HAI & PEPFAR: Strengthening Mozambique Health System by Improving HIV Care  Jennifer Kasper, MD, MPH Former Pediatric Tech...
Outline <ul><li>PEPFAR I Facts </li></ul><ul><li>Brief overview of Mozambique </li></ul><ul><li>PEPFAR I in Mozambique </l...
PEPFAR Focus Countries   <ul><li>Botswana </li></ul><ul><li>Cote d'Ivoire </li></ul><ul><li>Ethiopia </li></ul><ul><li>Guy...
Mozambique Civil War (1980-1992)
Basics about Mozambique <ul><li>Population ~20 million  </li></ul><ul><li>74% live on less than $2/day </li></ul><ul><li>A...
HIV Prevalence: Top 10 Countries   Zimbabwe 25.84 Botswana 25.10 Namibia 19.94 Zambia 19.10  Swaziland 18.50 South Africa ...
<ul><li>~ 3 million PLWHA </li></ul><ul><li>~ 400,000 require ART </li></ul><ul><li>Also high prevalence of  </li></ul><ul...
Mozambique Health Sector  Capacity for AIDS Treatment <ul><li>Physicians per 100,000: 3 = 650 (100 pediatricians) </li></u...
Donor-Induced Management Burden Mozambique (2008) <ul><li>$228 million (1/3 CDC, 2/3 USAID) </li></ul><ul><li>> 200 health...
Foreign Policy May/June 2004 Additional management burden by donors & NGOs Tanzania  1,371 different projects to manage
<ul><li>Health Alliance International  supports the development of  equity-oriented policies  and  public-sector health sy...
HAI’s Approach <ul><li>Work from  within  health system at all levels  (national, provincial, district and health faciliti...
HAI’s Approach <ul><li>Plan jointly - respond to local priorities at provincial and district level </li></ul><ul><li>Stren...
HAI’s Approach <ul><li>Integrate vertical programs into comprehensive PHC, expanding and decentralizing services: </li></u...
HIV Treatment Expansion Plan 2003 HF Providing HAART 1 PLWHA Registered 2,000 Eligible in HAART 94 Guro Tambara Chemba Mar...
2004 Guro Tambara Chemba Maringue Macossa Sussundenga Machaze Machanga Muanza Cheringoma Chibabava HF Providing HAART  2 P...
2005 Guro Tambara Chemba Maringue Macossa Sussundenga Machaze Machanga Muanza Cheringoma Chibabava HF Providing HAART 7 PL...
2006 Guro Tambara Chemba Maringue Macossa Sussundenga Machaze Machanga Muanza Cheringoma Chibabava HF Providing HAART 17 P...
2007 Guro Tambara Chemba Maringue Macossa Sussundenga Machaze Machanga Muanza Cheringoma Chibabava HF Providing HAART 47 P...
HIV Treatment Plan 08-09 Guro Tambara Chemba Maringue Macossa Sussundenga Machaze Machanga Muanza Cheringoma Chibabava HF ...
<ul><ul><li>Hematology and chemistry in 22 of 36 laboratories  </li></ul></ul><ul><ul><li>CD4 decentralization and referra...
Successes from HAI/MOH Collaboration (as of June 2008) <ul><li>Work in all 23 districts in 2 provinces </li></ul><ul><li>V...
 
Pediatric Challenges <ul><li>PCR DNA </li></ul><ul><li>Breastfeeding </li></ul><ul><li>Care and follow-up in Child at Risk...
More Challenges <ul><li>Human resources </li></ul><ul><ul><li>“ Brain drain” </li></ul></ul><ul><li>Multi sector approach ...
How PEPFAR II can Improve upon PEPFAR I <ul><li>Pre-service training, task shifting  </li></ul><ul><li>Integrate into exis...
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 <ul><li>6 areas: </li></ul><ul><ul><li>Hiring practices </li></ul></ul><ul><ul><li>Compensation  </li>...
 
References <ul><li>PEPFAR 5th Report to Congress </li></ul><ul><li>WHO, PEPFAR, UNAIDS. Task-Shifting: Rational Redistribu...
