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COMMUNITY HEALTH ASPECTS

OF HIV/AIDS

Dan Kaseje, MBChB, MPH, PhDDan Kaseje, MBChB, MPH, PhD

Professor of Public Health,Professor of Public Health,

December, 2009December, 2009

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CONTEXT� 9yrs ago, world leaders set goals to free humanity from the

shackles of extreme poverty, hunger, illiteracy &disease by 2015

� They established quantitative benchmarks for poverty,

hunger, education, gender equity, child/maternal mortality,

malaria and HIV, environmental sustainability and global

partnership for development.

� But progress has been slow, casting doubts as to the

possibility of achieving the goals in Sub-Sahara Africa.

� Less than 6 yrs away, progress is threatened by

unprecedented economic crisis that has led to diminished

resources, fewer opportunities for lower income countries,

worsening already unacceptable DISPARITY (between and within

countries).

Proportion of people living on less than $1.25 a day, 1990, 1999 and 2005 (Percentage)

The global economic crisis derails fight against poverty

� Worldwide, the number of people living in extreme poverty in 2009 is 90 million higher than anticipated before the Global economic crisis

� Minimal poverty reduction in SS Africa, farthest from target

� Steady global reduction

International food price index and consumer food price index in selected countries, 2008 (Year 2000=100)

A decrease in international food prices fails to translate into more

affordable food at local markets� A decrease in international

food prices in the second

half of 2008 was expected to

lower prices in local mkts

� This has not materialized,

and consumer access to

food in many developing

countries, such as Brazil,

India and Nigeria did not

improve as expected

� FOOD PRICE INDEX

HIGHEST IN SS AFRICA.

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SUPPLY SIDE�There is poor preparedness for emerging scenario, inadequate

skills mix (particularly leadership and management) to face

the context

�Competing systems of care contribute to delays in care seeking

(since available, accessible, acceptable) yet ignored and

unregulated (effectiveness unknown). Delayed care seeking leads

to COSTLY CONSEQUENCES�Solutions which tend to be developed outside the context of the problem (by professionals), too simplistic against complex situations surrounding the households, entrapped in the a vicious cycle of poverty and ill-health, as well as layers of disabling socio-economic realities (culture, stigma, discrimination)

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SUPPLY SIDE�CONDOM (less than 50% coverage)

�MALE CIRCUMSCISION (20%)

�VCT, PMTCT (only 10% know their status)

�TREATMENT OF STI (less than 20% access treatment)

�Home based testing

�ART, HAART

�OVC interventions

�Home based care

(all effective yet not reaching hh, individuals enough to change

situation)

THERE IS COMLEX INTERFACE: HH TO CARE

Tertiary Hospital

Secondary Hospital

Primary Hospital

Health Centre, Maternity and Nursing Home

Dispensary/Clinics

Community: Village/Household/Family/Individuals

Interface: Distance, transport, costs, culture etc

Demand side: 70%HH IN POVERTY TRAP

ILL HEALTHILL HEALTHTRAPPED TRAPPED HOUSEHOLDSHOUSEHOLDSPOVERTYPOVERTY

THE VICIOUS CYCLETHE VICIOUS CYCLE

Demand: affected by

�Distance

�Costs (direct and indirect)

�Gender and other discriminations

�Decision making processes

�Stigma

�Extreme poverty and hunger

�Illiteracy�Problems are greatest where resources are least (inverse law)

Girls’ secondary school enrolment in relation to boys’,1998/1999 and 2006/2007 (Girls per 100 boys)

The gender gap increases in

secondary school enrolment,

girls fall behind due to poverty,

hunger and RH issues

� The gap is wider where overall

enrolment is lower, increases

in secondary school enrolment tend to be accompanied by

reductions in gender disparities.

� Target to eliminate

disparities by 2005 target

was missed

Secondary school net attendance ratio of boys andgirls, by place of residence and household wealth,1998/2007 (Percentage)

POVERTY IS MAJOR CAUSE OF DISPARITY

� Gender parity has been

reached in urban areas

and among the richest 40

per cent of households.

� In contrast, girls are

more likely to be

excluded from primary

education in rural and

when they reside in the

poorest households.

