HAI & PEPFAR: Strengthening Mozambique Health System by
Improving HIV Care
Jennifer Kasper, MD, MPHFormer Pediatric Technical Advisor and HIV
Program Manager, Health Alliance InternationalBoard Member, Doctors for Global Health
Physicians for Human Rights Student ConferenceJanuary 31, 2009
Outline
• PEPFAR I Facts• Brief overview of Mozambique• PEPFAR I in Mozambique
– Financial support – General approach– Primary NGOs and subpartners
• Health Alliance International– General approach– Scope of work– Successes
• PEPFAR Challenges• How PEPFAR II can Improve
upon PEPFAR I• NGO Code of Conduct
PEPFAR Focus Countries
• Botswana• Cote d'Ivoire• Ethiopia• Guyana• Haiti
• Kenya• Mozambique• Namibia
Nigeria• Rwanda
• South Africa• Tanzania• Uganda• Vietnam• Zambia
Mozambique Civil War (1980-1992)
Basics about Mozambique• Population ~20 million
• 74% live on less than $2/day
• Average life expectancy 43yrs
• Infant Mortality Rate 96/1000
• Under 5 child mortality 138/1000
• 24% children underweight
• 48% births attended by skilled
personnel, maternal mortality
520/100K live births
UNDP 2007/2008, UNICEF 2008
HIV Prevalence: Top 10 Countries HIV Prevalence: Top 10 Countries
ZimbabweZimbabwe 25.8425.84BotswanaBotswana 25.1025.10NamibiaNamibia 19.9419.94ZambiaZambia 19.10 19.10 SwazilandSwaziland 18.5018.50South AfricaSouth Africa 16.7016.70Mozambique 16.00MalawiMalawi 14.9214.92
TanzaniaTanzania 9.429.42LesothoLesotho 8.358.35
• ~ 3 million PLWHA
• ~ 400,000 require ART
• Also high prevalence of
– Syphilis (~8%)
– Malaria (13-80%)
– TB (624/100,000)
– Malnutrition (25-40%)
• Central region pop 3 million
– 400K PLWHA (24K <15yo)
– 68K need ART (12K <15yo)
HIV Prevalence in Mozambique
Mozambique Health Sector Capacity for AIDS Treatment
• Physicians per 100,000: 3 = 650 (100 pediatricians)
• ~500 doctors trained in HAART (3 week
course)
• Nurses per 100,000: 21 = 2400
• Health expenditure per capita approx $10
(2.7% GDP spent on hlth)
• ~ 1200 health facilities
• Medical school in Maputo; newer one in
Sofala; one being developed in Nampula
• Functioning drug procurement and
distribution system
Donor-Induced Management BurdenMozambique (2008)
• $228 million (1/3 CDC, 2/3 USAID)• > 200 health NGOs (50 prime partners and
> 100 sub-partners)• > 150 independent sites of operation• 10-20 program categories• Independent planning cycles,
implementation• Reliability dependent on donor policies• “Neocolonization” – NGO spheres of
control
Foreign Policy May/June 2004
Additional management burden by
donors & NGOs
Tanzania
1,371 different
projects to manage
Health Alliance International supports the development of equity-oriented policies and
public-sector health systems. Our vision is a just world with
universal access to quality health care.
HAI’s Approach• Work from within health system
at all levels (national, provincial, district and health facilities)
• Offices in MOH– Advisors working with MOH
program managers
– Multidisciplinary teams: • Clinical advisors, MCH, M&E,
laboratory, HBC and community mobilization/VCT program assistants
• Integrated supervision, technical support, clinical mentoring
• Financial and logistics support
HAI’s Approach• Plan jointly - respond to local priorities at
provincial and district level• Strengthen human resources
– Pre-service training, task shifting, lay workers – Funds to hire recent graduates– Strategies to improve staff allocation
• Improve infrastructure: – Outpatient services, laboratories, maternity
wards – Staff housing – Training center
• Promote operations research – Beira Operations Research Center
• Strengthen supply chain management
HAI’s Approach
Integrate vertical programs into comprehensive
PHC, expanding and decentralizing services:
– Integration of OIs and ART
– PMTCT as part of basic package ANC services
– C&T into routine clinical services
– HIV/TB programs
– HBC strengthening links between
health care facility and community
– Food support and insecticide treated
bednets with HIV care and ANC
HF Providing HAART1
PLWHA Registered2,000
Eligible in HAART94
HIV Treatment Expansion
Plan
2003
GuroGuro TambaraTambara
ChembaChemba
MaringueMaringueMacossaMacossa
SussundengaSussundenga
MachazeMachaze
MachangaMachanga
MuanzaMuanza
CheringomaCheringoma
ChibabavaChibabava
2003
GuroGuro TambaraTambara
ChembaChemba
MaringueMaringueMacossaMacossa
SussundengaSussundenga
MachazeMachaze
MachangaMachanga
MuanzaMuanza
CheringomaCheringoma
ChibabavaChibabava
HF Providing HAART 2
PLWHA Registered 7,300
Eligible in HAART600
2004
2003
2004
