Extent and nature of integration of the HIV response in Malawi


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Case study presented during the Pre-Conference meeting "Bridging the Divide: Inter-Disciplinary Partnerships for HIV and Health Systems", 16-17 July 2010, Vienna.

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  • LB: Why do you say that HR is not applicable at national level? I think the emergency Human resource plan is a good example of a national level HR policy that is developed in full synergy between HIV programmes and MoH. GFATM was part of hat EHRP and therefore also fully integrated. Or am I misunderstanding your framework?
  • Extent and nature of integration of the HIV response in Malawi

    1. 1. Extent and nature of integration of the AIDS response in Malawi Dr. Thyra de Jongh Dr. Lucie Blok Royal Tropical Institute (KIT) Development, Policy and Practice Amsterdam, The Netherlands Vienna, July 2010
    2. 2. Project overview <ul><li>Objectives </li></ul><ul><li>Map extent and nature of integration of: </li></ul><ul><ul><ul><li>AIDS programme into general health system </li></ul></ul></ul><ul><ul><ul><li>GFATM supported activities into national AIDS programme </li></ul></ul></ul><ul><ul><ul><li>Examine synergistic effects between AIDS response and health system </li></ul></ul></ul><ul><ul><li>Methods </li></ul></ul><ul><ul><li>Semi-Structured Interviews with key stakeholders at national, regional, and district level + secondary data sources </li></ul></ul><ul><ul><ul><li>43 interviews (40 informants) </li></ul></ul></ul><ul><ul><ul><li>2 regions: 4 districts </li></ul></ul></ul><ul><ul><li>Framework analysis guided by SYSRA toolkit for mapping integration of priority programmes ( Atun et al., Health Policy and Planning 2010; 25(2)) </li></ul></ul>Amsterdam, The Netherlands www.kit.nl
    3. 3. Malawi – Country context Amsterdam, The Netherlands www.kit.nl Population 14.8 million GNI per capita Int. $810 (PPP) Population living on <1 US$ per day 74% HDI 162 nd out of 179 Life expectancy at birth 53 years HIV prevalence (15-49) 12% TB prevalence (/100,000) 310
    4. 4. HIV/AIDS in Malawi <ul><li>Generalised epidemic </li></ul><ul><ul><ul><li>Geographic and urban-rural disparities </li></ul></ul></ul><ul><li>Predominantly heterosexual transmission </li></ul><ul><li>Most at-risk populations: CSW and mobile populations (e.g. truckers, cross-border traders) </li></ul>Amsterdam, The Netherlands www.kit.nl 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%
    5. 5. Amsterdam, The Netherlands www.kit.nl
    6. 6. The Malawi AIDS response <ul><li>Three Ones principle: </li></ul><ul><ul><ul><li>National AIDS Commission (OPC, 2001) </li></ul></ul></ul><ul><ul><ul><ul><li>Biomedical response: HIV/AIDS Unit (MoHP) </li></ul></ul></ul></ul><ul><ul><ul><li>HIV/AIDS National Action Framework </li></ul></ul></ul><ul><ul><ul><ul><li>2005-2009, extended for 2010-2012 </li></ul></ul></ul></ul><ul><ul><ul><li>National HIV/AIDS Activity Reporting System </li></ul></ul></ul>Amsterdam, The Netherlands www.kit.nl
    7. 7. Financing of the AIDS Response Amsterdam, The Netherlands www.kit.nl <ul><li>HIV/AIDS Pool fund </li></ul><ul><li>GFATM (70%), WB (13%), GoM (4%), DFID/CIDA/NORAD </li></ul><ul><li>Bulk managed by NAC (PR) </li></ul>Round 1 2003-2008 $343 mln <ul><ul><li>RCC </li></ul></ul>2008-2012 Round 5 2006-2011 $17.6 mln Round 7 2008-2010 (Phase I) $15.1 mln
    8. 8. Amsterdam, The Netherlands www.kit.nl
    9. 9. Amsterdam, The Netherlands www.kit.nl
    10. 10. Factors influencing integration <ul><li>Opportunities </li></ul><ul><li>Presence of joint funding mechanisms (SWAp & HIV/AIDS pool) </li></ul><ul><ul><ul><li>GFATM signatory to both mechanisms </li></ul></ul></ul><ul><li>Strong internal and external commitment to HSS </li></ul><ul><ul><ul><li>R1 HIV/AIDS, R5 HSS grants </li></ul></ul></ul><ul><li>Good track-record for HIV/AIDS response and grant management </li></ul><ul><ul><ul><li>National Strategy Application (Round 9, rejected) </li></ul></ul></ul><ul><li>Barriers </li></ul><ul><li>Heavy donor reliance, in particular on GFATM </li></ul><ul><ul><ul><li>Earmarked funds; Separate reporting and M&E requirements </li></ul></ul></ul><ul><li>Weak systems for e.g. M&E, procurement & supply </li></ul><ul><li>Division of responsibilities between NAC and MoHP </li></ul>Amsterdam, The Netherlands www.kit.nl
