Health system: what dynamic changes are needed to better
serve Children and youth living with HIV
Rene Ekpini, On behalf of Dr Mickey Chopra
Chief & Associate Director Health, UNICEF
New York
Country % reduction
Country % reduction
EthiopiaGhanaKenyaNamibiaSouth nAfricaSwazilandZambiaZimbabwe
3131436049395545
BotswanaBurundiCameroonCote d’IvoireLesothoMalawiUganda
22302420212624
About 330,000 children were newly infected with HIV in 2011
Decline in new HIV infections among children, UNAIDS 2009-2011
Key operational bottlenecks to MTCT elimination
C• Geographic coverage (Population –
Facility): bringing services closer to all women and children in need
Q• Quality/efficacy of interventions: providing
the most efficacious/quality interventions
U • Access to and utilization of services Wor
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unit
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Health Systems Strengthening
Strategic shift 1:
assess the performance of the MNCH platform
Weak linkages and retention in care within the PMTCT cascade and the MNCH care continuum in Tanzania,
2012
Strategic shift 2:
Identify where the missing mothers and
children are
% of pregnant women living with HIV receiving ARVs for PMTCT, in
Botswana
Where are the missing mothers and children in
Botswana?
Strategic shift 3:
investigating the weakest links through
supply and demand bottleneck analysis
What and who to assess? Determinants Description
Enablin
g Environment
Social Norms Widely followed social rules of behaviour
Legislation/Policy Adequacy of laws and policies
Budget/expenditure Allocation & disbursement of required resources
Management /Coordination Roles and Accountability/ Coordination/ Partnership
Supply
Availability of essential commodities/inputs
Essential commodities/ inputs required to deliver a service or adopt a practice
Access to adequately staffed services, facilities and information
Physical access (services, facilities/information)
Demand
Financial access Direct and indirect costs for services/ practices
Social and cultural practices and beliefs
Individual/ community beliefs, awareness, behaviors, practices, attitudes
Continuity of use Completion/ continuity in service, practice
Qty Quality Adherence to required quality standards (national or international norms)
Investigating the weakest links
• Identify the weakest links in the health and community systems
• Identify the managerial shortcomings
• Investigate the root causes (the WHY)
Commodities – Human resources – Geographic access – Initial utilization – continuous utilization – Effective coverage/quality – Demand side barriers
Local governance – Service organization – PSM – HR – Information management – Financial management
Identifying key PMTCT bottlenecks in Samfya district, Zambia
(health facility and qualitative surveys data)
Some are left
out (ANC1: 52%)
Some are drop out or start
late(ANC4: 24%)
Some don’t have
access
Source: UNICEF 2012, HPP bottleneck analysis in Samfya district
Facilities don’t have
enough HIV tests
Key bottlenecks
Root causes
Management weaknesses
Frequent stock out of HIV test kits
Geographical inaccessibility
More than ½ of HIV infected women missed in MCH despite high ANC testing rates
Investigating the why - whether driven by geographic access, quality, or demand-side
factors Delayed reporting & underestimation
1. Inadequate infrastructure
2. Seasonal mobility 3. Irregular outreach
Inadequate logistics management and forecasting skillsFailure to coordinate ANC and EPI outreach services
1. Low ANC utilization2. Perceived poor
quality of ANC due to frequent stock-outs and staff attitude
HIV tests: See aboveANC: Failure to prioritize demand creation & community-based activities
More than ½ of HIV+ women drop out after HIV testing
1. CD4 requirement2. Late booking3. Long distance4. Perceived quality of
care
HIV tests: See aboveANC: Failure to prioritize demand creation & community-based activities
14
WCA regional averages (Source: DHS data)
56%
40%
37%
23%
19%
17%
12%
0% 10% 20% 30% 40% 50% 60% 70%
Cost (money)
Distance
Transport problems
Not wanting to go alone
No female provider
Don't know where to go
No permission to go
Sources: Anthony Hodges. Presentation at the ACSD meeting, Dakar, 22-26 June 2009
Diagnosing the weakest links: why women do not access health
services?
Strategic shift 4:
tailoring programme strategies and
interventions to prioritize, and
maximize investment and impact
Conceptual framework
C• Simplifying approaches to increase service
coverage and access in health facilities and communities
Q• Optimizing service quality and intervention
effectiveness
U • Increasing uptake and retention in care
Wor
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Health Systems Strengthening: capacity building; improved service delivery; timely monitoring for
course correction
Key bottlenecks Root causes Management weaknesses
Proposed Solutions/
Strategies
Frequent stock out of HIV test kits
Geographical inaccessibility
More than ½ of HIV infected women missed in MCH despite high ANC testing rates
Delayed reporting & underestimation
1. Inadequate infrastructure
2. Seasonal mobility 3. Irregular outreach
Inadequate logistics management and forecasting skills
Failure to coordinate ANC and EPI outreach services
1. Train DHMT in SCM esp. in forecasting
2. Establish monthly radio reporting in concerned RHC
1. Integrate ANC and EPI outreach services
2. Build zonal waiting mothers home
1. Low ANC utilization
2. Perceived poor quality of ANC due to frequent stock-outs and staff attitude
HIV tests: See aboveANC: Failure to prioritize demand creation & community-based activities
1. Prioritize ANC and SBA promotion through C-MNCH in district plan
2. Empower women (e.g. spouses of local leaders) as MNCH champions
3. Establish 6-monthly quality of care monitoring More than ½ of
HIV+ women drop out after HIV testing
1. CD4 requirement2. Late booking3. Long distance4. Perceived quality
of care
HIV tests: See aboveANC: Failure to prioritize demand creation & community-based activities
1. Introduce POC CD4 testing 2. Establish a pregnancy register
for cohort follow up3. Establish C-based PMTCT for
early ID, support and follow up through CHWs: adherence, SMS-based reminders
Investigating the why - whether driven by geographic access, quality, or demand-side
factors
Engaging communities as partners
↘left out ↘ drop
outs↗adherence
Supply
Demand creationQuality
1. Regular integrated ANC-PMTCT-EPI outreach
services to the unreached populations
2. Promotion of timely ANC and SBA through
women and women’s groups
3. Early identification and referral of pregnancy
through CHW home visits
4. Adherence counseling by CHWs through home visits and support groups
5. Active follow up by CHWs using innovative technologies e.g. SMS reminders
Part
ners
hip
with
the
Pedi
atric
ART
gro
up
on S
MS
Mwa
na
proj
ect
Partnership with the
MCH and EPI program
groups on outreach
services
Partnership with Community-based groups (leader spouses, women)
and programs (iCCM, IMCI, SMAGs)
Strategic shift 5:
improving local capacity on data
collection, analysis, and use for decision
making
Summary 1. Accountability and sustainability: ensure
government commitment and ownership
2. Equity reaching the unreached: identify where the missing mothers and children are to ensure equitable access
3. Investigate the weakest links focusing on the root causes to tailor programme interventions and ensure prioritization and more efficient use of resources
4. Access: bringing services closer to communities, families and individuals through innovation and engaging communities as partners
5. Local capacity: build local capacity for better use of data for decision making
6. Harmonized support: leveraging partners