Testing Innovative Health Delivery Models
Over the last decade, the vast scale-up of antiretroviral therapy (ART) globally has resulted in immensely increased access to HIV treatment for adults and children. This scale-up has taken place in the context of stressed health care systems with overstretched human resources and limited infrastructure in resource-limited countries. Studies of new care models of HIV care and treatment delivery demonstrated that providing differential care pathways for patients with variable intensity of needs may improve outcomes and have favorable effects on patient retention in care, clinic congestion and other health systems outcomes.
Yet in 2016, little systematic work had been done in Zambia to test the environment for a substantial move towards more efficient healthcare delivery models for HIV and other chronic diseases. There was a profound sense that the health system is missing out on the substantial power of communities and patient-friendly delivery systems to support people in HIV care and treatment programs to meet the lifelong challenge of remaining in care.
With sponsorship from the Bill and Melinda Gates Foundation, Dr. Holmes and Centre for Infectious Disease Research in Zambia (CIDRZ) colleagues Drs. Izukanji Sikazwe and Carolyn Bolton-Moore, along with Dr. Elvin Geng of UCSF and others, launched the Community ART Study in Zambia. It included two strategies simultaneously in order to obtain both broad-based insights into the demand and preferences for differentiated care in Zambia, as well as practical insights about implementation and outcomes of leading models of differentiated care that are already under consideration in Zambia.
Community ART Study in Zambia
Strategy 1 – Mixed methods, including survey research, discrete choice experiments, interviews and focus group discussions to ascertain the preferences and perceptions regarding various models of differentiated care among Zambian patients, family members, community members including traditional leaders, healthcare providers, community networks of people living with HIV/AIDS, and healthcare administrator/policymakers.
Strategy 2 – Concurrent implementation of four models of differentiated care that incorporate an innovative systems approach to information technology, including integration of mobile technologies into the existing medical information system, as well as real time monitoring and quality assurance. A rigorous framework of implementation science and impact evaluation around these models was deployed to assess their overall quality, feasibility, costs and cost-effectiveness and fit within the health system.
Close collaboration with the government of Zambia led to the incorporation of early data and insights from these studies into national policymaking processes. With the benefits of this early foray into new models of care, Zambia became a leader in the broad implementation of differentiated service delivery models based on the needs and preferences of users and is a member of the HIV Coverage, Quality, and Impact Network (CQUIN) on differentiated service delivery (DSD).
In addition to its practical policy implications, the study has resulted in numerous publications and analyses are ongoing.
- Bolton Moore, et al. A Review of Differentiated Service Delivery for HIV Treatment: Effectiveness, Mechanisms, Targeting, and Scale.
- Geng, et al. Research to Improve Differentiated HIV Service Delivery Interventions: Learning to Learn as We Do. Plos Med.
- Zanolini, et al. Understanding Preferences for HIV Care and Treatment in Zambia: Evidence From a Discrete Choice Experiment Among Patients Who Have Been Lost to Follow-up. Plos Med.