Taking treatment of chronic lifelong conditions to scale: applying the positive deviance approach to health programme management

Lead Research Organisation: Institute of Development Studies
Department Name: Research Department

Abstract

In sub-Saharan Africa, and in South Africa in particular, there are significant numbers of people living with HIV/AIDS. Increasingly, there are growing numbers of people who are also living with non-communicable disease such as diabetes and heart disease. Although HIV is infectious and diseases like diabetes are not, they share similarities in that they require lifelong management to ensure health. HIV treatment requires a consistent regimen of antiretroviral therapy (ART), while diabetes may require a change in diet as well as regular medication. For policy makers planning health care in South Africa, it is a big challenge to make sure that the state health system has a cost-effective plan to keep these people on treatment and accessing care throughout their lifetime. Although the South African government has made ART available free of charge, recent studies have indicated that many with HIV stop taking the drugs over time. This problem has worsened as the programme has expanded. This is dangerous for their health and is also worrying from a public health standpoint as it could lead to strains of the disease that are resistant to ART as well as increasing the chance of them passing the virus on. Significantly, some clinics dispensing ART have much higher rates of people continuing to pick up their treatment. This study aims to fill knowledge gaps about the factors that influence whether people stay in care, focusing on the ART programme in the Western Cape Province of South Africa. The results of the research will help us work with policy makers in the Department of Health and leaders of community-based organisations to design a larger project that will involve implementing a country-wide programme to achieve more continuous care for people with chronic lifelong conditions.

The study will involve researchers from different disciplines who are trained in medicine, the analysis of health systems and policies, social anthropology, public health and pharmacy. We will adopt a method that analyses existing numerical data monitoring how regularly people are collecting the ART drugs at clinics, and other HIV-related data. This will be used to identify which health facilities are performing better than others in terms of keeping people on treatment and engaged in their clinical care. We will focus our work on facilities serving poor populations who are socially marginalised. We will then go on to do more in-depth research in a few facilities which we have assessed as "good performers" and "bad performers" respectively. We will look in more detail at the information about HIV care and also look at indicators of whether people with diabetes are staying in care, using diabetes as an example for non-communicable disease. We will also collect information by observing practices in clinics, and interviewing staff and patients. Interviews will be conducted with decision-makers in the provincial and national Departments of Health. We will investigate the reasons for differences in performance and identify constraints to positive performance. We suspect that the facilities that are managing to keep patients in care, have more innovative organisational practices and have in addition forged partnerships with community-based organisations. This can then help to better support people to take part in managing their chronic illness themselves as well. Such "self-management" is an important factor in poorer settings where the health system cannot provide intensive support from health professionals. We will identify generic factors that are helping to keep people on ART in care and that, if adopted more generally, could contribute to improving care for other chronic conditions also. We will have a workshop with the Department of Health and other stakeholders to discuss how the lessons learned can improve the programmes for chronic disease at national level. This will assist in the design of a bigger intervention and a further research proposal.

Technical Summary

The objective of this proposal is to conduct an interdisciplinary qualitative and quantitative study to address knowledge gaps about retention in care in the antiretroviral therapy (ART) programme in Western Cape, South Africa. This will inform the design of a larger intervention project with stakeholders for improving implementation, at scale, for a national-level programme to achieve high levels of treatment for chronic lifelong conditions (CLLCs). This study will adopt a "positive deviance" approach for implementing health programmes by identifying facilities which are outliers and analysing constraints to good performance for retention in care. We hypothesise that good performance relies on partnerships between the formal health system and community organisations to support disease self-management. The study will address these questions:
- What are the most important factors contributing to good performance for retention in care for facilities that are positive deviants in the ART programme?
- What are the major constraints to similar performance in other localities and how could an intervention for disseminating lessons from positive deviants help stakeholders overcome them?
- Which generic factors from the ART programme could contribute to good performance for other CLLCs?
Phase 1 of the study involves desk-based validation of the central database for chronic medication distribution and the routine management data from facilities for HIV. Facilities will be mapped by typology and paired according to an analysis of good and bad performers for retention in care for ART. In Phase 2, facility-level studies will involve investigating the data for HIV and also diabetes, as a tracer condition for all NCD. Qualitative research will explore the reasons for differences between facilities. In Phase 3, data analysis will facilitate communication of lessons learned and Phase 4 will involve a workshop with stakeholders to design a large scale intervention for CLLCs.

