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Table 1 System effects of ART expansion in Uganda

From: Scaling up antiretroviral therapy in Uganda: using supply chain management to appraise health systems strengthening

System Outcomes Description of System Causes and Effects Primary Sub-system affected
More people on ART The country has rapidly expanded ART with a 50% coverage of those in need by the end of 2009. Effects include creation of demands that require the systems to sustain an appropriate level of care. Service delivery, with knock-on effects on all other sub-systems
Supply shortages (essential drugs) and expiry (ARVs) Little investments in strengthening supply systems for essential drugs, lack of qualified staff leading. Effects include poor health outcomes, inefficiencies, financial and credibility losses. Technologies, with knock-on effects on all other sub-systems
New supply chain management systems and governance structures for ART Interest for short-term targets easier achieved through parallel systems. New structures and interests difficult to readjust later on. Effects include poor outcomes, vicious circles between weak systems and vertical approaches. Governance, Technologies, Information, as well as the other sub-systems
ART program related mismanagement Partly due to lack of absorptive capacity for rapid and large funding. Effects include misappropriation, withdrawal of funding, inefficiencies. Governance, with knock-on effects on all other sub-systems
Brain drain, lack of qualified and motivated staff Focus on short-term trainings, lack of training, higher salaries and other incentives within disease-specific programs compared to the public sector Human Resources, knock-on effects on all sub-systems
Lack of appropriate data Parallel, partly inefficient as well as unfeasible programme specific information systems. Effects include failure to focus on one national information system that meets quality standards, inefficiencies, superfluous tasks at facility level. Information, knock-on effects on all sub-systems