Project ID: 102770
Status: Active
Duration: September – January 2006
IDRC Funding: CAD $1,129,750
Recipient Institution(s): UCT Lung Institute, University of the Free State, CIET Africa
IDRC Funding Unit(s): Governance, Equity and Health (GEH)

**click here to download this project's two-page brochure
**click here to download the "Operational Public Sector ART" abstract

Background

South Africa, with a population of 42 million, has more HIV-positive citizens than Europe, Canada and the United States combined. The burden of opportunistic infections is increasing and life expectancy is dropping, estimated to fall below 40 years of age by 2010. Following contentious political debate, the national government announced in August 2003 that it would provide universal anti-retroviral treatment (ART) and follow-up care to those in need.

Amid strong concerns that providing universal ART coverage might overburden an already fragile health system, the rollout of ART began nationwide in June 2004. To address these legitimate concerns, there is need for a rigorous assessment of a range of ART’s potential impacts: on patients, communities, and health workers; on existing curative and preventative programmes; on corruption and system leakage; and finally on the broader socio-political dynamics at play in South Africa.

The Free State is one of nine provinces in South Africa and has a population of 2.8 million. It is home to 500,000 HIV-infected citizens, 30,000 of whom are eligible for ART treatment, with about the same number joining this group each year. In September 2003, the Free State Department of Health approached the GEH-supported PALSA project (Practical Approach to Lung Health South Africa), recognizing the many shared attributes between PALSA and a programme that might be suitable for ART implementation. Building on a long relationship with researchers at the University of the Free State, the FSDoH eventually invited the PALSA research group to assist in the planning, training, rollout and evaluation of an eventual province-wide ART rollout, with research providing visibility, transparency and accountability to the roll-out process and improving the effectiveness and strength of the primary health care system itself.

The Project

The Free State began distribution of anti-retrovirals in June 2004, with a target of 2,166 patients in its first year of operation. However, despite the commitment of the Free State government, like other provinces the Free State is facing major implementation challenges, among them the procurement of sufficient quantities of drugs. The South African national ART policy, in conjunction with the commitment of the FSDoH to implementation, provides an opportunity for operational research to add value to both policy and programming.

Project Objectives

The project has been divided into two phases. The first phase began in March 2004, with the overarching goal of collecting baseline data on community and health system perceptions and performance related to the access and utilization of HIV-related and preventive health and social services – which may be positively or negatively affected by the ART rollout campaign. Secondly, the first phase attempted to consolidate the partnership with the FSDoH and other key stakeholders through implementing pre-rollout training activities and finalizing a collaborative longitudinal monitoring and evaluation research programme aimed at informing and strengthening public health sector capacity to implement an effective, accountable and equitable ART rollout in the Free State. The second phase will continue to document, support and evaluate the policy process and the implementation. At the health system and policy level it will analyze the impacts of the roll-out on clinics, health workers, patients/clients, other priority programmes, and the policy process. It will also assess the effectiveness and impacts on quality of care of workplace-based face-to-face versus conventional training of health workers in anti-retroviral therapy, using guidelines developed through the IDRC-supported PALSA project. At the community level, it will monitor perceptions, institutional and community data on system access, functioning and leakage, and communicate solutions for reducing system leakage, increasing the effectiveness of health services, and strengthening linkages between community-based activities and health services. The combined two phases address issues of strengthening health systems, governance and accountability. It is a collaborative project involving two South African universities, one South African NGO, a Canadian university, and the FSDoH.

The combined two phases address issues of strengthening health systems, governance and accountability:

1. Support the government’s effort to strengthen the primary health care system to deal with the HIV/AIDS burden in the Free State.
2. Build accountability and improve the effectiveness of the service offer to citizens through evaluating training of health workers and documenting the impact of the ART rollout in the Free State at the institutional (including clients/patients) and community level.
3. Inform and strengthen public health sector capacity to implement an effective, accountable and equitable ART rollout in the Free State and potentially other provinces and other parts of Southern Africa.

Project specific objectives

1. Based on analysis of combined community and service data, elaborate and communicate community-led solutions for reducing system leakage and increase the effectiveness of the health service offer.
2. Measure the community-level impact of modification of health service practices as a consequence of changes in strategies by the Health Department and other agencies.
3. Examine how ART influences clients/patients over a two year period.
4. Examine the relationships and influence between the ART programme and health services.
5. Document the context, processes and policies of the ART rollout in the Free State.
6. Provide face-to-face training of nurses on the PALSA PLUS guidelines and support materials in the eight intervention clinics.
7. Conduct a qualitative evaluation of the training process and the implementation of the PALSA PLUS guidelines in the eight intervention clinics.
8. Determine if face-to-face training of the PALSA PLUS guidelines improves quality of care of HIV/AIDS care over and above the planned training strategies in the Free State.
9. Document the cost of the face-to-face training and support for implementation of PALSA PLUS in the Free State.
10. Study the impact of the ART rollout on priority health programmes, specifically tuberculosis and childhood immunisation.
11. Facilitate and support the research and development process; take up research results with policy and programme implications with a view to improving service delivery.

Expected Outcomes

The project will provide a comprehensive picture of the expectations and perceptions regarding public sector ARVs among a variety of stakeholders. The pre-exposure baseline will be essential to understand and attribute subsequent impact of the rollout programme over time, contributing to a comprehensive and evidence-based understanding of the context into which ARVs will arrive. Baseline research will also play a vital role in consolidating relationships of trust and collaboration both among the research teams and between the research programme as a whole and the other key stakeholders. The programme holds the potential for research to contribute in a lasting way to health policy, management and care - informing other provinces, and potentially other parts of Southern Africa, by providing evidence for effective national and regional anti-retroviral rollouts.

Project Contacts

CIETAfrica
Neil Anderson: neil@ciet.org  

Free State Department of Health
Eric Bateman: ebateman@uctgsh1.uct.ac.za  

University of the Free State
Dingie van Rensburg vrensh.hum@mail.uovs.ac.za  

Relevant Links

Operational Plan for Comprehensive HIV and AIDS Care, Management and Treatment for SA
Treatment Action Campaign
CIET South Africa
Centre for Health Systems Research and Development, University of Free State
Free State Health Portal

• Public Sector Anti-Retroviral Treatment (ART) South Africa (Phase I)
  

• Terms and Definitions