ACCESS GAINS AND LOSSES OF ‘DOWN-REFERRAL’ Decentralisation of patients taking ART from hospitals to PHC centres in rural South Africa Mosa Moshabela, Helen Schneider, Susan Cleary, Paul Pronyk and John Eyles 6 TH IAS Conference 20 TH 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 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

Hospital Users Down- Referred Users Bivariate Regression Model VariableCategoryN=220 (%)N=109 (%) Odds Ratio 95% Confidenc e Interval P- value Socio-demographic Age (Years)50 or older39 (17.7)29 (26.6) SexFemale168 (76.4)80 (73.4) Marital Status Widowed/ Separated 96 (43.6)52 (47.7) Formal Education None35 (15.9)32 (29.4) EmploymentNone180 (81.8)86 (78.9) Socio-economic Status Poorer (Lowest 40%) 108 (49.1)48 (44.0) Disability GrantYes111 (50.5)34 (31.2)

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 CHARACTERISTICSCATEGORY Short-term ART AdherencePrevious 3 Days >95% ↔ Long-term ART Adherence No Missed Doses Since Initiation ↑ CD4 Count KnowledgeYes (Most recent CD4 value) ↓ Duration on ARTMean Months ↑ CD4 Count at ART InitiationMean Cells/ul ↔ Most Recent CD4 CountMean 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 ↑ Private Chemist ↔--- Private Doctor ↑ <0.001 Traditional Healer ↔ --- Self-Care Practice↑ <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