HAI & PEPFAR: Strengthening Mozambique Health System by Improving HIV Care

HAI & PEPFAR: Strengthening Mozambique Health System by

Improving HIV Care

Jennifer Kasper, MD, MPHFormer Pediatric Technical Advisor and HIV

Program Manager, Health Alliance InternationalBoard Member, Doctors for Global Health

Physicians for Human Rights Student ConferenceJanuary 31, 2009

Outline

• PEPFAR I Facts• Brief overview of Mozambique• PEPFAR I in Mozambique

– Financial support – General approach– Primary NGOs and subpartners

• Health Alliance International– General approach– Scope of work– Successes

• PEPFAR Challenges• How PEPFAR II can Improve

upon PEPFAR I• NGO Code of Conduct

PEPFAR Focus Countries

• Botswana• Cote d'Ivoire• Ethiopia• Guyana• Haiti

• Kenya• Mozambique• Namibia

Nigeria• Rwanda

• South Africa• Tanzania• Uganda• Vietnam• Zambia

Mozambique Civil War (1980-1992)

Basics about Mozambique• Population ~20 million

• 74% live on less than $2/day

• Average life expectancy 43yrs

• Infant Mortality Rate 96/1000

• Under 5 child mortality 138/1000

• 24% children underweight

• 48% births attended by skilled

personnel, maternal mortality

520/100K live births

UNDP 2007/2008, UNICEF 2008

HIV Prevalence: Top 10 Countries HIV Prevalence: Top 10 Countries

ZimbabweZimbabwe 25.8425.84BotswanaBotswana 25.1025.10NamibiaNamibia 19.9419.94ZambiaZambia 19.10 19.10 SwazilandSwaziland 18.5018.50South AfricaSouth Africa 16.7016.70Mozambique 16.00MalawiMalawi 14.9214.92

TanzaniaTanzania 9.429.42LesothoLesotho 8.358.35

• ~ 3 million PLWHA

• ~ 400,000 require ART

• Also high prevalence of

– Syphilis (~8%)

– Malaria (13-80%)

– TB (624/100,000)

– Malnutrition (25-40%)

• Central region pop 3 million

– 400K PLWHA (24K <15yo)

– 68K need ART (12K <15yo)

HIV Prevalence in Mozambique

Mozambique Health Sector Capacity for AIDS Treatment

• Physicians per 100,000: 3 = 650 (100 pediatricians)

• ~500 doctors trained in HAART (3 week

course)

• Nurses per 100,000: 21 = 2400

• Health expenditure per capita approx $10

(2.7% GDP spent on hlth)

• ~ 1200 health facilities

• Medical school in Maputo; newer one in

Sofala; one being developed in Nampula

• Functioning drug procurement and

distribution system

Donor-Induced Management BurdenMozambique (2008)

• $228 million (1/3 CDC, 2/3 USAID)• > 200 health NGOs (50 prime partners and

> 100 sub-partners)• > 150 independent sites of operation• 10-20 program categories• Independent planning cycles,

implementation• Reliability dependent on donor policies• “Neocolonization” – NGO spheres of

control

Foreign Policy May/June 2004

Additional management burden by

donors & NGOs

Tanzania

1,371 different

projects to manage

Health Alliance International supports the development of equity-oriented policies and

public-sector health systems. Our vision is a just world with

universal access to quality health care.

HAI’s Approach• Work from within health system

at all levels (national, provincial, district and health facilities)

• Offices in MOH– Advisors working with MOH

program managers

– Multidisciplinary teams: • Clinical advisors, MCH, M&E,

laboratory, HBC and community mobilization/VCT program assistants

• Integrated supervision, technical support, clinical mentoring

• Financial and logistics support

HAI’s Approach• Plan jointly - respond to local priorities at

provincial and district level• Strengthen human resources

– Pre-service training, task shifting, lay workers – Funds to hire recent graduates– Strategies to improve staff allocation

• Improve infrastructure: – Outpatient services, laboratories, maternity

wards – Staff housing – Training center

• Promote operations research – Beira Operations Research Center

• Strengthen supply chain management

HAI’s Approach

Integrate vertical programs into comprehensive

PHC, expanding and decentralizing services:

