Transcript Equity and the Expansion of Access to Treatment and Care

Equity and the Expansion of
Access to Treatment and Care
in Southern Africa
Based on case studies commissioned
by Equinet and Oxfam GB
With active support from UNAIDS and
SADC Health Desk
Presentations and case
study powerpoints from
the
EQUINET/Oxfam GB
workshop at the 13th
ICASA Conference
With support from UNAIDS and DfID
Defining equity
 Equity is concerned with
– Disparities that are considered unfair and
avoidable
– Distribution and share of available resources
– Focus on wealthy and powerful as much as on
the poor and marginalised
– Value-based – linked to human rights an social
justice discourse (not charity or aid)
Defining the parameters of equity
 Comparison between socially defined groups
–
–
–
–
–
Socio-economic
Geographic
Gender
Racial
Patient groups
 Compared across different levels
– From the global to the local
 Looking at the underlying determinants of health
and access to health care and treatment
Why be concerned with equity?
 Resource constraints mean that difficult
decisions have to be made
 Widening disparities increasingly
unacceptable and undesirable
 Necessary to address poverty
Why be concerned with equity?
 Redistribution and social solidarity under
attack
 Marginalised voices need to be amplified
 Public health principles of maximising costeffectiveness
Why Southern Africa?
Figure 1: Life expectancy trends in southern Africa 1960 - 2000
80
70
no. years
Angola
60
Botswana
50
Congo, Dem. Rep. of
the
Lesotho
Malawi
Mauritius
40
Mozambique
Namibia
30
Seychelles
South Africa
20
Swaziland
Tanzania, U. Rep. of
10
Zambia
Zimbabwe
0
1960
1970
1980
1990
year
2000
2001
The global context
GDP per
capita
(PPP US$)
%
adults(1549)living
with
HIV/AIDS
Number of
people
living with
HIV/AIDS
Under-5
mortality
rate2001
Life
expectancy
at birth
(years) 2001
SubSaharan
Africa
1,690
9
28.5 million
172
46.5
OECD
countries
23,569
0.28
Neg.
14
77
Programme
 Case Studies
–
–
–
–
Malawi
South Africa
Zimbabwe
Nutrition
 Framework of equity challenges for accessing
care and treatment
 Discussion : Safeguarding equity and improving
access to treatment
Programme (cont)
 Recommendations to:
– Southern African governments and heath policy
makers
– Global health institutions and donors
 Wrap-up
Framing the Equity Challenges of
Increasing Access to Treatment Equitably
 The broader development agenda
 The broader health systems context
– Financing and resource allocation
– Culture and ethos
 Health care infra-structure
Framing the Equity Challenges of
Increasing Access to Treatment Equitably
 Prevention - Treatment
 Sharing the burden between the commercial
and public sectors
 Regulation / Standards - Access
 Patient selection
“Equity in ART? But the whole health system
is inequitable”
Equity in Health Sector Responses to HIV/AIDS
in Malawi
Presented by Dr Andrina Mwansambo
National AIDS Commission, Malawi
Paper commissioned by
Southern African Regional Network on Equity in Health
(EQUINET)
in co-operation with OXFAM (GB)
Overview of presentation
1. Situation analysis – HIV/AIDS
epidemic in the context of Malawi
2. Impact of HIV/AIDS on the health
sector
3. Equity in access to ART and health
sector responses to HIV/AIDS
4. Summary
1. Situation analysis
The situation of poverty in Malawi is ‘widespread, deep and
severe’
 65% of the population is poor
 1/5 children die before the age of 5 years
 Maternal mortality ratio 1,120/100,000
The HIV/AIDS epidemic undermines efforts to reduce poverty
 National prevalence 8.4%
 Prevalence highest in south, urban areas and in younger
age groups
 Vulnerability to HIV/AIDS is influenced by
– Gender relations – sexual norms, violence
– Poverty
– Age
1. Situation analysis
Malawi’s health system – a plurality of providers with, on paper,
‘reasonable’ coverage
 54% of rural population has access to a health facility within
5km
But ‘the poor wait longer, receive fewer drugs and ‘pay’ more in
comparison to the wealthy’
 Severe staffing shortages, especially in rural areas – overall
50% posts unfilled
 50% doctors work in the four central hospitals
 1.9 nurses per health facility – many have only one
 User perception of poor quality – poor staff attitudes, long
waiting times, lack of confidentiality, & limited accountability to
service users
2. Impact of HIV/AIDS on the
health sector
HIV has created an increasing and changing pattern of demand
for health services….
