CASE STUDY #062
INTERNAL PROJECT SHOWCASE
ARV Chronic Clubs
City-partnered anti-retroviral (ARV) clubs help to drastically cut down the time that HIV patients spend at health clinics
IDP LINKAGES
Caring city
Opportunity city
Well-run city
The Integrated
Development Plan is a
plan for how the City will
prioritise its budget
spending over a five-year
cycle. The IDP is agreed
between local government
and residents, and is
adjusted to accommodate
SUMMARY
changing needs.
South Africa has the highest number of people living with HIV in the world. The ARV Clubs project
addresses the need for effective anti-retroviral treatment which reduces illness and death resulting from
HIV. By removing patients from overcrowded clinics and monitoring adherence closely, they can be
effectively managed.
BACKGROUND
Congested public medical facilities and the increasing number of HIV patients created a need to rethink the
ant-retroviral (ARV) model of treatment. The solution was the development of ARV Clubs, where patients
can receive their check-ups and medication speedily.
Patients who are eligible and wish to be enrolled are divided into groups (or clubs) of approximately 30
people. These patients go directly to a ‘club room’ on their given date and time without needing to queue
for their records. Patients have their weight checked and are given a symptom screen. If they are well, they
are given their pre-packed medication and leave. The visit time for a patient is usually under 30 minutes.
Patients still in the ‘normal’ clinic system also benefit as they no longer have the club patients adding to
the general congestion at the facility, and can aspire to joining a club when they are eligible.
About 20% of all patients receiving their ARVs at primary care facilities are currently doing so through
the club system.
The project is a joint initiative between the City’s Health Directorate, Médecins Sans Frontières (MSF), the
ENABLERS
City Health Directorate
Primary Health Care
Department
This case study describes one of the City of Cape Town’s innovative projects that demonstrates how the
City applies design-led thinking to support City strategies and goals and help to improve the lives of
residents. For more, scan the QR code alongside or see www.capetown.gov.za/WDC2014/
CITY OF CAPE TOWN WORLD DESIGN CAPITAL 2014 INTERNAL PROJECTS SHOWCASE
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Western Cape Government Department of Health and the Institute for Healthcare Improvement (IHI).
The pilot club system was facilitated by MSF in Ubuntu, Khayelitsha, and the result was increased patient
satisfaction and better attendance and medication-taking. Following the 18-month pilot, City Health, in
partnership with the Western Cape Government Department of Health, IHI and MSF, adopted this system at
17 City and Provincial health facilities in December 2010, using this breakthrough series model.
Both patients and staff benefit: Stable patients can enjoy the streamlined interaction with the clinic, and
staff deal with satisfied patients and a reduced workload thanks to the reorganised process. The model is
being rolled out to all sites which provide ARVs.
In 2012, the ARV Club project won a prestigious Platinum Impumelelo Award for social innovation.
DESIGN THINKING
Design-led thinking is a
collaborative and usercentric process through
which challenges are
INTEGRATED DEVELOPMENT PLAN LINKAGES
CARING CITY: The impact of life-long routine visits every two months to overcrowded facilities by HIV
patients was recognised, and systems changed to minimise the burden. The ARV Clubs offer convenient
and time-efficient care to HIV patients who use what are often overcrowded medical facilities.
OPPORTUNITY CITY: Quick access to life-long medication greatly limits the negative impact of visits.
This means that patients can continue their lives (work, childcare, homecare etc.) with minimal interruption while receiving optimal care.
WELL-RUN CITY: The club model represents a far more efficient way of ensuring quality care for large
numbers of patients. By decongesting facilities, those patients that attend facilities are no longer competing with stable HIV patients for space and care.
identified and creatively
addressed to deliver
innovative and relevant
solutions. With the
responsibilities placed on a
city administration, the
core driver for embracing
design-led thinking is the
improvement of the
quality of life of citizens,
the ethos that underpins
HOW HAS DESIGN BEEN USED?
Of the key tools which support design-led thinking in project conception, creation and implementation, the
following are fundamental to the success of this project:
+ INNOVATION CO: The ARV Clubs were first piloted at the Ubuntu Clinic in Khayelitsha. The Ubuntu
Clinic, the largest ARV site in the metro, had already been operating for some years before the general
ARV roll out, making it an appropriate site for piloting an intervention to cater for large numbers of
stable long-term patients. Médecins Sans Frontières (MSF) input at the clinic allowed for close monitoring through collaboration, and a number of aspects of the club model were tried before deciding on a
system that could be rolled out to other facilities.
+ DREAM TEAM: A steering committee consisting of a number of role-players partnering to make the
project a success was set up. The project was run from the Western Cape Province Health Department
in collaboration with the City’s Health Directorate (representing the service providers), with representatives from MSF (who had piloted the model) and IHI (who had experience with rolling out interventions using a ‘breakthrough’ series that involved staff in implementing the intervention).
