Exploring a diagonal approach

28 May 2011

Health is a fundamental requirement for development. If farmers, teachers, housekeepers and nurses are ill and cannot do their jobs, it affects a community’s access to nutrition, education, safe drinking water and health care – all of which can increase vulnerability to disease and lead to more illness in society. When the United Nations launched the Millennium Development Goals (MDGs) in 2000, they made a commitment to break the vicious circle of poverty and ill health by making health a priority for development cooperation. Financial development assistance for health increased from US$10.5 billion in 2000 to US$27 billion in 2010.¹

Considerable improvements have been made. For example, antiretroviral treatment (ART) has been introduced for the treatment of HIV/AIDS. Before ART was available in rural Africa, almost two million people died every year. Most deaths occurred at home, imposing a huge burden on families, who were frequently unable to continue paying for treatment. Often, patients were abandoned and left to die alone because primary health care networks were overstretched and hospital wards were already crowded with AIDS patients.

Changing picture
This picture has changed. ART has had a huge impact on African families, communities and society as a whole. Now that treatment is available, more and more people are ready to learn more, to talk about HIV, to protect themselves better and to show up for testing and counselling.

In parallel with this good news, a controversial debate has emerged on the drawbacks of the MDG approach and on global health policy in general. Yet critics argue that HIV/AIDS interventions absorb too big a share of the resources allocated for improving health. According to a report jointly published by the World Health Organization (WHO), the Organisation for Economic Co-operation and Development (OECD) and the World Bank, 32% of all official development assistance for health since 2000 has been spent on HIV/AIDS intervention.² Some countries in sub-Saharan Africa, including Kenya and Uganda, spend more than half their health budgets on alleviating HIV/AIDS.³

This contrasts sharply with what is spent on, for example, acute respiratory infections. Such infections, according to an article published in the British Journal of Medical Practice in 2008, represent 26% of the communicable disease burden in the developing world, but attract only 2.5% of direct funding.⁴ Perhaps the strongest criticism in the debate comes from Roger England, who argued in the British Medical Journal in 2008 that the ‘international HIV/AIDS industry’ – under which umbrella he includes Western companies, consultants and HIV/AIDS bureaucracies – usurps precious resources. He even goes so far as to suggest that UNAIDS should be closed down because its mandate is harmful.⁵

While most critics might not be prepared to go this far, there is a consensus that in their mission to achieve the health-related MDGs, global health initiatives have encouraged disease-specific or ‘vertical’ health programming. And there is widespread agreement that such vertical programmes have led to a fragmentation of primary health care. Staffing, equipment, infrastructure and data management have been planned, designed and allocated according to the budgets and requirements of various disease-specific programmes rather than according to the local disease burden and the requirements of the local health service providers.

Many vertical ART programmes have funded new laboratory equipment and supplies of reagent, and established protocols for laboratory-based routine monitoring of ART patients. Yet, according to one of the largest studies on antiretroviral treatment in sub-Saharan Africa, the DART Trial (Development of Antiretroviral Treatment in Africa Trial), routine laboratory monitoring of ART patients is ineffective in settings where resources are limited – and this is so from a clinical as well as from an economic point of view.⁶ The trial highlighted instances where funding and personnel were deployed to carry out non-essential testing of HIV-positive patients who were doing perfectly well on ART, while essential diagnostic tests were not available, or affordable, for patients with other acute illnesses. The DART Trial showed that ART patients could be monitored effectively without laboratory equipment. It recommended that where laboratories and personnel are limited, they should be allocated in such a way that they deliver high-quality care to all patients, not just to those with HIV.

‘Do no harm’
The human resources crisis is another sensitive area where vertical ART programmes have adversely affected health systems. Parallel management structures and monitoring and reporting schemes have diverted well qualified doctors and nurses away from looking after patients to administer projects. A study in McKinsey Quarterly revealed that in Tanzania, a district medical officer spends 100 days a year writing reports for international organisations.⁷ And in his commentary in The Lancet, former Mozambican Minister of Health, Paulo Garrido, wrote that ‘in many countries, funds are not needed specifically for AIDS, tuberculosis, or malaria. Funds are firstly and mostly needed to strengthen national health systems so that a range of diseases and health conditions can be managed effectively.’⁸

With the aim of stemming the brain drain from the public health sector, 50 international institutions have signed the NGO Code of Conduct to ‘do no harm’ to public health systems – that is, to limit the unintended negative effects of their health programmes.⁹ (For more information on this, see the interview with Wendy Johnson on pages 10 and 11.)

