Perceptions of the Role of NGOs in Direct Service Delivery of ART Perspectives from health professionals and patients in Kabwe, Zambia Rosie Soffair MBBS BSc International Health BSc Project, University of Leeds
Introduction There is a generalised HIV/AIDS epidemic in Zambia (estimated prevalence 14.3%). Non Governmental Organisation (NGO) programmes, such as that run by Médecins Sans Frontières (MSF) in Zambia, have proved the feasibility and efficacy of providing antiretroviral therapy (ART) in low-resource settings.
Consensus agreed that stand alone NGO provision of ART remains appropriate to supplement overwhelmed Ministry of Health services.
Conversely, exacerbation of health worker attrition from the public sector and questions regarding the sustainability of the NGO programme were highlighted. Rural communities remain most disadvantaged with regard to accessing ART. Both NGO and government are criticised for concentrating services in urban areas:
“Right now we are seeing NGOs which are just mushrooming. To us it’s a good thing, because they are also helping the clients and also decongesting our places.”
“In Zambia, NGOs are mostly confined to urban centres. And if we are only 130km away from Lusaka and there is only one NGO providing ART, what about 600km away?”
The study was conducted over 4 weeks in June 2009 in Kabwe, a District in Zambia with mixed service provision of ART.
Government Health Worker
NGO Health Worker
There is a locally initiated referral network, unique to Kabwe, operating for all organisations involved in HIV/AIDS services. It has proved extremely effective for referral between sectors.
Kabwe: capital of Central Province, 130km North of Lusaka.
Former copper mining town; suffered drastic economic decline after the crash of the copper prices and closure of the mines.
ART requires continuity of care within the health system for life; there are concerns about the sustainability and negative implications of NGO provision on public health systems. Now that ART provision is free through the public sector, this qualitative project (conducted with the Zambian National HIV/AIDS Council) aims to examine the perceptions of health care workers and patients toward the ongoing role of NGOs in direct service delivery of ART in order to inform future ART policy and programming.
Limitations The small scale of the study limits its applicability to the wider context in Zambia. The NGOs interviewed play a role in delivering ART and the presence of positive bias must be considered. The researcher being a young, white English speaking female may have influenced the responses given and the cultural interpretation of those responses.
One stand alone NGO exists providing ART to 600 patients.
Study Design Two primary sites were identified for the study; a faith based NGO providing ART through a stand alone facility and one MOH clinic. 17 semi-structured interviews were conducted. Purposive sampling was used to identify 3 participants from four groups: 1.
Health care workers (HCWs) delivering ART through an NGO programme
HCWs delivering ART through a public health sector facility
Patients receiving ART through the NGO programme
Patients receiving ART through the same public sector facility.
Ethics Ethical approval for the research was sought and granted from the University of Leeds Ethics Committee, the University of Zambia (UNZA) Biomedical Research Ethics Committee and the Ministry of Health (MOH) in Zambia.
Primary provider of ART is Ministry of Health, through 9 facilities. The studied health centre provides 3300 patients with ART.
“We are not a clinic that operates 24 hours. The client who may have been brought in a critical state may not benefit because the equipment necessary to resuscitate them may not be present at the centre. We refer those clients.”
Diagram summarising the reasons given by participants for ART provision by this NGO along with the key issues which challenge the appropriateness of NGO provision.
Superior health worker motivation, shorter waiting times, longer consultation times and maintenance of patient anonymity were benefits of the NGO delivery approach.
Perceptions amongst all participants indicated that stand alone provision of ART by NGOs remains appropriate, provided that there is good collaboration with MOH.
“I think why most people go to the NGOs is that they don’t want to be recognised by others, some sort of stigma. Maybe somebody doesn’t want to go to the government hospital because there may be people who know them and know that he or she is HIV positive.”
Both sectors have service limitations; therefore the activity of both, in combination with effective referral between the two, could be argued to improve the quality of ART service for patients.
The co-ordinated referral system active in Kabwe appears to be a feasible, replicable model which could be adopted by other districts in Zambia, to coordinate fragmented organisations to the benefit HIV management.
In addition, five key informants were interviewed from leading NGOs involved in ART, the National Aids Council and the public sector, in order to reduce the subjectivity of the results.
Semi-structured interviews (SSI) were conducted to gather data. Inductive and deductive thematic content analysis was performed on the data manually.
Diagram summarising the benefits and the challenges of the NGO delivery approach.
I thank my supervisors Tolib Mirzoev and Harold Witola fo their help organising this project and providing advice and support. I am extremely grateful to Mercy Ulaya and Kelly Chanika for all their assistance in Zambia, along with the participants who kindly gave their time to take part in this study.
Zambian National HIV/AIDS Council, Lusaka
With Mercy Ulaya, PMTCT/VCT Specialist at National AIDS Council