 Little information on demand for out-patient services (as a
proxy, TB notification rates have increased five fold over last
twenty years)
 40% of all admissions, or 70% of admissions to medical wards
are HIV-related
…..against a background of decreasing capacity to supply those
services
 Context of declining resources
 2% annual attrition of health care workers due to death 2%
 Chronic absenteeism – illness, caring for family members,
funerals
 Increased workload for an understaffed & demoralised health
3. Equity in health sector
responses to HIV/AIDS
Continuum of care for HIV/AIDS?
 Most policies in place or well
advanced
 Couple of areas where response
is well established nationwidepublic, CHAM & private sector
– TB control
– STI management
Anti-retroviral therapy (including
Prevention of Mother to Child
Transmission)
Voluntary Counselling and Testing
Home-Based Care & Palliative care
Opportunistic infections prophylaxis
Nutrition support
Behaviour Change Communication
Sexually Transmitted Infections
Management
TB Treatment
 Others?
– Depend on specific donor inputs –
– Patchy coverage with islands of
excellence
Other opportunistic infections
treatment
Infection management
3. Equity in health sector
responses to HIV/AIDS
Inequities in access to continuum of care?
 Limited geographical coverage, based at district centre or
limited service implementation
E.g. PMTCT in 9 hospitals
- 95% of mothers have ante-natal care, but only 35% deliver at health
facilities, few at hospitals
 Social barriers to access
E.g. VCT
- evidence of gender differences in access, especially at stand-alone
sites
- fear of knowing HIV status?
 Even within a comprehensive national response – barriers to
access remain
E.g. TB
- costs urban poor 6 times available monthly income for TB diagnosis
- people drop-out of diagnosis
- social stigma
3. Equity in health sector
responses to HIV/AIDS
Access to anti-retroviral therapy (ART)
 Guidelines for ART in place – delivery in district system using a
‘public health’ approach
– Standardised regimens
– Clinical criteria for entry (not laboratory testing)
– Monitoring on clinical criteria
 AIDS Policy – ‘access to eligible persons of ‘affordable’ ART’
 Three systems for ART delivery currently in place
– GOM/MOHP – at cost, Lilongwe & Blantyre
– MSF-led provision, free of charge in Chiradzulu and Thyolo districts
– Private providers
 Performance of programmes – information limited
– ? Drug interruptions in 21% cases, 4% of cases severe toxicity
3. Equity in health sector
responses to HIV/AIDS
Equity in access to anti-retroviral therapy (ART)?
 Need estimated at 200,000, 1370 beneficiaries in 2002
 Under GFATM, scale up is imminent for 25,000 + people
 Most likely to be on first-come, first served basis, if people meet
clinical criteria
But, initial beneficiaries likely to be less vulnerable:
 People already accessing the ‘at cost’ system operated by
GOM/MOHP (higher socio-economic status)
 High awareness of ART (high education level)
 Able to afford the direct and opportunity costs of care seeking,
and repeated visits for therapy (proximity to district centre )
 Able overcome social barriers to knowing HIV status and
access VCT
3. Equity in health sector
responses to HIV/AIDS
Responses to Human Resource crisis?
 Emergency training plan & Health Services Commission
 No workplace policy for HIV/AIDS - although now mandate for 2% budget
allocation
 Moves to improve waste management and infection control, but current
situation poor
– Amongst health workers giving vaccinations or curative injections, 49%
and 57% respectively reported suffering at least one needle-stick injury
during the last twelve months.
– In 44% of a sample of 29 health facilities, injection safety boxes were
stored in a manner that was not safe
4. Summary
Can provision of continuum of care be equitable ?
 Equity is promoted through availability of quality care at the
periphery
– Current inequities relate to general health services - understaffing and
weak infrastructure & management
 New Essential Health Package should address inequities
–
–
–
–
BUT under resourced – finances and staff
90% of health facilities currently cannot deliver EHP
Need for outputs for Global Fund will require rapid ‘project’ approach
HIV epidemic and response will cause depletion of staff unless –
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
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Work as much as possible with current staffing levels
Use non-clinically qualified staff as far as possible e.g. VCT
Infection protection measures in place
Access to ART for staff
Performance-related incentives
4. Summary
Can provision of anti-retrovirals be equitable ?
 Needs to be delivered through mechanisms that do not exclude
poor/vulnerable
– Feasible – but limited impact immediately
– Guidelines point to whole service ‘public health approach’
– More specific targeting required?
 Needs to be in context of comprehensive response – continuum
of care
– Continuum response patchy & slower in implementation
 Needs to be delivered so as not to take away resources from
essential health services
– ‘Additional’ services require heavy staff load
– Project based approach for funding under GFATM
– Parallel drug procurement and distribution (initially)
4. Summary
‘Equity’ in access to ART – who benefits?