The experiences of SolidarMed, a Swiss health development organisation, are a good example of how to put the do no harm principle into practice in primary health care. Long before the advent of ART, SolidarMed had been collaborating with district hospitals on primary health care development plans, targeted investments, support for nursing schools, improved housing for health workers, community-based mother and child health care, and initiatives for the prevention of malaria and tuberculosis.

SMART
In 2005, SolidarMed started running an HIV/AIDS treatment and prevention programme called SMART in ten district sites in Tanzania, Mozambique, Lesotho and Zimbabwe. The organisation learned that the key to fighting HIV/AIDS was to build the capacities of local health systems – it does not work the other way round. Certainly, managing HIV/AIDS requires money for drugs, but what’s much more important is a strong health workforce, reliable health services that reach out to rural communities and adequate district health management capacities.

In an effort to mitigate the drawbacks of vertical health programmes, SolidarMed pursued three strategies:

• It integrated SMART into existing SolidarMed primary health care programmes and long-standing hospital partnerships.
• It harmonised SMART with existing HIV/AIDS programmes and brought it in line with national health policy. From the beginning, SMART was designed to complement government ART programmes and to be in line with national policy on HIV/AIDS. In memorandums of understanding, SolidarMed and district health authorities defined the terms of a harmonised and multi-stakeholder approach.
• It used some of SMART’s budget lines to strengthen capacity. A number of budget lines are earmarked for general capacity building interventions, such as infrastructure and salary top-ups, that are not specifically related to HIV/AIDS services.

As a result, SMART pursues a ‘diagonal’ programme approach – one where ART-specific interventions are embedded in wider primary health care support. However, as the following examples show, the SMART project has been a learning experience for SolidarMed, and there have been adverse as well as positive effects on local health systems.

Outcomes
Bricks and mortar: SMART provided funding for the substantial reconstruction and renovation of hospital out-patient departments and peripheral health facilities at all ten of its sites – providing primary care to a population of roughly two million. SMART created more and better space for all patients as well as more housing for health personnel. However, extending and renovating out-patient departments have often been tailored to the particular needs of HIV/AIDS clients and patients to the exclusion of patients with other chronic diseases and. Sometimes, these efforts have not anticipated the integration of treatments for HIV/AIDS and tuberculosis.

Laboratories and pharmacies: Antiretroviral treatment requires improved diagnostic means and laboratory-based patient monitoring. Upgrading laboratories with new equipment and additional staff training remains one of SMART’s priorities. At some sites, this capacity- building component has been beneficial for all areas of primary care. For example, the improvement of blood chemistry and haematology facilities has meant that patients suffering from anaemia now receive adequate treatment. However, in terms of the regular supply of essential chemical reagents and drugs, it is again the HIV-positive patients that benefit most from the vertical funding schemes. At times, hospitals have large quantities of antiretroviral drugs and CD4 test reagents while the paracetamol shelf in the pharmacy is empty. Also, while clients on ART are getting routine lab tests done free of charge even when they feel perfectly well, seriously ill patients not infected with HIV cannot afford a laboratory test. In 2009, in one of the SMART partner hospitals, it was noted that more than 80% of all laboratory tests performed were for HIV patients.

Human resources: ART has been a great relief not only for patients, but also for health workers. Prior to SMART, the only treatment options primary care nurses could offer AIDS patients were painkillers, antibiotics, hospital referral or registration in a home-based care project. We saw with SMART that the roll-out of ART to primary health facilities had a positive impact on the motivation of rural health workers. Seeing patients recover from opportunistic infections, gain weight and resume their everyday lives enhanced job satisfaction. SMART also provided a wide range of training opportunities for all health workers.

In addition to various training sessions related to the clinical management of HIV/AIDS and opportunistic infections, SMART has reinforced the clinical mentoring and supportive supervision of peripheral health workers by consultants and district hospital outreach teams. By investing in buildings, furniture, equipment and means of transport and communication, SMART has had a positive impact on working conditions – a key factor in attracting and retaining personnel. Unfortunately, the positive effects of SMART on the health workforce are undermined by severe staff shortage in remote areas. This In understaffed areas, the decentralization of ART and the steadily growing number of patients is a heavy burden on the small numbers of health workers struggling to provide essential primary health care with extremely limited resources.

Maternal and neonatal health: The roll-out of antiretroviral treatment has had both positive and negative effects on maternal health. On the positive side, pregnant women now have free access to HIV testing and counselling, and if they test positive, they can protect their babies from HIV infection. The care and treatment of babies exposed to HIV/AIDS has been an important focus at all SMART sites. As a result, the general quality of paediatric primary health care has improved. Also, because one in five maternal deaths globally is attributable to HIV/AIDS, ART programmes have a direct effect on maternal health.