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HAI & PEPFAR: Strengthening Mozambique Health System by Improving HIV Care

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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

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

    1. 1. HAI & PEPFAR: Strengthening Mozambique Health System by Improving HIV Care Jennifer Kasper, MD, MPH Former Pediatric Technical Advisor and HIV Program Manager, Health Alliance International Board Member, Doctors for Global Health Physicians for Human Rights Student Conference January 31, 2009
    2. 2. Outline <ul><li>PEPFAR I Facts </li></ul><ul><li>Brief overview of Mozambique </li></ul><ul><li>PEPFAR I in Mozambique </li></ul><ul><ul><li>Financial support </li></ul></ul><ul><ul><li>General approach </li></ul></ul><ul><ul><li>Primary NGOs and subpartners </li></ul></ul><ul><li>Health Alliance International </li></ul><ul><ul><li>General approach </li></ul></ul><ul><ul><li>Scope of work </li></ul></ul><ul><ul><li>Successes </li></ul></ul><ul><li>PEPFAR Challenges </li></ul><ul><li>How PEPFAR II can Improve upon PEPFAR I </li></ul><ul><li>NGO Code of Conduct </li></ul>
    3. 3. PEPFAR Focus Countries <ul><li>Botswana </li></ul><ul><li>Cote d'Ivoire </li></ul><ul><li>Ethiopia </li></ul><ul><li>Guyana </li></ul><ul><li>Haiti </li></ul><ul><li>Kenya </li></ul><ul><li>Mozambique </li></ul><ul><li>Namibia Nigeria </li></ul><ul><li>Rwanda </li></ul><ul><li>South Africa </li></ul><ul><li>Tanzania </li></ul><ul><li>Uganda </li></ul><ul><li>Vietnam </li></ul><ul><li>Zambia </li></ul>
    4. 4. Mozambique Civil War (1980-1992)
    5. 5. Basics about Mozambique <ul><li>Population ~20 million </li></ul><ul><li>74% live on less than $2/day </li></ul><ul><li>Average life expectancy 43yrs </li></ul><ul><li>Infant Mortality Rate 96/1000 </li></ul><ul><li>Under 5 child mortality 138/1000 </li></ul><ul><li>24% children underweight </li></ul><ul><li>48% births attended by skilled personnel, maternal mortality 520/100K live births </li></ul>UNDP 2007/2008, UNICEF 2008
    6. 6. HIV Prevalence: Top 10 Countries Zimbabwe 25.84 Botswana 25.10 Namibia 19.94 Zambia 19.10 Swaziland 18.50 South Africa 16.70 Mozambique 16.00 Malawi 14.92 Tanzania 9.42 Lesotho 8.35
    7. 7. <ul><li>~ 3 million PLWHA </li></ul><ul><li>~ 400,000 require ART </li></ul><ul><li>Also high prevalence of </li></ul><ul><ul><li>Syphilis (~8%) </li></ul></ul><ul><ul><li>Malaria (13-80%) </li></ul></ul><ul><ul><li>TB (624/100,000) </li></ul></ul><ul><ul><li>Malnutrition (25-40%) </li></ul></ul><ul><li>Central region pop 3 million </li></ul><ul><ul><li>400K PLWHA (24K <15yo) </li></ul></ul><ul><ul><li>68K need ART (12K <15yo) </li></ul></ul>HIV Prevalence in Mozambique
    8. 8. Mozambique Health Sector Capacity for AIDS Treatment <ul><li>Physicians per 100,000: 3 = 650 (100 pediatricians) </li></ul><ul><li>~500 doctors trained in HAART (3 week course) </li></ul><ul><li>Nurses per 100,000: 21 = 2400 </li></ul><ul><li>Health expenditure per capita approx $10 (2.7% GDP spent on hlth) </li></ul><ul><li>~ 1200 health facilities </li></ul><ul><li>Medical school in Maputo; newer one in Sofala; one being developed in Nampula </li></ul><ul><li>Functioning drug procurement and distribution system </li></ul>
    9. 9. Donor-Induced Management Burden Mozambique (2008) <ul><li>$228 million (1/3 CDC, 2/3 USAID) </li></ul><ul><li>> 200 health NGOs (50 prime partners and > 100 sub-partners) </li></ul><ul><li>> 150 independent sites of operation </li></ul><ul><li>10-20 program categories </li></ul><ul><li>Independent planning cycles, implementation </li></ul><ul><li>Reliability dependent on donor policies </li></ul><ul><li>“ Neocolonization” – NGO spheres of control </li></ul>
    10. 10. Foreign Policy May/June 2004 Additional management burden by donors & NGOs Tanzania 1,371 different projects to manage