 If consider access to the treatment alone, then ART will be
inequitable in the short and medium term
– Explicit measures are needed to ensure equity in longer term – a
‘road map’
 In the Malawi situation of limited resources, question of
equity should consider what will be the equity in access to
benefits of the investment of ART provision
– ‘how’ ART is rolled-out will have the greatest impact on equity in
access to care (for HIV/AIDS and all other care)
– Potential to deplete or support resources for the Essential Health
Package
Acknowledgements
 Authors of the technical paper
–
–
–
–
Dr Julia Kemp
Jean-Marion Aitken
Sarah LeGrand
Dr Biziwick Mwale
 All those who have taken part in stakeholder
interviews or who have contributed materials for
the analysis
Zimbabwe’s challenge:
Ensuring Equity in the Health Sector’s Response to
Treatment Access for HIV and AIDS.
by
Tendayi Kureya, and
Sunanda Ray
Review Commissioned by
Southern African Regional Network on Equity in Health (EQUINET)
in co-operation with OXFAM (GB) with support from DRC, DfID
Structure of the review
 Part 1: Preparing the study
 Part 2: Framing the context for treatment
in Zimbabwe
 Part 3: Current situation regarding
treatment
 Part 4: Conclusions and
recommendations
Part 2: Framing the Context for
Treatment in Zimbabwe
 The burden of HIV in Zimbabwe is huge.
– High HIV prevalence, nearly 800,000 OVCs and high
incidence in the youth. Most felt at the family level as the
health care system fails to cope.
– Some economic sectors are severely affected: A case study with a bus
company revealed that 54% of absenteeism is associated with attending
funerals, followed by HIV-related illnesses at 35%.
 Current socio-economic problems worsen the plight of remote
health centres. Many hospitals are unable to supply even
basic medications.
 Stigma still shroud HIV and AIDS.
 High inflation rates reduce the true value of public spending
on health.
On equity and health service
delivery
– 90% of population rely on public service health
delivery systems.
– Only 1million are on medical AID.
– 70% of population is rural.
– 49% of population is serviced by mission
hospitals.
– In 1996, health sector had 1020 doctors, 50% of
them in private practice, and some 50,000
traditional healers.
– 50% of inpatients are HIV positive.
 Size of population needing treatment is huge:
estimated between 200,000 to 600,000
Part 3: Current situation regarding treatment
 Government’s response to HIV and AIDS began as early
as 1985
– Set up NAC and its structures and policy framework in 2000.
Declared state of emergency in 2002
 Medicines Control Authority Of Zimbabwe has
registered 6 patented and two generic ARVs,
including one for local production.
 Guidelines for Implementing ART have been
developed by MoHCW. There is no regulation of doctors
that can prescribe ARVs.
 Pharmacies are already stocking ARVs with price ranges
of US$30-400 Local production at around US$15
equivalent in Z$ is planned
 There is limited Access to information on treatment
options available in the country. Activism is still low.
ART programmes
 155 Hospitals participating in PTCT programmes
and some are participating in the fluconazole initiative.
Only one hospital, Luisa Guidotti Mission has an
expanded ARV programme
 Some NGOs and funding organisations are involved
in various programmes: CDC, ZACH on the CHAPPL
prog. The Centre already has people on ART.
 Some Corporations are providing ART, e.g. Delta
Corporation, De Beers, apart from prevention
programmes.
 CIMAS and PSMAS Medical AID schemes now
cover ART.
Part 4: Conclusions and
recommendations
 Major Conclusions
– There is considerable momentums to
establish ART programmes, especially from
the NGO sector. An equitable national
programme, however, should mobilize through
the public health sector to reach all the people
who need treatment
– National efforts still fall short because there is
no sufficient will, funding and activism.
– Generic versions of drugs make ART a
potential reality for all in Zimbabwe, but
require significant external financial input
Areas needing urgent focus include:
– commitment to ensuring that services are provided on the
–
–
–
–
–
basis of need rather than ability to pay. E.g: There is a proposal to
place ccentres of excellence away from areas of greatest need.
Sharing Information on, and Coordination of national ART
programmes
The national HIV policy and strategic framework is silent in
advocating for ART. If resistance to first line ARV medications
develops, more expenditure will be required using second line
drugs for fewer people.
monitoring and evaluation on expenditure of resources
allocated and activities done.
Funding: the funds currently available are not sufficient for
equitable provision of treatment.
GIPA: Limited involvement of people infected or affected by HIV
or AIDS. Community education and mobilisation is not fully
planned for as an integral part of the treatment package.
