SUPPORT Summaries
Evidence of the effects of health system interventions
for low- and middle-income countries
Evidence of the effects of health system interventions
for low- and middle-income countries
May, 2017 - SUPPORT Summary of a systematic review | print this article | download PDF
Many people living with HIV who need antiretroviral therapy are unable to access or remain in care. This is often because of the time and cost required to travel to health centres. One strategy to address this problem is to move antiretroviral delivery from hospitals to more peripheral health facilities or even beyond health facilities. This could increase the number of people with access to care, enhance retention in treatment programmes, improve health outcomes and reduce costs to people living with HIV and AIDS and health services. However, there are some concerns about the quality of decentralised care and whether health outcomes are equivalent to more centralised care.
Key messages
A summary of studies addressing a clearly formulated question that uses systematic and explicit methods to identify, select, and critically appraise the relevant research, and to collect and analyse data from the included studies.
SUPPORT – was an international project to support the use of policy relevant reviews and trials to inform decisions about maternal and child health in low- and middle-income countries, funded by the European Commission (FP6) and the Canadian Institutes of Health Research.
Although there has been considerable progress in improving access to antiretroviral therapy (ART) to date, global coverage for ART is still around 50% of those eligible for treatment, and 25% of people on treatment are not retained in care within 24 months of initiating ART. Decentralisation of ART care delivery from hospitals to more peripheral health facilities is an important strategy for addressing these problems. Decentralisation of care broadly means relocating services from centralised sites (i.e. hospitals) to peripheral health centres or lower levels of healthcare, generally geographically closer to the homes of people living with HIV and AIDS. Three types of decentralisation can be considered:
• Partial decentralisation: starting ART at the hospital, then moving to a health centre to continue treatment.
• Full decentralisation: starting and continuing ART at a health centre.
• Decentralisation from facility to community: ART is started at a health centre or hospital and thereafter provided in the community. Support for treatment may be provided by a family member, a lay or community health worker or through outreach by a health worker based in a primary healthcare clinic.
| Review objectives: To assess the effects of decentralised HIV care in relation to initiation and maintenance of antiretroviral therapy. | ||
| Type of | What the review authors searched for | What the review authors found |
|---|---|---|
| Study designs & interventions | Randomised and non-randomised trials, controlled before-after studies and well-designed cohort studies assessing any form of decentralised care delivery model for the initiation of ART, continuation of ART, or both. |
16 included studies: two cluster trials, two prospective cohorts and 12 retrospective cohort studies.
The studies examined partial decentralisation (6 studies), full decentralisation (7), and decentralisation from facility to community (3). |
| Participants | HIV-infected patients at the point of initiating treatment, and patients already on treatment requiring maintenance and follow-up. |
HIV infected patients. Three included children only, two included adults and children and the rest included adults only. |
| Settings | Community, health centre and hospital settings. |
Studies from rural and urban areas in South Africa (4 studies), Malawi (3 studies), Ethiopia (2), Uganda (2), Kenya (1), Swaziland (1), and Thailand (1). One study examined data from five countries in Africa (Kenya, Lesotho, Mozambique, Rwanda and Tanzania). |
| Outcomes |
Primary: Lost to care at one year, death, and a composite outcome of both. Secondary: Time to starting antiretroviral therapy, new diagnoses of tuberculosis co-infection, virologic and immunologic response to ART, new AIDS-defining illness, patient satisfaction with care, and cost to the provider. |
ll primary outcomes, virologic and immunologic response to ART, costs to people living with HIV and AIDS and costs to the health service, and patient satisfaction with care. |
| Date of most recent search:March 2013 | ||
| Limitations:This is well-conducted systematic review with only minor limitations. | ||
Kredo T, Ford N, Adeniyi FB, Garner P. Decentralising HIV treatment in lower- and middle-income countries. The Cochrane database of systematic reviews. 2013;6: CD009987
High: This research provides a very good indication of the likely effect. The likelihood that the effect will be substantially different† is low.
Moderate: This research provides a good indication of the likely effect. The likelihood that effect will be substantially different† is moderate.
Low: This research provides some indication of the likely effect. Howevver, the likelihood that it will be substantially different† is high.