    11. 11. <ul><li>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 . </li></ul>
    12. 12. HAI’s Approach <ul><li>Work from within health system at all levels (national, provincial, district and health facilities) </li></ul><ul><li>Offices in MOH </li></ul><ul><ul><li>Advisors working with MOH program managers </li></ul></ul><ul><ul><li>Multidisciplinary teams: </li></ul></ul><ul><ul><ul><li>Clinical advisors, MCH, M&E, laboratory, HBC and community mobilization/VCT program assistants </li></ul></ul></ul><ul><ul><ul><li>Integrated supervision, technical support, clinical mentoring </li></ul></ul></ul><ul><ul><ul><li>Financial and logistics support </li></ul></ul></ul>
    13. 13. HAI’s Approach <ul><li>Plan jointly - respond to local priorities at provincial and district level </li></ul><ul><li>Strengthen human resources </li></ul><ul><ul><li>Pre-service training, task shifting, lay workers </li></ul></ul><ul><ul><li>Funds to hire recent graduates </li></ul></ul><ul><ul><li>Strategies to improve staff allocation </li></ul></ul><ul><li>Improve infrastructure: </li></ul><ul><ul><li>Outpatient services, laboratories, maternity wards </li></ul></ul><ul><ul><li>Staff housing </li></ul></ul><ul><ul><li>Training center </li></ul></ul><ul><li>Promote operations research </li></ul><ul><ul><li>Beira Operations Research Center </li></ul></ul><ul><li>Strengthen supply chain management </li></ul>
    14. 14. HAI’s Approach <ul><li>Integrate vertical programs into comprehensive PHC, expanding and decentralizing services: </li></ul><ul><ul><li>Integration of OIs and ART </li></ul></ul><ul><ul><li>PMTCT as part of basic package ANC services </li></ul></ul><ul><ul><li>C&T into routine clinical services </li></ul></ul><ul><ul><li>HIV/TB programs </li></ul></ul><ul><ul><li>HBC strengthening links between health care facility and community </li></ul></ul><ul><ul><li>Food support and insecticide treated bednets with HIV care and ANC </li></ul></ul>
    15. 15. HIV Treatment Expansion Plan 2003 HF Providing HAART 1 PLWHA Registered 2,000 Eligible in HAART 94 Guro Tambara Chemba Maringue Macossa Sussundenga Machaze Machanga Muanza Cheringoma Chibabava 2003
    16. 16. 2004 Guro Tambara Chemba Maringue Macossa Sussundenga Machaze Machanga Muanza Cheringoma Chibabava HF Providing HAART 2 PLWHA Registered 7,300 Eligible in HAART 600 2003 2004 Free ART in Public Health Sector
    17. 17. 2005 Guro Tambara Chemba Maringue Macossa Sussundenga Machaze Machanga Muanza Cheringoma Chibabava HF Providing HAART 7 PLWHA Registered 18,600 Eligible in HAART 2,520 CS HCB HR HPC HG HeathC CentH RurH ProvH GenH
    18. 18. 2006 Guro Tambara Chemba Maringue Macossa Sussundenga Machaze Machanga Muanza Cheringoma Chibabava HF Providing HAART 17 PLWHA Registered 36,270 Eligible in HAART 5,250 2003 2004 2005 2006 Decentralization to Rural Sites
    19. 19. 2007 Guro Tambara Chemba Maringue Macossa Sussundenga Machaze Machanga Muanza Cheringoma Chibabava HF Providing HAART 47 PLWHA Registered 63,390 Eligible in HAART 13,225 2003 2004 2005 2006 2007
    20. 20. HIV Treatment Plan 08-09 Guro Tambara Chemba Maringue Macossa Sussundenga Machaze Machanga Muanza Cheringoma Chibabava HF Providing HAART: 87 March 2008: 55 Registered: 180,000 March 2008: 92,600 HAART: 45,000 March 2008: 22,000 <15 y in HAART: 5,000 March 2008: 900 HeathC CentH RurH ProvH GenH Pending
    21. 21. <ul><ul><li>Hematology and chemistry in 22 of 36 laboratories </li></ul></ul><ul><ul><li>CD4 decentralization and referral: </li></ul></ul><ul><ul><ul><li>High volume, complex machines in provincial capitals </li></ul></ul></ul><ul><ul><ul><li>Lower volume, less complex in 3 rural districts </li></ul></ul></ul><ul><ul><li>55 PMTCT sites referring CD4 </li></ul></ul><ul><ul><li>20 hemoglobinometers in isolated sites w/o other lab equipment </li></ul></ul><ul><ul><li>Support referral system for early infant diagnosis (DNA-PCR) </li></ul></ul>Strengthening Laboratory Network Chemba Maringue Machaze Machanga Muanza Cheringoma Hem. + Chemistry Mangunde Sena Guro Tambara Macossa Sussundenga CD4+ Chemba Maringue Machaze Machanga Muanza Cheringoma Hem. + Chemistry Mangunde Sena CD4+ CD4+ Guro Tambara Macossa Sussundenga CD4+ CD4+ CD4+ Labs referring samples
