Online Program

Were pepfar investments associated with changes in outpatient visit volumes in Uganda (2005-2010)?

Monday, November 4, 2013 : 1:15 p.m. - 1:30 p.m.

Samuel Luboga, MBChB, MMed (Surg), PhD, Medical School, Makerere University, Kampala, Uganda
Bert Stover, PhD, University of Washington, Seattle, WA
Travis Lim, DrPH candidate, Division of Global HIV/AIDS – Health Economics, Systems and Integration Branch, Centers for Disease Control and Prevention, Atlanta
Eddie Mukooyo, MbChB, Resource Center, Uganda Ministry of Health, Kampala, Uganda
Fred Makumbi, PhD, School of Public Health, Makerere University, Kampala, Uganda
Angela S. Wood, MPH, School of Public Health, Department of Health Services, University of Washington, Seattle, WA
Amy Hagopian, PhD, Department of Health Services and Dept. of Global Health; Director, Community Oriented Public Health Practice MPH program, University of Washington, Seattle, WA
Noah Kiwanuka, PhD, School of Public Health, Makerere University, Kampala, Uganda
Nagesh Borse, PhD, CGH/Hesib/Hshr, Centers for Disease Control & Prevention, Atlanta, GA
Elizabeth (Lianne) Sheppard, PhD, Department of Biostatistics, University of Washington, Seattle, WA
Scott Barnhart, MD, MPH, Department of Global Health, University of Washington, Seattle, WA
While PEPFAR investments were associated with HIV-related survival, it's been less clear what the effects of this investment in HIV care has been for health care utilization generally. Understanding this could have implications for the next global health initiative.

We visited all of Uganda's 56 districts to collect monthly outpatient data for 2005-2010. Our unit of analysis was “district-month.” We fit population-averaged multivariable Poisson models, with “outpatient visits” (routine ambulatory clinical consultations) as outcome. Input was “annual number of PEPFAR-supported patients on ART per district” (categorized as low, medium or high). We adjusted for regional HIV prevalence, primary school enrollment, and annual national health budget.

The monthly average district PEPFAR-supported ART patients in Uganda increased from 1.36 per 1000 population in 2005, to 6.32 in 2010. Our data show outpatient visits for children under 5 fell from 33 to 31 per 1000 between 2005 and 2010, while visits for those age ≥5 grew from 64 to 75 per 1000 in the same period.

The average rate of under-5 outpatient visits is 2.3% lower in medium input district months, and 2.6% lower in high input districts (both p<0.001) compared to low PEPFAR investment district months. However, outpatient visits for patients ≥5 years were 1.1% higher for medium and 11.1% higher for high (p<0.001) district months compare to low investment district months.

PEPFAR ART support in Uganda is associated with increased outpatient visits for patients 5 and older, but was associated with somewhat lower rates in outpatient visits for youngest children.

Learning Areas:

Conduct evaluation related to programs, research, and other areas of practice
Public health or related research
Systems thinking models (conceptual and theoretical models), applications related to public health

Learning Objectives:
Discuss the effects of a vertical health problem intervention on the health system generally; Explain the uses of routine health system information in assessing a health intervention; Describe successful aspects of a collaboration between a U.S. university and an African university to investigate a health systems research question.

Keyword(s): System Involvement, HIV/AIDS

Presenting author's disclosure statement:

Qualified on the content I am responsible for because: I am the lead researcher on this project and a professor at Makerere University.
Any relevant financial relationships? No

I agree to comply with the American Public Health Association Conflict of Interest and Commercial Support Guidelines, and to disclose to the participants any off-label or experimental uses of a commercial product or service discussed in my presentation.

Back to: 3253.0: Systems thinking