A diagonal approach to building primary healthcare systems in resource-limited settings: women-centred integration of HIV/AIDS, tuberculosis, malaria, MCH and NCD initiatives

Authors


Corresponding Author Celine Gounder, Johns Hopkins University Center for Tuberculosis Research, CRB-2, Room M1.06, 1550 Orleans Street, Baltimore, MD 21287, USA. Tel.: +1 443 287 1036; Fax: +1 410 955 0740; E-mail: gounder@alumni.princeton.edu

Abstract

La nécessité d’une intégration des systèmes des soins de santé primaire pour les femmes offrant des services pour les maladies infectieuses et non transmissibles courantes dans les cadres à ressources limitées, est discutée.

Abstract

Se discute la necesidad de sistemas integrados de salud primaria para mujeres que ofrezcan cuidados para enfermedades infecciosas comunes y enfermedades no transmisibles, en emplazamientos con pocos recursos.

In 1978, the Declaration of Alma-Ata recognised the importance of primary health care to reducing health inequalities and social injustice, and the need to provide at least ‘education concerning prevailing health problems and the methods of preventing and controlling them; promotion of food supply and proper nutrition; an adequate supply of safe water and basic sanitation; maternal and child health care, including family planning; immunization against the major infectious diseases; prevention and control of locally endemic diseases; appropriate treatment of common diseases and injuries and provision of essential drugs’Declaration of Alma-Ata (1978).

However, on the 30th anniversary of the Declaration of Alma-Ata, Dr Margaret Chan, the Director General of the World Health Organisation (WHO) at that time, recognised that ‘… despite enormous progress in health globally, our collective failures to deliver in line with these values are painfully obvious and deserve our greatest attention’, and that ‘these reforms do not constitute a blueprint … for action’, but that ‘the details … must be driven by specific conditions and contexts, drawing on the best available evidence’World Health Organization (2008). It is in part due to the lack of specificity – with respect to conditions, target populations, implementation strategies and monitoring – that such little progress has been made in scaling up primary healthcare services. Other obstacles have included the scarcity of human resources for health; a vicious cycle of socioeconomic inequities hindering community empowerment and participation, resulting in inadequate attention to community needs; and poor inter-sectoral collaboration across health, education, agriculture, housing and public works to reduce poverty and advance development Lawn et al. (2008).

Diagonal approach to development of primary healthcare systems

A diagonal approach to developing primary healthcare systems has been described as a ‘strategy in which we use explicit intervention priorities to drive the required improvements into the health system, dealing with such generic issues as human resource development, financing, facility planning, drug supply, rational prescription and quality assurance’Frenk (2006). A diagonal approach to scale-up of primary healthcare systems has been successful in improving maternal and child health, as for example in Mexico, where interventions were incrementally built onto vertical programmes for immunisations, vitamin A supplementation, oral rehydration therapy and deworming Sepulveda et al. (2006).

The Millennium Development Goals (MDGs), which were adopted in 2000 as the next generation of ‘health for all’ goals, are specific, measurable, interim ‘health for all’ targets. MDGs 4, 5 and 6 specifically address maternal and child mortality as well as the burden of HIV, malaria and tuberculosis. Progress has been made towards achieving MDGs 4, 5 and 6 Stuckler et al. (2010); Gounder et al. (2011) and these accomplishments could be amplified through synergistic approaches that would form the basis for diagonal development of primary healthcare systems. In Malawi, for example, programmes to deliver antiretroviral therapy were modelled on the country’s successful TB control programme – specifically with respect to using health surveillance assistants to provide simple, standardised diagnostic and treatment services, and to use simple, standardised recording and reporting tools Harries et al. (2004). In addition to providing antiretroviral therapy and directly observed therapy for tuberculosis, health surveillance assistants are now taking on new responsibilities such as postnatal home visits Rohde et al. (2008).

The Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) is now integrating efforts to improve the health of mothers and children with programmes to combat HIV, TB and malaria, while prioritising investment in cross-cutting health systems strengthening with a focus on governance, health financing and pharmaceutical and health product management The Global Fund to Fight AIDS, Tuberculosis and Malaria (2012). The United States President’s Emergency Plan for AIDS Relief (PEPFAR) is also increasingly focusing on expansion of human resources for health as well as strengthening procurement and supply management systems and health information systems Moore and Morrison (2007); while the President’s Global Health Initiative has added a focus on women’s comprehensive health care to the goals of PEPFAR U. S. Global Health Initiative (2012). At the same time, the World Health Organisation is recognising the increasing importance of non-communicable diseases (NCDs) in resource-limited settings and is expanding its plan for prevention and control of NCDs, which focuses on tobacco use, harmful use of alcohol, unhealthy diet and physical inactivity Rosenbaum and Lamas (2011).

