Open Access Research article

How to improve patient retention in an antiretroviral treatment program in Ethiopia: a mixed-methods study

Yibeltal Assefa14*, Lut Lynen2, Edwin Wouters3, Freya Rasschaert2, Koen Peeters4 and Wim Van Damme45

Author Affiliations

1 Ethiopian Public Health Institute, Addis Ababa, Ethiopia

2 Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium

3 Department of Social Sciences, Antwerp University, Antwerp, Belgium

4 Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium

5 School of Public Health, University of Western Cape, Cape Town, South Africa

For all author emails, please log on.

BMC Health Services Research 2014, 14:45  doi:10.1186/1472-6963-14-45

Published: 29 January 2014



Patient retention, defined as continuous engagement of patients in care, is one of the crucial indicators for monitoring and evaluating the performance of antiretroviral treatment (ART) programs. It has been identified that suboptimal patient retention in care is one of the challenges of ART programs in many settings. ART programs have, therefore, been striving hard to identify and implement interventions that improve their suboptimal levels of retention. The objective of this study was to develop a framework for improving patient retention in care based on interventions implemented in health facilities that have achieved higher levels of retention in care.


A mixed-methods study, based on the positive deviance approach, was conducted in Ethiopia in 2011/12. Quantitative data were collected to estimate and compare the levels of retention in care in nine health facilities. Key informant interviews and focus group discussions were conducted to identify a package of interventions implemented in the health facilities with relatively higher or improving levels of retention.


Retention in care in the Ethiopian ART program was found to be variable across health facilities. Among hospitals, the poorest performer had 0.46 (0.35, 0.60) times less retention than the reference; among health centers, the poorest performers had 0.44 (0.28, 0.70) times less retention than the reference. Health facilities with higher and improving patient retention were found to implement a comprehensive package of interventions: (1) retention promoting activities by health facilities, (2) retention promoting activities by community-based organizations, (3) coordination of these activities by case manager(s), and (4) patient information systems by data clerk(s). On the contrary, such interventions were either poorly implemented or did not exist in health facilities with lower retention in care. A framework to improve retention in care was developed based on the evidence found by applying the positive deviance approach.


A framework for improving retention in care of patients on ART was developed. We recommend that health facilities implement the framework, monitor and evaluate their levels of retention in care, and, if necessary, adapt the framework to their own contexts.

Antiretroviral treatment; Retention; Attrition; Positive deviance; Framework