Thierry Mertens and Juliana Yartey World Health Organization, Geneva

1. 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

2. 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"

3. 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)

4. Perspective Strengthening health systems: fundamental to sustainable, quality and equitable expansion of delivery of essential health services

5. A comprehensive approach to the prevention of HIV infection in pregnant women, mothers and their infants • Primary prevention of HIV infectionin 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).

6. 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)

7. Figure 1. Percentages of Pregnant Women Receiving Antenatal Care at Least Once or Twice, by Country Source: WHO/UNICEF The Africa Malaria Report 2003

8. Malaria Control During PregnancyIntervention Package ANC Private Sector Commun ANC ITNs IPT CM ANC H. Facilities

9. Benefit: Mothers less malaria less anaemia Infants fewer of LBW Intermittent Preventive Treatment (IPT) Doses Given at Antenatal Clinic Visits after Quickening Rx Rx 20 10 30 Quickening Conception Birth Weeks of pregnancy

10. 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

11. 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 Health systems elements necessary to reaching MDG 6

12. PUBLIC SECTOR The system context: PRSP MDG Political and Financial Commitment GEN. HEALTH SERVICES Management of Delivery / Human Resources EPI ANC Infrastructure TB Social Mobilization and Demand Monitoring and Information Systems Private sector CCM

13. 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

14. Human resources: Physicians/100,000 Population Nigeria 18.5 Ivory Coast 9 Togo 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 Reference: "Human Resources for Health and Development: A Joint Learning Initiative" (HRH/JLI) Initiated by The Rockefeller Foundation

15. HRH Availability and Requirements in Tanzania for 2015 by Skill Level 9251 District Support Staff 150 9521 Technical Staff 2070 3247 Requirements Specialists 1470 Availability 20670 Personnel with Medical Skills 6100 33987 Nursing and Midwifery skills 17300 10462 Unskilled 11330 0 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

16. 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.

17. “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.

18. A. Situation analysis B. Need assessment Task 1. Set priorities Planning

19. 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

20. Option appraisal Options Feasi-bility Financial availability Long term sustaina-bility Accepta-bility Knock-on effects Equity effects Pilot to reality 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        Target setting (cont)

21. 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

22. 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

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