Ebener S. Scientist, World Health Organisation
Naphini P., Fleming P., Kafakalawa W., Kondowe O.D., Makwiza I., Manda K., Mzembe J., Moyo C.
HIV/AIDS is major public health concern in many countries in Africa. Making sure that people in need of HIV/AIDS care get access to treatment in an equitable way requires taking several parameters into account, making planning decisions sometimes difficult. Geographic data and analysis is an integral component to improve our knowledge about equitable access to anti-retroviral therapy (ART).
This article presents the case of Malawi, a land locked country in southeast Africa, and the cross-sector collaborative process that took place and resulted in two indicators describing the level of coverage offered by ART sites in 2006 as well as the location for potential new sites. This exercise allowed strengthening the connections between health sectors, key institutions involved in NSDI process and other international entities outside the country.
Intensive efforts have been made in recent years to increase awareness and to prevent the spread of AIDS in Malawi. These efforts have been reinforced in 2001 by the establishment of the National AIDS Commission (NAC) and Malawi’s first National AIDS Policy launched in 2004. Access to treatment is particularly limited in rural areas, as problems such as a lack of transportation prevent many people from getting access to health services. A good understanding of the geographic relationship that exists between the supply of ART and the demand among the population is useful for decision makers to plan for the location of additional treatment sites.
Performing such type of analysis requires taking into account conjointly the location and the maximum coverage capacity of each ART site, the geographic distribution of the population in need of treatment, the environment that the patient will have to cross to reach the care provider, as well as the transportation mode s/he would use. The geographic distribution of these parameters is generally the responsibility of different institutions. This is the case in Malawi where the location of ART sites is collected by the National AIDS Commission (NAC) and the Ministry of Health (MOH), the distribution of the population by the National Statistical Office (NSO), the roads and other topographical features by the National Road Authority (NRA) and the Survey Department.
These institutions do not necessarily work together, but have been brought together in the context of a joint project by the World Health Organization (WHO), REACH Trust Malawi and the Southern African Network on Equity in Health (EQUINET) aiming at promoting an equity and health systems approach towards treatment access and responses to HIV and AIDS in Southern Africa .
Challenges at the start of project
When the project started in 2006, the major challenges playing against a systemic analysis of the level of access to HIV/AIDS care were linked to the fact that dispersed mandates and capacities among various stakeholders, limited or even a lack of communication and/or working relations between institutions producing health data and/or geographic information of interest in public health (MOH, NAC, NGOs, Survey Department, National Statistical Office (NSO),…), nonparticipation of several stakeholders in the development of NSDI. For example, the MOH, lack of agreed upon data collection standards and protocols, different coding schemes were used without being linked together, lack of awareness about data resources and GIS skills available in the country and competition for funding. This was resulting in duplication of datasets of questionable quality as well as an important number of lost opportunities.
Addressing the challenges, leveraging the existing capacity and data at disposal as well as improving the working connection between stakeholders would not only benefit each of them but also ensure the compatibility and quality of the data necessary to take decisions. The opportunity to work on some of these issues came from the "Promoting equity and a health systems approach towards treatment access and responses to HIV and AIDS in Southern Africa: a joint project for WHO, REACH Trust Malawi / Southern African network on Equity in Health (EQUINET)" project. The GIS capacity and data availability assessment conducted, combined with the technical resources at disposal allowed going beyond the needs of the original project and to propose a different collaborative approach.
Results of Collaboration
The collaborative work concentrated on improvement of 4 GIS layers, namely the distribution of population, the geographic location of the health facilities, the road network, the river network. With WHO’s support, the different data sources identified have been compiled, cleaned and homogenised using satellite images/2009/july as ground reference. The improved dataset has then been combined with cover, a DEM as well as some survey and prevalence data to form the input data for the application of the Access- Mod extension for ArcView 3.x [2,3].
This extension developed by WHO provides users with the capacity to measure physical accessibility to health care, estimate geographical coverage (a combination of availability and accessibility coverage) of an existing health facility network, complement the existing network in the context of a scaling up exercise or to provide information for cost effectiveness analysis when no information about the existing network is available.
In the case of Malawi, the application of AccessMod resulted in two indicators. The first one presented in Figure 2 compares the spatial distribution of the travel time to the nearest ART site for the all prevalence population using AccessMod (red line) with the travel time reported by ART patients in the context of patient exit survey (blue line). The analysis of the comparison between the two lines provide important information regarding population behaviour (i.e. by passing) as well as the maximum travel time that most patients accept to travel (3 hours) The second one estimates the spatial distribution of the prevalence population not covered by the ART site network in place in 2006. This analysis demonstrates that scaling up treatment sites should mainly take place in the Southern and Central parts of the country despite the fact that these are the regions where a higher density of ART sites is already observed (Fig 3). The approach used should be applied to other services in and beyond health.
It is important to build NSDIs to solve real problems (e.g access to HIV/AIDS care) and only indirectly technical problems. NSDI should involve policy makers, donors and researchers to ensure that their data assist programmes produce societal benefits. The project presented here illustrates the benefits that might result from a collaborative effort using this driver.. The work accomplished so far in Malawi does nevertheless only represent a first step towards a sustainable NSDI. For the moment, the collaboration remains mainly facilitated by external partners and needs to learn from other experiences as well as find resources to become sustainable.