PMTCT, and National's - Health Systems Trust

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HEALTH CARE INFRASTRUCTURE Human Resources Counselling Lay counsellors are central to the PMTCT programme. Attempts have been made by all provinces to employ lay counsellors; however, several difficulties have been experienced and some pilot sites remain without counsellors. The employment conditions, remuneration, training and supervision of lay counsellors differ greatly between provinces. Monthly salaries range from R500 to R2900. It is evident from the results that provinces in which lay counsellors are better paid, achieve higher testing uptake rates (e.g. KwaZulu-Natal and the Western Cape). In addition, low counsellor salaries have resulted in high rates of counsellor turnover and the need for constant re-training. Health Worker Training Provinces have adopted various approaches to training health workers on PMTCT. The most widely used approach is the UNICEF/National DoH supported PMTCT and infant feeding counselling course. This is a 5-day residential training course that focuses on infant feeding counselling and filled a gap that other training courses neglected to cover adequately. The Western Cape and the Free State developed an on-site training course focusing on the PMTCT protocol and operational issues. Courses typically last 2 days. This approach enabled more health workers to be trained on crucial operational issues in a short period of time. The main difference between the two approaches is that the UNICEF/National DoH training aimed to develop trainers and infant feeding counsellors whereas the Western Cape and Free state aimed to prepare staff to implement services. Management Information management The move from an intensive research oriented information system for the pilot sites to a limited information system integrated into the national essential primary health care dataset for the expanded programme is proving difficult. Many provinces are still collecting the full research dataset using numerous registers. This has resulted in virtually no data being available outside of the pilot sites as health workers are simply too busy to collect the information. Approval has been given for PMTCT data to be incorporated into the national essential primary health care dataset; however, implementation appears slow. Management of drugs and supplies The evaluation found evidence of disruptions in the supply of test kits, nevirapine and formula milk in some provinces. This was due to a variety of reasons including the separation of PMTCT drugs and supplies from other essential primary level medicines, inadequate district and provincial capacity to manage this procurement, short expiry limits of nevirapine tablets and syrup, and poor quality of one particular type of testing kit resulting in delays when stocks had to be returned to the depots. Nevirapine is currently not on the Essential Drug List. Although registered as a Schedule 4 medicine, it is handled as a controlled substance (Schedule 5) in all facilities offering PMTCT services. This system is time-consuming for health workers, unnecessarily bureaucratic and may limit access to the drug. These problems influenced the number of women who participated in the programme. Greater involvement of the National Health Laboratory Service is needed to ensure regular quality control of rapid test kits. Furthermore, the planning for national antiretroviral treatment should weigh the need for security and documentation against the need for systems that are convenient and simple. 3
SCALING UP THE PMTCT PROGRAMME There have been attempts to scale up the PMTCT programme beyond the pilot sites in all provinces. The greatest coverage exists in the Western Cape and KwaZulu-Natal, where comprehensive, phased expansion plans have been developed and additional funding allocated. In other provinces, the focus has remained on improving the functioning of the pilot sites. This has resulted in well-resourced provinces with access to technical and academic expertise, wide NGO networks and strong local government, achieving success and rapid expansion, whilst less resourced provinces continue to struggle to provide a basic service even at the pilot sites. Human resources and facility infrastructure require ongoing investment to provide communities with basic services. This report recognizes that many of the existing challenges to the effective and wide-scale provision of PMTCT should be resolved through strengthening the health system and human resource capacity at various levels. Moreover, a more planned approach to scaling up of the programme would ensure greater sustainability and coverage and allow PMTCT to serve as a vehicle for improving maternal and child health care. KEY CHALLENGES AND RECOMMENDATIONS 1. The pilot sites have demonstrated that it is feasible to implement PMTCT in South Africa, but have also identified numerous operational challenges for establishing and expanding a PMTCT programme under routine health service conditions. These challenges should be addressed as a matter of priority for the pilot sites, particularly those that are not performing adequately. However, these challenges are not insurmountable, and with the necessary leadership, planning and resource allocation, can be addressed to make full expansion of PMTCT in South Africa a reality. 