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