– Integration of OIs and ART

– PMTCT as part of basic package ANC services

– C&T into routine clinical services

– HIV/TB programs

– HBC strengthening links between

health care facility and community

– Food support and insecticide treated

bednets with HIV care and ANC

HF Providing HAART1

PLWHA Registered2,000

Eligible in HAART94

HIV Treatment Expansion

Plan

2003

GuroGuro TambaraTambara

ChembaChemba

MaringueMaringueMacossaMacossa

SussundengaSussundenga

MachazeMachaze

MachangaMachanga

MuanzaMuanza

CheringomaCheringoma

ChibabavaChibabava

2003

GuroGuro TambaraTambara

ChembaChemba

MaringueMaringueMacossaMacossa

SussundengaSussundenga

MachazeMachaze

MachangaMachanga

MuanzaMuanza

CheringomaCheringoma

ChibabavaChibabava

HF Providing HAART 2

PLWHA Registered 7,300

Eligible in HAART600

2004

2003

2004

Free ART in Public Health Sector

GuroGuro TambaraTambara

ChembaChemba

MaringueMaringueMacossaMacossa

SussundengaSussundenga

MachazeMachaze

MachangaMachanga

MuanzaMuanza

CheringomaCheringoma

ChibabavaChibabava

HF Providing HAART7

PLWHA Registered18,600

Eligible in HAART2,520

2005

CS

HCB

HR

HPC

HG

HeathC

CentH

RurH

ProvH

GenH

GuroGuro TambaraTambara

ChembaChemba

MaringueMaringueMacossaMacossa

SussundengaSussundenga

MachazeMachaze

MachangaMachanga

MuanzaMuanza

CheringomaCheringoma

ChibabavaChibabava

HF Providing HAART17

PLWHA Registered 36,270

Eligible in HAART5,250

2006

2003 2004

2005 2006

Decentralization to Rural Sites

GuroGuro TambaraTambara

ChembaChemba

MaringueMaringueMacossaMacossa

SussundengaSussundenga

MachazeMachaze

MachangaMachanga

MuanzaMuanza

CheringomaCheringoma

ChibabavaChibabava

HF Providing HAART

47

PLWHA Registered

63,390

Eligible in HAART

13,225

2007

2003 2004

2005 2006

2007

GuroGuro TambaraTambara

ChembaChemba

MaringueMaringueMacossaMacossa

SussundengaSussundenga

MachazeMachaze

MachangaMachanga

MuanzaMuanza

CheringomaCheringoma

ChibabavaChibabava

HF Providing HAART: 87 March 2008: 55

Registered: 180,000March 2008: 92,600

HAART: 45,000March 2008: 22,000

<15 y in HAART: 5,000March 2008: 900

HIV Treatment Plan 08-09

HeathC

CentH

RurH

ProvH

GenH

Pending

Chemba

Maringue

Machaze

Machanga

Muanza

Cheringoma

Hem. + Chemistry

Mangunde

SenaSena

Guro Tambara

Macossa

Sussundenga

CD4+

Chemba

Maringue

Machaze

Machanga

Muanza

Cheringoma

Hem. + Chemistry

Mangunde

SenaSena

CD4+CD4+

CD4+CD4+

Guro Tambara

Macossa

Sussundenga

CD4+CD4+

CD4+

CD4+

Labs referring samples

–Hematology and chemistry in 22 of 36 laboratories

–CD4 decentralization and referral: • High volume, complex machines in provincial capitals

• Lower volume, less complex in 3 rural districts

–55 PMTCT sites referring CD4

–20 hemoglobinometers in isolated sites w/o other lab equipment

–Support referral system for early infant diagnosis (DNA-PCR)

Strengthening Laboratory Network

Successes from HAI/MOH Collaboration (as of June 2008)

• Work in all 23 districts in 2 provinces• Voluntary Counseling and Testing

– 103 sites– Cumulative total number tested since 2002: 280,000 – HIV prevalence 31%

• PMTCT– 156 sites; 250,000 served

• HIV/AIDS care and treatment– 55 sites; >100,000 served; 25,000 on ART

• Home-Based Care– 12 community-based organizations– Serve 7000 clients/month (60% HIV positive, 50% of these on ART)

• Radio, popular theater, world food program

Pediatric Challenges

• PCR DNA• Breastfeeding• Care and follow-up in

Child at Risk Clinic• Counseling children and

adolescents about their illness

• Adherence and its effects on overall child health and life expectancy

• OVC

More Challenges• Human resources

– “Brain drain”

• Multi sector approach

– Prevention – discordant couples

– Poverty, food security

– Socioeconomic improvement

• Structural problems

– Debt reduction

– Reversal of structural adjustment policies and

expansion of public spending

– Improve intra-governmental allocations

How PEPFAR II can Improve upon PEPFAR I

• Pre-service training, task shifting • Integrate into existing health infrastructure • Increase $ for treatment• Increase $ for PMTCT • Increase funding for OVC• Partnership for HIV-Free Generation – youth-initiated

and implemented activities • Opt-out testing for all clinical encounters• Discordant partners, married couples • Know your epidemic – concentrated (ex commercial

sex workers, IVDU, MSM) vs generalized pandemic

Distribution of Disease vs Distribution of Funding

A Balanced Approach to Health Care Delivery: Vertical, Horizontal, Diagonal?

US FINANCIAL SUPPORT: GLOBAL HEALTH AND DEVELOPMENT

NGO Code of Conduct• 6 areas:

– Hiring practices– Compensation – Training and support– Minimize mgmt burden on govt

due to multiple NGO projects– Help govt connect communities

to govt hlth systems– Provide better support to govt

thru policy advocacy

www.ngocodeofconduct.org

References• PEPFAR 5th Report to Congress• WHO, PEPFAR, UNAIDS. Task-Shifting: Rational

Redistribution of Tasks among Health Care Workforce Teams, Global Recommendations and Guidelines. 2008. www.who.int

• Granich R, Gilks CF, Dye C, DeCock KM, Williams BG. Universal voluntary HIV testing with immediate antiviral treatment as a strategy for elimination of HIV transmission: a mathematical model. Published online November 26, 2008. www.thelancet.com

• IOM. The US Commitment to Global Health: Recommendations for the New Administration. Washington, DC: National Academies Press; 2008. www.nap.edu

• www.ngocodeofconduct.org