A comparison of the institutionalization of ART interventions in four categories of health facilities in Uganda Zakumumpa Henry1, Bennett Sara 2, Ssengooba Freddie.1 1Makerere University, School of Public Health, Kampala, Uganda, 2 Johns Hopkins University, School of Public Health, Baltimore, United States CANADIAN EVALUATION SOCIETY- CES 2015: MONTREAL, CANADA

Background Uganda implemented a national antiretroviral therapy (ART) roll-out program between 2004 and 2009 with external donor support. ART was delivered in vertical mode and was not integrated with other facility services. There has been limited research evaluating program sustainability outcomes since the initial implementation phase. Institutionalization is widely regarded as an important indicator of program sustainability.

Objectives To measure the level of institutionalization of ART in 195 health facilities which received donor support between 2004 and 2009. To compare level of institutionalization scores by health facility category.

Methods Study population: Nationally-representative sample of health facilities across Uganda (n=195). Health facilities which initiated ART between 2004 and 2009 based on Ministry of Health June 2010 Report. Health facilities were categorized as Public, Private for Profit (PFP), Private Not for Profit (PNFP) and HIV Research Clinics

Methods Cont’d Data source: Adapted Level of Institutionalization (LoIn) scales developed by Goodman, et al (1993) was filled by 195 ART Clinic Managers. The 45-item questionnaire assessed institutionalization based on : a) Four ‘Sub-systems’ (Production, Maintenance, Supportive, Managerial) theorized to make up a health facility. b) b) Institutionalization was measured on two levels: Routines (Lower). Assesses the extent ART procedures are integrated within a facility. ii) Niche saturation (Highest) the maximum possible expansion of ART within an organization.

Data Analysis Descriptive statistics were generated and used to describe organizational characteristics and calculate and then rank health facilities into quartiles based on their mean institutionalization scores. Each health facility was assigned as score based on a calculation assessing attributes relating to institutionalization.

Results The overall mean institutionalization score for participating health facilities was 3.5 (Range, 1-4). The mean score for niche saturation, the highest level of institutionalization, was 3.2 (Range,1-4). Of the four systems, the production sub system, concerned with ART product delivery activities, scored the highest mean component score The Managerial sub system concerned with ART program supervision and evaluation had the lowest mean component score.

Summary of overall total means Results Cont’d Facility type Summary of overall total means Mean Standard Deviation Public 12.0 5.0 Private FP 10.8 5.7 Private NFP 13.2 5.2 HIV Research Clinics 17.7 7.0 * There was a statistical significance in the association between institutionalization score and health facility category (p < 0.05.)

Conclusions: ART interventions have become institutionalized at participating health facilities. However, scores for the highest level of institutionalization were moderate. Programs aimed at deepening the institutionalization of ART interventions in Private (PFPs) health facilities are recommended. ART program supervision and evaluation is deficient across all health facility categories and needs strengthening. Mainstreaming best practices of health facilities with the highest institutionalization scores could enhance the sustainability of ART in Uganda and other resource-limited settings.

Acknowledgment Participating health facilities for their cooperation and support. CARTA PhD Fellowship (Consortium for Advanced Research Training in Africa) for project research funding. Wilbrod Ntawiha of Uganda Bureau of Statistics for statistical analysis support. Makerere University School of Public Health Higher Degrees Committee for their input at various stages of the study.

Thank you! Asante sana! Merci! Danke schon!