+ CONSULTATION/COMMUNICATION: This was a fundamental part of the project on two levels. Firstly,
the multi-disciplinary expertise of the steering committee members meant that each made a critical
contribution that was invaluable to the success of the project. Secondly, the ‘breakthrough’ series run
by IHI is based on three learning sessions for staff from all the facilities participating (the initial pilot
involved 14 facilities), which ensures consultation and communication with all role-players. In the pilot
phase MSF worked closely with the Treatment Action Campaign, a civil society HIV advocacy group.
+ EVOLUTIONARY APPROACH: The steering committee met monthly, along with the club mentors for
the duration of the first roll-out phase (18 months). Over time, and through shared experience, it
became apparent which strategies worked well and which would result in problems down the line,
which helped the model to become more well-defined. However, there remains a fair degree of flexibility in terms of overcoming obstacles as each facility implements the model. For the breakthrough
phase, there were three learning sessions for all categories of staff involved in the club model implementation. At the first session the club model at Ubuntu Clinic was presented and staff asked to
engage in how they would implement such a model at their facilities. Participants were given tools to
CITY OF CAPE TOWN WORLD DESIGN CAPITAL 2014 INTERNAL PROJECTS SHOWCASE
the World Design Capital
programme.
DESIGN TOOLS
For an explanation of the
key constructs which
support design-led
thinking in project
conception, design and
implementation,see
the Toolbox.
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#062: ARV CHRONIC CLUBS
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assist them in thinking through problems (PDSA: Plan, do, study, adopt/adapt/abandon). Mentors were
allocated to facilities and the mentors would meet on a monthly basis to provide feedback and share
experiences so that they could better support their sites. The second learning session, six months later,
provided an opportunity for staff to discuss successes and problems. The third session, six months after
that, allowed for further learning and sharing as the number of clubs increased.
QUICK DELIVERY: To maximise the impact of the club model it was decided to roll it out to 14 large
ARV facilities that were experiencing problems with congestion. Targeting the largest facilities ensured
that the maximum number of patients could benefit, a ‘quick win’. The second wave of the roll out,
involving a further 19 facilities, was started 12 months after the first group as the success of the intervention became apparent. The breakthrough series for the first group was funded by the Impumelelo
award money (received in 2012), funds were set aside from the provincial ARV budget to ensure the
project would continue to expand. Twelve months later there was a further ‘mopping-up’ roll out to the
smaller facilities that did not yet have clubs. While the congestion at the smaller sites might not be
such a big problem, it is recognised that the benefits to the patient who is in a club is enormous, hence
the decision to extend the programme to these facilities.
OPEN ACCESS TO INFORMATION: The mentors meetings and the learning sessions allowed for
extensive sharing of information. With experience, and as it became clear that certain practices were
very useful, a standard operating procedure was drawn up and circulated to participating facilities to
ensure that these best practices were known to all. There was an agreement as to what data should be
collected and reported on so that the club system could be monitored. This has assisted in identifying
facilities that are running into trouble. The well-functioning facilities also demonstrate what sort of performance is possible.
EXECUTIVE MANAGEMENT TEAM: This project did not start until it had been ratified by the management teams of the service providers. For the City this meant that the project was presented and discussed at Health Management Team level, and ratified by this body, which is chaired by the executive
director of City Health. The steering committee reported back at regular intervals.
INNOVATION CHAMPS: The steering committee consisted of the champions from each of the roleplayers (Province, the City, MSF and IHI). It was not only the different skill-sets that each member contributed, but also their very real and passionate belief in what this project had to offer to both facilities
and patients that provided the energy to spread this project so successfully.
BIG THINKING, LOCALISED IMPACT: Real change with real benefits on the ground has been experienced. This project was rolled out with a number of objectives – to decongest the facilities and to
assist with making long term adherence to ART easier, eg. by expediting the visit time of patients who
are stable on ART. It is well documented in many studies that waiting time is often the area that
receives the lowest scores in patient satisfaction studies in public health settings.
COMMUNITY AT THE CENTRE, CREATIVITY ON THE FRINGE: At an individual level, no patient is
enrolled in a club without their permission. A big satisfaction factor for staff is that they have grateful
patients again. Congested facilities mean unhappy patients blaming staff, which results in high stress
levels on a daily basis.
DESIGN THINKING
Design-led thinking is a
collaborative and usercentric process through
which challenges are
identified and creatively
addressed to deliver
innovative and relevant
solutions. With the
responsibilities placed on a
city administration, the
core driver for embracing
design-led thinking is the
improvement of the
quality of life of citizens,
the ethos that underpins
the World Design Capital
programme.
DESIGN TOOLS
For an explanation of the
key constructs which
support design-led
thinking in project
conception, design and
implementation,see
the Toolbox.
FURTHER INFORMATION
Contact the project manager, Karen Jennings: karen.jennings@capetown.gov.za
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