Transcript MIP 2001 presentation BCT

Implications for Health Systems
and Service Delivery
Consultation on HIV/AIDS and Malaria Interactions, June
2004
Thierry Mertens and Juliana Yartey
World Health Organization, Geneva
Child care for HIV - South Africa
Children with IMCI features of HIV or known to be HIV
positive
 43 identified as needing HIV care
↓ 6/14%
 37 offered testing
↓ 7/19%
 30 accepted
↓ 5/17%
 25 with results
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From Kwazulu Natal and Mozambique, presentation of "HIVimpulse"
Summary
Selected aspects of interactions of HIV/AIDS and
Malaria

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
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Similar epidemiologic profile/geographic
distribution
Women and children: at-risk populations
Poverty
Biological interactions
•
•
•
•
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HIV infection increases risk/severity of malaria
Malaria increases severity of HIV
Increased MTCT of HIV infection
Women with dual infections have poorer birth outcomes
(foetal loss, preterm delivery, LBW)
Perspective
Strengthening health systems:
fundamental to sustainable, quality
and equitable expansion of delivery of
essential health services
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A comprehensive approach to the
prevention of HIV infection in pregnant
women, mothers and their infants

Primary prevention of HIV infection in all women

Prevention of unintended pregnancies among HIV-infected
women

Prevention of HIV transmission from HIV-infected women to
their infants (HIV testing and counseling, ARV drug use, safe
delivery practices, infant feeding counseling and support,)

Care and support to HIV-infected women, their infants and
family (incl. antiretroviral therapy, psychosocial and nutritional
support and RH care)
(Source: WHO, 2002: 3)
The Interagency Task Team (IATT) for the Prevention of HIV in Pregnant Women, Mothers and
Infants include UNAIDS, UNFPA, UNICEF, WHO and World Bank (WHO, 2003:5).
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
The IATT recommendation
“MTCT-prevention interventions should
not stand in isolation, but be integrated
where possible into existing health care
infrastructures and reproductive health
services.”
(Source: WHO, 2001a)
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Figure 1. Percentages of Pregnant Women Receiving Antenatal Care at Least Once or
Twice, by Country
Attending antenatal clinic at least once
Percentage
Attending antenatal clinic at least twice
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100
90
80
70
60
50
40
30
20
10
0
Eth Ni Ma Bu Nig Gu Ca Ta Ga To Co Be Gh Ke Ug Ma Zim
iop g er uri t rk in eri ine me nza bo go te d nin an nya and l aw ba
a
an a a a roo nia n
ia
'I v
a i bw
ia Fa
o
n
e
i re
so
Source: WHO/UNICEF The Africa Malaria Report 2003
Malaria Control During Pregnancy
Intervention Package
ANC
ITNs
IPT
CM
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ANC
Private
Sector
Commun
ANC
H. Facilities
Intermittent Preventive Treatment (IPT)
Doses Given at Antenatal Clinic Visits after Quickening
Benefit:
Mothers
Infants
less malaria
less anaemia
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Rx
fewer of LBW
10
Conception
Rx
20
30
Quickening
Weeks of pregnancy
Birth
Implications for Health Service
Delivery
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
Concurrent delivery of interventions for
prevention and control of Malaria and HIV/AIDS
in women and children with RH services

In Africa, about 70 percent of women attend
ANC at least once during pregnancy

Optimize opportunities of patient/client
contact with health care delivery facility
Scale-up can foster the strengthening and
development of health systems
1. Drug procurement policies
2. Financing (e.g. social insurance schemes)
3. Trained health workforce in
sufficient numbers
4. Health Information systems
5. Logistics management systems
6. Public-private partnerships
7. Community participation
8. Quality improvement
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Health systems
elements necessary to
reaching MDG 6
The system context:
PUBLIC SECTOR
PRSP
MDG
Political and Financial Commitment
GEN. HEALTH SERVICES
Management of Delivery /
Infrastructure
ANC EPI Human Resources
TB
Monitoring and
Information
Systems
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Social Mobilization and Demand
CCM
Private sector
Challenges
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
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Weak, overburdened health systems with
poor/inadequate infrastructure (VCT etc.)
Human resources
Financial/other resources
Coordination of funding
Communication/shared responsibility
Improved programming and service delivery,
quality of care
Management/Supervision
Nigeria
Ivory Coast
Togo
Human resources:
Physicians/100,000
Population
18.5
9
7.6
Cameroon
7.4
Ghana
6.2
Benin
5.7
Niger
3.5
USA
279
0
50
100
150
200
250
300
No. of physicians
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Reference: "Human Resources for Health and Development: A Joint Learning Initiative" (HRH/JLI)
Initiated by The Rockefeller Foundation
HRH Availability and Requirements in Tanzania for 2015 by Skill Level
District Support Staff
9251
150
Technical Staff
Specialists
9521
2070
3247
Requirements
1470
Availability
20670
Personnel with Medical Skills
6100
33987
Nursing and Midwifery skills
17300
10462
Unskilled
0
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11330
5000
10000
15000
20000
25000
30000
35000
40000
References: "Human Resources for Health and Development: A Joint Learning Initiative" (HRH/JLI)
Initiated by The Rockefeller Foundation
Subsidizing people who can pay?



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Evidence suggests that people who can
pay are being subsidized.
Subsidies may be highest for people
who consume sophisticated and costly
services.
Subsidies for people who can pay
reduces money for the poor.
“How can we include the excluded”


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Targeting strategies easy to conceive,
difficult to implement ( e.g. risk approach in
ANC) : how do we identify those “in hiding”.
Systemic thinking is moving towards
planning and budgeting to alleviate
constraints and bottlenecks.
Planning
A. Situation analysis
B. Need assessment
Task 1.
Set priorities
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Target setting

Conclusions:
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Overprovision of long-stay beds and
underprovision of acute beds
General shortage of staff
Community/hospital ratio for staff
indicates concentration of staff in
250
hospital settings
Low rate of Daily patient visits and 200
150
Admissions may indicate:
•
•
•
•
•
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Poor detection
Lack of referral
Lack of trained staff
Stigma
Inaccessible services
Current services (Step A)
Need (Step B)
100
50
0
A
t
cu
e
ds
be
L
g
on
st
ay
ds
be
N
s
se
ur
T
a
st
al
t
o
ff
f/b
af
St
ed
tio
ra
C
om
o
/h
m
sp
D
PV
A
dm
on
si
is
s
Target setting (cont)

Options
1.Reduce long stay
beds, discharge
patients
2.Redirect funds
from long-stay to
community
3.Motivate for
funding from
general health
4. Improve
information
system
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Option appraisal
Feasibility
Financial
availability
Long term
sustainability
Acceptability
Knock-on
effects
Equity
effects
Pilot to
reality
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?
?
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?
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

?
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×
?
×
?
?
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Service integration – some of the
advantages
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Improve access
Reduced stigma
addresses human resource shortages
Full integration vs partial (clinical) integration
Resource constraints - ‘piggy-back’ on existing
health/social programmes
Strengthening Health Systems
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Providing basic equipment, drugs and supplies
Improving service delivery/quality of care (evidencebased standards)
Decentralized planning and district level
responsibility
Functional referral systems for continuum of care
Strong linkages with the community
Empowering individuals, families & communities
with Info for appropriate health seeking
Conclusion

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Strong joint planning,
implementation and evaluation
towards integration of services
needed at global, regional and
national level.