Browsing by Author "Marchal, Bruno"

Now showing 1 - 11 of 11
  • Thumbnail Image
    Item
    Analyzing implementation dynamics using theory-driven evaluation principles: lessons learnt from a South African centralized chronic dispensing model
    (BioMed Central, 2017) Magadzire, Bvudzai Priscilla; Marchal, Bruno; Mathys, Tania; Laing, Richard; Ward, Kim
    BACKGROUND: Centralized dispensing of essential medicines is one of South Africa’s strategies to address the shortage of pharmacists, reduce patients’ waiting times and reduce over-crowding at public sector healthcare facilities. This article reports findings of an evaluation of the Chronic Dispensing Unit (CDU) in one province. The objectives of this process evaluation were to: (1) compare what was planned versus the actual implementation and (2) establish the causal elements and contextual factors influencing implementation. METHODS: This qualitative study employed key informant interviews with the intervention’s implementers (clinicians, managers and the service provider) [N = 40], and a review of policy and program documents. Data were thematically analyzed by identifying the main influences shaping the implementation process. Theory-driven evaluation principles were applied as a theoretical framework to explain implementation dynamics. RESULTS: The overall participants’ response about the CDU was positive and the majority of informants concurred that the establishment of the CDU to dispense large volumes of medicines is a beneficial strategy to address healthcare barriers because mechanical functions are automated and distribution of medicines much quicker. However, implementation was influenced by the context and discrepancies between planned activities and actual implementation were noted. Procurement inefficiencies at central level caused medicine stock-outs and affected CDU activities. At the frontline, actors were aware of the CDU’s implementation guidelines regarding patient selection, prescription validity and management of non-collected medicines but these were adapted to accommodate practical realities and to meet performance targets attached to the intervention. Implementation success was a result of a combination of ‘hardware’ (e.g. training, policies, implementation support and appropriate infrastructure) and ‘software’ (e.g. ownership, cooperation between healthcare practitioners and trust) factors. CONCLUSION: This study shows that health system interventions have unpredictable paths of implementation. Discrepancies between planned and actual implementation reinforce findings in existing literature suggesting that while tools and defined operating procedures are necessary for any intervention, their successful application depends crucially on the context and environment in which implementation occurs. We anticipate that this evaluation will stimulate wider thinking about the implementation of similar models in low- and middle-income countries.
  • Thumbnail Image
    Item
    An exploration of group-based HIV/AIDS treatment and care models in Sub-Saharan Africa using a realist evaluation (Intervention-Context-Actor-Mechanism- Outcome) heuristic tool: a systematic review
    (BioMed Central, 2017) Mukumbang, Ferdinand C.; Van Belle, Sara; Marchal, Bruno; van Wyk, Brian
    Introduction: It is increasingly acknowledged that differentiated care models hold potential to manage large volumes of patients on antiretroviral therapy (ART). Various group-based models of ART service delivery aimed at decongesting local health facilities, encouraging patient retention in care, and enhancing adherence to medication have been implemented across sub-Saharan Africa. Evidence from the literature suggests that these models of ART service delivery are more effective than corresponding facility-based care and superior to individual-based models. Nevertheless, there is little understanding of how these care models work to achieve their intended outcomes. The aim of this study was to review the theories explicating how and why group-based ART models work using a realist evaluation framework. Methods: A systematic review of the literature on group-based ART support models in sub-Saharan Africa was conducted. We searched the Google Scholar and PubMed databases and supplemented these with a reference chase of the identified articles. We applied a theory-driven approach—narrative synthesis—to synthesise the data. Data were analysed using the thematic content analysis method and synthesised according to aspects of the Intervention-Context-Actor-Mechanism-Outcome heuristic-analytic tool—a realist evaluation theory building tool. Results: Twelve articles reporting primary studies on group-based models of ART service delivery were included in the review. The six studies that employed a quantitative study design failed to identify aspects of the context and mechanisms that work to trigger the outcomes of group-based models. While the other four studies that applied a qualitative and the two using a mixed methods design identified some of the aspects of the context and mechanisms that could trigger the outcomes of group-based ART models, these studies did not explain the relationship(s) between the theory elements and how they interact to produce the outcome(s).