Very low: This research does not provide a reliable indication of the likely effect. The likelihood that the effect will be substantially different† is very high.
* This is sometimes referred to as 'quality of evidence' or 'confidence in the estimate'.
† Substantially different = a large enough difference that it might affect a decision.
See last page for more information.
16 studies were included in the review. All studies evaluated decentralisation of care and eight also evaluated task shifting from doctors to other types of healthcare providers. Three studies examined treatment in children only, two included adults and children and the rest included adults only.
Four studies considered this option:
|
Effect of partial decentralisation compared to usual care on patient outcomes |
||||||
|
People HIV patients Settings Community, health centre and hospital settings Intervention Partial decentralisation Comparison Usual care |
||||||
|
Outcomes |
Usual care |
Partial decentralisation |
Relative effect (95% CI) |
Certainty of the evidence (GRADE) |
||
|
Absolute effect (95% CI) |
||||||
|
Death or lost to care (combined) Follow-up: 12 months |
218 per 1000 |
100 per 1000 (63 to 155) |
RR 0.46 (0.29 to 0.71) |
Moderate |
||
|
Lost to care Follow-up: 12 months |
134 per 1000 |
74 per 1000 (60 to 93) |
RR 0.55 (0.45 to 0.69) |
Low |
||
|
Death Follow-up: 12 months |
84 per 1000 |
28 per 1000 (11 to 73) |
RR 0.34 (0.13 to 0.87) |
Low |
||
|
Cost of travel |
Mean 1.5 USD |
Mean 0.74 USD |
- |
Low |
||
|
Margin of error = Confidence interval (95% CI) RR: Risk ratio USD: United States Dollar GRADE: GRADE Working Group grades of evidence (see above and last page) |
||||||
Four studies considered this option:
|
Effect of full decentralisation compared to usual care on patient outcomes |
||||||
|
People HIV patients Settings Community, health centre and hospital settings Intervention Full decentralisation Comparison Usual care |
||||||
|
Outcomes |
Usual care |
Full decentralisation |
Relative effect (95% CI) |
Certainty of the evidence (GRADE) |
||
|
Absolute effect (95% CI) |
||||||
|
Death or lost to care Follow-up: 12 months |
365 per 1000 |
256 per 1000 (172 to 373) |
RR 0.7 (0.47 to 1.02) |
Very low |
||
|
Lost to care Follow-up: 12 months |
270 per 1000 |
81 per 1000 (46 to 146) |
RR 0.3 (0.17 to 0.54) |
Moderate |
||
|
Death Follow-up: 12 months |
97 per 1000 |
106 per 1000 (61 to 185) |
RR 1.1 (0.63 to 1.92) |
Very low |
||
|
Margin of error = Confidence interval (95% CI) RR: Risk ratio GRADE: GRADE Working Group grades of evidence (see above and last page) |
||||||
Two studies in adult populations from Kenya and Uganda considered this option.
Decentralisation from facility to community:
|
Effect of decentralisation from facility to community compared to usual care on patient outcomes |
||||||
|
People People living with HIV and AIDS Settings Community, health centre and hospital settings Intervention Decentralisation from facility to community Comparison Usual care |
||||||
|
Outcomes |
Usual care |
Decentralisation from facility to community |
Relative effect (95% CI) |
Certainty of the evidence (GRADE) |
||
|
Absolute effect (95% CI) |
||||||
|
Death or lost to care Follow-up: 12 months |
106 per 1000 |
101 per 1000 (66 to 155) |
RR 0.95 (0.62 to 1.46) |
Moderate |
||
|
Lost to care Follow-up: 12 months |
26 per 1000 |
21 per 1000 (8 to 57) |
RR 0.81 (0.3 to 2.21) |
Moderate |
||
|
Death Follow-up: 12 months |
55 per 1000 |
57 per 1000 (35 to 91) |
RR 1.03 (0.64 to 1.65) |
Moderate |
||
|
Total cost to people living with HIV and AIDS* |
USD 54/year |
USD 18/year |
- |
Low |
||
|
Costs to the health service^ |
USD 838 / year / patient |
USD 793 / year / patient |
- |
Low |
||
|
Margin of error = Confidence interval (95% CI) RR: Risk ratio GRADE: GRADE Working Group grades of evidence (see above and last page) |
||||||
*Transport, lunch, childcare costs, lost work time. Based on data from one study.
