Transcript Slide 1

The Realities of Integration
Noncommunicable Diseases and Tuberculosis and HIV in Ethiopia
Helen McGuire
Tope Adepoyibi
March 7, 2014
PATH/Eric Becker
Objectives
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Understand the importance of NCDs in global health and in
Ethiopia specifically.
Discuss key components and recommendations of a recent
assessment of integration opportunities for NCDs within HIV
and TB platforms in Ethiopia.
Identify obstacles and opportunities for integrating NCDs in
existing platforms based on the Ethiopian experience.
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Noncommunicable diseases:
A global health and development issue
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NCDs are forcing an est.
100 million people in
Africa into poverty
annually.
Late diagnosis and
inadequate care lead to
morbidity and mortality
in working age
populations of LMICs.
Prevalence rising for all
NCDs.
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Will NCDs lead us to healthcare systems that are
more responsive to people’s needs?
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Global response to NCDs
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PATH NCD Program
Innovate
Advocate
Integrate
Optimize
NCD progress in Ethiopia
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Ministry of Health Commitment to NCD agenda.
NCD team established.
Current NCD challenges noted and described in
Health Sector Development Program.
Integration identified as one of the solutions for
advancing NCDs.
Progress evident from HSDP III to HSDP IV.
Health Sector Development Programme IV (HSDP),
2010/11 – 2014/15
Funding
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How do we fund the
Competing health priorities
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WHO Global Action Plan
INTEGRATION
INTEGRATION
INTEGRATION
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Integrated health services
“The management and delivery of health services so that clients
receive a continuum of preventive and curative services,
according to their needs over time and across different levels of
the health system.”
(WHO, Technical Brief No.1, 2008)
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Concerns
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Integration will destabilize systems that are working well.
If integration than the ability to show results will be
threatened – difficult to report against targets.
Fear of reduction in funding.
AIDS exceptionalism – special case/needs to be separate from
the rest of the system.
Keep the EXCELLENCE;
Lose the EXCEPTIONALISM
– Dr. Grant Colfax, HIV/TB Director PATH
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Considerations for integrating care
to advance NCDs
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Assess support of policy makers and senior managers.
Assess readiness of current care platform.
Identify incentives for change.
Build required knowledge and skills among health workers.
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Considerations for integrating care
to advance NCDs
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Consider integration from the perspective of the person
seeking care, health worker, facility administrators.
Identify current barriers to care and any additional barriers
anticipated when trying to integrate NCDs into care.
Anticipate the ripple effect and mitigate any negative affects
of integration.
Reduce barriers to care – use technology suited to lowresource settings to support good care practices.
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Ethiopia assessment
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Ethiopian context
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173 of 186 countries in Human Development Index.
On track to meet most of millennium development goals.
Estimated population is 92.2 million (2007, CSA).
Administratively divided in to nine regional states and
two administrative towns.
44% of population are under 15 years.
Average lifetime fertility 4.8 births (DHS 2011).
The annual population growth rate is 2.6%.
Ethiopian context
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NCDs are under-reported.
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The large majority of the
population lives in rural areas =
83.6% vs. urban = 16.4% urban.
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Significant improvements in
laboratory services.
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Government commitment
growing to address NCDs.
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Assessment sites
Regions
Selected
Addis
Ababa
Amhara
Oromia
Population
2.9 million
18.4 million
30.5 million
# HIV cases
38,523
195,737
214,943
# TB cases
12,079
31,363
50,157
Notes
NCDs
responsible
for 43% of
deaths
FMOH Health and Related Indicators report - 2012
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Assessment objectives
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To determine the existing capacity of laboratory and clinical
services systems to carry out diabetes screening, diagnosis,
and monitoring.
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To determine the extent to which TB and HIV platforms
could be used to strengthen diabetes services.
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To determine the extent to which diabetes services could
be integrated with TB and HIV services.
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Labs for Life: Assessment methodology
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Laboratory assessment - utilizing modified WHO+PATH standard
assessment tools, divided into 13 categories.
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Key informant interviews – clinicians, health extension workers,
MoH officials, laboratory managers.
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Desk review – policies, guidelines, previous assessments,
publications.
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Facilities purposively selected to represent cross section of service
delivery: Regional, hospital and health centres and labs.
Completed
Laboratories
Interviews
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38
Laboratory findings
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Laboratory findings
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All lab services (DM, TB, HIV
etc.) are already integrated
from health center level
down.
Integration of lab services at
hospital level almost
complete.
Significant laboratory
strengthening activities
occurring through HIV and
TB programs.
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Laboratory findings
Requirements
TB and HIV
Diabetes
Adequate training
Yes
No
Presence of testing
protocols/guidelines
Yes
No
Availability and use of
recommended tests
Yes
No
Adequate external quality
assessment
Yes
No
Partial
Partial
Stockouts
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Labs for life – laboratory findings
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99% of laboratories participated in external quality
assessment (EQA) for at least TB and HIV testing.
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No laboratories participated in EQA for point of care
glucometer testing.
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Clinical chemistry analyzers were present and
functional at all hospitals and most health centres
(often through HIV program) but not used for glucose
testing.
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Therefore EQA for glucose testing on analyzers not
done.
Slide 23
Clinical and community findings
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Clinical and community
“The hospitalfindings
that the diabetes medicine is
Requirements
Adequate training
Presence of clinical
protocols/guidelines
Availability of treatment at
primary health care level
Community-based outreach
Treatment stockouts
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currently
is a very long
distance
go the
“We useavailable
prior knowledge,
memory
and to
reading
for elders.
from books”.
TB and HIV
Diabetes
For example
I remember the time that
a mother
that give birth who was a diabetes patient, and she
Yes to go to that long distance
No to access
was un able
the medication.
I think it would
be very nice if the medicine
can be
Yes
No
available
least at the about
healthdiabetes
center level”.
I am givingatinformation
though it is
not formally organized . I think it could be also
given in line with the HIV community conversation
program. Yes
That means I can provide itNo
together with
the HIV community education program.
Yes
No
Partial
Yes
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Clinical and community findings
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Clinicians and laboratory staff not 100% in favor of integration
of TB, HIV and diabetes services.
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Health extension favors unanimously supported integration.
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Limited opportunities for physical integration of services and
task shifting.
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Potential opportunities for cross program laboratory
strengthening.
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Recommendations
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Develop standardized diabetes protocols
and guidelines, and prioritize staff
training.
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Strengthen diabetes laboratory services
by leveraging TB and HIV quality
assurance platforms. For example ,
proficiency testing for POC glucometers
and glucose testing.
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Utilize TB and HIV model regarding the
decentralization of treatment (insulin and
oral therapies) beyond the hospital level.
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TB/HIV bi-directional screening done,
TB/diabetes bi-directional screening
recommended.
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Conclusion
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Integration is a cross-cutting theme of the WHO Global
Action Plan.
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Leveraging the health system strengthening achieved
through the MDG investments is necessary to advance NCDs
prevention and care.
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System must be augmented to include NCDs.
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Best practices learned from NCDs/HIV/TB/MCHN must be
shared, adapted and tested.
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“Knowing is not enough; we must apply
Willing is not enough; we must do”
---Goethe
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Thank you!
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