How integration of refugees into national health systems became a global priority: a qualitative policy analysis.

BACKGROUND: Despite a long history of political discourse around refugee integration, it wasn't until 2016 that this issue emerged as a global political priority. Limited research has examined the evolution of policies of global actors around health service provision to refugees and how refugee integration into health systems came onto the global agenda. This study seeks to fill this gap. METHODS: Drawing on a document review of 20 peer-reviewed articles, 46 global policies and reports, and 18 semi-structured interviews with actors representing various bilateral, multilateral and non-governmental organizations involved with refugee health policy and funding, we analyze factors that have shaped the global policy priority of integration. We use the Shiffman and Smith Policy Framework on determinants of political priority to organize our findings. RESULTS: Several important factors generated global priority for refugee integration into national health systems. Employing the above-mentioned framework, actor power increased due to network expansion through collaborations between humanitarian and development actors. Ideas took hold through the framing of integration as a human rights and responsibility sharing. While political context was influenced through several global movements, it was ultimately the influx of Syrian refugees into Europe and the increasing securitization of the refugee crisis that led to key policies, and critically, global funding to support integration within refugee hosting nations. Finally, issue characteristics, namely the magnitude of the global refugee crisis, its protractedness and the increasing urbanicity of refugee inflows, led integration to emerge as a manageable solution. CONCLUSION: The past decade has seen a substantial reframing of refugee integration, along with increased financing sources and increased collaboration, explains this shift towards their integration into health systems. However, despite the emergence of integration as a global political priority, the extent to which efforts around integration have translated into action at the national level remains uncertain.

HIV programme sustainability in Southern and Eastern Africa and the changing role of external assistance for health.

High human immunodeficiency virus (HIV)-prevalence countries in Southern and Eastern Africa continue to receive substantial external assistance (EA) for HIV programming, yet countries are at risk of transitioning out of HIV aid without achieving epidemic control. We sought to address two questions: (1) to what extent has HIV EA in the region been programmed and delivered in a way that supports long-term sustainability and (2) how should development agencies change operational approaches to support long-term, sustainable HIV control? We conducted 20 semi-structured key informant interviews with global and country-level respondents coupled with an analysis of Global Fund budget data for Malawi, Uganda, and Zambia (from 2017 until the present). We assessed EA practice along six dimensions of sustainability, namely financial, epidemiological, programmatic, rights-based, structural and political sustainability. Our respondents described HIV systems' vulnerability to donor departure, as well as how development partner priorities and practices have created challenges to promoting long-term HIV control. The challenges exacerbated by EA patterns include an emphasis on treatment over prevention, limiting effects on new infection rates; resistance to service integration driven in part by 'winners' under current EA patterns and challenges in ensuring coverage for marginalized populations; persistent structural barriers to effectively serving key populations and limited capacity among organizations best positioned to respond to community needs; and the need for advocacy given the erosion of political commitment by the long-term and substantive nature of HIV EA. Our recommendations include developing a robust investment case for primary prevention, providing operational support for integration processes, investing in local organizations and addressing issues of political will. While strategies must be locally crafted, our paper provides initial suggestions for how EA partners could change operational approaches to support long-term HIV control and the achievement of universal health coverage.

Converging global health agendas and universal health coverage: financing whole-of-government action through UHC.

UN member states have committed to universal health coverage (UHC) to ensure all individuals and communities receive the health services they need without suffering financial hardship. Although the pursuit of UHC should unify disparate global health challenges, it is too commonly seen as another standalone initiative with a singular focus on the health sector. Despite constituting the cornerstone of the health-related Sustainable Development Goals, UHC-related commitments, actions, and metrics do not engage with the major drivers and determinants of health, such as poverty, gender inequality, discriminatory laws and policies, environment, housing, education, sanitation, and employment. Given that all countries already face multiple competing health priorities, the global UHC agenda should be used to reconcile, rationalise, prioritise, and integrate investments and multisectoral actions that influence health. In this paper, we call for greater coordination and coherence using a UHC+ lens to suggest new approaches to funding that can extend beyond biomedical health services to include the cross-cutting determinants of health. The proposed intersectoral co-financing mechanisms aim to support the advancement of health for all, regardless of countries' income.

Does foreign aid affect innovation and institutional quality in middle-income countries?

