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

king

wit

h co

mm

unit

ies

for

com

mun

itie

s

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

king

wit

h co

mm

unit

ies

for

com

mun

itie

s

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