Mosa Moshabela , Helen Schneider, Susan Cleary, Paul Pronyk and John Eyles

1. ACCESS GAINS AND LOSSES OF ‘DOWN-REFERRAL’Decentralisation of patients taking ART from hospitals to PHC centres in rural South Africa Mosa Moshabela, Helen Schneider, Susan Cleary, Paul Pronyk and John Eyles 6TH IAS Conference 20TH July 2011, Rome, ITALY

2. Background

3. Centralized ART Delivery Systems • Introduction of ART through major hospitals down the hierarchy of the SA health system (NDOH): Also, Boyer et al. 2010, Bemelmans et al. 2010 Tertiary Secondary District

4. Why Down-referral? • Supply-side factors: • Hospitals have reached capacity, Human resource shortages • Strengthening the nurse-driven Primary Health Care System • Demand-side factors: • Loss to follow up attributed to distances, costs • ART access “reaching those at the margins of the health system” Bedelu et al. 2007, Decroo et al. 2009, Chan et al. 2010

5. METHODS

6. In 2008, REACH • 5-year project Researching Equity and ACcess to Health care • A-Framework of access: availability, affordability and acceptability (Knowledge and interaction) • 1266 participants across 4 diverse provinces, 2 rural and 2 urban sub-districts selected • Included +18 years and minimum of 2 weeks since ART initiation • Exit-interviews conducted and reviewed clinical records • Also, in-depth interviews, quality of care inventories, quality of care observations

10. RESULTS

17. Undesired Effects of Down-Referral in Rural South Africa Factors associated with Down-referral Prefer Doctor than a Nurse Skilled Care Consult Private Doctors Catastrophic Health Care Expenditure Is health care adequate? Practice Self-Care Knowledge Poor CD4 count Knowledge Lack of Formal Education

18. Conclusions • Down-referred patients save time and may save money • Down-referred patients also perceive less stigma and feel more respected • However, complementary health care increased; ‘better skilled’ staff and self-care behaviour • Associated increased catastrophic health care expenditure • Need to ensure use of trained nurses, good quality of care and equivalent packages of care • Otherwise, economic gains of down-referral remain under threat

19. Acknowledgements • Global Health Research Initiative (GHRI), a collaborative research funding partnership of the Canadian Institutes of Health Research, the Canadian International Development Agency, Health Canada, the International Development Research Centre, and the Public Health Agency of Canada. • Participants, REACH team, Department of Health in South Africa, participating public sector institutions, partnering academic institutions, research collaborators and research-user partners. • We are thankful to Dr Marie-Andree Somers for statistical input. • Discovery Foundation Academic Fellowship, Moshabela