In this study, we explore the dynamics between innovation, institutional quality, and foreign-aid flows in middle-income countries. Using an appropriate econometric model, we investigate the links between these variables in 79 middle-income countries (MICs) over 2005-2020. The results from our study show that foreign aid, institutional quality, and innovation have strong endogenous relationships. The short-run outcomes show that innovation Granger-causes institutional quality; foreign aid Granger-causes innovation; and quality of institutions Granger-causes foreign aid. The long-run outcomes indicate that institutional quality and innovation significantly affect the flow of foreign aid to the MICs. These results indicate that policy-makers in both foreign aid donor and recipient countries should pursue appropriate policies on foreign aid, quality of institutions, and innovation. For instance, in the short run, planners and evaluators in donor countries can direct their aid to MICs that have persistent challenges in improving their institutions and enhancing their innovative capabilities. In the long run, recipient countries ought to recognize that their institutional quality and innovation have a considerable impact on the inflows of foreign aid to their countries.

'All my co-workers are good people, but ': collaboration dynamics between frontline workers in rural Uttar Pradesh, India.

Multisectoral collaboration has been identified as a critical component in a wide variety of health and development initiatives. For India's Integrated Child Development Services (ICDS) scheme, which serves >100 million people annually across more than one million villages, a key point of multisectoral collaboration-or 'convergence', as it is often called in India-is between the three frontline worker cadres jointly responsible for delivering essential maternal and child health and nutritional services throughout the country: the Accredited Social Health Activist (ASHA), Anganwadi worker (AWW) and auxiliary nurse midwife (ANM) or 'AAA' workers. Despite the long-recognized importance of collaboration within this triad, there has been relatively little documentation of what this looks like in practice and what is needed in order to improve it. Informed by a conceptual framework of collaborative governance, this study applies inductive thematic analysis of in-depth interviews with 18 AAA workers and 6 medical officers from 6 villages across three administrative blocks in Hardoi district of Uttar Pradesh state to identify the key elements of collaboration. These are grouped into three broad categories: 'organizational' (including interdependence, role clarity, guidance/support and resource availability); 'relational' (interpersonal and conflict resolution) and 'personal' (flexibility, diligence and locus of control). These findings underscore the importance of 'personal' and 'relational' collaboration features, which are underemphasized in India's ICDS, the largest of its kind globally, and in the multisectoral collaboration literature more broadly-both of which place greater emphasis on 'organizational' aspects of collaboration. These findings are largely consistent with prior studies but are notably different in that they highlight the importance of flexibility, locus of control and conflict resolution in collaborative relationships, all of which relate to one's ability to adapt to unexpected obstacles and find mutually workable solutions with colleagues. From a policy perspective, supporting these key elements of collaboration may involve giving frontline workers more autonomy in how they get the work done, which may in some cases be impeded by additional training to reinforce worker role delineation, closer monitoring or other top-down efforts to push greater convergence. Given the essential role that frontline workers play in multisectoral initiatives in India and around the world, there is a clear need for policymakers and managers to understand the elements affecting collaboration between these workers when designing and implementing programmes.

Geographic prioritisation in Kenya and Uganda: a power analysis of donor transition.

Introduction Donor transition for HIV/AIDS programmes remains sensitive, marking a significant shift away from the traditional investment model of large-scale, vertical investments to control the epidemic and achieve rapid scaling-up of services. In late 2015, the United States President's Emergency Plan for AIDS Relief (PEPFAR) headquarters instructed their country missions to implement 'geographic prioritisation' (GP), whereby PEPFAR investments would target geographic areas with high HIV burden and reduce or cease support in areas with low burden.Methods Using Gaventa's power cube framework, we compare how power is distributed and manifested using qualitative data collected in an evaluation of the GP's impact in Kenya and Uganda.Results We found that the GP was designed with little space for national and local actors to shape either the policy or its implementation. While decision-making processes limited the scope for national-level government actors to shape the GP, the national government in Kenya claimed such a space, proactively pressuring PEPFAR to change particular aspects of its GP plan. Subnational level actors were typically recipients of top-down decision-making with apparently limited scope to resist or change GP. While civil society had the potential to hold both PEPFAR and government actors accountable, the closed-door nature of policy-making and the lack of transparency about decisions made this difficult.Conclusion Donor agencies should exercise power responsibly, especially to ensure that transition processes meaningfully engage governments and others with a mandate for service delivery. Furthermore, subnational actors and civil society are often better positioned to understand the implications and changes arising from transition. Greater transparency and accountability would increase the success of global health programme transitions, especially in the context of greater decentralisation, requiring donors and country counterparts to be more aware and flexible of working within political systems that have implications for programmatic success.

