Compiled by E. Mohammed Rafique, Resource Person and M. K. Nabeel, Research Associate Issue Date: 24 September 2008:Echoing the present debate within international public health circles, members responded eagerly to the query on HIV and Health System Strengthening (HSS). Respondents explored the relationship between HIV programmes and health systems and suggested improving vertical programs that tend to ignore the broader health system.
Discussing the connection between HIV programming and health systems, members identified several areas within the system, which have grown stronger because of the country’s response to the HIV epidemic. For example, the blood transfusion services were not in good shape before the advent of HIV, participants stated. However, implementing the various components related to blood safety through the National AIDS Control Programme (NACP), simultaneously established the target numbers of First Referral Units, as well as streamlined and improved services in the existing blood banks.
Another positive development was in the area of prevention and treatment of Sexually Transmitted Infections (STI). Respondents noted that, ‘socially sidelined’ professions that work for STI patients, like venereologists and counsellors have gained acceptance due to the strengthening of STI treatment components within HIV programmes.
Discussants stated that other improvements in the health system as result of HIV programmes were:
· Infrastructure of TB diagnostic and care centres improved because of joint HIV-TB programmes
· Reproductive and sexual health services, specifically, the improvements in condom programming and Family Planning and Welfare services
· Human resources and capacity building
· Training programmes on infection prevention practices and communication skills for healthcare providers
Another area where health systems are benefiting from the response to HIV is human rights, along with ethical and legal issues in relation to health, members said. For instance, in Kerala a pilot project for reducing stigma by a rights-based approach benefited both the People Living with HIV (PLHIV) and the health system. Likewise, members observed that an increasing number of people and organizations are giving importance to these issues. Moreover, as compared to earlier days, non-professionals and healthcare providers are now more sensitive to ethics. However, they pointed out that more improvement is required on legal issues.
Citing examples from India ’s low-cost generic ARV drugs, respondents lauded the patent rules in India . Improving availability and access to medicines has proved beneficial to the entire health system. Nevertheless, they voiced concerns about the quality of drugs due to the emphasis on generic drugs.
Sharing the experience of implementing the Wold Health Organization’s (WHO) Integrated Management of Adult and Adolescent Illness (IMAI) in Karnataka and Tamil Nadu, members showed, how decentralisation of HIV programmes at the district and sub-district levels can help HSS. Besides, they also mentioned experiences shared from West Bengal, Uttar Pradesh, Rajasthan, Chhattisgarh, Jharkhand and Delhi that demonstrate the strong beneficial linkages made by HIV programmes within existing health systems.
In spite of demonstrating successful models of excellence by some HIV programmes, respondents raised concerns about sustainability, as HIV programmes are generally dependent on external funding for their work. Additionally, mainstreaming and integrating HIV programmes within health systems can help reduce the dependency on availability of funds. Accordingly, the third phase of NACP has set specific provisions for mainstreaming HIV into broader health programmes and systems.
Discussants also pointed out that the service norms of NGOs have improved through the implementation of various HIV programmes over the years, and successful models of Public Private Partnerships (PPP) have emerged. These developments have directly benefited health systems. However, NGOs need to coordinate better their activities as per national plans envisaged in the Three Ones principle. In addition, members recommended developing a “NGO code of conduct” to capitalise on the activities in health system strengthening in the context of HIV.
In addition to highlighting the positive impact of HIV programmes on health systems, some respondents questioned whether increased spending for HIV programmes in some regions has actually harmed health systems. Nonetheless, members agreed that planners must view HIV programmes as part of an integrated system, and not in isolation as they are not mutually exclusive. Moreover, a dichotomy of Vertical against Horizontal health programmes is meaningless, as improvement of one will benefit the other.
Though HIV programmes have offered opportunities to strengthen health systems, respondents stated that only a few implementing agencies have made use of such prospects. Researchers in India , members argued, need to understand better the intricacies of how the spending on HIV programmes affects other areas of health systems. For example, additional research brought to light a comparative analysis from Mozambique, Uganda and Zambia, which identified health information systems, drug supply systems and human resources as important areas for donors and governments to reinforce, as they expand HIV programmes.
Finally, members emphasized the need to make stronger health systems to sustain successful HIV programmes. Moreover, the HSS approach will not only benefit national and regional health priorities, but also make judicious use of resources when attempting to achieve specific HIV related outcomes.