ICAP News - October 2007

Decentralization of HIV/AIDS services from hospitals to health centers brings services closer to where people live, enhancing their ability to access services and adhere to care and treatment. Decentralization is especially critical for people living in rural areas. ICAP has embraced decentralization as a key to the successful expansion of HIV services, and is working directly with in-country partners, health centers, district and regional offices to support decentralization initiatives. In various countries where it works, ICAP has decentralized services through rapid needs assessment, intensive site support, infrastructure improvements, recruitment of needed staff, training of existing site personnel, and supporting district teams. This issue of ICAP E News highlights innovative approaches developed by ICAP to support decentralization activities in Ethiopia, Mozambique, and South Africa.

Decentralization Brings HIV Services to Rural Mozambique
For people living with HIV/AIDS on the islands of Inhaca and Catembe in Mozambique, decentralization of HIV/AIDS services from hospitals to health centers has had many benefits. Before their local health centers began offering such services, these individuals had to travel seven miles by boat to obtain care at two general hospitals in Maputo. In addition to incurring transportation costs, they typically had to wait for hours at these overcrowded facilities. All of these factors impeded their ability to access services and gain the benefits of care and treatment.

Under a decentralization policy initially launched by the Ministry of Health in 2003, ICAP has been supporting the rapid expansion of HIV/AIDS services to health centers in Mozambique. The plan is designed to bring services closer to patients, especially in rural areas where most of the population lives, and to assist in decongesting hospitals where such services are typically delivered. Currently, in Mozambique, ICAP supports 33 HIV/AIDS service sites of which 15 facilities are health centers.

To facilitate the initiation of HIV/AIDS services at health centers, which typically offer only primary care services, a comprehensive assessment is conducted to identify infrastructure, staffing, and training needs. Based on this assessment, physical space is reorganized or renovated, additional personnel are hired, and existing staff are trained to perform HIV/AIDS services. Because HIV services are fully integrated in the primary care services provided at these health centers, all staff participate in the integration process and all patients gain from the infrastructure and service enhancements.

ICAP clinical advisors provide close supportive supervision during and after the integration process. This includes helping to address challenges such as the integration of health centers into laboratory/supply networks and the adoption of new monitoring and evaluation tools for HIV services.

As more health centers in Mozambique provide HIV/AIDS services, they will increasingly serve as entry points for HIV care. ICAP is working with the Ministry of Health to develop new referral mechanisms to ensure that patients who obtain their care at health centers can obtain specialized services at district hospitals.

Photo caption: A patient obtains HIV services at a rural clinic in Mozambique.
For more about ICAP Mozambique, visit here.

HIV Services Expand to Primary Health Care Facilities in Rural South Africa
In South Africa, ICAP has been supporting the national government and the Eastern Cape Province's Department of Health in their efforts to expand comprehensive HIV/AIDS services to people living in rural areas. A major focus of this effort has been shifting primary responsibility for delivering HIV/AIDS services, including antiretroviral therapy (ART), from congested hospitals to primary health care (PHC) facilities.

ICAP has supported three different decentralization approaches in South Africa. Under the hospital-based model, patients initiate ART at a district hospital and are referred to primary health clinics for ongoing care and treatment. A second approach allows patients to initiate ART at PHCs and obtain their medications at district hospitals. Under a third model, PHCs both initiate ART and provide ongoing care.

Enrollment in HIV care and treatment has increased steadily at PHCs offering HIV services. Over the last two years, seven PHCs associated with St. Patrick’s Hospital in the rural northeastern part of the Eastern Cape Province have been providing ongoing care and treatment to more than half of the hospital’s HIV patients.

For its part, ICAP is working closely with both PHCs and hospitals to build their capacities for delivering HIV/AIDS services. A mentorship program trains nurses as “advanced practitioners” who can guide their colleagues in HIV/AIDS management, including provision of ART. Another initiative trains pharmacy assistants who can dispense HIV medicines. ICAP also provides infrastructure support and equipment purchases, clinical training and mentoring, monitoring and evaluation support, and psychosocial and adherence support.

Photo caption: A nurse practices performing a cranial examination at an ICAP-supported HIV/AIDS training workshop in South Africa.
For more about ICAP South Africa, visit here.

Forging Strong Linkages between Hospitals and Health Centers Key to Decentralization in Dire Dawa, Ethiopia
ICAP is working closely with Regional Health Bureaus (RHBs) in Ethiopia to support provision of comprehensive HIV/AIDS services, including antiretroviral therapy, at 42 facilities in Oromia, Somali, Harari and Dire Dawa. In an effort to make these services more accessible to patients and to alleviate the high patient load at Dil-Chora Hospital in Dire Dawa town, ICAP collaborated with the Dire Dawa RHB to design strategies to decentralize the provision of comprehensive HIV/AIDS services to health centers.

The process began with the development of standard operating procedures (SOPs) by the RHB with ICAP support. The SOPs defined eligibility criteria for transferring patient care from hospitals to health centers and initiating care and treatment at health centers and vice-versa. They also detailed processes for laboratory sample transportation and patient transfer/referral. Following the endorsement of the RHB, the SOPs were distributed and implemented.

For its part, ICAP worked closely with the health centers to identify and address their needs for the implementation of HIV services. This included training and mentoring of health care providers, provision of basic medical equipment and furniture, supporting establishment of effective transportation mechanisms for laboratory samples, and facilitating regular catchment area meetings of staff from the hospital and health centers to discuss referral linkages and other related issues.

Persons living with HIV/AIDS, trained as peer educators, have played important roles in the implementation process. In particular, by rotating between Dil-Chora Hospital and the health centers, they have helped to strengthen referral linkages among the facilities.

As of May 2007, Dire Dawa health centers provided HIV care to approximately 700 patients, including 200 people who transferred from the hospital.

ICAP credits the success of decentralization in Dire Dawa to the strong linkages forged between the hospital and health centers through regular catchment area meetings, the involvement of peer educators, and close coordination with the RHB throughout the implementation process.

Photo caption: ICAP clinical advisors participate in a catchment meeting with staff from Dil-Chora hospital and the health centers.
For more about ICAP Ethiopia, visit here.

Tanzania's First Lady Leads Panel Discussion on Health Needs of Women and Children in Resource-limited Settings
On Sept. 21, ICAP and Columbia University’s Mailman School of Public Health co-hosted a panel discussion in New York with the First Lady of the United Republic of Tanzania, Her Excellency Mama Salma Kikwete. The program, titled “Responding to the Health Needs of Women and Children in Resource-Limited Settings,” provided perspectives on health initiatives in Tanzania and other countries with discussion of successes and challenges in supporting services and health systems in resource-limited settings. In Tanzania, ICAP works with the Ministry of Health and Social Welfare to build broad capacity in support of Tanzania's AIDS Control Program.

Caption: Her Excellency Mama Salma Kikwete (left) responds to a question during the panel discussion. ICAP Director Wafaa El-Sadr (right) hosted the panel discussion. Photo by Charles E. Manley.
For more about ICAP Tanzania, visit here.