  • Thumbnail Image
    Item
    A realist approach to eliciting the initial programme theory of the antiretroviral treatment adherence club intervention in the Western Cape Province, South Africa
    (BioMed Central, 2018) Mukumbang, Ferdinand C.; Marchal, Bruno; Van Belle, Sara; van Wyk, Brian
    BACKGROUND: The successful initiation of people living with HIV/AIDS on antiretroviral therapy (ART) in South Africa has engendered challenges of poor retention in care and suboptimal adherence to medication. The adherence club intervention was implemented in the Metropolitan area of the Western Cape Province to address these challenges. The adherence club programme has shown potential to relieve clinic congestion, improve retention in care and enhance treatment adherence in the context of rapidly growing HIV patient populations being initiated on ART. Nevertheless, how and why the adherence club intervention works is not clearly understood. We aimed to elicit an initial programme theory as the first phase of the realist evaluation of the adherence club intervention in the Western Cape Province. METHODS: The realist evaluation approach guided the elicitation study. First, information was obtained from an exploratory qualitative study of programme designers’ and managers’ assumptions of the intervention. Second, a document review of the design, rollout, implementation and outcome of the adherence clubs followed. Third, a systematic review of available studies on group-based ART adherence support models in Sub-Saharan Africa was done, and finally, a scoping review of social, cognitive and behavioural theories that have been applied to explain adherence to ART. We used the realist evaluation heuristic tool (Intervention-context-actors-mechanism-outcome) to synthesise information from the sources into a configurational map. The configurational mapping, alignment of a specific combination of attributes, was based on the generative causality logic – retroduction. RESULTS: We identified two alternative theories: The first theory supposes that patients become encouraged, empowered and motivated, through the adherence club intervention to remain in care and adhere to the treatment. The second theory suggests that stable patients on ART are being nudged through club rules and regulations to remain in care and adhere to the treatment with the goal to decongest the primary health care facilities. CONCLUSION: The initial programme theory describes how (dynamics) and why (theories) the adherence club intervention is expected to work. By testing theories in “real intervention cases” using the realist evaluation approach, the theories can be modified, refuted and/or reconstructed to elicit a refined theory of how and why the adherence club intervention works.
  • Thumbnail Image
    Item
    Realist evaluation of the antiretroviral treatment adherence club programme in selected primary healthcare facilities in the metropolitan area of Western Cape Province, South Africa: a study protocol
    (BMJ, 2016) Mukumbang, Ferdinand C.; Van Belle, Sara; Marchal, Bruno; van Wyk, Brian Eduard
    INTRODUCTION: Suboptimal retention in care and poor treatment adherence are key challenges to antiretroviral therapy (ART) in sub-Saharan Africa. Communitybased approaches to HIV service delivery are recommended to improve patient retention in care and ART adherence. The implementation of the adherence clubs in the Western Cape province of South Africa was with variable success in terms of implementation and outcomes. The need for operational guidelines for its implementation has been identified. Therefore, understanding the contexts and mechanisms for successful implementation of the adherence clubs is crucial to inform the roll-out to the rest of South Africa. The protocol outlines an evaluation of adherence club intervention in selected primary healthcare facilities in the metropolitan area of the Western Cape Province, using the realist approach. METHODS AND ANALYSIS: In the first phase, an exploratory study design will be used. Document review and key informant interviews will be used to elicit the programme theory. In phase two, a multiple case study design will be used to describe the adherence clubs in five contrastive sites. Semistructured interviews will be conducted with purposively selected programme implementers and members of the clubs to assess the context and mechanisms of the adherence clubs. For the programme’s primary outcomes, a longitudinal retrospective cohort analysis will be conducted using routine patient data. Data analysis will involve classifying emerging themes using the contextmechanism- outcome (CMO) configuration, and refining the primary CMO configurations to conjectured CMO configurations. Finally, we will compare the conjectured CMO configurations from the cases with the initial programme theory. The final CMOs obtained will be translated into middle range theories. ETHICS AND DISSEMINATION: The study will be conducted according to the principles of the declaration of Helsinki (1964). Ethics clearance was obtained from the University of the Western Cape. Dissemination will be done through publications and curation.