Free ART in Public Health Sector
GuroGuro TambaraTambara
ChembaChemba
MaringueMaringueMacossaMacossa
SussundengaSussundenga
MachazeMachaze
MachangaMachanga
MuanzaMuanza
CheringomaCheringoma
ChibabavaChibabava
HF Providing HAART7
PLWHA Registered18,600
Eligible in HAART2,520
2005
CS
HCB
HR
HPC
HG
HeathC
CentH
RurH
ProvH
GenH
GuroGuro TambaraTambara
ChembaChemba
MaringueMaringueMacossaMacossa
SussundengaSussundenga
MachazeMachaze
MachangaMachanga
MuanzaMuanza
CheringomaCheringoma
ChibabavaChibabava
HF Providing HAART17
PLWHA Registered 36,270
Eligible in HAART5,250
2006
2003 2004
2005 2006
Decentralization to Rural Sites
GuroGuro TambaraTambara
ChembaChemba
MaringueMaringueMacossaMacossa
SussundengaSussundenga
MachazeMachaze
MachangaMachanga
MuanzaMuanza
CheringomaCheringoma
ChibabavaChibabava
HF Providing HAART
47
PLWHA Registered
63,390
Eligible in HAART
13,225
2007
2003 2004
2005 2006
2007
GuroGuro TambaraTambara
ChembaChemba
MaringueMaringueMacossaMacossa
SussundengaSussundenga
MachazeMachaze
MachangaMachanga
MuanzaMuanza
CheringomaCheringoma
ChibabavaChibabava
HF Providing HAART: 87 March 2008: 55
Registered: 180,000March 2008: 92,600
HAART: 45,000March 2008: 22,000
<15 y in HAART: 5,000March 2008: 900
HIV Treatment Plan 08-09
HeathC
CentH
RurH
ProvH
GenH
Pending
Chemba
Maringue
Machaze
Machanga
Muanza
Cheringoma
Hem. + Chemistry
Mangunde
SenaSena
Guro Tambara
Macossa
Sussundenga
CD4+
Chemba
Maringue
Machaze
Machanga
Muanza
Cheringoma
Hem. + Chemistry
Mangunde
SenaSena
CD4+CD4+
CD4+CD4+
Guro Tambara
Macossa
Sussundenga
CD4+CD4+
CD4+
CD4+
Labs referring samples
–Hematology and chemistry in 22 of 36 laboratories
–CD4 decentralization and referral: • High volume, complex machines in provincial capitals
• Lower volume, less complex in 3 rural districts
–55 PMTCT sites referring CD4
–20 hemoglobinometers in isolated sites w/o other lab equipment
–Support referral system for early infant diagnosis (DNA-PCR)
Strengthening Laboratory Network
Successes from HAI/MOH Collaboration (as of June 2008)
• Work in all 23 districts in 2 provinces• Voluntary Counseling and Testing
– 103 sites– Cumulative total number tested since 2002: 280,000 – HIV prevalence 31%
• PMTCT– 156 sites; 250,000 served
• HIV/AIDS care and treatment– 55 sites; >100,000 served; 25,000 on ART
• Home-Based Care– 12 community-based organizations– Serve 7000 clients/month (60% HIV positive, 50% of these on ART)
• Radio, popular theater, world food program
Pediatric Challenges
• PCR DNA• Breastfeeding• Care and follow-up in
Child at Risk Clinic• Counseling children and
adolescents about their illness
• Adherence and its effects on overall child health and life expectancy
• OVC
More Challenges• Human resources
– “Brain drain”
• Multi sector approach
– Prevention – discordant couples
– Poverty, food security
– Socioeconomic improvement
• Structural problems
– Debt reduction
– Reversal of structural adjustment policies and
expansion of public spending
– Improve intra-governmental allocations
How PEPFAR II can Improve upon PEPFAR I
• Pre-service training, task shifting • Integrate into existing health infrastructure • Increase $ for treatment• Increase $ for PMTCT • Increase funding for OVC• Partnership for HIV-Free Generation – youth-initiated
and implemented activities • Opt-out testing for all clinical encounters• Discordant partners, married couples • Know your epidemic – concentrated (ex commercial
sex workers, IVDU, MSM) vs generalized pandemic
Distribution of Disease vs Distribution of Funding
A Balanced Approach to Health Care Delivery: Vertical, Horizontal, Diagonal?
US FINANCIAL SUPPORT: GLOBAL HEALTH AND DEVELOPMENT
NGO Code of Conduct• 6 areas:
– Hiring practices– Compensation – Training and support– Minimize mgmt burden on govt
due to multiple NGO projects– Help govt connect communities
to govt hlth systems– Provide better support to govt
thru policy advocacy
www.ngocodeofconduct.org
References• PEPFAR 5th Report to Congress• WHO, PEPFAR, UNAIDS. Task-Shifting: Rational
Redistribution of Tasks among Health Care Workforce Teams, Global Recommendations and Guidelines. 2008. www.who.int
• Granich R, Gilks CF, Dye C, DeCock KM, Williams BG. Universal voluntary HIV testing with immediate antiviral treatment as a strategy for elimination of HIV transmission: a mathematical model. Published online November 26, 2008. www.thelancet.com
• IOM. The US Commitment to Global Health: Recommendations for the New Administration. Washington, DC: National Academies Press; 2008. www.nap.edu
• www.ngocodeofconduct.org