Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2018 Apr 25;14(1):40.
doi: 10.1186/s12992-018-0351-z.

Scaling up ART adherence clubs in the public sector health system in the Western Cape, South Africa: a study of the institutionalisation of a pilot innovation

Hayley MacGregor  1 , Andrew McKenzie  2 , Tanya Jacobs  3 , Angelica Ullauri  4
Affiliations

Scaling up ART adherence clubs in the public sector health system in the Western Cape, South Africa: a study of the institutionalisation of a pilot innovation

Hayley MacGregor et al. Global Health. .

Abstract

Background: In 2011, a decision was made to scale up a pilot innovation involving 'adherence clubs' as a form of differentiated care for HIV positive people in the public sector antiretroviral therapy programme in the Western Cape Province of South Africa. In 2016 we were involved in the qualitative aspect of an evaluation of the adherence club model, the overall objective of which was to assess the health outcomes for patients accessing clubs through epidemiological analysis, and to conduct a health systems analysis to evaluate how the model of care performed at scale. In this paper we adopt a complex adaptive systems lens to analyse planned organisational change through intervention in a state health system. We explore the challenges associated with taking to scale a pilot that began as a relatively simple innovation by a non-governmental organisation.

Results: Our analysis reveals how a programme initially representing a simple, unitary system in terms of management and clinical governance had evolved into a complex, differentiated care system. An innovation that was assessed as an excellent idea and received political backing, worked well whilst supported on a small scale. However, as scaling up progressed, challenges have emerged at the same time as support has waned. We identified a 'tipping point' at which the system was more likely to fail, as vulnerabilities magnified and the capacity for adaptation was exceeded. Yet the study also revealed the impressive capacity that a health system can have for catalysing novel approaches.

Conclusions: We argue that innovation in largescale, complex programmes in health systems is a continuous process that requires ongoing support and attention to new innovation as challenges emerge. Rapid scaling up is also likely to require recourse to further resources, and a culture of iterative learning to address emerging challenges and mitigate complex system errors. These are necessary steps to the future success of adherence clubs as a cornerstone of differentiated care. Further research is needed to assess the equity and quality outcomes of a differentiated care model and to ensure the inclusive distribution of the benefits to all categories of people living with HIV.

Keywords: ART adherence; Chronic illness; Complex adaptive systems; Differentiated HIV care; HIV; Health system; Innovation; Scaling up; South Africa.

PubMed Disclaimer

Conflict of interest statement

Authors’ information

Hayley MacGregor is a medical anthropologist and co-leads the Health and Nutrition research cluster at the Institute of Development Studies. She originally completed medical training in South Africa. Andrew McKenzie is a public health doctor with extensive experience in strengthening health systems in sub-Saharan Africa. Tanya Jacobs is an independent consultant in public Health in South Africa. Angelica Ullauri has just completed a MPH at the University of Cape Town and was involved in the health systems and epidemiological component of the adherence club evaluation.

Ethics approval and consent to participate

The full project was approved by the Human Research Ethics Committee, University of Cape Town Faculty of Health Sciences, HREC REF 535/2015. Permission was also granted by the Western Cape Provincial Department of Health to work in the sample of facilities. Informed consent was obtained prior to all interviews.

Consent for publication

Professor Andrew Boulle has reviewed this manuscript as Principal Investigator of the UCT-held grant from the Bill and Melinda Gates Foundation and approved publication of the material. Written informed consent was obtained from the interview participants for reference to their anonymised views in the analysis of this manuscript. The consent forms are held by the authors and are available for review by the Editor-in-Chief.

Competing interests

The authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

References

    1. Boulle A, Schomaker M, May M, Hogg R, Shepherd B, Monge S, Keiser O, Lampe F, Giddy J, Ndirangu J, Garone D, Fox M, Ingle S, Reiss P, Dabis F, Costagliola D, Castagna A, Ehren K, Campbell C, Gill M, Saag M, Justice A, Guest J, Crane H, Egger M, Sterne J. Mortality in patients with HIV-1 infection starting antiretroviral therapy in South Africa, Europe, or North America: a collaborative analysis of prospective studies. PLoS Med. 2014;11(9). 10.1371/journal.pmed.1001718. - PMC - PubMed
    1. Boulle A. Antiretroviral therapy and early mortality in South Africa. Bull World Health Organ. 2008;86(9):678–687. doi: 10.2471/BLT.07.045294. - DOI - PMC - PubMed
    1. Osler M, Hilderbrand K, Hennessey C, Arendse J, Goemaere E, Ford N, Boulle A. A three-tier framework for monitoring antiretroviral therapy in high HIV burden settings. J Int AIDS Soc. 2014;17(1):1–8. doi: 10.7448/IAS.17.1.18908. - DOI - PMC - PubMed
    1. du Plessis J. The chronic dispensing unit. SA Pharm J. 2008;75(9):46–47.
    1. Thompson M, Mugavero M, Amico K, Cargill V, Chang L, Gross R, Orrell C, Altice F, et al. Guidelines for improving entry into and retention in care and antiretroviral adherence for persons with HIV: evidence-based recommendations from an International Association of Physicians in AIDS care panel. Ann Intern Med. 2012;156(11):817. doi: 10.7326/0003-4819-156-11-201206050-00419. - DOI - PMC - PubMed

Publication types

Substances