Planned Impact

This initial proposal has a number of direct beneficiaries, mainly within the HIV/AIDS community in the Western Cape. The project is also designed in such a way that it has the potential to inform further work with even wider beneficiary groups, both geographically and those with other chronic lifelong conditions (CLLCs), such as diabetes.

As is clear from the attached letter of support, this project would be implemented in collaboration with the National Department of Health in South Africa. The University of Western Cape is currently responding to a request of the Provincial Department of Health of the Western Cape to investigate the dispensing of chronic medication by a contracted pharmaceutical company. In the Western Cape, this distribution of medication, including ART, thus already exists, the users of which will be the ultimate beneficiaries of this research. Below is a list of beneficiaries and how they stand to benefit from this research:

* Low income populations in the Western Cape in need of ART: By identifying transferable factors in facilities with higher-than-average retention rates in ART, the expectation is that other facilities in the area will also be able to improve their retention rates. Ultimately this has the potential to improve the health and wellbeing of those living with HIV. Retaining HIV positive individuals in ART is critical in reducing further infections (treatment as prevention) as well as in limiting the evolution of ARV-resistant strains of the HI virus. This has potential economic benefits as well, allowing them to remain productive members of society while simultaneously reducing potential time and monetary costs associated with their care.

* Local facilities: Both facilities that are currently above-average performers and those who are below-average performers may benefit from findings about what factors contribute positively to ART retention rates. This could improve efficiency in ART distribution for the pharmacuetical distribution company, as well as the inconvenience to facilities of returning undelivered stock.

* Local community-based organisations (CBOs) and civil society organisations (CSOs): Local CBOs, patient advocacy groups and other CSOs - such as the Treatment Action Campaign, the Community Media Trust and Medicins Sans Frontieres - will be included in the communication of findings from the proposed study. The hope is that they will be able to use that information to hold facilities to account and maintain pressure on them to implement relevant changes.

* Western Cape Department of Health: By improving the retention rate across facilities, the provincial Department of Health may benefit from greater efficiencies in the distribution of ART and less leakage within the current system. Greater adherence to ART may also reduce the rate of new HIV infections, which could have significant cost savings for the province across drugs, facilities and workforce.

Following this development study, should we be successful in acquiring further funding, we would hope that these benefits could be made on a wider scale, both geographically and in terms of other CLLCs. This is further articulated in the Impact Pathways section of this proposal. But to summarise, other provincial Departments of health, notably from the Eastern Cape, a resource-poor province, have expressed interest in research collaboration. At a national level, the Department of Health is currently being challenged to re-engineer primary care as part of its commitment to universal health coverage (UHC). Lessons from this study could inform the future design of national programmes to support people with a number of CLLCs, including diabetes and HIV/AIDS.

Publications

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Kelly AH (2017) The publics of public health in Africa. in Critical public health

 
Description Health systems thinking reinforced in provincial Department of Health
Geographic Reach Local/Municipal/Regional 
Policy Influence Type Influenced training of practitioners or researchers
 
Description Influence on understandings of differentiated care for HIV
Geographic Reach National 
Policy Influence Type Influenced training of practitioners or researchers
 
Title Qualitative methods for applying complex adaptive systems thinking in health system research 
Description The above 'type' does not adequately describe the qualitative research tools that were developed by the research team. Hayley MacGregor and Gerry Bloom attended a Future Health Systems meeting on health systems as complex adaptive systems in 2014. This stimulated thinking about how to combine interview and other qualitative methods in the scoping study to ask questions about components of the health system and synergies between them, and to identify focal innovation in the health system. 
Type Of Material Model of mechanisms or symptoms - human 
Provided To Others? No  
Impact Hayley MacGregor will lead on a publication to explain how the complex adaptive systems framing of the scoping study and these methods aided our research and our analysis. 
 