Interface between energy consumption, CO2 emissions, economic growth, and macroeconomic openness in financial action task force countries through the lens of a causality approach.

There is strong scientific evidence to suggest that carbon dioxide (CO2) emissions are one of the key drivers of global warming. Rising CO2 emissions across the globe have been traced back to increasing global trade and rapid industrial development powered by fossil fuels. High CO2 emissions have had an adverse effect on the quality of life and economic growth of communities across the globe. In this study, the Granger causality approach is used to examine scientifically some causal relationships between energy consumption, CO2 emissions, economic growth, and key macroeconomic variables (trade openness and foreign direct investment) in the panel of Financial Action Task Force (FATF) countries. FATF countries are signatories to agreements to adhere to good financial practices to ensure sustainable development of their economies. The empirical analysis was conducted for the period 1980 to 2020. Results indicate a strong endogenous relationship between the variables in the short and long run. The analysis suggests that careful co-curation of economic, trade, energy, foreign direct investment, and environmental management policies is needed to ensure sustainable economic development in the FATF countries. Global trade and foreign direct investment policies must foster new environmental-friendly industries and greater use of clean renewable energy among these countries. Note: Arrows indicate direction of possible causal links between the variables.

Understanding reasons for and strategic responses to administrative health data misreporting in an Indian state.

The misreporting of administrative health data creates an inequitable distribution of scarce health resources and weakens transparency and accountability within health systems. In the mid-2010s, an Indian state introduced a district ranking system to monitor the monthly performance of health programmes alongside a set of data quality initiatives. However, questions remain about the role of data manipulation in compromising the accuracy of data available for decision-making. We used qualitative approaches to examine the opportunities, pressures and rationalization of potential data manipulation. Using purposive sampling, we interviewed 48 district-level respondents from high-, middle- and low-ranked districts and 35 division- and state-level officials, all of whom had data-related or programme monitoring responsibilities. Additionally, we observed 14 district-level meetings where administrative data were reviewed. District respondents reported that the quality of administrative data was sometimes compromised to achieve top district rankings. The pressure to exaggerate progress was a symptom of the broader system for assessing health performance that was often viewed as punitive and where district- and state-level superiors were viewed as having limited ability to ensure accountability for data quality. However, district respondents described being held accountable for results despite lacking the adequate capacity to deliver on them. Many rationalized data manipulation to cope with high pressures, to safeguard their jobs and, in some cases, for personal financial gain. Moreover, because data manipulation was viewed as a socially acceptable practice, ethical arguments against it were less effective. Potential entry points to mitigate data manipulation include (1) changing the incentive structures to place equal emphasis on the quality of data informing the performance data (e.g. district rankings), (2) strengthening checks and balances to reinforce the integrity of data-related processes within districts and (3) implementing policies to make data manipulation an unacceptable anomaly rather than a norm.

An investigation of the relationship between the performance and management practices of health facilities under a performance-based financing scheme in Nigeria.

Whereas the effect of performance-based financing (PBF) on improving the quantity and quality of health services has been established, little is known about what matters for health facilities to improve performance under a PBF scheme. This study examined the associations between management practices and the performance of primary healthcare centres (PHCCs) under a PBF scheme in Nigeria. This study utilized longitudinal data on monthly institutional deliveries and outpatient visits collected between December 2011 and March 2016 from 111 randomly selected PHCCs in Adamawa, Ondo and Nasarawa states of Nigeria. A management practices scorecard, based on a health facility survey conducted in April/May 2016, was used to derive management practices scores for the 111 PHCCs. The management practices examined included activities to recruit and retain clients, staff's attention to performance targets, listening and responding to client feedback, teamwork building and addressing low-performing staff. A multilevel, multilinear regression model was used to investigate the associations between health facility performance (monthly number of institutional deliveries and outpatient visits) and management practices at the PHCCs, adjusting for key control variables (number of skilled health workers, the size of PHCC catchment population, PHCC quality score, seasonality and states). Following PBF introduction, PHCCs with medium management scores had 0.42 (95% CI 0.18-0.65; P < 0.001) and 9.93 (95% CI 6.15-13.71; P < 0.001) higher monthly improvement rates for institutional delivery and outpatient visits, respectively, compared to the PHCCs with low management scores. Also, the PHCCs with high management scores had 0.49 (95% CI 0.28-0.70; P < 0.001) and 5.10 (95% CI 1.76-8.44; P < 0.003) higher monthly improvement rates for institutional delivery and outpatient visits compared to the PHCCs with low management scores. These findings suggest the importance of management practices in facilitating the effect of PBF on health facility performance and the need to strengthen PHCC management practices in low- and middle-income countries.

