Rachel Chapman, Ph.D.University of Washington,SeattleDepartment of Anthropology

A Piece of the Action: Winning the Fight for Access to Women in the HIV/AIDS Epidemic in Africa

 

2013: ConferênciaGénero e Pluralismo Terapêutico

Acesso das Mulheres ao Sector de Saúde Privado em África

• Urgent work in a complex moment…

• How did we get here?

• When did public health care get so private?

Recent Roots 1960s-1970s:Primary Health Care (PHC) Movement goes

GLOBAL• 1975: WHO recognizes

traditional healing as important and valuable

• 1978: Alma Ata Conference – Primary Health Care Concept

• Health For All by 2000

Primary Health Care (PHC) Concept

• Low technology• Appropriate

technology• Rural based• Prevention• Local providers• Health care is a right

African Independence MovementsNationalization of Health, Land, Production

Health for All as symbol of social transformation

1980s – PresentMarket Fundamentalism and Austerity

• Neo-Liberal Economic Policies (Reagan, Thatcher)

• Characterized - Free market, de-regulation

• Implemented - Economic Restructuring– Structural Adjustment Programs (SAPs)– Debt Repayment/Foreign Investment – Erosion of social safety nets– Privatization

(water, oil, education, health…)

• PHC problems financing

1993: World Bank “Investing in Health”

1) Health = commodity International health care = business

2) Justification = Irresponsible debt/consumer responsibility- Cost recovery = FEES

• - Cost effectiveness = $ saved per intervention, - life measured in work years lost (DALYs) - weighed in relation to GNP

3) Conditions = governance and democracy = global “business managed democracy” (Beder 2004)

4) World Bank surpasses WHO as health policy

What follows the gutting, commoditization and privatization of health?• Investment in multi-tiered system

and growing health inequalities

• Rollback in primary health care goals and advances

• Contraction of public services

• Draining of public resources into private sector (often under the table)

• Explosion of NGOs, other private providers to fill the gap (civil society discourse)

Aid can be a burden: Tanzania, 2000-2002

Source: Foreign Policy, Ranking the Rich 2004

SAPs weakened national health systems in Africa

Ministry of Health budgets slashed causing:

• Hiring and Salary Caps = Inadequate workforce (numbers, salaries, morale)

• Poorly maintained and equipped health facilities

• Inadequate transport, communication

• Weak procurement and distribution of medicines and supplies, stock ruptures, black market value

Global Distribution of Health Workers Selected Countries (WHO minimum 20)

Country Doctors (per 100,000)

Nurses (per 100,000)

Malawi 2 59 Tanzania 2 37 Mozambique 3 12 Ethiopia 3 21 Rwanda 5 42 Uganda 8 61 Zambia 12 174 Kenya 14 114 Zimbabwe 16 72 South Africa 77 408 Brazil 115 384 Cuba 591 744 Source: World Health Report, 2006

Case StudyPrivatization, Gender and Health in Mozambique

• Diverting cash resources in strapped households

• Need for cash increases micro-exploitation (sex-work, crime)

• Sapping highest skilled providers fleeing public sector conditions and salary freezes to private practice and NGOs “white follows green”$$$

• Unsupervised, unsustainable and uneven care through NGO pet projects,

• Thriving informal sector “dumba nenge” for drugs, treatments , providers (markets, traveling vendors, moonlighters)

Other forms of private care?

Professionalization of Indigenous Healersthrough AMETRAMO and Monetization of

services

Proliferation of Pentecostal and Zionist churches offering healing without official “fees”, majority of converts poor women

AMETRAMO Prices and Treatment List price women out

• Scanned Ametramo list

How does HIV/AIDS “gender” poverty and vulnerability?

Extended families (women) expected to provide care through

• “economy of affection” and

• “hidden health care system”

• Neither can fill in for eroded social welfare institutions. Both give way under pressure of poverty and disease.

Zimbabwe

Economy of Affection1. social protection

2. direct face-to-face reciprocities to get things done among family and neighbors

3. informal and largely invisible political economy

4. informal parallel institutions that buffer from the whims of the market and protect from falling into the wide gap left by the weakened and fettered arms of the state under neoliberal economic policy (Hyden 2006)

• Churches• Fostering• Rotating labor parties• Tithing• Collective farms• Food sharing• Any others?