Title Dataset from scoping study research 
Description The research team conducted research as part of the scoping study activities in the Development grant which has generated a significant qualitative dataset for analysis. This research started in August 2014 and completed in January 2015. The grant funded a scoping study of the ART treatment programme in six facilities in Western Cape. We adopted a "positive deviance" approach with the aim of identifying factors contributing to substantially better performance by some facilities with respect to retention in care (RiC) for HIV: three pairs of facilities were matched according to the nature of the HIV programme in terms of patient numbers and services provided, and characteristics of the population served. One pair was in a rural district and the other two were in the urban Cape metro. All facilities served populations of low socio-economic status. Prof. Boulle from the Western Cape Department of Health (now a collaborator) assisted with analysis of province-wide data comparing facilities according to percentage of people retained in care during 2013. Facilities were paired with one of the pair having a higher percentage. At each facility the team organised two sub-studies: one on programme organisation (management, staffing, a facility "champion" for RiC, organisation of care, data entry and engagement with HMIS data, and adherence models) and another on community orientation of facilities (partnerships with NGOs and deployment of community health workers, the systems for tracing patients lost to care, decentralised drug distribution and adherence "clubs"). Methods included: mapping the organisation of care, staffing, and NGO partnerships; observation; and interviews with staff and with patients. The team also interviewed management staff at provincial, district and facility level to explore how the system works for RiC, their opinion about key components of the system, local innovations and ways to improve the system. We triangulated these perspectives with the observations at facility level. We found that it was difficult to identify facilities performing substantially better than others in terms of RiC on account of shortcomings of the health management information system and very little difference between facilities in RiC indicators. However, we identified focal innovation and minor differences in programme management. We also identified organisational and institutional factors that contributed to loss of people to care. We noted the potential value of the existing management tools in the HIV programme, although we observed that there was no facility where potential synergies between these management approaches were fully leveraged. These findings allowed us to identify factors that would enable the system to achieve higher levels of RiC and the barriers to good performance in terms of the following conceptual lenses: (1) system operation (such as programme performance and dynamic interaction of components, incentive structures, staff champions and staff attitudes, infrastructure, drug distribution) (2) management approaches and health information (such as roles and responsibilities of personnel, management legacy, management tools, HMIS); and (3) therapeutic partnership between facilities and patients (such as patient-provider interactions, community partnerships, patient tracing and care). Barriers and strategies for addressing them now merit further investigation in a future research proposal, using these conceptual lenses. We found that facility managers were very concerned about several planned policy changes and the effect these might have on performance in the HIV programme. They said they were overwhelmed by responding to changes and providing services. Policy-makers at provincial level recognised that directives for improving the system are often not implemented as envisaged. It was noted that facilities rarely use monitoring and management data to improve services and that there is insufficient ownership of the programme at this level to encourage innovation beyond micro-experimentation. 
Type Of Material Database/Collection of data 
Provided To Others? No  
Impact We used the research findings to engage with the National and Provincial Departments of Health and to discuss a potential future intervention to improve performance in programmes providing care and support for HIV positive people as well as patients with other chronic lifelong conditions. Western Cape has published a vision for integrated Primary Health Care by 2030 and has made it a priority to address equity and improve care of people with non-communicable diseases substantially. It plans to adapt the management systems it created for ART for other chronic lifelong conditions (CLLCs). Our research and engagement with the Department of Health has aimed at contributing to this planning. The National DoH is publishing a white paper on national health insurance, developing policy and implementation plans for 'ideal' Primary Health Care clinics, and building outreach community care. These developments make the findings of this research very timely. The failure of health systems to respond to the increasing prevalence of CLLCs and provide effective care has had a deleterious impact on the health and livelihoods of the poor in South Africa and many LMICs. The findings of this study have provided an opportunity to engage in these discussions. We organised meetings with senior management in the Western Cape DoH and at national level. We concluded that the "ART Programme" is better viewed as a number of health system components that need to work together, rather than as an autonomous administrative entity, and that it is important to understand the complex context within which any intervention is implemented. This is important in the light of debates about whether to continue earmarked funds for HIV and the plans to provide similar levels of care and support to people with non-communicable diseases. Since we could not identify positive deviants from whom to learn "best practice approaches", we agreed that the best strategy was to implement an organisational change intervention as a way of learning about the operation of the system, the major barriers to improvement and strategies for overcoming these barriers. This would involve finding ways to improve the performance of the ART programme and to extend this approach to cover people with diabetes, using modified versions of the available management tools and approaches. These conclusions formed the basis for a full proposal that was submitted to the HSRI scheme in 2015. This application was not successful in obtaining funding, but we are actively pursuing other funding possibilities. The collaboration with Andrew Boulle from the Western Cape DOH and UCT, and with Andrew McKenzie from HPI Institute, will continue as we collaborate at present in research on ARV clubs in the Western Cape and their role in retaining HIV positive patients in care. 
 
