On 1 December the international community celebrates World AIDS Day, which this year is ambitiously themed ‘Getting to Zero. Zero New HIV Infections. Zero Discrimination and Zero AIDS Related Deaths.’
Recently, we have indeed seen very promising developments in prevention and treatment. For instance, treating people with anti-retrovirals can reduce the risk of onward transmission to a partner by as much as 96%.
However, preventing new infections, including mother-to-child transmission, and providing HIV treatment to all those who need it is next to impossible without a well-functioning health system. Anti-retroviral treatment requires that the patient be regularly monitored and supported in adhering to the regime, which requires that he or she has access to a health facility. Similarly, where the quality and accessibility of health services is poor, many HIV positive pregnant women do not access antenatal care, resulting in unnecessary transmission of HIV from an infected mother to her baby.
In the new book I have edited together with my LSHTM colleagues Prof. Anne Mills and Prof. Martin McKee ‘Good health at low cost’ 25 years on (downloadable for free) we offer clues to help policy-makers in low and middle income countries build stronger health systems that can effectively tackle their HIV/AIDS epidemics (among other diseases).
In the book, we raise the question of why some low and middle income countries achieve good health while others fail. Five countries that have seen remarkable improvements in the health of their populations are the focus of the book: Bangladesh, Ethiopia, Kyrgyzstan, Tamil Nadu and Thailand.
Thailand in particular leads the way, having achieved the health MDGs in early 2000s and now working towards the more ambitious ‘MDG Plus’. Over a period of 40 years, the country has implemented successive pro-rural, pro-poor five-year national health plans that transcended political divides. Support from government leaders and the public health sector helped consistently strengthen the health system over generations. In particular, the focus was on improving child and maternal health, with the provision of services by the public sector (primary health centres). Long-term government policies were critical to expanding district health systems. In 2002 Thailand introduced universal healthcare covering the entire population.
As a result, when the AIDS pandemic hit 30 years ago, the Thai health system was in relatively good shape to respond to the emergency. Between 1975 and 2005 life expectancy increased, with female outpacing male due to the impact of AIDS. Studies showed that HIV was the leading cause of disability-adjusted life years lost both for men and women.
Subsequently, successful prevention and treatment turned a generalised epidemic into a concentrated epidemic among specific groups and have brought the number of new infections down dramatically from a peak in 1990. Particular successes have been noted in mother-to-child transmission, which has been integrated into general antenatal care. Nurses in district hospitals are trained to provide HIV counselling in pregnancy, offering advice about prevention and mother-to child transmission.
Although each country has a different story to tell, we were able to identify some common characteristics of a well-functioning health system, able to tackle the epidemic of AIDS. These included: leadership by individuals with a commitment to health gain; capacity within the individuals and institutions necessary to design and implement health reform; continuity to provide the stability that is required for reforms to succeed; the ability to seize windows of opportunity; and the ability to take context into account in order to develop appropriate and relevant policies.
Our research has shown that piecemeal interventions, however sound by themselves, cannot improve health without long-term commitment and attention to health system building. Despite the new advances, ending the HIV/AIDS epidemic is crucially dependent on functioning health systems.
Health systems represent the cornerstone in achieving universal access targets for HIV treatment and prevention. The lessons in our book go some way in helping policy-makers understand the key pillars required in transforming health systems and with it health care.
Contributed by Dina Balabanova, Senior Lecturer in Health Systems/Policy, London School of Hygiene and Tropical Medicine