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.

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.