The TO initiative is a partnership between WHO, UNAIDS and Pangaea, funded by the Bill and Melinda Gates Foundation. On January 26th 2012, the Ministry of Health and Child Welfare convened a meeting with partners to consider how the global Treatment Optimization Initiative, can support national HIV treatment priorities, particularly antiretroviral therapy.
Aim of the global Treatment Optimization initiative:
- To maximize the utility of existing therapeutic, diagnostics and delivery systems, providing greater health outcomes within existing planned and committed resources
- To achieve this, individual work-streams (on drugs, diagnostics and health services) have been established, all underpinned by reducing costs and mobilizing communities.
Five priorities were established to help drive and support the Zimbabwe-focused TO initiative. One of the priorities is to enhance the decentralization of HIV treatment delivery systems. A follow-up meeting was arranged to identify steps to enhance decentralization efforts.
In March 2012, WHO in collaboration with the Ministry of Health and Child Care and Pangaea held a consultative meeting to examine approaches for community-oriented HIV service delivery and linkages of such models with healthcare delivery systems in improving demand for and use of HIV treatment and prevention in sub-Saharan Africa. The meeting brought together 40 stakeholders including community-based activists and service providers, researchers, health policy analysts, and national programme managers from Ministries of Health, to examine models of community-centred HIV service delivery in sub-Saharan Africa. The intent of the meeting was to share experience of community-oriented service delivery models and build the body of knowledge and evidence on the impact of community engagement on health outcomes in all aspects of the HIV treatment cascade (testing, linkage to care, initiation of treatment, lifelong care, and retention across the continuum of care). The findings from this meeting informed WHO as the agency develops service delivery guidelines, as part of the 2013 consolidated guidelines, in HIV treatment and prevention.
The meeting participants reviewed current efforts and discussed priorities for scaling up these activities.
Within the framework of Treatment 2.0, key objectives of this meeting were to:
- Inform normative guidance for HIV service delivery to improve the demand for, access to and use of HIV treatment.
- Support scale up of community systems strengthening for service delivery and advocacy.
- Define models of HIV treatment service delivery that rely on community systems and which integrate health care delivery systems and community-based mechanisms.
- Identify promising country-level practices for community-level HIV service delivery that could potentially be adapted in other settings.
Plenary presentations focused on approaches to improve and scale up HIV testing and counselling, linkage to health services, and initiation of ART, treatment adherence, and retention in care. Participants discussed how progammes and project experience and data could be used to support WHO service delivery guidelines development, determine the key components for scale up, and define areas for further operational research.
The Deputy Minister of Health and Child Welfare of Zimbabwe, the Honourable Dr. Douglas T. Mombeshora, opened the meeting by welcoming participants to Zimbabwe. He affirmed the importance of community mobilisation as a key pillar of Treatment 2.0 and reiterated the government of Zimbabwe’s commitment to the global response to AIDS and to meeting the MDGs by 2015.
Dr. Custodia Mandhlate, WHO Country representative in Zimbabwe, also welcomed the participants, highlighting that one of the fundamental principles of primary health care is involvement of communities. This was captured in the Alma Ata Declaration on Primary Healthcare in 1978 and reaffirmed in the Ouagadougou Declaration on Primary Healthcare and Health Systems in Africa in 2008. She affirmed that empowering community health workers must be revived in the context of the response to the HIV epidemic, and its integration, where appropriate, with other key health and social priorities.
Before concluding the meeting, participants shared the following reflections and observations emerging from the content of the previous days discussions with the aim of setting forth principles and values to guide the WHO guidelines development process, the furtherance of the Treatment 2.0 agenda, and the Treatment Optimisation Framework.
Resources
- Efforts to estimate the costs of community mobilisation are needed to enhance UNAIDS’ Strategic Investment Framework and other advocacy initiatives to hold governments and donors accountable to their commitments to HIV/AIDS.
- New and sustainable funding streams should be established to support core costs and capacity building for community-based organisations and networks playing a role in treatment optimisation.
