Home Articles Knowledge of HIV Articles HIV and the Strengthening of Health Systems
HIV and the Strengthening of Health Systems
The response to the HIV pandemic is exceptional in the history of
Medicine and Social sciences. HIV has brought the importance of various
oft-forgotten and sidelined issues to the fore-front of health care
especially in the developing world. There are very few responses to
a disease which address an array of health and social issues like
stigma, marginalization, human rights, ethics, involvement of affected
individuals in formulating the response, economics of the disease,
cost-effectiveness of the response, politics, epidemiology, advocacy,
gender issues, management, biology of the virus, interactions in its
host, as well as a horde of other attendant consequences. Hence, thanks
to HIV, we have learnt a lot during the last twenty-five years. As
I am involved in strengthening health systems especially the Government
ones in our State, I am interested in learning from the experiences
of the Solution Exchange Community on:
Areas of Health Care Systems that have been strengthened as a direct
result of the responding to HIV
Examples from the developing world of the areas in health care delivery,
where success or lessons learnt from HIV have been transferred and
Impact of HIV epidemic response on the health care delivery in the
developed world and ways in which the developing countries can learn
In HIV, the chances of getting TB are more as the immune system
is affected. Authorities have recognised this combined burden, leading
to HIV-TB joint programmes. Consequently, the diagnostic and therapeutic
facilities have steadily improved over time. This has contributed
significantly to Health System Strengthening in terms of both infrastructure
and human resources. State-of-the-art TB Lab systems at Field Level,
Success stories of DOTS under RNTCP and provision of ICTCs and ART
at District Centres are all examples for this. Improvements in Health
System in turn are leading to better management of TB and HIV Co-infection.
Due to the advent of HIV, chances for educating people have increased,
and hence more and more people even from rural areas know about
the diagnostic, therapeutic and educational facilities available
in the government system. As a result of improved HIV awareness,
TB detection has also improved. Now PLHIV are coming forward by
themselves or as referrals to the TB & Chest department as per
indications, where they avail free consultation in the government
The effects of HIV and the AIDS pandemic management policies have
made a positive impact on Health Systems worldwide. There is even
greater potential to improve health program management in both Government
and Non-Government Systems in the coming years.
As HIV program management is multi-disciplinary, the programming
has been more holistic as compared to the more or less vertically
administered programmes like Malaria, Blindness or TB. The need
for this model is increasingly recognised in other areas of health
Socially sidelined groups like sex workers started getting more
attention. Professions like that of Venereologists and Counsellors
gained importance leading to better STI prevention, detection, management
and treatment. These will have beneficial effects on community health.
Quality of the condoms distributed as well as other areas of condom
programming received better attention after the advent of HIV. This
led to better usage of condoms giving rise to direct beneficial
effects on family welfare and health.
Service norms for NGOs improved because of HIV and now we have
good examples of Public Private Partnerships also coming up in this
sector. Community involvement is being increasingly recognised,
sought and interwoven into the program management. Working partnerships
have been put on stronger footing among various Government agencies,
National and International stakeholders. These again are beneficial
to Health Systems, as they provide a framework for emulation.
Overall Project Management have been strengthened which will benefit
the future and ongoing projects of the state and sub-state units.
Based on our observations from this project, we realised that in
order to improve such linkages for strengthening Health Systems,
we have to focus on four important areas:
1. Capacity Development: This component also includes
the piloting of behavior change strategies to improve provider-patient
interactions, management of funds to improve access for the poor,
strengthened referral systems and improved supervision systems.
Specifically, capacity development is required in the following
Health service delivery and financing for the disadvantaged population
Quality assurance and effective utilization of health information
for planning and managementPerformance and compliance to standards in key HIV services
TB program analysis to improve detection and to strengthen DOTS
Addressing demand for health care services in public and private
Financing Effective fund management from donor and Government
2. Outreach System Strengthening: From the four
walls of health centers, the reach of essential preventive and promotive
health services need to be extended to the hearts of communities.
The utilization of such services needs to be monitored for its efficiency.
3. Integration of HIV services with Reproductive Health
and TB Services: Integrated Counseling and Testing Centres
(ICTCs) and the Prevention of Parent-To-Child Transmission (PPTCT)
clinics need to be integrated with mainstream Reproductive Health
services. Similarly, there is a need to have better integration
with RNTCP also. Such integration will also usher in synergistic
quality improvement for services related to Maternal and Child health,
HIV and TB.
