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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 applied
  • Impact of HIV epidemic response on the health care delivery in the developed world and ways in which the developing countries can learn from them
  • 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 sector.

    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 also.
  • 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 areas.

  • Health service delivery and financing for the disadvantaged population
  • Quality assurance and effective utilization of health information for planning and management
  • Performance 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 sectors
  • Financing Effective fund management from donor and Government agencies
  • 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 the system.
  • 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 and transparent.
  • 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.