Implementing antiretroviral therapy rollout to strengthen the health care

system

Dr Olive Shisana

Human sciences Research Council

Outline of the Presentation Background Inequities in access to health care Health disparities HIV/AIDS epidemic Impact of HIV/AIDS on the health care

system How the roll out of the ARV programme can

improve the health care system

ARV rollout & strengthening public health care system

The delivery of AIDS treatment and prevention also offers the chance to build up health systems in the poorest countries, providing health benefits for all. "By tackling it decisively we will also be building health systems that can meet the health needs of today and tomorrow. This is an historic opportunity we cannot afford to miss." (WHO)

Background

Antiretroviral therapy -Pattern of chronic care, individual patients receive continuous follow-up treatment for the remainder of their lives, rather thanthe occasional acute interventions that characterize the response to most infectious diseases. -If health systems can be strengthened to accommodate this new pattern the management practices developed for antiretroviral therapy (appointment systems, integrated medical records, drug supply systems, and adherence support) can also be applied to the management of other common, chronic conditions such as diabetes and hypertension.

Background, cont’d

Inequities in access to health care “Those with more money are most likely

to choose private health care as a first option while those with least money are far less likely to do so.

This choice is also linked to belonging to a medical aid scheme. The wealthy sectors of South Africa’s population almost all belong to a scheme, whereas the poorest cannot afford this cover.” HST

Inequities in access to health care “Whites hardly use public hospitals and Africans

hardly use private hospitals. With regard to primary care (mainly the use of

general practitioners and pharmacists) the picture is slightly different. While again Whites hardly use public primary health care services, this is also true for Indians and to a lesser extent, Coloureds. 41% of Africans do use private services for primary health care.” (HST)

Demographic profile of patients Sex

31.6% 31.3%

53.0%

68.4% 68.7%

47.0%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

Total Public Sector Private SectorType of Health Sector

% o

f S

ex D

istr

ibu

tio

n

Male

Female

Demographic profile of patients by age

21.1% 21.2%

14.3%

78.9% 78.8%

85.7%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

Total Public Sector Private Sector

Type of Health Sector

% A

ge d

istr

ibu

tion

Child (0-14)

Adult (15-49)

Percent bed occupancy by type of facility

93.7%

49.1%

87.8%

78.1%

91.9%

51.0%

89.2%

77.2%

91.8%

53.6%

89.3%

78.4%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

District Hospital Private Hospital Public Hospital TotalType of Health Facility

% b

ed o

ccup

ancy 1995

1997

2000

Mean length of stay in type of facility by HIV/AIDS status

20.3

6.3

12.213.7

5.2 6

15.6

8.2

0

5

10

15

20

25

District Hospital Private Hospital Public Hospital TotalType of Facility

Mea

n le

ngth

of s

tay

(in d

ays)

AIDS Patients Non-AIDS Patients

Health disparities

Population Pyramids in two regions of the Eastern Cape - 1999

Extent of HIV/AIDS Epidemic in South Africa

More than 5 million SA are living with HIV/AIDS

Females have a higher HIV prevalence than males

Africans have a higher prevalence than other race groups

Locality-type prevalence

15.6%

28.4%

15.8%

11.3%12.4%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

40.0%

Tribal Authority Farms Urban Formal Urban Informal Total

Geotype

Per

cen

t

HIV prevalence in adults (15–49 years) by Locality-type, South Africa

Impact of HIV/AIDS on the health sector

Impact on health workers Proportion of HIV+patients in hospitals is

high Increase in admissions of HIV/AIDS

patients Bed occupancy Length of stay in hospital

HIV Prevalence among health workers HIV+ Health workers in the public health sector

16.3%17.5%

15.9%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

Overall Public Primary Health care facility/clinic Public HospitalsSector of facility

% H

ealth

wor

kers

HIV

+

HIV Prevalence among patients HIV+ patients in the public health sector

27.9%25.7%

46.2%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

Overall Public Primary Health care facility/clinic Public Hospitals

Type of Facility

% P

atie

nts

HIV

+

Percent of health facility needing more staff to cope with the demand for HIV/AIDS care, South Africa 2002

81.4

41.2

87.0

78.8

0

10

20

30

40

50

60

70

80

90

100

Primary Health Facility/ Clinic

Private hospital State Academic /State

Total

Health facilities with staff assigned to provide HIV/AIDS care

55.6%

34.4%

64.3%

54.5%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

District Hospital Private Hospital Public Hospital TotalType of Health Facility

% S

taff

ass

ign

ed t

o p

rovi

de

HIV

/AID

S c

are

IMPACT OF HIV/AIDS ON HEALTH WORKERS AND THEIR WORK

Nearly 50% were exhausted and stressed because –

Inability to prevent the spreading of HIV/AIDS Increase of HIV/AIDS patients I.e.

overcrowded facilities HIV/AIDS patients require high level of

attention and care Drop in quality of care – race against time

and numbers Lack of health services for non-HIV patients

GENERAL ISSUES RELATING TO HEALTH WORKERS’ WORK ENVIRONMENT

Increased workload during past year (73,4%) Workload has doubled since a year ago (22,3%) Working longer than officiall hours (39,4%) No job satisfaction (16,3%) Low staff morale (33,8%) Treated for stress-related illnesses during past

year (16,2%) and most had to take sick leave (63.9%)

Benefits of ARV Roll Out; Increased financing to improve the health care system

Over the next four and a half years, over R750 million is proposed for upgrading systems in the healthcare infrastructure in areas such as drug distribution, patient information systems and monitoring of reaction to the drugs.

The cost of implementing the plan was R296 million for the rest of fiscal year 2003/4, growing to nearly R4.5 billion in 2007/8.

Benefits of the ARV Roll out 2003/04 (R millions) New Healthcare Staff: 21

Laboratory Testing: 20*Antiretroviral Drugs: 42Nutrition: 63Other Health System Upgrades: 70Programme Management (National & Provincial): 16Capital Investment: 30Research: 34Total: 296Note: Includes R20 Million advance payment to NHLS through March '04.

South Africa’s ARV programme 2004/5 New Healthcare Staff: 322

Laboratory Testing: 152Antiretroviral Drugs: 369Nutrition: 343Other Health System Upgrades: 171Programme Management (National & Provincial): 103Capital Investment: 75Research: 55Total: 1590

South Africa’s ARV programme 2005/06 New Healthcare Staff: 432

Laboratory Testing: 311Antiretroviral Drugs: 725Nutrition: 421Other Health System Upgrades: 184Programme Management (National & Provincial): 128Capital Investment: 100Research: 55Total: 2358

Benefits of ARV roll out on the health care system

1. Fewer staff would be lost due to illness, absenteeism, low staff morale, low mortality.

Length of stay in hospital would decrease, leading to reduction in overcrowding (Lazarus Effect)

Improvement in patient management information systems and hence better quality of health care

Better treatment for other diseases

Benefits of ARV: Involvement of the Private Sector U.N. Secretary-General Kofi Annan has said, "No company and no

government can take on the challenge of AIDS alone. What is needed is a new approach to public health--combining all available resources, public and private, and using all opportunities, local and global."

Currently in South Africa the private sector are said to have now put mechanisms in place to give ARVs to workers.

Harmony Mines, with support from the South African Department of Health has taken over the Lesedi Project and have begun replication in several South African mining regions.

The project established mobile clinic services and a peer educator network to reach women at risk in the vicinity of the Harmony Mines.