Project Lead(s): Walter Schlech
Issue
More than 80% of HIV funding in sub-Saharan Africa comes from international donors (Global AIDS Fund and PEPFAR).There is a substantial funding gap in the face of increasing numbers of people living with HIV, which may well increase in the future if international funding is reduced.
Universal access to HIV services is essential for people living with HIV. Patients who do not access regular HIV care have a significantly higher mortality rate.
There is a need for new, socially acceptable solutions to sustain HIV care in the face of new fiscal realities in resource-limited countries.
Solution
Implemented in Uganda, the project tested an innovative model of care at a large, multi-service, public HIV/AIDS clinic in Kampala, to evaluate whether middle-income, HIV-positive patients – a growing demographic in Sub-Saharan Africa – would be willing to pay extra in return for more convenient and better services.
The objective was to develop a cross-subsidization model to maintain a free public HIV service for the very poor in Uganda, partially sustained by patients willing and able to pay for more individualized HIV care with extra convenience and benefits (such as clinics outside of working hours).
A cross-sectional qualitative research design was adopted for the study to assess the feasibility of the model and 14 focus group discussions (FGDs) among male and female HIV-positive patients were conducted.
More affluent patients were offered after-hour clinics, which offered convenience, privacy, rapid services, access to enhanced care and antiretroviral therapy. Respondents were willing to pay for consultations, extra drugs and extra lab tests, provided the charges were affordable.
Respondents agreed that a portion of money collected could be used to help poorer patients in the general clinic by providing food and drugs, and helping them initiate businesses.
Outcome
The study revealed that patients were comfortable with the concept of an ‘after hours’ clinic. Two pay-for-service clinics were established.
By nine months of operation, 419 patients were enrolled and the clinics were cost-neutral.
Thirty-eight lives were saved, as 11 patients previously failing on ART are now on an improved regimen and 27 patients were started on ART. In addition, 51 lives were improved, as 49 patients enrolled in ART had an improvement in CD4 count, and 2 patients lost to follow up have returned to care in the new clinic.
In addition, patients viewed the model favourably, as they felt it could help to address a number of challenges they face while accessing care in the general free clinic, including long wait times, fear of stigma, poor adherence to clinic appointments and ARV treatment, and potential transfer out to other centres because of limited capacity in the general clinic.
Continuing to provide free services to the poor with the financial support of a co-pay service is still felt to be an essential part of the delivery model. Expansion of the co-pay clinic services may provide even better support in the future. Results of the project have been published.