1. Socioeconomic benefits of ART Decentralization in Malawi and Uganda: Lessons from the Lablite Project Levison Chiwaula, Deborah Ford, Misheck J Nkhata, Travor Mabugu, Edward Tumwesige, Paul Revill, Faith Mirimo, Janet Seeley, James Hakim, Charles F Gilks, Joep J Van Oosterhout, Diana M Gibb and the Lablite Project team

2. Lablite project Implementation project in Malawi, Uganda and Zimbawe to evaluate ART roll-out to rural primary health care (PC) Included a district hospital/HC IV (hub) with 2-4 primary care facilities (spokes) at 4 sites Phalombe, Southern Malawi Kalungu, Central Uganda Agago, Northern Uganda Zvimba, Northern Zimbabwe

3. Has ART decentralisation improved access to ART? Following ART decentralisation is ART accessible to patients from all socio-economic groups? Are the there differences in SES between patients at the hubs (early ART providers, secondary care facilities) and spokes (primary care)? Has ART decentralisation reduced the cost, distance and time for patients accessing care?

4. Methods A hub and 2 spokes (with new ART provision) were included in Malawi and Uganda Patient questionnaire including questions to capture socio-economic data and information on access to ART Interviews conducted (Malawi, 2013; Uganda, 2014) with 3 types of patients: Patients who were on ART at the hub Patients who had initiated ART at a spoke Patients who had transferred to a spoke on ART

5. Participants MalawiUganda HF hospital (hub) Mpasa (spoke) Sukasanje (spoke) Bukulula HC IV (hub) Kiragga (spoke) Lukaya (spoke) New initiations 262422 Transfers-in25291815 Total patients 445153464037

6. Characteristics of participants MalawiUganda Hub (n=44) Spokes (n=104) Hub (n=46) Spokes (n=77) Sex: female62%79%59%81% Age: median (IQR)38 (30-46)36 (30-47)40 (31-49)33 (26-42) Education None/pre-primary Some primary Completed primary Completed secondary or higher 17% 64% 17% 2% 22% 60% 17% 2% 17% 50% 24% 9% 24% 44% 32% 0% Main occupation Farmer Employee Family business Casual Other 80% 7% 10% 5% 0% 64% 5% 25% 7% 0% 72% 9% 13% 7% 0% 56% 22% 12% 4% 7%

7. Socio-economic status of participants in Malawi Participants at the spokes were poorer than those at the hub: 57% vs 23% in the lowest 2 quintiles (p<0.001) Wealth quintile

8. Socio-economic status of participants in Uganda ART patients at Kiragga (rural area) were poorer but ART patients at Lukaya were richer than at the hub Across all 3 facilities only 7% of participants were in the 2 lowest quintiles (compared with 16% for the region) Wealth quintile

9. Access to current ART facility Median (IQR) or %MalawiUganda Hub (n=44) Spokes (n=104) Hub (n=46) Spokes (n=77) Distance to facility (km)5 (2-17)6 (2-11)7 (4-17)3 (1-5) Time to facility (mins)60 (30-120) 60 (30-60)30 (15-40) Mode of transport Foot Bicycle Motor vehicle* 48% 45% 7% 74% 26% 0% 22% 17% 61% 51% 9% 40% * Mainly bus in Malawi, motorbike-taxi in Uganda

10. Patients who transferred in to a spoke on ART Reason for transferMalawi (n=54) Uganda (n=33) Patient request: closer to home62%52% Clinician referral: closer to home38%6% To reduce costs-12% To reduce waiting time in clinic-9% Change in circumstances*-15% Other-6% * e.g. divorce, moved house

11. Malawi: Benefits for patients who transferred in to a spoke on ART 100 200 300 400 0100200300400 Minutes to previous facility 0 Minutes to new facility 2/3 outliers transferred-in from out of district so may have moved home All individuals below the red line took less time to travel after transferring -in to their new facility Travel time reduced from median 2.5 hours to 1 hour Travel distance reduced from median 13km to 6km Food cost per visit reduced from median $0.23 to $0.21 Malawi: Benefits to patients who transferred to a spoke

12. Uganda: Benefits to patients who transferred to a spoke 0 100 200 300 400 0100200300400 Minutes to previous facility Minutes to new facility All individuals below the red line took less time to travel after transferring -in to their new facility Travel time reduced from median 55 minutes to 30 minutes Travel distance reduced from median 8 km to 2 km 14/31 who had previously used motor vehicle (boda boda) now walked

13. Conclusions Significant numbers of patients choose to receive ART closer to home when it becomes available In Malawi where ART roll-out is well-established the national ART programme is reaching people in all SES Poorer individuals are more likely to be seen in primary care and are particularly benefiting from decentralisation In Uganda we found less evidence for equal ART coverage across SES although there is wide disparity in SES between regions and at our most rural PC facility there were people on ART from the lowest SES Bringing ART closer to peoples’ homes improves ease of access through reductions in distance, time and cost to access treatment

14. Acknowledgements MRC CTU at UCL, London Prof Diana Gibb (PI) Dr Deborah Ford (Statistician) Ms Caroline Grundy (Project Coordinator) Dr Sarah Joseph (Epidemiologist) Dr Margaret Thomason (Clinical Project Manager) Dr Annabelle South (Policy Impact) Dr Susan Hoskins (Epidemiologist) IDI, Kampala Prof Elly Katabira (Co-PI) Dr Ivan Mambule (Co-PI) Dr Senjovu Kaggwa (Clinician) JCRC, Kampala Prof Peter Mugyenyi (Co-PI) Dr Cissy Kityo Co-PI Dr George Abongomera (Project Coordinator) Dr Harriet Namata (Statistician) MRC/UVRI, Entebbe Prof Janet Seeley (Co-PI) Dr Sylvia Muyingo (Statistician) Dr Faith Mirimo (Health Economist) Mr Edward Tumwesigye (Research assistant) Dignitas International, Zomba, Malawi Dr Fabian Cataldo (Co-PI) Dr Adrienne Chan (Co-PI) Mr Misheck Nkhata (Project Coordinator) Mr John Sadalaki (Project Coordinator) University of Zimbabwe, Harare Prof James Hakim (Co-PI) Dr Andrew Reid (Co-PI) Dr Travor Mabugu (Health Economist) Ms Margaret Muzambi (Project Coordinator) Mr Macco Ndhlovu (Research assistant) Imperial College, London Prof Charles F Gilks (Co-PI) University of York Prof Mark Schulpher (Health Economist) Mr Paul Revill (Health Economist) Ms Jessica Ochalek (Health Economist) University of Malawi, Zomba Dr Levison Chiwaula (Health Economist)