An evaluation of the implementation of the 3-tiered ART monitoring system in South Africa

Background and Purpose: South Africa has the largest public antiretroviral (ART) service in the world but until recently it was unable to report from primary sources the numbers of patients on ART and was unable to monitor the program outcomes using routine data. In December 2010 the South Africa National Department of Health adopted a standardized ART monitoring strategy referred to as the 3-Tiered Strategy. The System provides facilities with different options for cohort monitoring based on the resources and infrastructure available. The technical design of the three tiers is pragmatic and appropriate to the facility-level context. The process to implement the System was articulated through an implementation plan. The health management information system was aligned to collate data produced by the System and standard operating procedures were produced to guide system use. Methods: The study comprised a mixed-methods approach to evaluate the implementation of the system in accordance with the implementation plan. Program data were analysed, program documents were reviewed and key informants were interviewed in order to capture the complex and multidimensional nature of the countrywide implementation activities. Results: By October 2014 full implementation had been achieved in 2,139 ART facilities, of a total 3,772 facilities that report ART data. And, of facilities that had reached full implementation, 87% of facilities had submitted data. At the time of analysis, the outcome data available were representative of 55% of active patients on ART. Qualitative results elicited facility-level challenges as well as structural barriers to effective implementation. The study demonstrated that South Africa's introduction of the 3-Tiered Strategy for ART monitoring was championed by senior management in the NDOH who fostered a collaborative environment and structured implementation approach which resulted in wide-scale uptake of the recommended systems, predominantly the electronic register. Conclusions: The implementation of a basics first health information system has yielded a complete set of enrolment and retention on ART data; however there are systemic and structural barriers to the sustainable production of these and additional cohort outcome data. The study has brought attention to the organizational restructuring and the holistic health system interventions required to implement such a system