Effectiveness of healthcare delivery system reform in optimizing care for people living with Hiv during Coronavirus pandemic era at Gateway clinic, Malawi

Abstract

Since the start of COVID-19 pandemic, delivery of healthcare has turned out to be more difficult because of health service delivery policy changes to accommodate COVID-19 prevention, pressure on already frail health systems and clients’ fears of interacting with health facilities hence shunning health services. HIV health services are some of the crucial services that have been affected in Malawi and policy changes (from six monthly visits to two visits every three months in the first six months of treatment and suspension of some routine services) were effected to optimize care while preventing the spread of COVID. This facility-based cross-sectional study was conducted to evaluate the effectiveness of healthcare delivery system reform in optimizing care for persons with HIV infection in the coronavirus pandemic era, at Gateway clinic, Malawi. The specific objectives were to determine the reliability of healthcare service reform, assess patient satisfaction with healthcare service reform and assess the responsiveness of the healthcare providers with regards to healthcare reform in optimizing care for persons with HIV infection in the Coronavirus pandemic era at Gateway clinic in Malawi. Participants includedrandomly selected 93 people living with HIV accessing HIV care and 5health care workers providing HIV care at Gateway clinic (purposively selected) and they provided information through interviews using questionnaires and key informant interview guide respectively. Quantitative data was analyzed using descriptive statistics, bivariate and multivariate logistic regression while qualitative analysis used thematic approach. Results showed that demographic characteristics did not have a significant association with effectiveness/optimization of healthcare but reliability, client satisfaction and responsiveness of healthcare workers did. Reliability of the healthcare system reduced during COVID-19 following the reforms by 5.4% compared to pre-COVID-19 pandemic period (95% CI: -0.4–-0.1, p0.0004)following a significant drop in capability of the facility, quality and effectiveness of care (at least 10% drop). A p-value of 0.0004 denotes a statistical significance of the difference in reliability. Similarly, there was an overall reduction in client satisfaction with healthcare during the Coronavirus pandemic (a 5% drop, 95% CI: -0.2–-0.02, p0.0108), largely because clinic operating hours became less convenient to the clients (2%). A p-value of 0.0108 denotes a statistical significance of the difference in client satisfaction over the two periods. Responsiveness of healthcare workers during COVID-19 pandemic reduced by 5.5% (95% CI: -0.9–-0.6, p<0.001). Differences were statistically significant with a p-value of <0.001. Overall, clients who perceived this reduction indicated that healthcare provided was less effective during COVID-19 pandemic. It is, therefore, important for policy makers and health system leadership to trade carefully when making policy reforms that influence changes to approaches for implementation of well-established programs and services (i.e. HIV care), especially during emergencies (i.e. pandemics). This in essence underscores the importance of wider consultations and considerations to safeguard the gains that have been realized over a long period of time in HIV program (progress towards the 95-95-95 UNAIDS targets). The following recommendations are therefore made; integration of telehealth into existing health system as an alternative to in-person engagement between clients and providers, implementation of client-centred approaches that deliberately target to meet clients’ needs i.e. flex-clinic operating hours, and training for healthcare providers to improve responsiveness and efficiency in service delivery during emergencies.