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

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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

From Kwazulu Natal and Mozambique, presentation of "HIVimpulse"

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SummarySelected aspects of interactions of HIV/AIDS and Malaria

Similar epidemiologic profile/geographic distribution

Women and children: at-risk populations Poverty Biological interactions

• 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)

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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

0102030405060708090

100

Perc

enta

geAttending antenatal clinic at least once

Attending antenatal clinic at least twice

Source: WHO/UNICEF The Africa Malaria Report 2003

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Malaria Control During PregnancyIntervention Package

IPTIPT ITNsITNs

CMCM

ANCANC ANCANCPrivatePrivateSectorSectorCommunCommun

ANCANCH. FacilitiesH. Facilities

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Intermittent Preventive Treatment (IPT)Doses Given at Antenatal Clinic Visits after Quickening

Weeks of pregnancy

Conception Birth20 3010

Quickening

Rx Rx

Benefit: Mothers less malaria

less anaemia

Infants fewer of LBW

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Implications for Health Service Delivery

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

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Scale-up can foster the strengthening and development of health systems

Health systems elements necessary to reaching MDG 6

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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PUBLIC SECTOR

GEN. HEALTH SERVICES

PRSP MDGPolitical and Financial Commitment

Infrastructure

Monitoring and Information Systems

Management of Delivery / Human Resources

Social Mobilization and Demand

The system context:

ANCTB

EPI

CCM Private sector

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Challenges 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

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Human resources: Physicians/100,000 Population

279

3.5

5.7

6.2

7.4

7.6

9

18.5

0 50 100 150 200 250 300

USA

Niger

Benin

Ghana

Cameroon

Togo

Ivory Coast

Nigeria

No. of physicians

Reference: "Human Resources for Health and Development: A Joint Learning Initiative" (HRH/JLI) Initiated by The Rockefeller Foundation

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HRH Availability and Requirements in Tanzania for 2015 by Skill Level

11330

17300

6100

1470

2070

150

10462

33987

20670

3247

9521

9251

0 5000 10000 15000 20000 25000 30000 35000 40000

Unskilled

Nursing and Midwifery skills

Personnel with Medical Skills

Specialists

Technical Staff

District Support Staff

Requirements

Availability

References: "Human Resources for Health and Development: A Joint Learning Initiative" (HRH/JLI) Initiated by The Rockefeller Foundation

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Subsidizing people who can pay?

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.

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“How can we include the excluded”

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.

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PlanningPlanningB. Need assessmentA. Situation analysis

Task 1.Set priorities

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Target setting Conclusions:

Overprovision of long-stay beds and underprovision of acute beds

General shortage of staff Community/hospital ratio for staff

indicates concentration of staff in hospital settings

Low rate of Daily patient visits and Admissions may indicate:

• Poor detection• Lack of referral• Lack of trained staff • Stigma• Inaccessible services

050

100150200250

Acute

beds

Long st

ay bed

s

Nurses

Total st

aff

Staff/b

ed ra

tio

Comm/hosp DPV

Admiss

ions

Current services (Step A)Need (Step B)

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Target setting (cont) Option appraisal

4. Improve information system

??×?×

3.Motivate for funding from general health

?

2.Redirect funds from long-stay to community

???

1.Reduce long stay beds, discharge patients

Pilot to reality

Equity effects

Knock-on effects

Accepta-bility

Long term sustaina-bility

Financial availability

Feasi-bility

Options

Service integration – some of the advantages

Improve access Reduced stigma addresses human resource shortages Full integration vs partial (clinical) integration Resource constraints - ‘piggy-back’ on existing

health/social programmes

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Strengthening Health Systems

Providing basic equipment, drugs and supplies Improving service delivery/quality of care (evidence-

based 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

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Conclusion

Strong joint planning, implementation and evaluation towards integration of services needed at global, regional and national level.