Concurrent efforts targeting women and children’s health, HIV, TB, malaria and NCDs, and initiatives to strengthen health systems more broadly provide the foundation upon which women-centred primary healthcare systems can be built. Women reliably come into contact with the healthcare system when they seek maternal and child health, reproductive health and family planning services, and provide a point of entry for engaging the family in primary health care. A woman-centered approach to developing women-centred approach to developing primary healthcare systems would help raise women’s societal value beyond their reproductive capacity and role as family caregivers. While the burden of obstetric morbidity and mortality remains high, the leading causes of mortality among women between the ages of 15 and 44 also include HIV/AIDS, tuberculosis, malaria and non-communicable diseases (NCDs), and among older women disease burden is largely due to NCDs (see Table I) Declaration of Alma-Ata (1978). Women in resource-limited settings face syndemics of obstetric-related morbidity and mortality, HIV, tuberculosis and malaria, as well as increasing incidences of obesity, smoking, hypertension, diabetes, vascular disease, obstructive lung disease and cancer.

Table I. Leading causes of morbidity and mortality among women worldwide World Health Organization (2003); World Health Organization International Agency for Research on Cancer (2008); World Health Organization (2009a,b); U. S. Agency for International Development (2011); Lozano et al. (2011)
DiseaseNumber of deaths annually
  1. *Including 56 100 HIV-related deaths during pregnancy.

Ischaemic heart disease3 371 000
Stroke3 051 000
Lower respiratory tract infections2 014 000
Chronic obstructive pulmonary disease (COPD)1 405 000
HIV/AIDS1 013 000*
Smoking800 000
Tuberculosis700 000
Diabetes633 000
Hypertensive heart disease530 000
Breast cancer458 503
Lung cancer427 586
Cervical cancer27 508
Gastric cancer273 489
Hepatic cancer217 592
Direct and indirect obstetric causes (excluding HIV)217 400
Malaria in pregnancy10 000

The diseases affecting women are inter-related and provide the basis for service integration

The diseases of women in resource-limited settings are biologically, epidemiologically and socioeconomically inter-related. It is essential to characterise these relationships, as this will provide the basis for specific interventions for service integration; this specificity facilitates implementation and monitoring and evaluation.

HIV is a major cause of maternal mortality; increases the risk of active TB; exacerbates the severity of malaria; and increases the risk of NCDs such as cervical cancer and vascular disease. TB is the biggest killer of HIV-infected persons; increases the risk of mother-to-child transmission (MTCT) of HIV in pregnant women co-infected with TB and HIV; in the presence or absence of HIV infection may lead to poor pregnancy outcomes; may be transmitted vertically; and may worsen glycemic control in diabetics. Like TB, malaria co-infection leads to poor pregnancy outcomes including increased risk of MTCT of HIV. Smoking, second-hand smoke and indoor air pollution are important causes of TB and other lower respiratory tract illnesses. Diabetics are at a three-fold higher risk for TB as non-diabetics Jeon and Murray (2008). Smoking, second-hand smoke, obesity and diabetes during pregnancy are associated with pre-eclampsia, spontaneous abortion, still birth, congenital anomalies, macrosomia, obstructed labour, need for caesarean delivery, post-partum haemorrhage and risk of neonatal mortality and diabetes in the offspring.

Many of the common medications prescribed to women interact, most notably: hormonal contraceptives; non-nucleoside reverse transcriptase inhibitors, protease inhibitors and dapsone for HIV/AIDS; isoniazid and rifamycins for tuberculosis; most anti-malarials; sulfonylureas and thiazolidinediones for diabetes; hydroxymethylglutaryl (HMG) CoA reductase inhibitors for hyperlipidemia; and steroids for obstructive lung disease. Some medications are contraindicated during pregnancy such as efavirenz and artemisinin combination therapies during the first trimester, and angiotensin-converting enzyme inhibitors for hypertension. The complexity of these drug interactions leads to lapses in care, such as delaying antiretroviral therapy (ART) until after pregnancy.

Integrating services at the point of service delivery

Women face numerous barriers to accessing health care even before having to navigate fragmented health services and referral systems. Furthermore, referrals between services and facilities will always suffer from losses to follow-up. An integrated one-stop-shopping approach to service delivery that is centred on women and their families has already been used by MTCT Plus programmes and should be expanded to encompass other diseases of epidemiologic importance to women.

PMTCT programmes developed with the recognition that HIV-related services are an essential component of antenatal care. Integration of family planning into HIV care increases use of contraception including condoms Kosgei et al. (2011). Providing co-trimoxazole and isoniazid preventive therapy (IPT) to HIV-infected persons or pregnant women improves patient satisfaction, keeps patients engaged in care and prevents losses to follow-up Rosenbaum and Lamas (2011); Tiam (2012). Integration of services for stigmatised diseases (e.g. HIV) with other healthcare services (e.g. prenatal care) has also been shown to decrease fears of stigma because it allows women to access services without disclosing that they have a stigmatised disease Topp et al. (2010); Winestone et al. (2012); van den Akker et al. (2012).

