ABSTRACT
Background. Implementation of healthcare regulatory policies, especially in low- and middle-income countries where the private health sector is predominant, is challenging. Karnataka, a southern state in India, enacted the Karnataka Private Medical Establishments Act (KPMEA) with an aim to ensure quality of care in the private healthcare establishments. After more than a decade the implementation of KPMEA is suboptimal. Methods. We used a case study design. The case was ‘implementation of KPMEA’. The case study site was Bengaluru Urban district in Karnataka. Data from key informant interviews, focus group discussions held at the state, district and subdistrict levels and key policy documents, minutes of the meetings, data from the State Department of Health and Family Welfare, district level KPMEA data and litigations at the High Court of Karnataka were analysed using a framework. Results. The policy (KPMEA) content is inadequate and requires clarity in certain provisions of the Act. There was a lack of coordination between the implementing agencies. Workforce shortages were evident. Factors that impede the enforcement of the Act include poor knowledge and lack of competency of the officials on the content and the implementation mechanics of the policy, insufficient policy oversight from the state on the districts, corruption, political interference and lack of support from the local public, especially during raids on illegal establishments. Conclusions. A regulatory policy such as KPMEA needs a clear, comprehensive content and directions for operationalization. However, improving the content of the policy is not easy as some aspects of the policy remain contentious with the private healthcare providers/ establishments. Addressing health governance issues at all levels is key to effective enforcement.
ABSTRACT
Background: An estimated 7.9 million people were living with HIV in South Africa in 2017, with 63.3% of them remaining in antiretroviral therapy (ART) care and 62.9% accessing ART. Poor retention in care and suboptimal adherence to ART undermine the successful efforts of initiating people living with HIV on ART. To address these challenges, the antiretroviral adherence club intervention was designed to streamline ART services to 'stable' patients. Nevertheless, it is poorly understood exactly how and why and under what health system conditions the adherence club intervention works.Objectives: The aim of this study was to test a theory on how and why the adherence club intervention works and in what health system context(s) in a primary healthcare facility in the Western Cape Province.Method: Within the realist evaluation framework, we applied a confirmatory theory-testing case study approach. KaplanMeier descriptions were used to estimate the rates of dropout from the adherence club intervention and virological failure as the principal outcomes of the adherence club intervention. Qualitative interviews and non-participant observations were used to explore the context and identify the mechanisms that perpetuate the observed outcomes or behaviours of the actors. Following the retroduction logic of making inferences, we configured information obtained from quantitative and qualitative approaches using the interventioncontextactormechanismoutcome heuristic tool to formulate generative theories.Results: We confirmed that patients on ART in adherence clubs will continue to adhere to their medication and remain in care because their self-efficacy is improved; they are motivated or are being nudged.Conclusion: A theory-based understanding provides valuable lessons towards the adaptive implementation of the adherence club intervention