Zakumumpa Henry, Kwiringira Japheth, Rujumba Joseph, Ssengooba Freddie
a School of Public Health , Makerere University , Kampala , Uganda.
b Faculty of Social Sciences , Kyambogo University , Kampala , Uganda.
Glob Health Action. 2018;11(1):1523302. doi: 10.1080/16549716.2018.1523302.
In the context of declining international assistance for ART scale-up in Sub-Saharan Africa, the institutionalization of ART programs through integrating them in the organizational routines of health facilities is gaining importance as a program sustainability strategy.
The aims of this study were; (i) to compare the level of institutionalization of ART programs in health facilities in Uganda and (ii) to explore reasons for variations in the degree of program institutionalization.
In Phase One, we utilized Level of Institutionalization Scales developed by Goodman (1993) to measure the degree of institutionalization of ART interventions in 195 health facilities across Uganda. The 45-item questionnaire measured institutionalization based on four sub-systems (production, maintenance, supportive, managerial) theorized to make up an organization assessed against two levels of institutionalization; routines (lowest) niche saturation (highest). In Phase Two, four health facilities were purposively selected (2 with the highest and 2 with the lowest institutionalization scores) for a multiple case-study involving semi-structured interviews with ART clinic managers(n = 32), on-site observations and document review.
The two highest scoring health facilities had a longer HIV intervention implementation history of between 8 and 11 years. The highest scoring cases associated intervention institutionalization with sustained workforce trainings in ART management, the retention of ART-trained personnel and generating in-house ART manuals. The turnover of ART-proficient staff was identified as a barrier to intervention institutionalization in the lowest-ranked cases. Significant differences in organizational contexts were identified. The two highest-ranked health facilities were well-established, higher-tier hospitals while the lowest scoring health facilities were lower-level health facilities.
The level of institutionalization of ART interventions appeared to be differentiated by level of care in the Ugandan health system. Interventions aimed at strengthening program institutionalization in lower-level health centers at the level of human resources for health could enhance ART scale-up sustainability.
在撒哈拉以南非洲扩大抗逆转录病毒治疗（ART）的国际援助减少的背景下，通过将ART项目纳入卫生设施的组织常规使其制度化，作为一项项目可持续性战略正变得越来越重要。
本研究的目的是：（i）比较乌干达卫生设施中ART项目的制度化水平；（ii）探讨项目制度化程度差异的原因。
在第一阶段，我们使用了古德曼（1993年）开发的制度化量表来衡量乌干达195个卫生设施中ART干预措施的制度化程度。这份包含45个条目的问卷基于四个子系统（生产、维护、支持、管理）来衡量制度化程度，这四个子系统理论上构成一个组织，并根据两个制度化水平进行评估；常规（最低）、生态位饱和（最高）。在第二阶段，有目的地选择了四个卫生设施（2个制度化得分最高的和2个得分最低的）进行多案例研究，包括对ART诊所管理人员进行半结构化访谈（n = 32）、现场观察和文件审查。
得分最高的两个卫生设施有8至11年更长的艾滋病毒干预实施历史。得分最高的案例将干预措施的制度化与ART管理方面持续的劳动力培训、保留接受过ART培训的人员以及编写内部ART手册联系起来。在得分最低的案例中，ART熟练工作人员的流动被确定为干预措施制度化的一个障碍。确定了组织环境存在显著差异。排名最高的两个卫生设施是成熟的上级医院，而得分最低的卫生设施是基层卫生设施。
乌干达卫生系统中ART干预措施的制度化水平似乎因护理级别而异。旨在加强基层卫生中心在卫生人力资源层面项目制度化的干预措施，可以提高ART扩大规模的可持续性。