Tremendous progress has been made in testing TB patients for HIV, and efforts are now being made to screen HIV-infected patients – including pregnant women with high rates of HIV – for TB Gounder et al. (2011). Malaria prevention should be incorporated into antenatal care through provision of insecticide-treated bed nets (ITNs) and intermittent preventive treatment (IPTp). Unfortunately, integration of services has often been carried out using separate staff – such as PMTCT nurses and lay counsellors or TB/HIV integration officers – which can foster conflict and inhibit a truly team approach to patient care.

Integration around cadres of healthcare workers

Scarcity of human resources – both with respect to sheer numbers as well as competency – plagues service delivery at all levels. Care should be organised around the scope of work each cadre of healthcare worker can perform, not according to disease.

HIV programmes have been innovative in confronting the human resource crisis through task-shifting – devolving certain aspects of care to lower cadre health providers – and community- and home-based care; these innovations may be used as foundations upon which additional interventions may be layered. Nurse- versus physician-delivered ART has been shown to have equivalent HIV-related clinical outcomes Sanne et al. (2010). Non-physician clinicians have been shown to perform male medical circumcisions as safely and with similar rates of adverse events as physicians Ford et al. (2012). Much of health care in resource-limited settings is already delivered by nurses rather than physicians, but this can be further down-shifted to lay counsellors and community healthcare workers (e.g. Health Surveillance Assistants in Malawi, Health Extension Workers in Ethiopia). Care delivered by lay healthcare workers in the community has been shown to be non-inferior to clinic-based care with respect to key HIV-related outcomes Selke et al. (2010). Home-based HIV testing and TB case-finding by community healthcare workers have been successful in raising case-detection rates Shanaube (2011). Decentralised, out-patient clinic- and community-based care for multidrug-resistant TB has proven to be more successful, with higher culture conversion rates and shorter time to treatment initiation, than care delivered by an urban referral hospital Loveday et al. (2012).

Numerous tasks could be devolved to lay healthcare workers in clinics or the community and might include: distributing contraception including progesterone injections; providing misoprostol for treatment of post-partum haemorrhage; testing for HIV; screening for symptoms of TB, collecting sputum for testing from symptomatics, and dispensing IPT to asymptomatic HIV-infected persons at high risk for TB; rapid testing for malaria; delivering insecticide-treated bed nets to homes and dispensing IPTp to pregnant women; checking blood pressures and finger-stick blood glucose levels; performing urine dipsticks for proteinuria and glycosuria; facilitating linkages to follow-up by facility-based care; and providing health education. Higher tier healthcare workers including nurses and physicians would be better employed to perform duties that require greater synthetic, analytical and management skill.

Integrating common management functions

Common management functions including logistics, procurement and supply chain management, supervision, monitoring and evaluation could also be strengthened in integrated fashion. Tools for longitudinal monitoring of patients – be these paper-based health passports, registers and treatment cards, personal digital assistants Muyoyeta (2011), mobile phones (e.g. Rwanda’s TRACnet), or electronic health records (EHRs) Douglas et al. (2010)– are needed to facilitate integration and coordination of women’s health care across services, as well as programme evaluation, supervision, mentoring, drug-forecasting and resource allocation. More sophisticated EHRs with clinical decision support can be used to improve adherence with algorithms and standard operating procedures; to alert providers about indicated clinical interventions, abnormal findings or drug-drug interactions; and to flag patients who need to be reengaged in care Douglas et al. (2010). Data on pregnancy, HIV and tuberculosis are already being recorded in integrated fashion to some degree in antenatal, pre-ART, ART and TB registers. EHRs that manage data on HIV, TB and diabetes are now being deployed Douglas et al. (2010). Monitoring and evaluation systems should no longer be conducted in parallel by different disease management structures, but should be streamlined and integrated to facilitate co-management of those chronic conditions of greatest epidemiologic importance to women.

Conclusion

Maternal and child health, reproductive health and family planning services are reliable points of contact between women and the healthcare system; these points of contact represent a missed opportunity to engage women in longitudinal care. ANC, PMTCT and HIV care and treatment programmes were the first to provide population-wide longitudinal care for chronic diseases and should be used as the foundation for delivering primary and preventive health care for women in place of the acute care that passes for primary care in most resource-limited settings (Figure 1). Additional services should be integrated based on epidemiologic burden including those to reduce morbidity and mortality due to TB, malaria, tobacco, obesity, hypertension, diabetes and cancer.

Figure 1.

 An integrated model for women’s primary health care in resource-limited settings. FP, family planning; STIs, sexually transmitted infections; ITNs, insecticide-treated bed nets; IPTp, intermittent preventive treatment to pregnant women; MCH, maternal and child health; ACF, active case-finding; IPT, isoniazid preventive therapy; PMTCT, prevention of mother-to-child transmission of HIV; ART, antiretroviral therapy.

Acknowledgements

The work was supported by research grants from the US National Institutes of Health and the Bill and Melinda Gates Foundation. The funding sources had no role in the conception, writing or editing of this manuscript.

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