Title dataset from Health system analysis for Gates work 
Description We conducted and recorded interviews with the same range of health care providers in 14 health facilities, and with district and provincial level managers and practitioners. We also typed up fieldnotes from observation in the facilities. 
Type Of Material Database/Collection of data 
Provided To Others? No  
Impact The analysis of the interview data allowed us to identify and refine the thematic and conceptual categories for our report. 
 
Description Development Grant partners 
Organisation University of Glasgow
Department Public Health
Country United Kingdom 
Sector Academic/University 
PI Contribution The School of Public Health were research partners on the Development grant. The time of Prof Wim van Damme was covered by a South African National Research Foundation SARCHI grant for his position as a research chair at UWC. He had to withdraw from the grant in Nov 2014 due to sickness. Prof van Damme's SARCHI funding also covered the stipend for Ferdinand Mukumbang, who was one of the research assistants in the scoping study as a pre-doctoral student. He went on to become a full doctoral student at UWC in 2015.
Collaborator Contribution Dr Hazel Bradley from UWC contributed to the development of a full proposal to the HSRI initiative. This application was unsuccessful and we intend to seek alternative funding for this research. She is involved in these discussions.
Impact Hayley MacGregor and Hazel Bradley intend to write a paper on the community distribution of drugs for patients with chronic lifelong conditions, based on the fieldwork in the Development grant.
Start Year 2013
 
Description Exchange of ideas for a focus for following research. 
Organisation Government of South Africa
Department Department of Health
Country South Africa 
Sector Public 
PI Contribution Dr Gerry Bloom discussed findings from the study and possibilities for next steps with Dr Yogan Pillay (South African National Department of Health, HIV directorate) at an international meeting on Universal Health Coverage. Dr Pillay subsequently shared recent work from the Department of Health published in the South African Medical Journal on clinical practice guidelines for the National Health Insurance programme. Dr Andrew McKenzie, who is resident in South Africa, has subsequently been in contact with Yogan Pillay to meet in Pretoria to discuss priority areas for further research.
Collaborator Contribution Dr Andrew McKenzie has developed into a key research partner and with Hayley MacGregor and Gerry Bloom would like to develop further research with the South African Department of Health.
Impact We hope to develop a new research proposal.
Start Year 2018
 