Strategies to promote evidence use for health programme improvement: learning from the experiences of embedded implementation research teams in Latin America and the Caribbean.

BACKGROUND: To achieve global health targets, innovative approaches are needed to strengthen the implementation of efficacious interventions. New approaches in implementation research that bring together health system decision-makers alongside researchers to collaboratively design, produce and apply research evidence are gaining traction. Embedded implementation research (EIR) approaches led by decision-maker principal investigators (DM PIs) appear promising in this regard. Our aim is to describe the strategies study teams employ in the post-research phase of EIR to promote evidence-informed programme or policy improvement. METHODS: We conducted a prospective, comparative case study of an EIR initiative in Bolivia, Colombia and Dominican Republic. Guided by a conceptual framework on EIR, we used semi-structured key informant interviews (n = 51) and document reviews (n = 20) to examine three decision-maker-led study teams ("cases"). Focusing on three processes (communication/dissemination, stakeholder engagement with evidence, integrating evidence in decision-making) and the main outcome (enacting improvements), we used thematic analysis to identify associated strategies and enabling or hindering factors. RESULTS: Across cases, we observed diverse strategies, shaped substantially by whether the DM PI was positioned to lead the response to study findings within their sphere of work. We found two primary change pathways: (1) DM PIs implement remedial measures directly, and (2) DM PIs seek to influence other stakeholders to respond to study findings. Throughout the post-research phase, EIR teams adapted research use strategies based on the evolving context. CONCLUSIONS: EIR led by well-positioned DM PIs can facilitate impactful research translation efforts. We draw lessons around the importance of (1) understanding DM PI positionality, (2) ongoing assessment of the evolving context and stakeholders and (3) iterative adaptation to dynamic, uncertain circumstances. Findings may guide EIR practitioners in planning and conducting fit-for-purpose and context-sensitive strategies to advance the use of evidence for programme improvement.

Impact of Classical Counterconditioning (Quiet Kennel Exercise) on Barking in Kenneled Dogs-A Pilot Study.

Excessive barking is a major source of noise pollution in dog kennels and negatively impacts welfare. Because resources are often limited, minimizing barking in the simplest and most easily implementable way is imperative. This pilot study implemented a Quiet Kennel Exercise (QKE) that utilized classical counterconditioning to change the dogs' negative emotional state (which can lead to barking) to a more positive emotional state. Therefore, barking motivation is reduced, so barking should decrease. This study aims to show proof of concept that decreasing barking through classical counterconditioning is effective. It was conducted in one ward of day-time boarding kennels at North Carolina State University College of Veterinary Medicine. Data was collected three times per day and included decibel readings, number of dogs present, and number of dogs barking during a 5-day initial baseline and 10-day intervention period. During baseline, people passing through the ward acted as they normally would. During intervention, passersby were asked to simply toss each dog a treat regardless of the dogs' behaviors in the kennel. Descriptive results show improvement in maximum level of barking after QKE, fewer dogs barking over time, dogs barking less each time, and the most improvement noted in the afternoon.

Public sector engagement of private healthcare providers during the COVID-19 pandemic in Uttar Pradesh, India.

The COVID-19 pandemic has strained public health resources and overwhelmed health systems capacity of countries worldwide. In India, the private sector is a significant source of healthcare particularly in large states like Uttar Pradesh (UP). This study sought to examine: (i) the government's approach to engaging the private health sector in the COVID-19 response in UP; (ii) the effects of government's engagement on private providers' practices and (iii) the barriers and facilitators to effective private sector engagement during the period. While the literature acknowledges weaknesses in private sector engagement during emergencies, our study provides deep empirical insight into how this occurs, drawing on the UP experience. We reviewed 102 Government of UP (GOUP) policy documents and conducted 36 in-depth interviews with government officials, technical partners, and private providers at district- and state-levels. We developed timelines for policy change based on the policy review and analyzed interview transcripts thematically using a framework analysis. We found that GOUP's engagement of the private sector and private providers' experiences varied substantially. While the government rapidly engaged and mobilized private laboratories, and enlisted private hospitals to provide COVID-19 services, it undertook only limited engagement of solo private providers who largely acted as referral units for suspected cases and reported data to support contact tracing efforts. Informal private providers played no formal role in the COVID-19 response, but in one district supported community-level contact tracing. Allopathic, alternative medicine, and diagnostic private providers faced common barriers and facilitators affecting their engagement relating to provider fear, communication, testing capacity, case reporting, and regulations. The establishment of mixed diagnostic networks during COVID-19 demonstrates the potential for public-private collaboration, however, our study also reveals missed opportunities to engage smaller-scale private health providers and establish mechanisms to effectively communicate and mobilize them during the pandemic, and beyond.

