Accessing antiretroviral treatment in the rural Eastern Cape : patients' perceptions of a decentralised pre-packing model of care and the impact on direct out-of-pocket spending.
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Abstract
Background:
With an estimated 5.51 million HIV infected South Africans, HIV/AIDS contributes significantly to
the burden of disease in the country, with far-reaching socio-economic implications particularly for
poor and vulnerable groups. High out-of-pocket health expenditure associated with HIV/AIDS care
has a serious impact on vulnerable individuals and is likely to severely affect the wellbeing of the
affected household. Geographic inaccessibility of centralised, hospital-based antiretroviral treatment
(ART) services and excessive transportation costs may contribute to patient attrition and these
barriers are exacerbated in rural populations.
Aim:
The objectives of this study are to ascertain the out-of-pocket expenses that are incurred by patients
travelling to their ART down-referral site, and compare this with the out-of-pocket expenses of those
patients from the same catchment area still receiving their ART from the central hospital. The study
also aims to determine whether or not the down-referral programme has impacted the patients’
economic status and improved their treatment experience.
Methods:
A semi-quantitative cross sectional study design was employed. Zithulele Hospital ARV Clinic and
five different PHC collection points within the hospital’s catchment area were selected as the study
sites. Included in the study were 44 hospital-based patients and 73 clinic-based patients registered on
the Zithulele Hospital HIV Programme. Using a standard questionnaire, all socio-economic data and
information related to mode of transportation and associated costs, as well as other out-of-pocket
spending associated with accessing ART, was collected. Clinical data was recorded from patient
medical records during the interview.
Results:
The average monthly household income was R1653 (R301.05 per capita) for hospital-based patients
and R1617 (R392.66 per capita) for clinic-based patients. Income was predominantly sourced from
either child support or pension grants. Study participants had an overall unemployment rate of 94%
and, subsequently, 75% of hospital-based patients and 68.5% of clinic-based patients were living
below the food poverty line of R400 per month. A higher proportion of hospital-based patients used
taxis (80.5% versus 28.8%) while more clinic-based patients walked to the facility for their treatment
(71.2% versus 14.6%). In terms of monthly transport costs, hospital-based patients spent on average
R71.92, significantly more than the R25.81 spent by clinic-based patients. With a point estimate of
1.169, regression analysis indicated that for every one Rand increase on transport, the odds of the
patient being hospital-based rather than clinic-based are 16.9% higher. There were higher levels of
satisfaction recorded amongst the hospital-based group (95.5% compared to 89%) but despite this,
100% of the clinic-based patients listed their respective clinic as their preferred ART collection
point.
Conclusion:
Decentralisation and down-referral of patients to their nearest primary healthcare clinic minimises
out-of-pocket spending in rural communities while maintaining good levels of satisfaction with the
healthcare service provided. It is important to consider the social, geographical and cultural context
of the individuals seeking and utilizing healthcare before interventions are implemented.
Description
M. Pharm. University of KwaZulu-Natal, Durban 2014.
Keywords
Antiretroviral agents--South Africa--Eastern Cape., HIV infections--Treatment--South Africa--Eastern Cape--Costs., AIDS (Disease)--Treatment--South Africa--Eastern Cape--Costs., Health services accessibility--South Africa--Eastern Cape., Theses--Pharmacy and pharmacology.