1Antwerpen 26-27 November 2008
PRIMARY HEALTH CARE in Times of Globalisation
Primary Health Care & Disease Control
The case of AIDS programmes in Africa
Marianne Pirard, Marie Laga, Wim Van Damme, Gorik OomsInstitute of Tropical Medicine, Antwerpen
2Primary Health Care in Times of Globalisation
The Alma Ata Declaration
VII Primary Health Care1. …2. addresses the main health problems in the community, providing
promotive, preventive, curative and rehabilitative services accordingly;
3. includes at least: education concerning prevailing health problems and the methods of preventing and controlling them; promotion of food supply and proper nutrition; an adequate supply of safe water and basic sanitation; maternal and child health care, including family planning; immunization against the major infectious diseases; prevention and control of locally endemic diseases; appropriate treatment of common diseases and injuries; and provision of essential drugs;
4. …
3Primary Health Care in Times of Globalisation
Public Health Debates
• Comprehensive vs Selective PHC
• Horizontalists vs Verticalists
• General Health Care vs Disease Control
• Ideology & Allocation of funds
• Antwerp Declaration
Walsh JA & Warren KS, Selective Primary Health Care: An interim strategy for disease control in developing countries.N Engl J Med 1979;30:967-74.
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AIDS and Health Systems
HIV/AIDS epidemic: health system (HS) & health staff under stress
AIDS response: exceptional measures for an emergency
Allegations:AIDS response disproportionate & undermining HS
Growing Consensus:Need for Health Systems Strengthening (HSS)
Are we spending too much on HIV?
Roger England, BMJ 2007;334;344
5Primary Health Care in Times of Globalisation
AIDS response & System wide effects
Brainstorming with 67 MPH students at ITM• Overview positive and negative effects on HS
Focus group discussion with 11 selected students• HIV experts & Health System managers• Ethiopia, Malawi, Mozambique, Tanzania, Uganda
Antwerp in Geneva Workshop with 30 participants• Implementers, activists, academics & funders• Country experiences, multi-country studies• Modified Chatham rules
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Brainstorming
7Primary Health Care in Times of Globalisation
Grid used for overview of HS effects
Buildings blocks
Human Resources
Resources, Infrastructure M&E Service Delivery
Levels
Facility level & Local Health Systems
N E G
P O S
National Health System
N E G
P O S
Global Systems
N E G
P O S
8Primary Health Care in Times of Globalisation
Reported negative effects on local HS
Human Resources Resources, Infrastructure, M&E Service Delivery
VIETNAM, CAMBODIA: AIDS specific Incentives
MOZAMBIQUE: Parallel supply systems
UGANDA, VIETNAM, CAMBODIA, INDIA:
Disharmony Focus on 1 problem (HIV)
TANZANIA, THAILAND: Different salary scales &
working conditions > demotivation of staff
UGANDA: Competition for space (offices,
consultation)
THAILAND: Distortion of team work
(referral to HIV staff)
MOZAMBIQUE: Increased workload
MOZAMBIQUE: Parallel M&E
MOZAMBIQUE: Integration without allowances
> refusal by general staff
ETHIOPIA: Shift clinicians to HIV org
ETHIOPIA: Clinical services closed,
HC without doctors
MALAWI: CHW diverted to AIDS services
MALAWI:EPI coverage ?
UGANDA, INDIA: HIV training consuming HW time
9Primary Health Care in Times of Globalisation
Reported positive effects on local HS
Human Resources Resources, Infrastructure, M&E Service Delivery
KENYA: HIV project recruits nurses for
General services
NIGERIA: Resources
CAMBODIA: Strengthened OI services >
Utilisation Gen HS TANZANIA:
Training OI care >skills beyond HIV care
NIGERIA: Improved drug distribution
NIGERIA: Resources >
Utilisation Public Hosp
UGANDA:New skills (counselling)
UGANDA: ARV program: free drugs for
diarrhea, malaria
UGANDA: PMTCT services >
ANC quality & coverage ETHIOPIA:
improved lab services for all ptsUGANDA, CAMEROON:
biosafetyUGANDA:
Community based services
CAMBODIA: Attention & Access Chronic care
INDIA: STI surveillance
INDIA: strengthened STI services
quality > utilisation
10Primary Health Care in Times of Globalisation
Focus group discussion
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Effects on human resources
Different working conditions of HIV staff lead to demoralization of general staffUganda“...When they are allocated HIV responsibilities, it is associated with incentives/allowances, and this affects the morale of other staff…”
Tanzania“… Because of ART, the GHI are going to establish an emergency hiring scheme... they are paying them, say 5 times more than the ones employed by the government (200 USD vs 1500 USD)…”
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Effects on HR: Internal Braindrain
Major shifts of health workers from general health services to HIV programmes undermine the HS
Uganda “…in my unit, at least 3 midwives were moved away, those people were involved in ANC and labour ward and really that gap was felt…”
Ethiopia “…in one district we may have only one doctor, they take that staff away … you find the whole health system is affected... in terms of access…”
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Effects on HR: policy & funding
A policy to harmonise human resource managementMozambique“…Government decided to put in place funds and guidelines to avoid
paying different salaries and to avoid this movement of staff…”
HIV funds used for training of health professionals for general health services
Tanzania “…they now can use World Bank money to train medical doctors and nurses for general services …”
Malawi“.. we have the Sector Wide Approach, that is funding for expanding the training of clinicians – such as clinical officers and medical assistants…”
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Effects on service delivery
Neglect of other problemsTanzania
“…The focus now is ART, ART, ART and other diseases are neglected…”
Increased ANC coverageMozambique
“…At the beginning the women who know that there is HIV testing in the Antenatal Clinic tend to escape. But after one year it is improving. We see an increasing effect on the utilisation…”
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Parallel vs Integrated AIDS responses
Without an integration policy: very diverse effects on HSUGANDA“… with those HIV organisations that come in as parallel vertical structures
it is very, very difficult because they have a different accountability system, …. the problem is that their equipment is specifically for their own purpose, … so it is very difficult to share, or divert or integrate, ….”