Stakeholder perspectives on proposed policies to improve distribution and retention of doctors in rural areas of Uttar Pradesh, India.

BACKGROUND: In India, the distribution and retention of biomedical doctors in public sector facilities in rural areas is an obstacle to improving access to health services. The Government of Uttar Pradesh is developing a comprehensive, ten-year Human Resources for Health (HRH) strategy, which includes policies to address rural distribution and retention of government doctors in Uttar Pradesh (UP). We undertook a stakeholder analysis to understand stakeholder positions on particular policies within the strategy, and to examine how stakeholder power and interests would shape the development and implementation of these proposed policies. This paper focuses on the results of the stakeholder analysis pertaining to rural distribution and retention of doctors in the government sector in UP. Our objectives are to 1) analyze stakeholder power in influencing the adoption of policies; 2) compare and analyze stakeholder positions on specific policies, including their perspectives on the conditions for successful policy adoption and implementation; and 3) explore the challenges with developing and implementing a coordinated, 'bundled' approach to strengthening rural distribution and retention of doctors. METHODS: We utilized three forms of data collection for this study - document review, in-depth interviews and focus group discussions. We conducted 17 interviews and three focus group discussions with key stakeholders between September and November 2019. RESULTS: We found that the adoption of a coordinated policy approach for rural retention and distribution of doctors is negatively impacted by governance challenges and fragmentation within and beyond the health sector. Respondents also noted that the opposition to certain policies by health worker associations created challenges for comprehensive policy development. Finally, respondents believed that even in the event of policy adoption, implementation remained severely hampered by several factors, including weak mechanisms of accountability and perceived corruption at local, district and state level. CONCLUSION: Building on the findings of this analysis, we propose several strategies for addressing the challenges in improving access to government doctors in rural areas of UP, including additional policies that address key concerns raised by stakeholders, and improved mechanisms for coordination, accountability and transparency.

Examining policy intentions and actual implementation practices: How organizational factors influence health management information systems in Uttar Pradesh, India.

This study investigates the implementation of a recent health management information systems (HMIS) policy reform in Uttar Pradesh, India, which aims to improve the quality and use of HMIS data in decision-making. Through in-depth interviews, meeting observations and a policy document review, this study sought to capture the experiences of district-level staff (street-level bureaucrats) who were responsible for HMIS policy implementation. Findings revealed that issues of weak HMIS implementation were partly due to human resources shortages both in number and technical skill. Delays in recruitment and the presence of inactive staff overburdened existing staff and weakened the implementation of HMIS activities at the block- and district-levels. District staff also explained how inadequate computer literacy and limited technical understanding further contributed to low HMIS data quality. The organizational culture was even more constraining: working within a very rigid and hierarchical organization was challenging for district data staff, who were expected to manage day-to-day HMIS activities, but lacked the discretion and authority to do so effectively. Consequently, they had to escalate minor issues to district leadership for action and were expected to follow their supervisors' directives- even if they contradicted HMIS policy guidelines. High performance pressures associated with achieving top district rankings deviated focus away from HMIS data quality issues. Many district-level respondents described their superiors' "fixation" with becoming a top-ranking district often resulted in disregard for the quality of data informing district rankings. Furthermore, the review of district rankings only partially encouraged district-level leadership to investigate reasons for low-performing indicators. Instead, low district rankings often resulted in punitive action. The study recommends the importance of incorporating the perspectives of district staff, and recognizing their discretion, and authority when designing policy implementation processes, and finally concludes with potential strategies for strengthening the current HMIS policy reform.

Exploring perceived effects from loss of PEPFAR support for outreach in Kenya and Uganda.

INTRODUCTION: In 2015, the President's Emergency Plan for AIDS Relief undertook policy shifts to increase efficiencies in its programming, including transitioning HIV/AIDS funding away from low burden areas. We examine the impact of these changes on HIV outreach in Kenya and Uganda. METHODS: Qualitative data collection was conducted as a part of a broader mixed-methods evaluation. Two rounds of facility-level case studies and national-level interviews were conducted in Kenya and Uganda, with health facility, sub-national and central Ministry of Health staff, HIV clients, and implementing partners. RESULTS: In both countries, the loss of outreach support affected community-based HIV/AIDS education, testing, peer support, and defaulter tracing. DISCUSSION: Loss of external support for outreach raises concerns for countries' ability to reach the 90-90-90 UNAIDS target, as key linkages between vulnerable communities and health systems can be adversely affected. CONCLUSION: Development partners should consider how to mitigate potential consequences of transition policies to prevent negative effects at the community level.