^ Staff, transport, drugs, laboratory, training, supervision, capital and utilities costs. Based on data from one study.
| Findings | Interpretation* |
|---|---|
| APPLICABILITY | |
| 14 of the studies included in the systematic review were conducted in low -income countries and 2 in middle-income countries. |
All but one of the included studies were from Africa. The applicability of the findings to other low-income settings is therefore unclear. The findings may be applicable in settings where a reasonable infrastructure exists for the decentralisation of HIV treatment. This needs to include facilities, referral systems, human resources and supplies. In some countries, obstacles to task shifting or decentralization include regulations governing the work scope of different health workers and the views of labour unions representing health workers. The acceptability of decentralisation to people living with HIV and AIDS and to healthcare providers needs to be considered. Service planners also need to consider the impacts of decentralisation on total costs for both people living with HIV and AIDS and the health service. |
| EQUITY | |
| There was no information in the included studies regarding the differential effects of the interventions on resource-disadvantaged populations. |
The resources needed to support decentralised care, and to ensure appropriate referral between levels of care, may be less available in disadvantaged settings. Decentralising care from facilities to the community may improve access to care and outcomes for disadvantaged groups, and thereby improve equity, through reducing total costs to people living with HIV and AIDS and reducing the number of people lost to care. |
| ECONOMIC CONSIDERATIONS | |
| The systematic review found that decentralisation may reduce total costs to people living with HIV and AIDS and to the health services. |
Little data on costs were available for different decentralisation options. Different models of decentralising HIV treatment may have different cost impacts for people living with HIV and AIDS and for health services. Care needs to be taken that the costs to individuals are not increased through, for example, higher travel costs or user fees. Local costing studies may be desirable before scaling up these interventions. Decentralisation may lead to changes in the use of healthcare provider time, supplies and laboratory tests at peripheral health facilities, with implications for other services delivered at these sites and for local budgets. The longer term economic consequences of decentralisation are not clear and need to be monitored. |
| MONITORING & EVALUATION | |
| Two cluster trials, two prospective cohorts and 12 retrospective cohorts contributed data to this review. |
Large pragmatic trials may be helpful in evaluating some decentralisation options. Where decentralisation is implemented at scale, monitoring may be needed of costs and of impacts on workload, support needs and supply chains at peripheral facilities. |
|
*Judgements made by the authors of this summary, not necessarily those of the review authors, based on the findings of the review and consultation with researchers and policymakers in low-income countries. For additional details about how these judgements were made see: www.supportsummaries.org/methods |
|
Brinkhof MW, Pujades-Rodriguez M, Egger M. Mortality of patients lost to follow-up in antiretroviral treatment programmes in resource-limited settings: systematic review and meta-analysis. PloS one. 2009;4(6):e5790.
Callaghan M, Ford N, Schneider H. A systematic review of task- shifting for HIV treatment and care in Africa. Human Resources for Health. 2010;8:8.
Denno DM, Chandra-Mouli V, Osman M. Reaching youth with out-of-facility HIV and reproductive health services: a systematic review. The Journal of Adolescent Health: official publication of the Society for Adolescent Medicine. 2012;51(2):106-21.
Young T, Busgeeth K. Home-based care for reducing morbidity and mortality in people infected with HIV/AIDS. Cochrane Database Syst Rev. 2010(1):CD005417
Agustín Ciapponi, Instituto de Efectividad Clínica y Sanitaria, Buenos Aires, Argentina
None declared. For details, see: www.supportsummaries.org/coi
This summary has been peer reviewed by: Tamara Kredo and Mike Callaghan.
Kredo T, Ford N, Adeniyi FB, Garner P. Decentralising HIV treatment in lower- and middle-income countries. The Cochrane database of systematic reviews. 2013;6:CD009987.
Keywords
evidence-informed health policy, evidence-based, systematic review, health systems research, health care, low and middle-income countries, developing countries, primary health care.
decentralisation, down referral, delivery of health care, health services, accessibility, HIV, retention in care, antiretroviral therapy.
