Can Changes in Service Delivery Models Improve Program Quality and Efficiency? A Closer Look at HIV Programs in Kenya and Uganda

Background: With the scale-up of antiretroviral treatment, many health facilities in low- and middle-income countries have implemented innovative practices targeted at overcoming operational challenges and delivering efficient quality HIV services. However, many of these practices remain largely unexplored as a means to better reach the global 90-90-90 targets. Setting: A study was conducted on selected facilities in districts of country programs supported by The Global Fund to Fight AIDS, Tuberculosis, and Malaria. The aims of the study were to understand how facilities seek to improve the delivery and uptake of HIV services and to examine what innovative practices might be contributing to their success. Methods: The study used a qualitative approach through observations, document reviews, and semistructured interviews with site management and clinical staff to identify service delivery innovations in 30 health facilities in Kenya and Uganda. Results: Eleven innovative practices were observed along the HIV care cascade. These practices led to improvements in the quality of testing, treatment, and retention across the facilities. Effective human resource and data management processes also enabled the implementation of these innovative practices. Conclusions: Many facilities use innovative practices along the HIV care cascade to address bottlenecks and challenges. These have the potential to improve the quality and efficiency of service delivery and support the attainment of the 90-90-90 treatment targets. Replicating these practices would require further implementation research and a mind shift of donors, governments, and implementers from a metric of coverage to a stronger focus on efficiency and impact.