extent and nature of integration of the hiv response in malawi

Extent and nature of integration of the AIDS response in Malawi

Dr. Thyra de JonghDr. Lucie Blok

Royal Tropical Institute (KIT)Development, Policy and PracticeAmsterdam, The Netherlands

Vienna, July 2010

Project overviewObjectives

• Map extent and nature of integration of:

AIDS programme into general health system GFATM supported activities into national AIDS programme

• Examine synergistic effects between AIDS response and health system

Methods

• Semi-Structured Interviews with key stakeholders at national, regional, and district level + secondary data sources

43 interviews (40 informants)

2 regions: 4 districts

• Framework analysis guided by SYSRA toolkit for mapping integration of priority programmes (Atun et al., Health Policy and Planning 2010; 25(2))

Amsterdam, The Netherlands www.kit.nl

Malawi – Country context


Population 14.8 million

GNI per capita Int. $810 (PPP)

Population living on <1 US$ per day

74%

HDI 162nd out of 179

Life expectancy at birth 53 years

HIV prevalence (15-49) 12%

TB prevalence (/100,000) 310


HIV/AIDS in Malawi• Generalised epidemic

• Geographic and urban-rural disparities

• Predominantly heterosexual transmission

• Most at-risk populations: CSW and mobile populations (e.g. truckers, cross-border traders)

PLWHA (2007) 930,000

New HIV infections per year (estimated) 100,000

Deaths due to HIV/AIDS (2007) 68,000

Number of patients receiving ART (2009) 198,846

ART coverage (2009) 65%

The Malawi AIDS responseThree Ones principle:

1. National AIDS Commission (OPC, 2001)

• Biomedical response: HIV/AIDS Unit (MoHP)

2. HIV/AIDS National Action Framework

• 2005-2009, extended for 2010-2012

3. National HIV/AIDS Activity Reporting System


Financing of the AIDS Response


HIV/AIDS Pool fund

• GFATM (70%), WB (13%), GoM (4%), DFID/CIDA/NORAD

• Bulk managed by NAC (PR)

Round 1 2003-2008$343 mln

RCC 2008-2012

Round 5 2006-2011 $17.6 mln

Round 72008-2010 (Phase I)

$15.1 mln

Factors influencing integrationOpportunities

• Presence of joint funding mechanisms (SWAp & HIV/AIDS pool) GFATM signatory to both mechanisms

• Strong internal and external commitment to HSS R1 HIV/AIDS, R5 HSS grants

• Good track-record for HIV/AIDS response and grant management National Strategy Application (Round 9, rejected)

Barriers

• Heavy donor reliance, in particular on GFATM Earmarked funds; Separate reporting and M&E requirements

• Weak systems for e.g. M&E, procurement & supply

• Division of responsibilities between NAC and MoHP


System-wide effects of the AIDS response

Health System Processes & Institutions

• Improved accountability of MoHP & GoM through role of NAC and significant donor reliance

• Increased appreciation and capacity for M&E

• Increased capacity for health and HIV/AIDS research

“The structures that need to be developed for research supervision definitely have been put in place through HIV research, like the ethics committees, the regulatory committees; all of these things have been put in place or are beginning to fall in place based mainly on research coming out of HIV.”


Health System Inputs

• Emergency Human Resource Plan (DFID & R1 GFATM)+Increased capacity for pre-service medical training

+Improved HCW retention through salary top-ups

• Increased in-service training and career opportunities+Improved HCW skills and staff morale

- High staff absenteeism due to workshops and trainings

• Improvements in infrastructure and ICT

• Improved laboratory capacity, maintenance and QA“What the CD4 system does is, it reminds people of the need to have a maintenance

culture. And the CD4 equipments are maintenance intensive; for you to be able to have a good system running, you must have your maintenance culture in place.”



Stakeholder involvement & collaboration

• Greater inter-sectoral collaboration (e.g. MGFCC)

“Looking at HIV/AIDS programming, what I’ve seen is that it is probably the single most disease or condition that has made various partners come together to make the response in my time basically.”

• Driver for increased private sector & community involvement

GFATM sub-recipients from NGOs and CSOs

• Some, though limited, interaction between health programmes

Continued “verticalisation”



Health System Outputs and Outcomes

• Improved access to health care, through e.g.: Reduced HIV/AIDS related mortality in HCWs due to access to ART Expansion of network of Community Health Workers (HSAs)

• Improved health-seeking behaviour and service utilisation Improved referral systems (e.g. TB/HIV) Health education

• Improved quality of care through e.g.: Improved interpersonal skills, e.g. for VCT

Increased reliance on laboratory investigations Clinical skills training

• Impact on non-HIV outcomes unknown or unclear



Conclusions• AIDS response as rally point for addressing HS weaknesses;

positively impacted e.g.:• HRH • Infrastructure• M&E and research capacity • Community involvement• Quality of care

• AIDS response negatively influenced e.g.:• HRH in public sector: brain drain to HIV/AIDS programmes

(management) and NGOs

• Staff absenteeism due to uncoordinated trainings & workshops

• Reinforced parallel systems and “vertical” working methods

• Missed opportunities for comprehensive HSS because of overly vertical set-ups


HIV/AIDS and health systems: the way ahead?

“It’s a chicken and egg question: […] should HIV/AIDS, this chronic disease, become the platform for all other primary healthcare or should the primary health platform lead for the HIV/ AIDS response, which is one chronic disease?” (Development Partner)

“The HIV money is going to go away one day. How soon, we all don't know. Most of the systems now are being built around HIV. And I'm always hoping that when the HIV money goes away that the systems that have been built, have been built on rocks and not on sand.” (National Programme Manager)



AcknowledgementsCollege of Medicine (Malawi)• Victor Mwapasa

• John Kadzandira

• Adamson Muula

• Kelita Kamoto

• Edwin Libamba

National AIDS Commission• Dr. Biswick Mwale

HIV/AIDS Unit (MoHP)•Dr. Eric Schouten

GFATM (Geneva)•Dr. Sai P. Kumar

extent and nature of integration of the hiv response in malawi

Documents

aids response

national aids programme

health policy

nature of integration

practice amsterdam

general health system

ppp population

synergistic effects