Management Sciences for Health (MSH) set out 40 years ago with a mission of reforming health care management in developing countries. Often times, available resources go unused simply because of a lack of organizational capabilities. MSH’s approach emphasizes training local leadership that is effective in both utilizing present resources and advocating additional support from the area’s governmental authorities. MSH in this way mediates a partnership between health care stakeholders and governments.
Such capacity building has become increasingly the focus of international donors, which realize that they cannot keep funding health services forever. Rather than following a strictly service delivery model, they need to create the conditions for a self-actuating health infrastructure. Competent, independent health system management can ensure sustainable, efficient health care delivery adapted to community conditions while reducing dependence on international funding. Since MSH’s founding anticipated this trend, it has become a major international force, at present operating in 80 countries with a staff of 2,500.
The current international effort to scale-up HIV treatment and prevention has created enormous pressures for sustainability. Health funds as a whole are stretched tight and donor’s willingness to contribute has decreased because of the current global financial crisis. Controversy continues as to whether the funds poured into HIV are hurting efforts targeting other medical conditions.
Meanwhile, global HIV costs are increasing as treatment moves to earlier stages of the disease, and medical interventions prove able to greatly prevent infection in the first place. As part of its effort to meet this challenge, MSH is working in six Nigerian states (Adamawa and Taraba in the east, and Kebbi, Kogi, Kwara and Niger to the west) to improve local communities’ ability to curb the HIV epidemic with the resources available to them.
The current version of MSH’s program for enhancing Nigeria’s HIV care is known as ProACT, or the Prevention Organizational Systems—AIDS Care and Treatment Project. Before ProACT, MSH’s original involvement in the area was a program called simply ACT, the AIDS Care and Treatment Project. “When I was director of ACT,” says Paul Waibale, ProACT’s founder, “it became clear to me that the usual approach to Nigeria was just to go in and provide services and then get out. From my experience, I knew that we needed to build sustainable elements into the project by strengthening institutions. We built relations with the states and hospitals. Even as we reached the public with expanded treatment access, we also gave an element of ownership to the governments and hospitals.”
ACT was a short-term (20-month) project with a $28 million budget from the United States Agency for International Development (USAID). Based on ACT’s record, Waibale was able to sell USAID on a five-year program supported by a $60 million grant. ProACT operates in the same six Nigerian but covers a somewhat larger number of health facilities (25 hospitals and 56 associated primary care clinics). Its scope, however, is greatly expanded.
Med Makumbi, ProACT’s current project director says, “The ProACT approach arises from the understanding that there are bottlenecks in service delivery. You need to look at leadership and management, the way services are organized and led. We build relationships with service providers but also make a substantial investment in local leaders, getting them involved in planning and being part of the effort.”
ProACT does not offer HIV services directly. Instead, it works with stakeholders at all levels, from patient populations to hospitals to the state ministries of health to create an integrated health delivery system for HIV. The project in particular aims to motivate state health ministries to scale-up services, partly by presenting officials with well-documented surveys of unmet needs. For this reason, it is training hospital staff to be effective advocates at the state level as well as high-quality care providers. There is also a community-based component that develops support for HIV patients, HIV testing and counseling outreach and prevention education.
ProACT’s initial steps include assessments of service provision in each state. Its staff is then able to meet with the state political leadership on the basis of a documented evaluation of HIV needs. The organization advises state health ministries in developing new HIV strategic plans, whose content varies according to the specific nature of the state’s current HIV services and its unmet needs. Makumbi relates, “There was a positive response from all the states where we are working, but its extent depends on the commitment and leadership qualities of the people in charge. By interacting with officials closely, we identify critical figures, our ‘champions,’ who are able to influence others in the fight and mobilize more state resources.”
Three of the six states are now increasing the HIV facilities mostly on their own initiative. A major issue in every state is that the hospitals are old and in need of modernization. But the states have other pressing problems besides the hospitals. ProACT and its hospital allies meet repeatedly with the ministries of health to demonstrate the lapses in infrastructure.
“The states are allocating different amounts for HIV,” says Waibale, “We challenged them to do more. One of the state hospital groups got the Ministry of Health to set up three new treatment sites.” This success occurred in Kogi state. It was the aftermath of an advocacy training session ProACT held for hospital management and state officials in Kogi and Niger states. The Kogi working group that grew out of the seminar convinced the government to release its own and U.S. funding for the expansion, including the three new HIV clinics.
