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Table 4 Comparison between adaptations made to the health system for patients with HIV and NCDs

From: Practicalities and challenges in re-orienting the health system in Zambia for treating chronic conditions

Health systems HIV NCD
Delivery system design Clinical HIV services have been decentralised to enable care and treatment at PHC level. There is division of tasks between different disciplines. Higher levels facilities attend to complicated cases and include recent introduction of an advanced treatment centre. Intention to establish such centres in each Province. Clinical care for NCDs is suboptimal at PHC level. Higher level facilities predominantly manage uncomplicated and complicated cases Very limited specialist infrastructure (e.g. one Cancer hospital) Intention to establish specialist centres at all provincial hospitals.
Decision support Established ART guidelines and trained personnel (including NGO/FBO caregivers) which provides capacity for patient surveillance, recruitment, adherence and retention: enables early detection of complications (HIV and ART-induced NCDs). Updated treatment guidelines not yet released. Limited NCD care expertise at PHC level such that patients are referred to higher levels (where there is shortage of specialist health professionals).
Clinical information systems Electronic information system being installed at PHC facilities (will improve patient monitoring, quality of service and patient medical data). Relatively reliable data for assessment of HIV incidence and prevalence but not yet for NCD co-morbidities. Paper-based information system and lack of NCD specification in H-MIS data collection. NCD specification indicators to be added to tertiary hospital H-MIS data collection. Technical constraints prevent inclusion of NCD data on HIV electronic information system Smart care.
Community HIV NCD
Self-management support Decentralisation of ART and introduction of electronic information system creates scope for greater individual –focused care. Self-management concept well established via the diverse care and support services of CHBC programmes. Some CHBC programmes have extended support to NCD patients but lack financial support and training. Self-management principles for NCD patients not yet included in CHA skills training.
Outcomes HIV NCD
Productive Interactions CHBC programmes provide foundation for HIV literacy in communities, care and treatment skills amongst families and via volunteer caregivers. Revitalisation of PHC is expanding capacity and scope of PHC facilities for co-ordinated interventions with CHBC programmes. Limited NCD literacy amongst the population exacerbated by lack of care and treatment skills amongst CHBC programmes and PHC health professionals. Suboptimal infrastructure for linking service provision between different levels of care (primary up to tertiary level) and between different disciplines.
Improved outcomes Zambia achieved ‘universal coverage’ of ART (>80% coverage). Lack of data on efficacy of NCD services (e.g. disease monitoring, appropriate referral).