2. Strong leadership and management are needed at both provincial and national levels, to address existing shortcomings in pilot sites, and for expansion beyond these sites. Financial resources were made available by the National DoH to strengthen provincial capacity for PMTCT, but often the appointments made were not at a sufficiently senior level, and many had inadequate technical expertise required for this task. Provinces and National DoH need to address this jointly to ensure that each province has the required dedicated leadership and management capacity to support PMTCT implementation. 3. A clear policy framework and updated national implementation guidelines are urgently needed on key issues such as infant feeding, and infant testing. The evaluation has provided insights into infant feeding choices, availability of free formula at facilities and support systems to promote safe infant feeding. The continued supply of free formula in a scaled up PMTCT programme needs re-consideration at national and provincial levels, with specific attention to issues of equity, duration for which free formula is provided, the quality of counselling provided, effects on the infant feeding practices of HIV positive and HIV negative women and on child health outcomes. 4. Human resource capacity to provide the additional requirements for PMTCT, in particular counselling and testing, and training and support of professional staff, needs to be addressed. The availability of lay counsellors has in several of the pilot sites eased the workload of nurses and improved the uptake of HIV testing amongst pregnant women. National policy is required to clarify the role and responsibilities of, and the employment and remuneration of lay counsellors for HIV care. 5. Completion of the data for the PMTCT pilot sites has been demanding on health service providers, and has not necessarily provided useful data for local management and service delivery. Essential PMTCT data, as approved by NHISSA, should be the only items collected at all facilities. These items should be incorporated into the district health information system, so that it can flow through the same channels as all PHC data. The expanded research data items collected in the 18 pilot sites, should only be collected for specific research purposes, and discontinued once this research has been completed. REFERENCES 1. National Department of Health. National HIV and Syphilis antenatal sero-prevalence survey in South Africa 2002. Pretoria, National Department of Health, 2003. 4
Page 3 and 4: An Evaluation of the Prevention of
Page 5 and 6: CONTENTS 1. Executive summary 2. In
Page 7: Dispensing of Nevirapine Nevirapine
Page 11 and 12: AIM OF THE EVALUATION METHODOLOGY A
Page 13 and 14: OVERVIEW OF THE PMTCT PILOT SITES *
Page 15 and 16: DESCRIPTION OF ROUTINE PMTCT INDICA
Page 17 and 18: Nevirapine (NVP) dispensing rate to
Page 19 and 20: 6.1 Antenatal Counselling and Testi
Page 21 and 22: This rate has increased slightly si
Page 23 and 24: Group education followed by individ
Page 25 and 26: WHO 2 recommends that at least 50%
Page 27 and 28: APPENDIX 6.1: EXAMPLE OF A PEER COU
Page 29 and 30: Figure 6.2.1: Nevirapine dispensing
Page 31 and 32: 6.3 Infant Testing and Outcomes BAC
Page 33 and 34: DISCUSSION HIV Diagnosis in Infants
Page 35 and 36: Current Status of Infant Testing Cu
Page 37 and 38: Proposed Infant HIV Test Timelines
Page 39 and 40: 6.4 Maternal and Infant Follow Up I
Page 41 and 42: RECOMMENDATIONS FOR IMPROVING THE P
Page 43 and 44: KEY FINDINGS FROM THE EVALUATION In
Page 45 and 46: There is a need for caution when in
Page 47 and 48: Differences in provincial policies
Page 49 and 50: With only moderate support (one hom
Page 51 and 52: 4. Ensure on-going Support After De
Page 53 and 54: 6.6 Health Care Infrastructure This
Page 55 and 56: Two options exist for the contracti
Page 57 and 58: B. TRAINING OF HEALTH CARE WORKERS
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Logistical and administrative suppo
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6.6.2 Management A. NATIONAL MANAGE
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C. MANAGEMENT OF CONSUMABLES AND SU
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The changes made in data elements a
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Data flow The PMTCT pilot programme
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Appendix 6.6 MTCT REGISTER (to be k
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The key to high coverage of the int
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Health Care Infrastructure • Stre
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Strategies to integrate PMTCT into
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SUMMARY We need a fundamental rethi
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PMTCT, and National's - Health Systems Trust

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