– END
HIV/AIDS TREATMENT ACCESS AND
EQUITY
South African Case Study
Paper Commissioned by
Southern African Regional Network on Equity in
Health (EQUINET)
in co-operation with OXFAM (GB)
with support from IDRC, DfID
HIV/AIDS TREATMENT ACCESS AND
EQUITY
South African Case Study
Antoinette Ntuli, Petrida Ijumba,
Ashnie Padarath, Lee Berthiaume
HST
Presented at ICASA Conference –
Nairobi Kenya,
21 - 26 September 2003
Socio-economic inequities




GDP per capita approx. $ 3 000 masks the inequities
50% of the population receive 11% of country’s income
7% of the population receive> 40% of the total income
> 19 million trapped in poverty living on or below $55 per
month per person
 Female H/H have 50% higher poverty than male H/H
 72% of the poor live in rural areas – have little access to
land or employment
as
te
rn
18
17
12
11
10
10
7
10 10
9
8
6
7
2
0
30
15
12
Population -% of total
11
at
e
G
au
Kw
te
ng
aZ
ul
uNa
ta
l
Li
m
po
M
po
pu
m
al
an
No
ga
rth
er
n
C
ap
No
e
rth
W
W
es
es
t
te
rn
Ca
pe
So
ut
h
Af
ric
a
20
St
21 21
Ca
pe
40
Fr
ee
25
Ea
st
er
n
C
Fr ap
ee e
S
ta
te
G
K
a
u
w
aZ te
u l ng
uN
a
Li tal
m
M
pu pop
N ma o
or
l
th a ng
er
n a
N Ca
o
p
W rth e
es W
P
ro ter est
n
vi
nc C
ia a p
lA e
ve
ra
ge
E
Inequitable income and employment
opportunities
37
35
36
25
20
21
GDP per capita
15
37
34 36
30
28
16
27 27
30
25
31
29
27
23
25
18
19
14
7
5
10
5
0
1998
2002
Inequitable access to basic
facilities
120
99
98
100
98
94
80
60
32
40
16
20
14
12
ng
D
In
si
de
Ta
p
m
sh
/C
he
Fl
u
w
lT
oi
ic
a
H
ou
al
m
Fo
r
el
li
le
t
si
ng
E
le
ct
ric
ity
0
Richest
Poorest
Public – private divide
 Public
 Consumes < 40% of
healthcare financing
 About $110 per capita
 > 80% of the population
 Employ 33% of
specialists
 Over-used and underresourced
 Private
 Consumes > 60% of
health care financing
 About $ 800 per capita
 < 20% of the population
 Employ 77% of
specialists
 Over- serviced
Inequitable distribution of health
personnel between private and
public sector
100
90
80
70
60
50
40
30
20
10
0
94
93
76
75
73
59
41
25
24
6
27
7
Publlic Sector
Private Sector
Inequities within the public
health sector
 Wealthier provinces have 8-9 health workers per
1000 people, the poorer provinces have 4
 There is a wide gap in per capita spending across
provinces
 There is a wide gap in per capita spending across
districts in the same province
 Only 15% of the health budget is spent on PHC
(i.e. the most equitable level of care)
Inequities within the public health
sector (cont….)
 Poorer provinces
 lack leadership, management and supervisory
capacity, resulting in poor planning and use of resources
 Have poor performance (e.g. in PMTCT)
o Only 10-25% have access to VCT
o In at least 5 provinces the PMCTC programme
has not been expanded beyond the pilot sites
o About 50% of public facilities have access to
nevirapine but many lack human resources
Reforming the private sector
 Government has regulated the private sector
through for example :
 mandatory open enrolment
 Prescribed Minimum Benefits
 Despite these efforts there is :
 Shrinkage in number of beneficiaries
 No decrease in total expenditure
 Worsening of private – public inequities
 Fee for service reimbursement system and high
administration costs are used to guarantee
profits
Who has access to ARVs?
Of the estimated 4.8 million South Africans who are HIV + 500,000 need
ARVs now.
Over 4 million
dependent on the
public health sector
100,000 miners
are HIV +
525,000 belong
to medical schemes
and are HIV positive
Less than 20,000
have access to
ARVs
South Africa’s capacity to roll
out ARVs
• South Africa :
Is relatively a wealthy country-( e.g. its GDP is
5 times that of Malawi)
Has gross inequities - key blockage to
expansion of access to treatment and care
Has inconsistent political leadership
Has a high burden of disease
South Africa’s capacity to roll out
ARVs (cont…)
• Health systems challenges to
expanding treatment equitably are:
 The locking up of resources in the private sector
 Uneven health systems capacity
 Lack of adequate human resources
 Lack of functional PHC in some parts of the country
 Implementing a complex labour intensive programme
while the health system is undergoing massive
structural transformation
Way forward
 South Africa can afford to roll-out ARVs
 In principle the government has given the go
ahead
 The roll out must complement other public
health concerns ( e.g. MCH,TB, STI, nutrition)
 Therefore a clear roadmap is needed of how to:
 maintain a committed and consistent leadership
 persuade the private sector to invest in the ARVs
 guard against ARV roll out deepening existing
inequities
 use ARV roll out as a catalyst to restructure the
health system and become more equitable system