In Niger state, a taskforce growing out of the advocacy workshop forecast how the HIV epidemic was evolving and tried to make better use of donors’ funds. The taskforce fostered collaboration between heretofore separate international programs and brought them under state management.
“Joint advocacy with trained hospital advocates is a new model for Nigeria,” Waibale says. “We go to the officials with the advocates. The hospitals learn to speak for themselves and not be cowed.”
Advocacy efforts extend from the hospital staff down to the grassroots. Outside the hospitals, ProACT has developed the practice of working with the traditional regional leaders, frequently called emirs, whom it attempts to educate about the barriers facing persons with HIV when they try to access treatment. Services that various local leaders have established include food banks and a guesthouse for patients who have to travel considerable distances to reach their clinic. When patients visit the clinic, it can take several days to be examined, receive test results and obtain medications. The emirs can also intercede when organizational problems arise. One had the health ministry transfer the main HIV doctor because he was often unavailable.
Combating HIV stigma is another area where the traditional leaders can have an influence. “They have begun to play an important role in encouraging people to come in for testing, treatment and PMTCT [prevention of mother-to-child transmission],” says Waibale.
In one heavily Muslim town in Kebbi state, the emir invited 700 community leaders—all men—to discuss why pregnant women were not utilizing HIV and prenatal services. A major stumbling block was that the women needed their husband’s permission to come to the clinic. As awareness of the availability of HIV prevention and treatment services spread from the meeting, the first result was that many more men came to the clinic for their needs but large numbers of women eventually arrived, too.
The Kebbi meeting brings up the question of women’s empowerment as a contributor to the struggle against HIV. The meeting sought to involve male leaders in the support of women and their babies, but that is not the same as increasing women’s ability to take the initiative themselves. In this regard, Makumbi points to another aspect of the ProACT program: “Gender equality is a feature integrated into the overall program. Most of our ‘champions’ on the state level have been women, and we work to strengthen their role as people who have shown commitment to drive the program.”
The community effort in Kebbi also illustrates another major aspect of ProACT’s community relations, i.e., efforts to increase awareness of what types of HIV care and prevention are—or should—be available. ProACT works with care facilities to establish HIV-positive support groups composed of HIV patients themselves. The groups help patients understand HIV treatment standards, and this effort empowers patients to inquire when lapses occur. “This may not be direct pressure on politicians and providers, but, people ask for things they are not getting. They may hold officials accountable—we’re working for that, at least on local level,” says Makumbi.
The most significant impact of the support groups is on the individual level. The groups’ members are able to get advice from those in similar situations on a weekly or biweekly basis. They receive ongoing counseling on treatment, hygiene, self-care and treatment adherence and prevention of malaria and water-borne diseases. Partner education is another area they touch on. The groups encourage members to bring their partners for testing, prenatal care and PMTCT.
Many of these support groups grew big enough to be unwieldy even though many people had to travel far to attend the meetings. The ProACT-supported facilities then divided them up so that the patients now meet in their own neighborhoods. The result was that the groups became more cohesive and extended assistance to members who wanted to go back to school and even earn money. Some of the groups have received loans from microfinance banks to develop simple businesses that will make them economically independent and self-sustainable.
Revamping Service Delivery
In addition to its leadership and peer education components, ProACT’s clinical assessments monitor the quality of care at the HIV facilities it supports. The reports from these visits have led to a number of efforts to support clinical staff in their attempts to make improvements.
It turns out, not so surprisingly, that proper record keeping is fundamental to any attempt to improve services. However, hospitals and clinics in resource-limited settings often lack the staff or experience to keep detailed records. To remedy this situation, ProACT conducts workshops to train the staff that is present on proper record-keeping procedures. It also engages in onsite mentoring and supportive supervision to refine record-keeping operations, and teaches how to develop indicators of overall care quality and better systems to track individual patients’ service utilization and outcomes. This information is vital to improving individual facilities, and it forms the foundation for strategic planning at the state health ministry level.
On a programmatic level, the improved record keeping further enables the system to react quickly when care breaks down, as when patients start to miss appointments or stop showing up altogether. Volunteers from the support groups visit disappearing patients and review the reasons for their missed appointments. Utilizing HIV-positive volunteers decreases the stigma involved in this process and leads to more open discussions. A ProACT study in rural clinics in Adamawa state found that care resumed in 55% of patients who had been lost-to-follow-up.
