North West leads way in ARV roll-out
Public-private partnership shows solid benefits
The management of HIV is of critical importance to South Africa and even though government has implemented one of the largest antiretroviral treatment programmes in the world there are still capacity constraints in state circles in managing the ARV roll-out.
These constraints mean that government hospitals simply do not have sufficient trained staff to service all the patients that need to be helped, leading to long waiting times and higher than desirable levels of patients falling off of the programme.
A pilot project in the North West Province, however, has tied together the private and public health sectors and delivered a higher quality of care than would have been possible at public hospitals alone.
The project, managed by BroadReach Healthcare and funded by USAid, has allowed patients to receive their ARVs from a nominated GP rather than having to travel to the nearest hospital, which may require them to take the entire day off.
Dr John Sargent, the president and founding partner of BroadReach, said that the North West provincial government had seen some of the work BroadReach had done elsewhere in South Africa and had approached it to run a pilot project bringing the private sector into ARV treatment.
The project has just celebrated its fifth anniversary and Sargent said that one of its crowning achievements was that the default rate of patients was significantly lower than that of patients receiving treatment by means of conventional channels.
Dr Uma Nagpal, the district chief director for the Dr Kenneth Kaunda District, where the project is located, said that the default rate for patients treated at the public hospital was in the region of 10%, while the default rate of those on the pilot project was just 2%.
Part of the reason for this, she said, was that participating GPs took an active interest in their patients and when they did not arrive for a scheduled consultation, they took the time to track them down and find out why they had missed their appointment.
At hospital there was not always the capacity to trace defaulting patients and as some did not even have phones it made it difficult to ensure compliance.
Sargent said patients first went to the Wellness Centre at the Tshepong Hospital and, from there, those selected to be part of the programme were able to choose a participating GP from whom they would receive their medication, as well as regular check-ups. Patients still needed to go for six-monthly blood test at the Wellness Centre, but most of the follow-up services were provided by the designated GP.
While government supplies the ARV medication and laboratory services, USAid pays for the doctors’ consultations.
Real successes in improving healthcare
Over the five years close to 1 000 patients took part in the programme, with 17% transferring out of the programme back to the public hospital for the management of healthcare issues, such as pregnancy, TB co-infection or other complications.
Nagpal said that, from a clinical perspective, the programme had achieved real success in the improvement of the health of its patients, with viral loads dramatically lower and CD4 counts higher.
Sargent said that as a result of the cooperation of the public and private sectors the average cost per patient per month was only R100 more on the programme than it was for patients treated purely at the public hospital (R545 compared with R439).
This was offset by the fact that the improved general health of the patients meant that they were less likely to end up in hospital with opportunistic infections, but that cost saving was not factored into the cost of the programme.
If it was included, Sargent said, the public-private partnership could actually work out cheaper than if the service were provided directly by the state.
In addition to managing the distribution of ARVs, the programme has an educational component, with patients instructed on the management of the disease and how to live healthier lives.
With ARVs dramatically extending the lives of patients, there is also a real drive to reduce the stigma that being HIV positive has in the community, as it is still a very real issue in the management of the disease.
Extending the programme
Nagpal said the project had already been extended to Potchefstroom and the provincial health department was looking at extending it to other areas as well.
She said a lack of resources and funding was holding back expansion plans and pointed out that the programme could not be expanded too rapidly as GPs needed to be brought on board to service patients.
She commented that the success of the programme was a good indicator of what the proposed national health insurance scheme could achieve in cases in which private clinics and GPs worked side by side with state institutions to manage the health of patients.
“The NHI would make it easier to do this on a much larger scale,” she said.
Sargent said the HIV-management programme was not the only work that the organisation was doing with the South African health department.
It was also working with the department to strengthen the health system and working with 300 hospitals and clinics to bolster capacity. And the organisation is providing patient education services and assisting in the building of a clinic in Klerksdorp.