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Asia43%

Africa51%

6%

Africa

Asia

Rest of theworld

Maternal Death: 2005

Source: UNICEF global database 2009

(276,000)

(232,000)

(28,000)

Maternal deaths per 100,000 live births, 1990 and 2005 7

Giving birth safely is still

largely a privilege of the Rich

Maternal Health

“Maternal death rate is the largest health disparity in the world”

Who is dying?

Ronsmans C, Graham WJ. Maternal mortality: who, when, where and why. Lancet 2006; published online Sept 28. DOI:10.1016/S0140-6736(06)69380-X.

Why are they dying?• Direct Causes:

– Hemorrhage– Htn of

Pregnancy– Infections– Obstructed

Labor– Unsafe Abortion

• Indirect Causes:– HIV/AIDS– Malaria– Violence

Ronsmans C, Graham WJ. Maternal mortality: who, when, where and why. Lancet 2006; published online Sept 28. DOI:10.1016/S0140-6736(06)69380-X.

Proportion of women (15-49 years old) attended four or more times during pregnancy by skilled health personnel, 2003/2008 (Percentage)

Less than half of pregnant women in developing

countries have the benefit of adequate prenatal careOnly 40% of women

receive four or more

antenatal visits in

sub-Saharan Africa

to benefit from

PMTCT, less still

deliver in health

facility

Number of people living with HIV, number of people newly infected with HIV and number of AIDS deaths in the world (Millions), 1990-2007

New HIV infections and

AIDS deaths have

peaked 1996, 2005 but 33

million people are still

living with HIV, two

thirds in s-s Africa,

majority are women

Urgent innovations

needed to address the

interface complexities

to accelerate progress

�Many studies show benefits of collaborative action research

(providers, users, researchers and decision-makers), (Ross,

2003; Kogan et al, 2006; Lomas, 2000) in improving policy

and practice.

�Is this an opportunity for SAHARA to engage, facilitate

knowledge generation linked to actions to address problems

of uptake of effective technologies?�Partners engage in an iterative process of joint assessment, dialogue, planning and action (ADPA) for improvement

�Findings fed into dialogue enabling all parties to contribute toquestions and solutions based on own expertise.

Collaborative in Action Research, focusing

on the interface

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Collaborative research process�Dialogue promotes radical thinking, ability to search for new models, innovations, more likely to succeed.

�Dialogue synergizes efforts and motivation through ADPA cycle for continuous improvement.

�Actions taken to address barriers around households, that have to do with the social fabric, context in which they live

�The approach links action to available evidence,

demonstrates progress towards the goals, which justifies

continued action, in areas of influence/responsibility.

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Community Dialogue for cont. ImprovementCommunity Dialogue for cont. Improvement

�What is the situation from evidence? Why?

�What improvement can we accomplish in 1 year?

�What can we do to improve the situation?

�How will we measure the improvement?

Act Assess

Plan Dialogue

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Leverage Intellectual Resources and Knowledge To Develop New Approaches across the interface

Problem Characterization

Idea Generation

SolutionDevelopment

Drive Strategy

Problem

Knowledge Management

Consolidate Learnings | Cross-fertilize Ideas | Educate/Train | Guide Investments | Create a Knowledge Community

Innovation

Invest in Research | Challenge Thinkers | “Connect the Dots”

Leadership

Develop Vision | Mentor Talent | Transition to Execution

Support Execution: Clear the Way for Entrepreneurs to Succeed

Planning Implementation Scale Up

Support Execution

Partnership Platform

Planning | Organizing | Implementing | Assessing | Reporting Advocating | Social mobilization for change

Network

PHASA Skills | Provide Leadership | Enhanced Human Capacity

Capital/resourcing

Commercial | Non-Profit | Government

IMPACT

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Key messages

1. Scale up community-based strategies, partnerships,

to address both demand and supply, supported by

evidence

2. Promote collaborative action research, to drive

policy reforms aimed at accelerated continuous

improvement (successful local models embedded

into policy and practice)

3. Move beyond Afro-Pessimism to concrete action to

continuously improve starting at your own area of

responsibility and influence, increasing in ever

expanding concentric circles.

JICA Nyanza Health Management Project

THANK YOUTHANK YOU

Moving beyond Moving beyond AfroAfro--pessimism,pessimism,for the future of for the future of

AfricaAfrica