Round Table Report - UCT Main - University of Cape Town

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epidemic and from difficulties with diagnosing and managing HIV-associated tuberculosis. Figure 1 Number of Admissions 4500 4000 3500 3000 2500 2000 1500 1000 500 0 JAN 05 Medical admissions to Chris Hani Baragwanath Hospital, 2005-07 APR JUL Admissions OCT JAN 06 Linear (Admissions) APR JUL OCT JAN 07 Source: Jassat W: An evaluation of a public private partnership (PPP) involving outsourced clinical services. Unpublished presentation, 2007. APR Universal access to ART is unlikely to be achieved with the predominant model of ART service delivery currently being implemented in the public health system, namely, vertical services funded through ring-fenced resources and provided in 313 (at the time of presentation) accredited CCMT (comprehensive care, management and treatment) sites, based in hospitals, community health centres or PHC clinics, and provided by doctors, professional nurses and pharmacists. The need for ART is expanding by about 500,000 people per annum. In order to meet 80% of this need, each of the existing 313 accredited sites would have to enrol more than 100 new patients each month with current use of resources. Very few CCMT sites are able to achieve this level of enrolment. Quite the converse is true: as sites become more saturated, the rates of enrolment tend to decline – and simultaneously the ability to ensure retention in care. A number of responses to these challenges have emerged from experiences on the ground. These include: ■■ Reorganising provider roles across the phases of treatment (staging, preparation, initiation and follow-up) to remove delays and bottlenecks in accessing ART ■■ Simplifying follow-up routines, through triage processes that identify those who are stable and adherent ■■ Maximising the use of scarce resources ■■ Spreading the patient and work load more widely among facilities by positioning the service in the PHC system (much like the TB programme at present) and managed principally by nurses ■■ Mobilising the resources of the private sector for public service purposes. Despite the endorsement of such approaches through the PHC system, there are still many barriers to implementation at the political, the professional and the bureaucratic levels. The health system impacts of ART access are still either poorly understood or poorly researched. As suggested above, the ART programme has been a source of innovation and hope in the health system. At the same time, ART coverage levels remain too low to alter the impacts of HIV significantly where they have been felt most, in hospitals. In the Free State Province there is evidence to suggest displacement of nursing staff from the general PHC system into the ART programme, and in some provinces, a significant non-governmental sector – funded through mechanisms such as PEPFAR – has recruited scarce skills from the public health system. On the other hand, there has been a significant increase in administrative and support staff, and greater involvement of lay health workers in the PHC system. The impacts of these human resource shifts on other programmes – as a result of the Comprehensive Plan – are unclear. TB treatment outcomes in the Free State, for example, did not change between 2004 and 2006. In contrast to other new programmes and reforms implemented since 1994, the subjective response of front-line providers to the ART programme has been largely positive. From a health systems perspective, Schneider hinted at the next generation or next order of health systems challenges: ■■ Expanding access to ART while maintaining quality and innovation. ■■ Shifting the perspective of the programme from a site-based to a district, populationbased one. This will require the development of new programme frameworks, method ologies, implementation strategies and training, e.g. planning, monitoring, supervision. Health systems and antiretroviral access 7
■■ Developing integrated approaches to service delivery at a district level: in particular, finding ways to ensure that the investments in treatment mobilise a preventive response – without which the ART programme will become unsustainable – as well as integrating ART with TB and maternal-child health services. ■■ Addressing human resource constraints and obstacles, including nursing governance/ regulations and training, better integration of lay workers through career pathing and, more broadly, a review of the norms for PHC teams. Addressing these challenges will, according to Schneider, require a new cycle of innovation, learning and policy adaptation. There is the everpresent risk of losing momentum and entering a phase of despondency, stasis and inertia. The above observations and issues prompted the choice of themes and sessions for the Round Table. 2. Perspectives on universal access to ART: Is it possible? Both the Comprehensive Plan and the National Strategic Plan have universal access to ART as one of the main goals. The prospects of and challenges in meeting this goal constituted a key aspect of deliberations at the Round Table. 2.1 Regional and country perspectives Brian Pazvakavambwa 4 , presented data on ART access in the southern African region. He highlighted the examples of Botswana and Namibia, where 95% and 71% of people in need, respectively, were receiving ART in 2006 (Figure 2). This shows that progress towards universal access is indeed possible and attainable, though highly differential at the country level. 4 Brian Pazvakavambwa – AIDS Program Team Leader: WHO Inter-Country Support Team for Eastern and Southern Africa. Figure 2 Botswana Namibia Swaziland South Africa Lesotho Treatment – % of people in need receiving ART in Southern Africa, 2006 Source: B Pazvakavambwa: Closing Plenary of Round Table. Pazvakavambwa reminded the delegates that, despite the commendable achievements of a number of African countries, access to ART and other essential HIV interventions remains low across sub-Saharan Africa as a whole, which indicates that there is still considerable unmet need on the continent (Figure 3). Figure 3 100 90 80 70 60 50 40 30 20 10 0 31 33 Universal access progress in sub-Saharan Africa, 2006 Source: B Pazvakavambwa: Closing Plenary of Round-table. Simon Makombe 5 , guest speaker at the Round Table, gave a detailed account of Malawi’s approach to building access to ART. Malawi has a population of 11.5 million people with a per capita Gross National Product of US$200 (compared with US$5,000 for South Africa). Over a period of three years (2004 to 2007), more than 110,000 people (65% out of 170,000 people in need) were initiated onto ART, mainly – but not exclusively – through the public health system. These achievements were made possible by recognising that rapid and massive scale-up will not be achieved by a “medical model” that relies on doctors to deliver ARV treatment, or that gives providers a free choice of ARV regimens, or that requires mandatory laboratory monitoring and utilises computers to track patient follow-up. Instead, a “keep-it-simple” strategy was adopted, comprising the following principles: 5 Simon Makombe – HIV Unit, Ministry of Health, Malawi. 42 0 20 40 60 80 100 72 89 80 88 90 28 11 20 ART PMTCT Prev Service 71 95 12 10 VCT OVC Met Unmet 8 Schneider, Van Rensburg & Coetzee
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Round Table Report - UCT Main - University of Cape Town

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