I walked slowly through a maze of queues into the clinician's small office stacked high with patients' files. It was 7:30 a.m. on a cold winter morning and the facility was crowded with people. Through supporting various facilities of the Ministry of Health across Malawi, I've learned that on Tuesday and Thursdays the Migowi clinic in Phalombe District offers HIV treatment and care services as early as 4:30 a.m. so that the only medical officer on duty could see all the HIV patients.
This is the type of commitment that comes from many health care workers in Malawi. They put in the extra effort to help people, and this commitment has been challenged by the global shift in HIV treatment and care services, especially with the reduction in the cost of HIV treatment drugs. Since this reduction in the early 2000's, Malawi has seen a huge increase in the number of patients enrolled in care, from about 5,000 in 2004 to just over 500,000 in 2011.
The price of antiretroviral drugs has reduced from $10,000 per person a decade ago to around $200 annually in some developing countries. This price reduction resulted from a combination of global activist pressure on international pharmaceutical companies to slash costs; the emergence of competition from generic manufacturers; and direct negotiations by governments with pharmaceutical companies. Just like Malawi, many developing countries quickly took advantage of lower prices and developed policies enabling all eligible patients to access free HIV treatment. However, these new patients used HIV treatment and care services within an ailing health system that could not cope with the increased workload.
Malawi's health system has been hobbled for years with understaffed health facilities, inadequate diagnostic equipment and frequent shortages of essential drugs for patients. When the price of HIV treatments dropped, the government did not overhaul the national health system so that it could cope with an increased number of patients. Instead, the burden fell on the healthcare workers, who have to provide HIV treatment and care services with minimum infrastructure, equipment and limited incentives despite the increase in their daily workload.
The reduction of antiretroviral pricing, changes in treatment guidelines outlined by the World Health Organisation (WHO), and other major global shifts always have a huge impact on the numbers of patients accessing treatment and care services. But not enough thought is put into helping developing countries cope with the sudden increase in patients accessing these services. At the 7th International AIDS Society Conference in Malaysia this past July, WHO revised its guidelines for providing HIV treatment and care services.
With a more permissible threshold at which HIV positive individuals can start receiving antiretroviral treatment, the door has been opened to millions more patients without proper development of the existing health systems to handle these numbers. According to WHO estimates, the new treatment targets would expand the global pool of people in low and middle income countries eligible for ARV treatment to an estimated 26 million - far outstripping the already ambitious target of 15 million that the agency hopes to enroll in treatment by 2015.
What if healthcare workers are not willing to go the extra mile to provide care and treatment services in an already stretched system? How can countries maintain or improve the quality of care when their health systems are already overtaxed? Clinics and facilities providing HIV treatment and care services already suffer shortages of drugs and diagnostic services for monitoring treatment. The introduction of the new treatment guidelines that require routine monitoring only adds to the shortages.
While much has been done to improve access to HIV treatment and care services, governments, donors and international organizations need to devote more energy to planning for how their country's health systems can deliver quality treatment and care services. Global decisions on increasing treatment access are a step in the right direction, but the absence of effective health systems could easily undermine the progress made so far. After providing free HIV care and treatment services to all eligible patients from the early 2000's, a lot of lessons can be learned from different countries on how to strengthen the stretched health systems.
Treatment facilities need adequate and motivated staff to provide efficient services to patients so that a patient's quality of care isn't compromised. Clinicians need efficient supply chain systems for laboratory testing and adequate stocks of antiretroviral drugs to properly monitor and deliver treatment. Long lines in the early morning like those in Migowi--where a patient waiting for hours may get turned away due to a drug shortage--undermine trust in the health system at a time when people need it most, and ultimately diminish the impact of such important reforms.
Today, Phalombe remains at the forefront of Malawi's fight against HIV as its staff have implemented processes that help them cope with the surge in demand. This includes opening the facility early so all the patients can be seen, and providing monthly prescriptions of drugs to stable patients instead of the required 3 months, for fear of running out of stock. However, the responsibility is on governments and the donor community to quickly strengthen health systems to cope with the next expected increase in patient numbers. The battle against Africa's AIDS epidemic is widely seen to be at a turning point, but the logistics need to be in place to carry the campaign to victory.
Global decisions have helped developing nations make important steps in the fight against HIV, but it is in understanding and finding solutions to local challenges such as those at Migowi that will finally end the HIV epidemic.
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