SolidarMed observed that in Chiure in north-eastern Mozambique, where large parts of the SMART budget went to strengthen the local primary health care system, the programme has prompted more women to give birth in a health facility rather than at home. The percentage of births attended by skilled health personnel increased from 28% to 72% during the course of the programme.

The Chiure experience was not replicated throughout all SMART sites though. It has always been an objective of SMART to prevent the transmission of the HI virus from an HIV-positive mother to her baby. To this end, SMART promoted HIV testing and counselling as part of antenatal care as well as the prophylactic antiretroviral treatment of both mother and baby. Yet, at many SMART sites, such vertical measures have had little effect on maternal and neonatal health in general. Many women are still dying during pregnancy and childbirth, and infants are still dying from neonatal complications. A comprehensive package of emergency obstetric care is an imperative for maternal health, but ART programmes may have diverted scarce resources away from maternal and reproductive health to HIV/AIDS services.

Tuberculosis: In sub-Saharan Africa, HIV/AIDS has caused a massive spread of tuberculosis (TB). This is because TB is the most frequent opportunistic infection among AIDS patients, and the most common cause of death. Despite knowing that the two diseases were so closely interlinked, SMART missed the chance to pursue a collaborative approach in the early stages of the programme. Only recently has training on HIV/AIDS included the management of TB. TB patients are tested for HIV and people living with HIV/AIDS are screened for TB. To date, across the SMART sites, one in ten ART patients receives TB treatment as well. This is a proportion that is well below the expected case load of co-infected patients. From what is now known as a result of the SMART programme, starting to treat TB and HIV concurrently can have a positive effect on the quality of clinical care.

Community health workers: Because there is a chronic shortage of doctors and nurses and because ART has been extended into the primary health care arena, lay members of the community have become involved in prevention and first contact health care. These community health workers have attracted growing recognition as an integral component of the health workforce. In the past, community health schemes had proved unsustainable because of a lack of support, supervision and training. But more recently the WHO, in collaboration with the Global Health Workforce Alliance, has reviewed the concept of community health workers and issued recommendations on how to integrate them into health systems.¹⁰

Recent studies show that community health worker schemes have considerable potential. For example, a systematic review concluded that a combination of outreach and community care could reduce neonatal mortality by 37%. A report in The Lancet in 2007 showed that regular contact (18 visits over five years) between community health workers and mothers and their children during the first five years of the children’s lives was the most effective preventive intervention in ensuring survival of children under five.¹¹ Community health workers can also improve the survival prospects of severely ill children by administering basic case management before referral to hospital. Two million children die of pneumonia every year. A study published in the Bulletin of the WHO in 2008 concluded that community case management of pneumonia by community health workers is a feasible, effective strategy to complement facility-based management.¹²

Lay health workers and ‘expert patients’ – ART patients volunteering as HIV/AIDS counsellors – have become driving forces in the decentralisation of SMART. In Zimbabwe, SMART collaborates with the NGO Batanai, which runs community-based advocacy, training and service programmes for people living with HIV/AIDS. SMART and Batanai have established a network of village-based community HIV/AIDS support agents, who are ART patients themselves, and who provide adherence counselling and facilitate mutual support between patients. These support agents have a unique role in linking communities with first contact health facilities. In Lesotho, SMART trains and pays the salaries of HIV lay counsellors who have no medical background, but are based at rural health clinics to help with HIV/AIDS clients and patients. Carefully recruited, trained and supervised, they are becoming an important pillar of primary health care that extends beyond simply providing antiretroviral treatment.

Assessing local impact
The impact that SMART has had on local systems of primary health care is difficult to assess. Its effects over the years have been both positive and negative, and while many of the consequences were desired outcomes, some were unintentional and unanticipated. We also need to examine the extent to which non-HIV/AIDS patients have benefitted from SMART’s substantial investments in HIV/AIDS treatments.

The impact of SMART on the local health system has not been systematically evaluated yet. Its monitoring and evaluation efforts have been largely focused on the outcome of ART projects. SolidarMed visualises a health system comprising three interlinked domains. First, the delivery of primary care services through district hospitals and primary health care facilities; second, the realm of various kinds of community-based health activities; and third, a health system management scheme that is under the leadership of the district health authorities.¹³

The table below proposes a structure for discussing possible impacts of disease-specific programmes such as SMART on the local primary health care system.

