Scaling up ART adherence clubs in the public sector health system in the Western Cape, South Africa: a study of the institutionalisation of a pilot innovation
| dc.contributor.author | MacGregor, Hayley | |
| dc.contributor.author | McKenzie, Andrew | |
| dc.contributor.author | Jacobs, Tanya | |
| dc.contributor.author | Ullauri, Angelica | |
| dc.date.accessioned | 2018-05-03T11:18:30Z | |
| dc.date.available | 2018-05-03T11:18:30Z | |
| dc.date.issued | 2018-04-25 | |
| dc.date.updated | 2018-04-29T03:28:08Z | |
| dc.description.abstract | Background: In 2011, a decision was made to scale up a pilot innovation involving ‘adherence clubs’ as a form of differentiated care for HIV positive people in the public sector antiretroviral therapy programme in the Western Cape Province of South Africa. In 2016 we were involved in the qualitative aspect of an evaluation of the adherence club model, the overall objective of which was to assess the health outcomes for patients accessing clubs through epidemiological analysis, and to conduct a health systems analysis to evaluate how the model of care performed at scale. In this paper we adopt a complex adaptive systems lens to analyse planned organisational change through intervention in a state health system. We explore the challenges associated with taking to scale a pilot that began as a relatively simple innovation by a non-governmental organisation. Results: Our analysis reveals how a programme initially representing a simple, unitary system in terms of management and clinical governance had evolved into a complex, differentiated care system. An innovation that was assessed as an excellent idea and received political backing, worked well whilst supported on a small scale. However, as scaling up progressed, challenges have emerged at the same time as support has waned. We identified a ‘tipping point’ at which the system was more likely to fail, as vulnerabilities magnified and the capacity for adaptation was exceeded. Yet the study also revealed the impressive capacity that a health system can have for catalysing novel approaches. Conclusions: We argue that innovation in largescale, complex programmes in health systems is a continuous process that requires ongoing support and attention to new innovation as challenges emerge. Rapid scaling up is also likely to require recourse to further resources, and a culture of iterative learning to address emerging challenges and mitigate complex system errors. These are necessary steps to the future success of adherence clubs as a cornerstone of differentiated care. Further research is needed to assess the equity and quality outcomes of a differentiated care model and to ensure the inclusive distribution of the benefits to all categories of people living with HIV. | |
| dc.identifier.apacitation | MacGregor, H., McKenzie, A., Jacobs, T., & Ullauri, A. (2018). Scaling up ART adherence clubs in the public sector health system in the Western Cape, South Africa: a study of the institutionalisation of a pilot innovation. <i>Globalization and Health</i>, http://hdl.handle.net/11427/27864 | en_ZA |
| dc.identifier.chicagocitation | MacGregor, Hayley, Andrew McKenzie, Tanya Jacobs, and Angelica Ullauri "Scaling up ART adherence clubs in the public sector health system in the Western Cape, South Africa: a study of the institutionalisation of a pilot innovation." <i>Globalization and Health</i> (2018) http://hdl.handle.net/11427/27864 | en_ZA |
| dc.identifier.citation | MacGregor, H., McKenzie, A., Jacobs, T., & Ullauri, A. (2018). Scaling up ART adherence clubs in the public sector health system in the Western Cape, South Africa: a study of the institutionalisation of a pilot innovation. Globalization and health, 14(1), 40. | |
| dc.identifier.ris | TY - Journal Article AU - MacGregor, Hayley AU - McKenzie, Andrew AU - Jacobs, Tanya AU - Ullauri, Angelica AB - Background: In 2011, a decision was made to scale up a pilot innovation involving ‘adherence clubs’ as a form of differentiated care for HIV positive people in the public sector antiretroviral therapy programme in the Western Cape Province of South Africa. In 2016 we were involved in the qualitative aspect of an evaluation of the adherence club model, the overall objective of which was to assess the health outcomes for patients accessing clubs through epidemiological analysis, and to conduct a health systems analysis to evaluate how the model of care performed at scale. In this paper we adopt a complex adaptive systems lens to analyse planned organisational change through intervention in a state health system. We explore the challenges associated with taking to scale a pilot that began as a relatively simple innovation by a non-governmental organisation. Results: Our analysis reveals how a programme initially representing a simple, unitary system in terms of management and clinical governance had evolved into a complex, differentiated care system. An innovation that was assessed as an excellent idea and received political backing, worked well whilst supported on a small scale. However, as scaling up progressed, challenges have emerged at the same time as support has waned. We identified a ‘tipping point’ at which the system was more likely to fail, as vulnerabilities magnified and the capacity for adaptation was exceeded. Yet the study also revealed the impressive capacity that a health system can have for catalysing novel approaches. Conclusions: We argue that innovation in largescale, complex programmes in health systems is a continuous process that requires ongoing support and attention to new innovation as challenges emerge. Rapid scaling up is also likely to require recourse to further resources, and a culture of iterative learning to address emerging challenges and mitigate complex system errors. These are necessary steps to the future success of adherence clubs as a cornerstone of differentiated care. Further research is needed to assess the equity and quality outcomes of a differentiated care model and to ensure the inclusive distribution of the benefits to all categories of people living with HIV. DA - 2018-04-25 DB - OpenUCT DP - University of Cape Town J1 - Globalization and Health LK - https://open.uct.ac.za PB - University of Cape Town PY - 2018 T1 - Scaling up ART adherence clubs in the public sector health system in the Western Cape, South Africa: a study of the institutionalisation of a pilot innovation TI - Scaling up ART adherence clubs in the public sector health system in the Western Cape, South Africa: a study of the institutionalisation of a pilot innovation UR - http://hdl.handle.net/11427/27864 ER - | en_ZA |
| dc.identifier.uri | https://doi.org/10.1186/s12992-018-0351-z | |
| dc.identifier.uri | http://hdl.handle.net/11427/27864 | |
| dc.identifier.vancouvercitation | MacGregor H, McKenzie A, Jacobs T, Ullauri A. Scaling up ART adherence clubs in the public sector health system in the Western Cape, South Africa: a study of the institutionalisation of a pilot innovation. Globalization and Health. 2018; http://hdl.handle.net/11427/27864. | en_ZA |
| dc.language.iso | en | |
| dc.publisher | BioMed Central | |
| dc.publisher.department | Division of Infectious Disease and HIV Med | en_ZA |
| dc.publisher.faculty | Faculty of Health Sciences | en_ZA |
| dc.publisher.institution | University of Cape Town | |
| dc.rights.holder | The Author(s). | |
| dc.source | Globalization and Health | |
| dc.source.uri | https://globalizationandhealth.biomedcentral.com/ | |
| dc.source.uri | https://globalizationandhealth.biomedcentral.com/ | |
| dc.subject.other | HIV | |
| dc.subject.other | South Africa | |
| dc.subject.other | Health system | |
| dc.subject.other | Complex adaptive systems | |
| dc.subject.other | Innovation | |
| dc.subject.other | Scaling up | |
| dc.subject.other | Chronic illness | |
| dc.subject.other | Differentiated HIV care | |
| dc.subject.other | ART adherence | |
| dc.title | Scaling up ART adherence clubs in the public sector health system in the Western Cape, South Africa: a study of the institutionalisation of a pilot innovation | |
| dc.type | Journal Article | |
| uct.type.filetype | Text | |
| uct.type.filetype | Image |