Assessing the level of institutionalization of donor-funded anti-retroviral therapy (ART) programs in health facilities in Uganda: implications for program sustainability

Abstract

Background: In the context of declining international assistance for ART scale-up in Sub-Saharan Africa, the institutionalization of ART programs through integrating them in the organizational routines of health facilities is gaining importance as a program sustainability strategy. Objective: The aims of this study were; (i) to compare the level of institutionalization of ART programs in health facilities in Uganda and (ii) to explore reasons for variations in the degree of program institutionalization. Methods: In Phase One, we utilized Level of Institutionalization Scales developed by Goodman (1993) to measure the degree of institutionalization of ART interventions in 195 health facilities across Uganda. The 45-item questionnaire measured institutionalization based on four sub-systems (production, maintenance, supportive, managerial) theorized to make up an organization assessed against two levels of institutionalization; routines (lowest) niche saturation (highest). In Phase Two, four health facilities were purposively selected (2 with the highest and 2 with the lowest institutionalization scores) for a multiple case-study involving semi-structured interviews with ART clinic managers(n = 32), on-site observations and document review. Results: The two highest scoring health facilities had a longer HIV intervention implementation history of between 8 and 11 years. The highest scoring cases associated intervention institutionalization with sustained workforce trainings in ART management, the retention of ART-trained personnel and generating in-house ART manuals. The turnover of ART-proficient staff was identified as a barrier to intervention institutionalization in the lowest-ranked cases. Significant differences in organizational contexts were identified. The two highest-ranked health facilities were well-established, higher-tier hospitals while the lowest scoring health facilities were lower-level health facilities. Conclusions: The level of institutionalization of ART interventions appeared to be differentiated by level of care in the Ugandan health system. Interventions aimed at strengthening program institutionalization in lower-level health centers at the level of human resources for health could enhance ART scale-up sustainability.

“The number of clients is increasing but the supplies are reducing”: provider strategies for responding to chronic antiretroviral (ARV) medicines stock-outs in resource-limited settings: a qualitative study from Uganda

“…Uganda piloted a national ART roll-out program between 2004 and 2009 with external donor support from The President’s Emergency Plan for AIDS relief (PEPFAR) and The Global Fund to fight AIDS, Malaria and Tuberculosis [23, 24]. The national ART roll-out program commenced initially at the level of national and regional referral hospitals and was subsequently extended to lower-level health facilities [25], including in small for-profit clinics [2].…”

Training Exposure and Self-Rated Competence among HIV Care Providers Working with Adolescents in Kenya

“…Health care worker respondents were mostly female (71.8%), a median of 33 years old (IQR: [29][30][31][32][33][34][35][36][37][38][39], and nearly all reported postsecondary education (95.8%). The HCWs reported a median of 4 years (IQR: 2-8) of experience providing HIV care for all-age populations and slightly fewer years in providing care specifically to ALWH (median ¼ 3 years, IQR:1-6).…”

“…High turnover of trained personnel has been reported in other settings and may contribute to the variable training exposure and lack of services following national rollout efforts. 37,38 Despite these barriers, HCWs reported a moderately high degree of self-rated competence in providing services to this population.…”

Sustainment of Diverse Evidence-Based Practices Disseminated in the Veterans Health Administration (VHA): Development and Administration of a Pragmatic Instrument

“…Goodman and Steckler de ne institutionalization as the "long-term viability and integration of a new program within an organization" [24]. Institutionalization is conceptualized as a deeper, more mature form of sustainment; where the practice is fully routinized and embedded into clinical practice, beyond just relying on the effort of a single person [25]. Basic sustainment (whether a practice is in use) would be a prerequisite for practice institutionalization.…”