  • Thumbnail Image
    Item
    Realist evaluation of the antiretroviral treatment adherence club programme in selected primary healthcare facilities in the metropolitan area of Western Cape Province, South Africa: a study protocol
    (BMJ Publishing Group, 2016) Mukumbang, Ferdinand C.; Van Belle, Sara; Marchal, Bruno; Van Wyk, Brian
    INTRODUCTION: Suboptimal retention in care and poor treatment adherence are key challenges to antiretroviral therapy (ART) in sub-Saharan Africa. Communitybased approaches to HIV service delivery are recommended to improve patient retention in care and ART adherence. The implementation of the adherence clubs in the Western Cape province of South Africa was with variable success in terms of implementation and outcomes. The need for operational guidelines for its implementation has been identified. Therefore, understanding the contexts and mechanisms for successful implementation of the adherence clubs is crucial to inform the roll-out to the rest of South Africa. The protocol outlines an evaluation of adherence club intervention in selected primary healthcare facilities in the metropolitan area of the Western Cape Province, using the realist approach. METHODS AND ANALYSIS: In the first phase, an exploratory study design will be used. Document review and key informant interviews will be used to elicit the programme theory. In phase two, a multiple case study design will be used to describe the adherence clubs in five contrastive sites. Semistructured interviews will be conducted with purposively selected programme implementers and members of the clubs to assess the context and mechanisms of the adherence clubs. For the programme’s primary outcomes, a longitudinal retrospective cohort analysis will be conducted using routine patient data. Data analysis will involve classifying emerging themes using the contextmechanism- outcome (CMO) configuration, and refining the primary CMO configurations to conjectured CMO configurations. Finally, we will compare the conjectured CMO configurations from the cases with the initial programme theory. The final CMOs obtained will be translated into middle range theories. ETHICS AND DISSEMINATION: The study will be conducted according to the principles of the declaration of Helsinki (1964). Ethics clearance was obtained from the University of the Western Cape. Dissemination will be done through publications and curation.
  • Thumbnail Image
    Item
    Towards developing an initial programme theory: Programme designers and managers assumptions on the antiretroviral treatment adherence club programme in primary health care facilities in the metropolitan area of Western Cape province, South Africa
    (PLOS one, 2016) Mukumbang, Ferdinand C.; van Belle, Sara; Marchal, Bruno; van Wyk, Brian
    Background The antiretroviral adherence club intervention was rolled out in primary health care facilities in the Western Cape province of South Africa to relieve clinic congestion, and improve retention in care, and treatment adherence in the face of growing patient loads. We adopted the realist evaluation approach to evaluate what aspects of antiretroviral club intervention works, for what sections of the patient population, and under which community and health systems contexts, to inform guidelines for scaling up of the intervention. In this article, we report on a step towards the development of a programme theoryÐthe assumptions of programme designers and health service managers with regard to how and why the adherence club intervention is expected to achieve its goals and perceptions on how it has done so (or not). Methods We adopted an exploratory qualitative research design. We conducted a document review of 12 documents on the design and implementation of the adherence club intervention, and key informant interviews with 12 purposively selected programme designers and managers. Thematic content analysis was used to identify themes attributed to the programme actors, context, mechanisms, and outcomes. Using the context-mechanism-outcome configurational tool, we provided an explanatory focus of how the adherence club intervention is roll-out and works guided by the realist perspective.
  • Thumbnail Image
    Item
    Towards developing an initial programme theory: Programme designers and managers assumptions on the antiretroviral treatment adherence club programme in primary health care facilities in the metropolitan area of Western Cape Province, South Africa
    (Public Library of Science, 2016) Mukumbang, Ferdinand C.; van Belle, Sara; Marchal, Bruno; van Wyk, Brian
    BACKGROUND The antiretroviral adherence club intervention was rolled out in primary health care facilities in the Western Cape province of South Africa to relieve clinic congestion, and improve retention in care, and treatment adherence in the face of growing patient loads. We adopted the realist evaluation approach to evaluate what aspects of antiretroviral club intervention works, for what sections of the patient population, and under which community and health systems contexts, to inform guidelines for scaling up of the intervention. In this article, we report on a step towards the development of a programme theoryÐthe assumptions of programme designers and health service managers with regard to how and why the adherence club intervention is expected to achieve its goals and perceptions on how it has done so (or not). METHODS We adopted an exploratory qualitative research design. We conducted a document review of 12 documents on the design and implementation of the adherence club intervention, and key informant interviews with 12 purposively selected programme designers and managers. Thematic content analysis was used to identify themes attributed to the programme actors, context, mechanisms, and outcomes. Using the context-mechanism-outcome configurational tool, we provided an explanatory focus of how the adherence club intervention is roll-out and works guided by the realist perspective. RESULTS We classified the assumptions of the adherence club designers and managers into the rollout, implementation, and utilisation of the adherence club programme, constructed around the providers, management/operational staff, and patients, respectively. Two rival theories were identified at the patient-perspective level. We used these perspectives to develop an initial programme theory of the adherence club intervention, which will be tested in a later phase. CONCLUSION The perspectives of the programme designers and managers provided an important step towards developing an initial programme theory, which will guide our realist evaluation of the adherence club programme in South Africa.