 

Table 2: SMART’s impact on health systems

Relaunching primary health care
Of the 22.5 million people living with HIV/AIDS in sub-Saharan Africa, about ten million have reached an advanced stage and need ART. Despite steady up-scaling, 65% of the patients in urgent need of ART do not have access to it – some are not even aware they are HIV positive. And many more people who have been newly infected will need the treatment in the near future. This backlog of patients in need of treatment is a colossal challenge for fragile local health systems in rural Africa. The SolidarMed experience shows that decentralised ART provision only works when it is based on the foundation of a solid primary health care system, one where the health workforce – doctors, nurses and community health workers – is the core element.

Primary health care is multidimensional. It depends on self-determined community capacities, strong and durable infrastructure and equipment, and the comprehensive management of health workers, supply chains and health data systems. There is now a consensus between governments, civil society and global health initiatives that health systems should be people-centred rather than disease-centred.

A number of international organisations have adapted their funding criteria to accommodate disease-specific interventions that also strengthen the horizontal system of primary health care. In 2008, the WHO relaunched primary health care as one of the guiding principle of global health.¹⁴ In a reworking of the Alma-Ata Declaration, the WHO proposed health care reforms that would:

• Give universal access and social health protection
• Provide people-centred services
• Incorporate community-based public health policies
• Encourage participatory health management

A primary health care approach to ART will have to deal with growing numbers of patients. And in order to prevent resistance to antiretroviral drugs from developing, it will also have to ensure quality of care and ensure that patients on ART adhere to the treatment programme. At the same time, if ART programmes are designed in a diagonal rather than in a vertical way, primary health care will also benefit.

With thanks to Jochen Ehmer of SolidarMed for his valuable contribution to this article.

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Endnotes

1. Institute for health metrics and Evaluation (2010) Financing Global Health 2010: Development Assistance and Country Spending in Economic Uncertainty. Seattle, Washington, IHME and University of Washington.
2. WHO, OECD, World Bank (2008) Effective Aid, Better Health: Report prepared for the Accra high level forum on aid effectiveness.
3. Amico, P. et al. (2010) “HIV Spending as a Share of Total Health Expenditure: An Analysis of Regional Variation in a Multi-Country Study. In PLoS One, 5(9).
4. De Maeseneer, J. et al. 2008: Strengthening primary care: Addressing the disparity between vertical and horizontal investment. In British Journal of General Practice, vol. 8(546).
5. England, R. 2008: The writing is on the wall for UNAIDS. In British Medical Journal, vol. 336(7652).
6. Grundy, C. et al. (2009) Antiretroviral therapy can be delivered safely and successfully without routine laboratory monitoring in Africa. DART Policy briefing document. (The Development of AntiRetroviral Therapy in Africa (DART) Trial was a Public-Private Clinical Research Partnership on HIV/AIDS in Africa. It was carried out by a joint research partnership of research institutes in Uganda, Zimbabwe, and the UK, and funded by the UK Medical Research Council, DFID, and the Rockefeller Foundation. Drugs were provided by pharmaceutical companies.)
7. Conway, M. D. et al. (2007) Addressing Africa’s health workforce crisis. In McKinsey Quarterly.
8. Garrido, P. I. (2010) Women’s health and political will. In The Lancet, vol. 370, p.1289.
9. The NGO Code of Conduct for Health System Strengthening (2008) Seattle, Washington. Health Alliance International. http://ngocodeofconduct.org
10. WHO and Global Health Workforce Alliance (2010) Global Experience of Community Health Workers for Delivery of Health Related Millennium Development Goals: A Systematic Review, Country Case Studies, and Recommendations for Integration into National Health Systems.
11. Haines A. et al. 2007: Achieving child survival goals: potential contribution of community health workers. In The Lancet, vol. 369, pp.2121–31.
12. Marsh, D. R. et al. (2008) Community case management of pneumonia: at a tipping point? In Bulletin of the World Health Organization, vol. 86. pp. 381-89
13. With regard to community health resources, the SolidarMed health system concept differs from the WHO’s six building blocks framework. We believe that community-based health activities should be recognised and integrated as part of the health system. The WHO health system framework consists of the components leadership and governance, health financing, human resources for health, essential medical products and technologies, health information systems, and service delivery.
14. WHO (2008) Primary Health Care. Now more than ever. Geneva, World Health Report.
15. United Nations (2010) The Millennium Development Goals Report 2010. New York.
16. Hogan, M. C. et al. (2010) Maternal mortality for 181 countries, 1980–2008: a systematic analysis of progress towards Millennium Development Goal 5. In The Lancet, vol. 375, pp.1609–2 3.

  

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