- Existing funding streams should be oriented to support, not hinder, sustainable linkages between community-based service delivery programmes and formal health systems in order to maximise the value of funding for treatment.
Remuneration and Training of Community-Based Counsellors and Caregivers
- WHO guidelines on task shifting and service delivery should include clear guidance on remuneration, training, and the creation of pathways to professional employment for lay counsellors and HIV caregivers. CSS and the devolution of health care provision to the community (task-shifting) must not be used as a means to secure cheap labour and demonstrate cost effectiveness in this time of economic austerity.
Integration
- Integration is needed within HIV service intervention, such as prevention and treatment, while integrating into primary healthcare. At national and local levels, disparate organisations and government health departments provide testing, enrolment of patients into treatment and care, and community mobilisation, leading to duplication, burdens on patients and inefficiencies.
Gender
- A focus on treatment barriers facing women and girls is critical given disproportionate infection rates, especially in sub-Saharan Africa.
- It must be acknowledged that majority of HIV caregivers are women and strategies that provide relief from their burden of care (remuneration, training, psychosocial counselling) must be considered as part of the WHO guidelines development process.
- The high mortality and attrition rates of men must be addressed through the treatment optimisation framework. Men are dying at a rate of 2 to 1 compared to women because they are diagnosed late, adhere poorly to treatment, and are lost to follow up at very high rates.
Children and Adolescents & young people
- Expanding access to HIV testing, care and treatment to children and adolescent, and addressing specific issues including stigma and human rights violations in healthcare settings should be addressed as a priority.
AS a follow up to the meeting above ,on the 29th of March, the Ministry of Health & Child Welfare co-hosted, with WHO and Pangaea, a national meeting entitled, “Decentralization of HIV Prevention, Care and Treatment: Linking Community Interventions with health care delivery systems.” This meeting explored the challenges faced as the country endeavors to expand geographic access to HIV prevention, treatment, and care services but with a special focus on HIV Treatment and Care issues.
Participation in the meeting included representatives from organizations supporting HIV prevention, treatment, care services in Zimbabwe, including a mixture of policy makers, facility and community-based service providers, health managers, technical experts, HIV treatment funders, and the beneficiaries of HIV services especially people living with HIV. Approximately 100 people attended, 30 of which were from outside Harare. All participants were provided with IEC materials on the MOH&CW 2011 decentralization guidelines and the WHO 2010 HIV/AIDS treatment guidelines.
Key themes were identified as priorities during the meeting, including the importance of community systems in the care and treatment of people living with HIV, and the need for these community systems to be integrated with care provided through health facilities.
It was decided that a follow-up consultation focused on this topic that ensures and promotes comprehensive community engagement with public sector, was necessary in order to move towards developing an operational framework on strengthening linkages between public sector and community Systems to codify the integration of community and health care delivery systems. This consultation took place on the 6-7 of August, 2012, at the Bronte Hotel in Harare.
The objectives of the consultation were to:
- Identify effective community models that support HIV care and treatment, including HIV testing, linkage to and retention in care, with the goal of achieving universal access to HIV services by 2015.
- Recognize critical success factors and barriers to integration of community interventions with the health care system.
- Strengthen linkages between the community and health system at the different levels of health care delivery.
There was broad agreement that community systems have the potential to be more responsive to certain needs and priorities of beneficiaries (allocative efficiency) and comparatively cost effective (productive efficiency) because of lower levels of bureaucracy and better knowledge of local costs. The key is identifying how best to link the public sector and community systems to optimally meet the needs of the clients.
It was also recognised that service integration and linkages can improve care and reduce missed opportunities for key interventions such as HIV testing, provision of ART, PMTCT, and adherence support. Integration of care is an important strategy to improve patient retention in long-term HIV care and treatment.
NAC, with secretariat support from Pangaea, will convene a steering Committee drawing from various stakeholders appointed to develop an Operational Plan for Strengthening Linkages between public sector and community Systems, leveraging existing policies and documents that respond to the recommendations that were brought forward in this meeting.