa, participating public sector institutions, partnering academic institutions, research collaborators and research-user partners.
• We are thankful to Dr Marie-Andree Somers for statistical input.
• Discovery Foundation Academic Fellowship, Moshabela
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