    11. 11. System-wide effects of the AIDS response <ul><li>Health System Processes & Institutions </li></ul><ul><li>Improved accountability of MoHP & GoM through role of NAC and significant donor reliance </li></ul><ul><li>Increased appreciation and capacity for M&E </li></ul><ul><li>Increased capacity for health and HIV/AIDS research </li></ul><ul><li>“ 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.” </li></ul>Amsterdam, The Netherlands www.kit.nl
    12. 12. <ul><li>Health System Inputs </li></ul><ul><li>Emergency Human Resource Plan ( DFID & R1 GFATM ) </li></ul><ul><ul><ul><li>Increased capacity for pre-service medical training </li></ul></ul></ul><ul><ul><ul><li>Improved HCW retention through salary top-ups </li></ul></ul></ul><ul><li>Increased in-service training and career opportunities </li></ul><ul><ul><ul><li>Improved HCW skills and staff morale </li></ul></ul></ul><ul><ul><ul><li>High staff absenteeism due to workshops and trainings </li></ul></ul></ul><ul><li>Improvements in infrastructure and ICT </li></ul><ul><li>Improved laboratory capacity, maintenance and QA </li></ul><ul><li>“ 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.” </li></ul>System-wide effects of the AIDS response Amsterdam, The Netherlands www.kit.nl
    13. 13. <ul><li>Stakeholder involvement & collaboration </li></ul><ul><li>Greater inter-sectoral collaboration (e.g. MGFCC) </li></ul><ul><li>“ 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.” </li></ul><ul><li>Driver for increased private sector & community involvement </li></ul><ul><ul><ul><li>GFATM sub-recipients from NGOs and CSOs </li></ul></ul></ul><ul><li>Some, though limited, interaction between health programmes </li></ul><ul><ul><ul><li>Continued “verticalisation” </li></ul></ul></ul>System-wide effects of the AIDS response Amsterdam, The Netherlands www.kit.nl
    14. 14. <ul><li>Health System Outputs and Outcomes </li></ul><ul><ul><li>Improved access to health care, through e.g.: </li></ul></ul><ul><ul><ul><li>Reduced HIV/AIDS related mortality in HCWs due to access to ART </li></ul></ul></ul><ul><ul><ul><li>Expansion of network of Community Health Workers (HSAs) </li></ul></ul></ul><ul><ul><li>Improved health-seeking behaviour and service utilisation </li></ul></ul><ul><ul><ul><li>Improved referral systems (e.g. TB/HIV) </li></ul></ul></ul><ul><ul><ul><li>Health education </li></ul></ul></ul><ul><ul><li>Improved quality of care through e.g.: </li></ul></ul><ul><ul><ul><li>Improved interpersonal skills, e.g. for VCT </li></ul></ul></ul><ul><ul><ul><li>Increased reliance on laboratory investigations </li></ul></ul></ul><ul><ul><ul><li>Clinical skills training </li></ul></ul></ul><ul><li>Impact on non-HIV outcomes unknown or unclear </li></ul>System-wide effects of the AIDS response Amsterdam, The Netherlands www.kit.nl
    15. 15. Conclusions <ul><li>AIDS response as rally point for addressing HS weaknesses; positively impacted e.g.: </li></ul><ul><ul><ul><li>HRH • Infrastructure </li></ul></ul></ul><ul><ul><ul><li>M&E and research capacity • Community involvement </li></ul></ul></ul><ul><ul><ul><li>Quality of care </li></ul></ul></ul><ul><li>AIDS response negatively influenced e.g.: </li></ul><ul><ul><ul><li>HRH in public sector: brain drain to HIV/AIDS programmes (management) and NGOs </li></ul></ul></ul><ul><ul><ul><li>Staff absenteeism due to uncoordinated trainings & workshops </li></ul></ul></ul><ul><ul><ul><li>Reinforced parallel systems and “vertical” working methods </li></ul></ul></ul><ul><li>Missed opportunities for comprehensive HSS because of overly vertical set-ups </li></ul>Amsterdam, The Netherlands www.kit.nl
    16. 16. HIV/AIDS and health systems: the way ahead? <ul><li>“ 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) </li></ul><ul><li>“ 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) </li></ul>Amsterdam, The Netherlands www.kit.nl
    17. 17. Amsterdam, The Netherlands www.kit.nl Acknowledgements <ul><li>College of Medicine (Malawi) </li></ul><ul><ul><li>Victor Mwapasa </li></ul></ul><ul><ul><li>John Kadzandira </li></ul></ul><ul><ul><li>Adamson Muula </li></ul></ul><ul><ul><li>Kelita Kamoto </li></ul></ul><ul><ul><li>Edwin Libamba </li></ul></ul><ul><ul><li>National AIDS Commission </li></ul></ul><ul><ul><li>Dr. Biswick Mwale </li></ul></ul><ul><ul><li>HIV/AIDS Unit (MoHP) </li></ul></ul><ul><ul><li>Dr. Eric Schouten </li></ul></ul><ul><ul><li>GFATM (Geneva) </li></ul></ul><ul><ul><li>Dr. Sai P. Kumar </li></ul></ul>