“…What we do is try and re-distribute, for example, internet we do not set it in the (HIV) clinic, we can put it in a general office, … and that makes it a little less different. … it also depends on the strength of the overall management…”
“…We have organisations (like TASO, Uganda Cares) which … come through the government … you get a degree of integration which will strengthen the system…”
16Primary Health Care in Times of Globalisation
Integrated AIDS response
Integration policy : the case of Mozambique“ … at the ministerial level they decided we should go in
integrated way- even if there are vertical funds coming to the HIV programme…”
Improved Counselling Skills (beyond HIV)Mozambique
“… instead of Voluntary Counselling Test we say Health Counselling Test. That means instead of counselling people for HIV we start counselling people for health matters like diabetes, high blood pressure and so on…”
17Primary Health Care in Times of Globalisation
Increased donor investment in HS
Ethiopia“…If you look at training and equipment supplied, it is not only for HIV but also other health services benefit…
- the overall HMIS was improved with support from the HIV/AIDS programme.- … a training programme in M&E for people working in health centres was established in collaboration with Tulane University - the logistic management was strengthened with resources from the Clinton Foundation - Global Fund … puts money into health facility construction …”
18Primary Health Care in Times of Globalisation
‘Antwerp in Geneva’ WorkshopReport
Available from:http://www.itg.be/itg/GeneralSite/Generalpage.asp?WPID=501
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Does the AIDS response undermine HS?
Funding for global AIDS response:Increased dramatically No evidence to the detriment of funding for general health sector development
Impact of AIDS responses on health systems:Predominantly harmful or predominantly beneficial? Systematic evidence lacking
20Primary Health Care in Times of Globalisation
Evidence of harm to HS
Effect on health workers: the main concernWell-funded HIV programmes can drain HW from general services.Perverse incentives encourage HW to be away from clinic duties
Fragmentation of health services:Setting up parallel systems for ARV distribution: a missed opportunity to strengthen national drug distribution systems
Results based financing pushing for narrow targetsA drive to achieve a set target of N° of patients on ART in x time can weaken attention to achieve wider health service objectives.
21Primary Health Care in Times of Globalisation
Evidence of HS strengthening effects
The AIDS emergency was a wake-up call: Years of under-investing in HS lead to HS too weak to tackle a new epidemic.
All ‘building blocks’ of health systems received financial injections from the global AIDS response.
This renewed attention and financial injections have generated wider HS benefits in several settings.
22Primary Health Care in Times of Globalisation
Evidence of HS strengthening effects
Opportunities for synergies: PMTCT & Maternal & Child health servicesART treatment & management of TB
Integrated AIDS response leading to improved utilisation of general health services as a result of greater confidence
Malawi: a simple, standardised, inclusive, integrated ART programme strengthened primary care. Key: resource mobilisation for HRH
23Primary Health Care in Times of Globalisation
AIDS response: a boost for PHC
Improved counselling skills strengthened patient centredness
Models of care for AIDS patients: helpful to respond to other chronic diseases
Involvement of people living with HIV in ART programmes enhanced community participation in general
A rights based approach employed by AIDS activists could be expanded to general health care
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Conclusions: Building synergies
HIV programmes have a potential to contribute to HSS
Lessons learned from positive impacts need to beapplied more widely
Negative impacts can be controlled.Most critical domain: human resources
Priority for evidence:to learn how to maximise benefits and minimise harmsto exchange learning between countries
25Primary Health Care in Times of Globalisation
Comprehensive PHC: a uniting concept
Comprehensive PHC includes AIDS prevention and treatment
Health and access to care (including ARV treatment) are a human right and an entitlement
The new concept of sustainability adopted for AIDS treatment - based on domestic resources and sustained international funding -
should be expanded to general health care
The global aid architecture must be reorganised in a way:• To support national priorities and planning• To support comprehensive PHC for all,
not one part of comprehensive PHC at the expense of another
26Antwerpen 26-27 November 2008
PRIMARY HEALTH CARE in Times of Globalisation
The AIDS response is an ally not an enemy of PHC
27Primary Health Care in Times of Globalisation
Universal Access to AIDS Treatment &Prevention and Primary Health Care for All
One fight….
28Primary Health Care in Times of Globalisation
Thanks to all collaborators
• MPH Students, ITM, Antwerp• Workshop participants
• Yibeltal Assefa, National HIV programme, Ethiopia
• Virgil O.N. Onama IPH, Makerere University, Uganda
• Nathan Ford Infectious Diseases Epidemiology Unit, Cape Town, South Africa
• René Loewenson TARSC, Harare, Zimbabwe