  • Thumbnail Image
    Item
    Understanding the dynamics of accessing chronic medicines in the public sector: Implications for policy in South Africa
    (University of the Western Cape, 2016) Magadzire, Bvudzai Priscilla; Ward, Kim; Marchal, Bruno
    Access to medicines (ATM), specifically for those medicines that are related to the priority health needs of a population has been cited as a fundamental part of universal health coverage and a key element for service delivery and high-quality care. Therefore, ensuring reliable access to and appropriate use of safe, effective and affordable medicines is one of the core functions of an effective health system. With the rising demand for treatment of chronic diseases (e.g. HIV, diabetes and hypertension), ATM has increasingly received global attention. Yet as of 2011, it was estimated that at least one third of the world's population had no regular access to medicines. Globally, there is a dearth of in-depth country level evidence to influence policy responses, coupled with inadequate understanding of how pharmaceutical systems operate within broader health systems. This thesis comprises two main parts: 1) a situational analysis of the state of chronic medicines provision in the public sector in the Eastern Cape and Western Cape provinces of South Africa; and (2) an evaluation of an existing ATM model in one province. To situate this study within the ATM discourse, a conceptual framework was developed from a review of empirical and theoretical literature. The framework incorporated six ATM dimensions (availability, affordability, acceptability, accessibility, accommodation and quality) and their interplay at multiple levels including: health facility, individual, household and community levels. Then, at a health system level, the interaction of medicines (a health system building block) with other building blocks (information, financing, human resources, infrastructure and governance).
  • Thumbnail Image
    Item
    Unearthing how, why, for whom and under what health system conditions the antiretroviral treatment adherence club intervention in South Africa works: A realist theory refining approach
    (BioMed Central, 2018) Mukumbang, Ferdinand C.; Marchal, Bruno; Van Belle, Sara; van Wyk, Brian
    BACKGROUND: Poor retention in care and suboptimal adherence to antiretroviral treatment (ART) undermine its successful rollout in South Africa. The adherence club intervention was designed as an adherence-enhancing intervention to enhance the retention in care of patients on ART and their adherence to medication. Although empirical evidence suggests the effective superiority of the adherence club intervention to standard clinic ART care schemes, it is poorly understood exactly how and why it works, and under what health system contexts. To this end, we aimed to develop a refined programme theory explicating how, why, for whom and under what health system contexts the adherence club intervention works (or not). METHODS: We undertook a realist evaluation study to uncover the programme theory of the adherence club intervention. We elicited an initial programme theory of the adherence club intervention and tested the initial programme theory in three contrastive sites. Using a cross-case analysis approach, we delineated the conceptualisation of the intervention, context, actor and mechanism components of the three contrastive cases to explain the outcomes of the adherence club intervention, guided by retroductive inferencing. RESULTS: We found that an intervention that groups clinically stable patients on ART in a convenient space to receive a quick and uninterrupted supply of medication, health talks, counselling, and immediate access to a clinician when required works because patients’ self-efficacy improves and they become motivated and nudged to remain in care and adhere to medication. The successful implementation and rollout of the adherence club intervention are contingent on the separation of the adherence club programme from other patients who are HIV-negative. In addition, there should be available convenient space for the adherence club meetings, continuous support of the adherence club facilitators by clinicians and buy-in from the health workers at the health-care facility and the community. CONCLUSION: Understanding what aspects of antiretroviral club intervention works, for what sections of the patient population, and under which community and health systems contexts, could inform guidelines for effective implementation in different contexts and scaling up of the intervention to improve population-level ART adherence.
  • Thumbnail Image
    Item
    Unpacking the capacity development: A Systems exploration of a partnership of Africa universities to develop capacity in health workforce
    (University of Western Cape, 2020) Amde, Woldekidan Kifle; Lehmman, Uta; Sanders, David; Marchal, Bruno
    Health system in Sub-Saharan in Africa face multifaceted capacity challenges to fulfil their mandates of service provision and governance of their resources. Wide-ranging capacity development interventions exist to address these limitations. however, failure to take into account complexity into planning and implementation in the practice and research of these capacity development intervention predominate , hindering understanding and learning, and resulting in poor implementation or lack of sustainability of the capacity gains.
  • Thumbnail Image
    Item
    Using the realist interview approach to maintain theoretical awareness in realist studies.
    (SAGE Journals, 2020) Mukumbang, Ferdinand . C; Marchal, Bruno; Van Belle, Sara; van Wyk, Brian
    Realist evaluation submits that theories and models of how, why, for whom and under what circumstances programs work could be formulated by conceptualizing the relational links between the context within which programs are implemented, the generative mechanisms the programs trigger, and the outcomes of interest. Qualitative and quantitative data collection and analysis allow for the description of the relevant context, the generative mechanisms, and the emergent outcomes of programs and provide explanatory power to link these elements. The ‘realist interviewing technique’, whereby interviewees comment on a suggested ‘program theory’ to provide refinement, is proposed as a distinctive approach for conducting interviews in a realist-informed inquiry.