It is important to
identify challenges and barriers impeding care in order to develop the tools to
dismantle them. So in the weeks preceding the Three I’s for HIV/TB workshop,
participants were asked to fill out a questionnaire regarding implementation of
the WHO guidance on the Three I's for HIV/TB, access to HIV, TB and other
health services, and major barriers impeding care. The following responses were
listed as major barriers to uptake of the Three I’s for HIV/TB in the region — and these issues came up
repeatedly in discussions and group work throughout the week.
Too few health care staff and an over-burdened
health care sector
The most obvious and
consistent problem presented throughout the surveys and workshop was the lack
of adequately trained health care staff, clinics, and access to necessary
technologies such as testing facilities and essential medicines.
Clinics that have only
a handful of nurses and one or two doctors are common. Many communities are
serviced only by one or two hospital or clinics, or, in rural areas, the
closest health care provider exists outside of town, making it difficult to
access, especially given many people’s limited income and limited access to
transport.
Drug stock-outs are
far too common, with Swaziland, Botswana and Zambia all reporting interrupted
supplies within the last year. Similarly, basic tools like N-95 masks are
scarcely found in health care settings.
Represented countries
have very few laboratories for the population, especially in rural areas,
drastically diminishing diagnostic ability. Mozambique, for example, only has
one national reference laboratory and two regional laboratories
countrywide.
Structural concerns beyond public health
interventions
Several major structural
concerns that stretch far beyond TB and HIV control, and which affect many
aspects of peoples’ lives, were highlighted. Over-crowding and inadequate
housing means that interventions like infection control are often rendered
largely useless.
Several participants noted that many people affected by HIV and TB lived in shacks or other small houses,
with handfuls of people living in enclosed spaces, often with only one door and
perhaps no windows. As Paul Kasonkomana from
Zambia said, “most of the houses that I go to, especially in rural areas or
[informal settlements], have no windows and one door and sometimes up to 12
people staying in there. And you want me to talk to them about infection
control?”
Kasonkomana also noted that focusing on infection control does not address larger
socio-economic concerns such as gender inequality, inadequate nutrition,
limited access to transport, and inflexible employment opportunities. All of
these severely affect both people’s vulnerability to HIV and TB, as well as
ability to institute effective prevention techniques and access essential care.
Additionally, infection control within healthcare settings, such as clinics,
remains low in all represented countries, with triaging often only occurring
after TB diagnosis; while over-crowded facilities; lack of information about
proper cough etiquette and hygiene; and poor to average ventilation are common
in most countries.
Inadequate understanding of science and policy
by health care workers, the general public, government, and civil society
In communities across
Southern Africa, there remains a low level of understanding of the science,
policies, and politics behind public health, leading to limited policy
implementation; patients don’t recognise the importance of prevention
technologies, continued testing, and drug adherence. Health care workers don’t
fully understanding the benefits of technologies and policies or how they
should be implemented. As Chirwah Mahloko from Botswana said “you can’t demand
something that you don’t understand.” According to the pre-workshop surveys,
only Zambia and Botswana had facilitated mobilisation for the Three I’s for
HIV/TB, and even these activities left much to be desired. While representatives
claimed that surveillance and treatment of health care workers is adequate,
stock outs of N-95 masks continue to put HCWs at risk of infection.
Unacceptably low political will noted by all
participants
Despite signing
numerous declarations regarding the right to health, few governments provide
leadership, capacity, or financing to ensure that health care is accessible to
the majority of the population, with essential scale-up in services and
implementation of WHO guidelines greatly lacking. While all five represented
countries had national-level coordinating bodies to implement the Three I’s for
HIV/TB, none but Zambia had district/facility implementing bodies.
Lack of accurate data and little monitoring and
evaluation (M&E)
All workshop
participants noted the dire lack of data within southern Africa. “It is often
the countries with the highest HIV and TB epidemics that have the worst data,”
said the WHO’s Smyth, ”so the figures currently used for the region may
actually grossly under-represent the true burden of disease and lack of
services.” Monitoring and evaluation of the Three I’s for HIV/TB is especially
wanting, with only two of the five countries represented at the meeting having
a formal structure in this regard.
Disconnect between HIV and TB services
Despite continual and
persistent recommendations from the WHO and others that HIV and TB services work
together, in reality very few southern African countries have combined the two,
with patients being shuffled from one clinic and laboratory to another rather
than being able to access multiple services at a one-stop-shop.
Based on the
pre-workshop survey, only Swaziland, Mozambique and Zambia had national
committees focused on HIV and TB coordination. In the absence of integration,
more time, money, and effort is demanded of the patient, effectively dissuading
them from testing, receiving adequate treatment, and pursuing follow-up care.
Screening for TB among people living with HIV remains unacceptably low in all represented
countries, with contact tracing also poor in all countries but Botswana.
Limited relationship between government and
civil society
While participants
noted that represented countries had some level of interaction between civil
society and government, many felt that this was often tokenism, with civil
society partners being handpicked and not being included in more technical work
such as strategic planning.
Botswana’s Kelemi said that she often wondered if civil society
was “invited simply to say that they were included, but without our voices or concerns
and inputs really being considered.” In the pre-workshop survey, while
representatives from each country noted that there was formal engagement with
government and civil society, strategic planning was often restricted to the
Ministry of Health, and several countries were sceptical about which
organisations were chosen to be included in such activities. The Swaziland
survey specifically noted “marginalisation of civil society in [Ministry of
Health] meetings.”