    22. 22. Successes from HAI/MOH Collaboration (as of June 2008) <ul><li>Work in all 23 districts in 2 provinces </li></ul><ul><li>Voluntary Counseling and Testing </li></ul><ul><ul><li>103 sites </li></ul></ul><ul><ul><li>Cumulative total number tested since 2002: 280,000 </li></ul></ul><ul><ul><li>HIV prevalence 31% </li></ul></ul><ul><li>PMTCT </li></ul><ul><ul><li>156 sites; 250,000 served </li></ul></ul><ul><li>HIV/AIDS care and treatment </li></ul><ul><ul><li>55 sites; >100,000 served; 25,000 on ART </li></ul></ul><ul><li>Home-Based Care </li></ul><ul><ul><li>12 community-based organizations </li></ul></ul><ul><ul><li>Serve 7000 clients/month (60% HIV positive, 50% of these on ART) </li></ul></ul><ul><li>Radio, popular theater, world food program </li></ul>
    23. 24. Pediatric Challenges <ul><li>PCR DNA </li></ul><ul><li>Breastfeeding </li></ul><ul><li>Care and follow-up in Child at Risk Clinic </li></ul><ul><li>Counseling children and adolescents about their illness </li></ul><ul><li>Adherence and its effects on overall child health and life expectancy </li></ul><ul><li>OVC </li></ul>
    24. 25. More Challenges <ul><li>Human resources </li></ul><ul><ul><li>“ Brain drain” </li></ul></ul><ul><li>Multi sector approach </li></ul><ul><ul><li>Prevention – discordant couples </li></ul></ul><ul><ul><li>Poverty, food security </li></ul></ul><ul><ul><li>Socioeconomic improvement </li></ul></ul><ul><li>Structural problems </li></ul><ul><ul><li>Debt reduction </li></ul></ul><ul><ul><li>Reversal of structural adjustment policies and expansion of public spending </li></ul></ul><ul><ul><li>Improve intra-governmental allocations </li></ul></ul>
    25. 26. How PEPFAR II can Improve upon PEPFAR I <ul><li>Pre-service training, task shifting </li></ul><ul><li>Integrate into existing health infrastructure </li></ul><ul><li>Increase $ for treatment </li></ul><ul><li>Increase $ for PMTCT </li></ul><ul><li>Increase funding for OVC </li></ul><ul><li>Partnership for HIV-Free Generation – youth-initiated and implemented activities </li></ul><ul><li>Opt-out testing for all clinical encounters </li></ul><ul><li>Discordant partners, married couples </li></ul><ul><li>Know your epidemic – concentrated (ex commercial sex workers, IVDU, MSM) vs generalized pandemic </li></ul>
    26. 27. Distribution of Disease vs Distribution of Funding
    27. 28. A Balanced Approach to Health Care Delivery: Vertical, Horizontal, Diagonal?
    28. 29. US FINANCIAL SUPPORT: GLOBAL HEALTH AND DEVELOPMENT
    29. 30. NGO Code of Conduct <ul><li>6 areas: </li></ul><ul><ul><li>Hiring practices </li></ul></ul><ul><ul><li>Compensation </li></ul></ul><ul><ul><li>Training and support </li></ul></ul><ul><ul><li>Minimize mgmt burden on govt due to multiple NGO projects </li></ul></ul><ul><ul><li>Help govt connect communities to govt hlth systems </li></ul></ul><ul><ul><li>Provide better support to govt thru policy advocacy </li></ul></ul>www.ngocodeofconduct.org
    30. 32. References <ul><li>PEPFAR 5th Report to Congress </li></ul><ul><li>WHO, PEPFAR, UNAIDS. Task-Shifting: Rational Redistribution of Tasks among Health Care Workforce Teams, Global Recommendations and Guidelines. 2008. www.who.int </li></ul><ul><li>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 </li></ul><ul><li>IOM. The US Commitment to Global Health: Recommendations for the New Administration. Washington, DC: National Academies Press; 2008. www.nap.edu </li></ul><ul><li>www.ngocodeofconduct.org </li></ul>

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