Description Health Systems components for scale up of the antiretroviral club model for retention of HIV positive patients in South Africa 
Organisation Health Partners International (HPI)
Country United Kingdom 
Sector Hospitals 
PI Contribution During the HSRI Development grant, IDS approached Dr Andrew McKenzie, a highly experienced South African consultant on organizational change in health systems in Africa. We collaborated from November 2014 around the discussion with the Western Cape and National Departments of Health in South Africa regarding the design of an intervention to improve performance of the programme offering care for HIV positive people, and to extend that learning to other chronic lifelong conditions. We then established a formal collaboration to apply for a full HSRI grant, which was unsuccessful. Dr McKenzie has been a research partner for the health systems work that we were contracted to do on the Gates grant led by Andrew Boulle at the University of Cape Town. He worked with Hayley MacGregor to design this research and they will conduct the fieldwork together with Tanya Jacobs, and independent consultant on primary health care in South Africa, and Angelica Ullauri, a MPH student at the University of Cape Town
Collaborator Contribution IDS subcontracted Andrew McKenzie as a research partner in the health systems work for the University of Cape Town. He conducted fieldwork led by Hayley MacGregor to do a health systems evaluation of Adherence Clubs for chronic HIV care in the Western Cape Province.
Impact The output of this collaboration has been a health system contribution to the report that UCT will prepare for the Gates Foundation. The written report was submitted to Professor Andrew Boulle and to the Western Cape Department of Health in December 2016.
Start Year 2014
 
Description Health Systems components for scale up of the antiretroviral club model for retention of HIV positive patients in South Africa 
Organisation University of Cape Town
Department School of Public Health and Family Medicine
Country South Africa 
Sector Academic/University 
PI Contribution The collaboration started in June 2014 when we approached Prof Andrew Boulle (jointly appointed at Western Cape Department of Health and University of Cape Town) to assist us with the analysis of Western Cape provincial data for retention in care at facility level. This assisted in our selection of clinic sites for the scoping study research in the HSRI Development grant. We had conceptualised a 'positive deviance' approach and needed to identify clinics that were performing better with respect to quantitative indicators of retention in care. Hayley MacGregor remained in contact with Prof Boulle and discussed the emerging findings from the qualitative research in the scoping study as these related to epidemiological analysis of retention in care that he was conducting. In 2015 we decided to pursue formal research collaboration in the area of chronic lifelong conditions and retention in care. We submitted a full proposal to HSRI that was unsuccessful. University of Cape Town is the holder of a Gates Foundation grant (Andrew Boulle is PI) to examine conditions that would facilitate the scale up of an 'ARV club' model to improve retention in care for HIV. University of Cape Town subcontracted Institute of Development studies and our partners to do the health systems component of this work and we conducted and completed the work in 2016.
Collaborator Contribution In 2016 a proportion of the funding from an existing Gates Foundation grant has been allocated from University of Cape to the Institute of Development Studies. Following our discussions the collaborators at UCT have decided to include a health systems component in the research plan, which is focused on conditions that facilitate the scaling up of a intervention in the Western Cape to establish antiretroviral adherence clubs to improve retention in care for HIV. Hayley MacGregor at IDS led a team to do this work, which started in late March 2016, in collaboration with UCT and Andrew McKenzie (HPI Institute) and Tanya Jacobs.
Impact We started the research for this work from late March 2016. We completed the work at the beginning of June and submitted a draft report to the department for feedback in September. We presented the findings in August 2016 and the final report was submitted in December 2016. Our report complements the epidemiological analysis that has been led by Prof Boulle, by contributing research material and analysis of the health system components required for successful scale up and diffusion of the antiretroviral club model in the Western Cape and beyond. The Gates Foundation is interested in analysis of how the model has been established in the Western Cape, what the conditions are that enhance sustainability of the intervention, and what aspects of the model are applicable for dissemination elsewhere in South Africa and other countries facing a similar burden. In South Africa there is interest from the Department of Health in the learning from this model for other chronic lifelong conditions.
Start Year 2014
 