4. Program monitoring, evaluation, and advocacy: Provide
analyses to capture information on health systems performance and
assess achievement of national health objectives. This component
includes working with partners to identify opportunities for scale
up of successful models and strategies and providing technical assistance
to implementing agency on monitoring and generating data for its
performance monitoring plan.
Following areas of our health system have been revitalized &
strengthened because of the response to HIV:
Capacity building of STI service providers and blood banks staff
in the Government Sector.
Strengthening of referral system due to ICTC, STD clinics and
their linkages with other departments in the Government Sector
Concept of District AIDS Prevention & Control Unit, which
is now part of District Health Society, will further strengthen
Involvement of Government staff in HIV programmes like sentinel
surveillance, monitoring & supervision, blood banks, STI Clinics
and ICTCs has resulted in building ownership of programme and developing
commitment from the staff members towards health including HIV.
The roll out of the ART centers and establishment of link ART
centers have done wonders to the present health systems.
The strengthening is mainly dependant on various factors like leadership,
political commitment, transparency and ownership among government
functionaries. While in some places, the strengthening process has
been successful at other places, it has just started to improve.
Areas like STI clinics and blood banks will be further strengthened
with NACP III. Now since NACP has linkages with NRHM, we can hope
for the best.
The advent of HIV has strengthened policy and practice of hospital
acquired infection control. Most countries have formulated guidelines
for this. The universal work precautions, biomedical waste management
and post-exposure prophylaxis guidelines which came in to practice
in all health care facilities have contributed in strengthening
Health Systems in its own way.
We shall list down some other areas of the Health System that were
strengthened because of HIV.
Improved attention to Ethical and Rights Issues. Concepts like
Confidentiality and Informed Consent gained importance.
Role of counselling in health care recognized and accepted.
Stigma on other STDs reduced.
HIV highlighted the role of social determinants in health and
the need to incorporate strategies accordingly in health management.
With lessons learnt from HIV, Behavioral Change Communication
(BCC) is now an important component in preventive health care.
Role of advocacy in system improvement came to be recognised.
Due to training and support in HIV, Human Resource related to
HIV improved with collateral benefit to the entire Health System.
Health communication with all levels of community increased within
the country and internationally. Flow of information became fast
In Pharmaceutical industry, quality control improved not just
with drugs but with other vaccines and sera also because of the
extensive research related to HIV.
Diseases that are important to the powerful will always attract
resources. In Kerala, the heavy investments in Non Communicable
Diseases (NCDs) such as in Cardiology and Neurology coupled with
underinvestment in areas like Mental Health and Communicable Diseases
demonstrates this fact. In the international aid scene, we can see
that diseases that are important to the west attract resources.
This is more evident in the case of diseases like Malaria, for which
there are no effective vaccines. HIV, considered as a major threat
for the west, garnered unprecedented investments in its relatively
short history. It also ensured that these investments were kept
away from mainstream health care. Hence, while you set up lab and
counselling facilities for HIV testing, these were not available
for other diseases. To some extent, the helplessness and feeling
of rejection by the medical fraternity assisted this. Even then,
those who caught on to the real reasons behind the directives on
how to spend money were able to play along and leverage that money
to strengthen health systems. However, these were few and far between.
The arrival of ART changed the attitude of the medical fraternity
and they began to take over a more predominant role. Internationally
there was a revolt against vertical investments that focused only
on HIV. They alleged that these investments were made by diverting
human and material resources from other more 'deserving' areas.
NACP III was prepared in recognition of this. Now the programme
makes explicit investments in the Health Care System. Therefore,
if the proposals are implemented as planned, they would surely contribute
to strengthening of our Health System.
A major contribution of HIV is the recognition of social determinants
of epidemics. At a time when medical solutions were not available,
issues such as empowerment, reduction of stigma and psychological
support gained prominence. However, this has not translated into
dealing with other conditions. Even behavior change counselling
for STIs has not caught up adequately. Health administrators are
missing a major opportunity here. One of the former Project Directors
of Kerala SACS had planned to use the extensive investments in ICTCs
to support mental health care in Kerala. This can also be extended
to dealing with other required areas like post-partum crises, family
planning and public health interventions for NCDs. Another contribution
of HIV in strengthening Health Systems is in the area of ART. We
will see sophisticated investments in areas related to ART like
resistance testing, thereby further contributing to system strengthening.
As pointed out by other members, blood safety gained hugely from
its association with HIV. STI treatment too was brought back into
mainstream medical practice with HIV prevention measures.