Among the reasons that patients avoid HIV care is that they are confused about the timing of their appointments. Others are embarrassed to attend a clinic that is publicly identified as specializing in HIV. A solution to these issues adopted with ProACT support is to integrate HIV care with other medical treatment at the care facility. Including HIV in the same clinic with other treatment avoids stigmatizing the HIV patients and provides more comprehensive medical care. Another ProACT study in Adamawa confirmed that it reduces patient dropout.
Expansion of HIV counseling and testing, which involves major outreach efforts supported by ProACT, depends on improved record keeping, too. Better record keeping improves continuity of care, as more patients who test positive for HIV are linked to medical services and receive treatment according to national guidelines. A study in one clinic found that after the ProACT record-keeping intervention, the percentage of patients testing positive for HIV who then received a basic CD4 count assay to gauge the stage of the disease increased from 63% to 75%. Meanwhile, the percent screened for tuberculosis after a positive HIV test rose from 36% to 74%.
Even before people test positive, peer education is a part of ProACT’s prevention initiative. These interventions utilize volunteers to reach out to the specific at-risk groups to which they belong—including youth in and out of school, commercial sex workers and their clients and intravenous drug users. The peer educators support consistent condom use and behavior change as well as abstinence for youth who are not yet sexually active. There is a conscious effort to recruit women who can educate other women on safe sex practices and negotiating their use with partners.
An impediment to providing HIV care in Nigeria and other developing countries is a shortage of highly trained personnel. Often, though, lower-level staff members are able to step in and provide certain services if the people with the accepted degree of competence are lacking. “Nurses or clinical technicians rather than a doctor—or even some of the volunteers that we work with—can do testing and counseling,” notes Makumbi. ProACT trains such staff to take on greater responsibilities within the institutions it supports.
Some of the hospitals also provide student internships to supplement qualified health workers. In addition, supplemental staff can come from graduate assistance programs and Nigeria’s mandatory one-year youth service program, which will assign science graduates to rural hospitals. ProACT will pay the expenses for such personnel if necessary.
“This task-shifting is not controversial among senior staff because there is a big shortage in human resources. The hospitals where we work are not in places professionals want to go,” says Ndulue Nwokedi, ProACT’s deputy program director.
Hospitals’ laboratories frequently face a critical personnel shortage. These labs are essential for monitoring HIV disease progression and response to treatment. When ProACT evaluators detect laboratory understaffing, the project offers training to laboratory technicians that enables them to do some of the work that better educated “laboratory scientists” are supposed to do. This training includes good laboratory practices, measuring patients’ CD4 counts, and laboratory management and leadership.
The Next Act
ProACT has had an impressive impact in the areas where it operates. As of March 2012, ProACT-sponsored facilities had counseled and screened 620,478 people, 36,041 (6%) of whom tested positive for HIV. Of those identified as positive, 26,986 (75%) have entered treatment, with 15,294 (57%) of those initiating anti-HIV drug regimens.
There have been several serious challenges to the ProAct program along the way. As Nwokedi recalls, “The [hospitals’] reception [of ProACT] is usually very warm at the beginning. There is interest across the board, but as patient load increases eight to 12 months later, concerns are raised about work load and the human resource capacity to absorb it.” ProACT has struggled to make up the shortage of personnel through a variety of strategies.
It organizes Quality Improvement Teams at the care centers to maintain medical standards through the most efficient use of present resources. There is also the joint advocacy at the health ministries to supply more staff, which has uneven results. “The states have to understand that ProACT is not there to replace the governments’ efforts but to build their capacity,” says Makumbi. Lastly, there are the task-shifting measures described above.
Another concern is the political and religious violence occurring in several parts of Nigeria. None of the ProACT states are “high alert” states. Nonetheless periodic crises limit travel and force ProACT staff to rely more on the telephone than it otherwise would. Patients can still get to their government-run clinics and the states have been able to keep them supplied.
Then there is Nigerian politics’ long turbulent history. Funds budgeted for HIV are not necessarily allocated, and in any case, the commitments of one governor may not hold for future governors. All of this raises the question of what happens when ProACT’s grant ends in 2014. If ProACT has done its job, the local leadership and management skills it has imparted will enable service providers to continue on their own.
Waibale hopes that the states will implement long-term strategic plans as soon as possible that detail who will supply HIV drugs and where care funding will come from. This will help in assuring continuity but is not a guarantee. “We have changed attitudes and processes,” he says, “but state and federal oversight will still be required. There will still be a need for technical assistance.” In the end, improving health systems’ management and organization will not end their dependence on wider society. Operating with restricted resources in a highly competitive political setting makes continuing outside assistance a necessity.
By David Gilden