Description Improving performance for programmes for care of chronic lifelong conditions in South Africa 
Organisation National Department of Health
Country South Africa 
Sector Public 
PI Contribution We established a partnership with both the provincial Western Cape Department of Health and the National Department of Health in South Africa for the HSRI Development grant research. Discussions helped us shape the focus of the scoping study and we were given access to six facilities in the Western Cape and access to meetings with key decision-makers. Both departments gave letters of support as partners on the Development grant application and on the follow up application for a full grant, which was unsuccessful. We have continued the collaboration with the Western Cape Department of Health through Prof Boulle, who has a joint appointment in the Western Cape Department of Health and the University of Cape Town. In 2016 we conducted a health systems evaluation of the use of adherence clubs for chronic HIV care in the Western Cape and presented a written report to the Western Cape Department of Health. We presented the findings of the evaluation to stakeholders in the Department of Health in August 2016.
Collaborator Contribution Dr Gerry Bloom engaged with Dr Yogan Pillay from the national HIV and TB programme around mutual learning between BRICS countries with respect to TB. Dr Yogan Pillay then contributed to an IDS policy brief led by Dr Bloom on this topic. Promoting mutual learning between BRICS countries was a key aspect of the impact plan for the grant.
Impact IDS Policy Brief on mutual learning between BRICS countries led by Co-PI Dr Gerry Bloom.
Start Year 2014
 
Description Skype call with CQUIN network at Columbia University 
Organisation Columbia University
Department Mailman School of Public Health
Country United States 
Sector Academic/University 
PI Contribution Our health systems work on ARV adherence clubs came to the attention of Peter Ehrenkranz (Senior programme officer, HIV Treatment) at the Gates Foundation . He in turn brought our work to the attention of Dr Miriam Rabkin, Director for Health Systems Strategies for ICAP, which is a health systems strengthening initiative of the Mailman School of Public Health at Columbia University. He arranged for us to have a skype call with Dr Rabkin to share insights. She was interested in the findings of our research and asked us to present these at their CQUIN network meeting in Mozambique in February.
Collaborator Contribution Hayley MacGregor, Andrew Boulle, and Andrew McKenzie joined a skype call. Andrew McKenzie attended the subsequent meeting in Maputo and presented our work to a large group from all over the continent, sharing experiences on health systems initiatives for differentiated care for HIV.
Impact Attendance at a meeting in Maputo and presentation of our research and findings that are currently in press for publication in Globalization and Health.
Start Year 2018
 
Description Conference of Public Health Association of South Africa (Durban) 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Professional Practitioners
Results and Impact Ferdinand Mukumbang, the pre-doctoral student involved in the project at the University of Western Cape (by this stage a full doctoral student), presented the findings of the scoping study research with Prof Brian van Wyk, a research team member from UWC.
Year(s) Of Engagement Activity 2015
 
Description Engagement with key NGO stakeholder for rural districts in the Western Cape 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Professional Practitioners
Results and Impact Research team members met with and initiated ongoing engagement with Dr Nelis Grobbelaar and his team at the PEPFAR-funded ANOVA Institute, a key NGO assisting in health systems strengthening in rural areas in the Western Cape, including the Winelands District where we had sites for the scoping study.
Year(s) Of Engagement Activity 2014
 
Description Large feedback meeting on research findings and plans for an intervention 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Professional Practitioners
Results and Impact The research team invited the different stakeholders and practitioners that we had engaged with or interviewed as part of the work of the scoping study in the Development grant. We hosted a big event at the University of Western Cape and presented the preliminary findings of our research and our plans for an intervention to be included in a full grant proposal to the HSRI scheme.
Year(s) Of Engagement Activity 2015
 
Description Meeting with Head of TB and HIV, National Department of Health and his deputies 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Policymakers/politicians
Results and Impact We had an initial meeting in Oct 2014 with the Head of HIV and TB for the national Department of Health, who was already a research partner in the Development grant and had engaged with Gerry Bloom in efforts to stimulate mutual learning between health policy-makers in BRICS countries. He then organised and chaired a wider dialogue at the National Department of Health in Pretoria, which was attended by his deputies and five members of the research team, as well as Dr Andrew McKenzie. The purpose of the meeting was to give feedback on initial findings from the scoping study (which was almost completed at that point) and to discuss an intervention for the full research proposal to the HSRI.
Year(s) Of Engagement Activity 2014
 