Effects of transition on HIV and non-HIV services and health systems in Kenya: a mixed methods evaluation of donor transition.

BACKGROUND: In 2015 the US President's Emergency Plan for AIDS Relief (PEPFAR) initiated its Geographic Prioritization (GP) process whereby it prioritized high burden areas within countries, with the goal of more rapidly achieving the UNAIDS 90-90-90 targets. In Kenya, PEPFAR designated over 400 health facilities in Northeastern Kenya to be transitioned to government support (known as central support (CS)). METHODS: We conducted a mixed methods evaluation exploring the effect of GP on health systems, and HIV and non-HIV service delivery in CS facilities. Quantitative data from a facility survey and health service delivery data were gathered and combined with data from two rounds of interviews and focus group discussions (FGDs) conducted at national and sub-national level to document the design and implementation of GP. The survey included 230 health facilities across 10 counties, and 59 interviews and 22 FGDs were conducted with government officials, health facility providers, patients, and civil society. RESULTS: We found that PEPFAR moved quickly from announcing the GP to implementation. Despite extensive conversations between the US government and the Government of Kenya, there was little consultation with sub-national actors even though the country had recently undergone a major devolution process. Survey and qualitative data identified a number of effects from GP, including discontinuation of certain services, declines in quality and access to HIV care, loss of training and financial incentives for health workers, and disruption of laboratory testing. Despite these reports, service coverage had not been greatly affected; however, clinician strikes in the post-transition period were potential confounders. CONCLUSIONS: This study found similar effects to earlier research on transition and provides additional insights about internal country transitions, particularly in decentralized contexts. Aside from a need for longer planning periods and better communication and coordination, we raise concerns about transitions driven by epidemiological criteria without adaptation to the local context and their implication for priority-setting and HIV investments at the local level.

The impact of loss of PEPFAR support on HIV services at health facilities in low-burden districts in Uganda.

BACKGROUND: Although donor transitions from HIV programs are more frequent, little research exists seeking to understand the perceptions of patients and providers on this process. Between 2015 and 2017, PEPFAR implemented the ´geographic prioritization´ (GP) policy in Uganda whereby it shifted support from 734 'low-volume' facilities and 10 districts with low HIV burden and intensified support in select facilities in high-burden districts. Our analysis intends to explore patient and provider perspectives on the impact of loss of PEPFAR support on HIV services in transitioned health facilities in Uganda. METHODS: We report qualitative findings from a larger mixed-methods evaluation. Six facilities were purposefully selected as case studies seeking to ensure diversity in facility ownership, size, and geographic location. Five out of the six selected facilities had experienced transition. A total of 62 in-depth interviews were conducted in June 2017 (round 1) and November 2017 (round 2) with facility in-charges (n = 13), ART clinic managers (n = 12), representatives of PEPFAR implementing organizations (n = 14), district health managers (n = 23) and 12 patient focus group discussions (n = 72) to elicit perceived effects of transition on HIV service delivery. Data were analyzed using thematic analysis. RESULTS: While core HIV services, such as testing and treatment, offered by case-study facilities prior to transition were sustained, patients and providers reported changes in the range of HIV services offered and a decline in the quality of HIV services offered post-transition. Specifically, in some facilities we found that specialized pediatric HIV services ceased, free HIV testing services stopped, nutrition support to HIV clients ended and the 'mentor mother' ART adherence support mechanism was discontinued. Patients at three ART-providing facilities reported that HIV service provision had become less patient-centred compared to the pre-transition period. Patients at some facilities perceived waiting times at clinics to have become longer, stock-outs of anti-retroviral medicines to have been more frequent and out-of-pocket expenditure to have increased post-transition. CONCLUSIONS: Participants perceived transition to have had the effect of narrowing the scope and quality of HIV services offered by case-study facilities due to a reduction in HIV funding as well as the loss of the additional personnel previously hired by the PEPFAR implementing organizations for HIV programming. Replacing the HIV programming gap left by PEPFAR in transition districts with Uganda government services is critical to the attainment of 90-90-90 targets in Uganda.