Description Meeting with head of the Cape Metro at the Provincial Department of Health and his deputies 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Professional Practitioners
Results and Impact This was a larger dialogue with policy makers and practitioners at the Western Cape Department of health with several members of the research team, as well as Dr McKenzie and Prof Boulle. We presented the preliminary findings of the scoping study which was just being completed, and discussed future collaboration in a full HSRI proposal. We laid out preliminary plans for an participatory intervention to improve and evaluate care for people with chronic lifelong conditions.
Year(s) Of Engagement Activity 2014
 
Description Meeting with policy-makers (National Department of Health) 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Policymakers/politicians
Results and Impact A member of the research team met with the lead consultant for the programme at the National Department of Health to provide care for chronic disease in South Africa. This introduced her to our work and provided a channel for future engagement at this level. Her perspectives contributed to our thinking about an intervention to improve support for chronic lifelong conditions.
Year(s) Of Engagement Activity 2014
 
Description Meeting with policy-makers Western Cape Department of Health 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Policymakers/politicians
Results and Impact Two members of the research team met with the head of the Impact Evaluation Unit, a key policy-maker for health systems interventions in the Western Cape Department of Health. We presented the conceptualisation of our research which sparked questions and discussion about health systems as complex adaptive systems and the value of this perspective in planning more sustainable interventions to improve care. We obtained her support for the study and commitment from her to engage with us as we started developing plans for a full proposal and an intervention.
Year(s) Of Engagement Activity 2014
 
Description Presentation of Findings to Western Cape Department of Health 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Policymakers/politicians
Results and Impact In August 2014, Hayley MacGregor, Andrew McKenzie and Andrew Boulle presented the findings of the Gates-funded work on retention in care and the role of HIV adherence clubs at the Western Cape Department of Health. We also invited policy makers from the metro department of health, and health managers and HIV managers from key districts. MSF also attended the presentation. The intention was to present and get feedback on the epidemiological analysis as well as they health systems analysis. There was a lively discussion which has led to further interest and follow up from policy makers with respect to 1) the relevance for adherence models for NCDs 2) the role of the steering group in supporting the next phase of scale up of the adherence clubs 3) the role of a private public partnership for the packaging and community distribution of medication for stable patients with chronic illness. There has also been further follow up from MSF and the International Aid Society with respect to our analysis of the models for differentiated care for HIV.
Year(s) Of Engagement Activity 2016
 
Description Western Cape Department of Health research day (Cape Town) 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Policymakers/politicians
Results and Impact The Western Cape Department of Health hosts an annual research day to hear the findings from research studies that have been conducted in the province. Members of the research team presented the findings from the scoping study.
Year(s) Of Engagement Activity 2015
 
Description Winelands District research day (Western Cape) 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Professional Practitioners
Results and Impact Hayley MacGregor and the research officer from the University of Western Cape who had participated in the scoping study fieldwork presented at a research day in Worcester in the Winelands District. This day was organised by the NGO called ANOVA, with the Western Cape Department of Health. The aim was to disseminate research findings from studies done in the district to health practitioners working in the district. This presentation of the scoping study findings sparked question and discussion about the study and generated engagement with key practitioners and policy makers.
Year(s) Of Engagement Activity 2015
 
Description meeting with epidemiologist (Provincial Department of Health) 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Policymakers/politicians
Results and Impact Members of the research team met with Andrew Boulle from the Impact Evaluation Unit at the Provincial Department of Health of the Western Cape in South Africa. The purpose was to engage him as a key academic and policy maker, to convince him of the value of our planned scoping study for the Development grant, and to get access to his analysis of retention in care databases at facility level in the selected districts.
This engagement led to an ongoing collaboration to design an intervention to improve the performance of the ARV programme in the Western Cape based on our analysis of facility-level barriers to retention in care. He became a Co-PI in the follow on full proposal submission to the HSRI scheme, and we continue to collaborate. He became a key advocate for our perspective and research at the Provincial Department of Health. He claims to have learnt more about a health systems approach and has now included a health systems component in current research and involved us in that grant.
Year(s) Of Engagement Activity 2014