How is austerity gendered?• counter-geographies of

survival: micro

1. “regrouping …around the pooled resources of households and, especially, the survival skills and desperate ingenuity of women”

2. Hyper-masculinity and the rise of “nightmarish crime and predatory gangs”

3. explosion of male and female sex-work in urban and rural settings

UNAIDS 2010 Report on the global AIDS epidemic

Despite overall MMR decreases:HIV Played a Major Role in Increasing MMR

mostly Sub-Saharan Africa

NO SURPRISE…

Overlapping Global Shadows• Global Maternal

Mortality (WHO)• Global HIV Infection• (UNAIDS)

Overlapping Shadows?• Global Maternal

Mortality (WHO)• Global HIV Infection• (UNAIDS)

HIV and Maternal Mortality(UNICEF. 2010. Interagency Estimates of Maternal Mortality Levels and Trends: 1990-2008)

• Direct: associated increase in pregnancy complications – anemia,– post-partum hemorrhage– puerperal sepsis

• Indirect: increased susceptibility to opportunistic infections – Pneumocystis carinii– pneumonia, – tuberculosis – malaria.(McIntyre. 2003)

• Maternal HIV in Sub-Saharan Africa

• HIV accounts for an estimated 10X increased risk of maternal death, esp. symptomatic women (Moodley, et al. 2011)

Early Response: Prevention of Mother to Child Transmission (PMTCT)

• pregnant women living with HIV in sub-Saharan Africa who received antiretroviral drugs to prevent transmission of HIV to their children:

• 2005: 15%• 2009: 54%

Bias: women as• Reproducers and• Fetal environments

• Around the world to Mozambique with HAI

My Research Project1. Why don’t women with access to prenatal care get

prenatal care?

2. What is the cause of underutilization of public prenatal clinic services?

3. What are all reproductive health options for women in post-war Mozambique?

4. How does inequality get into Mozambican women’s bodies?

5. What are the unexamined costs of Western policies of economic austerity and privatization?

6. What can be done about it?

Guro Tambara

Chemba

MaringueMacossa

Sussundenga

Machaze

Machanga

Muanza

Cheringoma

Chibabava

HF Providing HAART (new) 1 (1)

PLWHA Registered (%) 2,000 (1)

Eligible in HAART (%) 94 (0)

HAI/MOH HIV Treatment Expansion Plan through NGO/public sector collaboration

2003

2003

Guro Tambara

Chemba

MaringueMacossa

Sussundenga

Machaze

Machanga

Muanza

Cheringoma

Chibabava

HF Providing HAART (new) 2 (1)

PLWHA Registered (%) 7,300 (2)

Eligible in HAART (%) 600 (1)

HIV Treatment Expansion Plan2004

2003

2004

Guro Tambara

Chemba

MaringueMacossa

Sussundenga

Machaze

Machanga

Muanza

Cheringoma

Chibabava

HF Providing HAART (new) 5 (3)

PLWHA Registered (%) 18,600 (5)

Eligible in HAART (%) 2,500 (4)

HIV Treatment Expansion Plan2005

2003 2005

2004

Guro Tambara

Chemba

MaringueMacossa

Sussundenga

Machaze

Machanga

Muanza

Cheringoma

Chibabava

HF Providing HAART (new)

17 (13) PLWHA Registered (%)

36,270 (9) Eligible in HAART (%)

5,250 (9) Children <15 y in HAART (% of those in HAART)

420 (8)

HIV Treatment Expansion Plan2006

2003 2004 2005 2006

Guro Tambara

Chemba

MaringueMacossa

Sussundenga

Machaze

Machanga

Muanza

Cheringoma

Chibabava

HF Providing HAART (new)

47 (30) PLWHA Registered (%)

63,390 (16) Eligible in HAART (%)

13,225 (22) Children <15 y in HAART (% of those in HAART)

1,323 (10)

HIV Treatment Expansion Plan2007

2003 2004 2005 2006 2007

Guro Tambara

Chemba

MaringueMacossa

Sussundenga

Machaze

Machanga

Muanza

Cheringoma

Chibabava

HF Providing HAART (new) 53 (7)

PLWHA Registered (%) 100,490 (25)

Eligible in HAART (%) 23,903 (40)

Children <15 y in HAART (% of those in HAART)

3,585 (15)

HIV Treatment Expansion Plan2008

2003 2004 2005 2006 2007 2008

• 87 facilities offering HAART (55 March 2008)

• 180,000 PLWHA registered for HIV care (49% of the infected) (92,600 March 2008)

• 45,000 in HAART (64% of eligible)

(22,000 Mar. 2008, 31% of eligible)

• All HUs with TB treatment in Sofala and Manica testing for HIV and strengthening of TB screening in PLWHA

• 202 CPN with PMTCT (156 March

2008)

2009 Treatment PlanManica and Sofala scale-up

through of existing public network Guro Tambara

Chemba

MaringueMacossa

Sussundenga

Machaze

Machanga

Muanza

Cheringoma

Chibabava

CS

HCB HR

HPC

HG Proj.

THE PROBLEM - Major loss to follow-up (LTFU):

women and exposed infants drop from programs to treat maternal HIV and prevent maternal to child transmission at any step along the “treatment cascade”

pMTCT strategy in MozambiqueFigure 1. PMTCT patient flow

Children followed in pediatric clinic

and tested for HIV at 18 months

Mothers breastfeed

through 6 months, followed by

“rapid transition”to regular foodMaternity

Woman / newborn given dose of NVP

Pre-natal consultPregnant woman counseled

and tested for HIV

Treatment center (if exists): HIV clinical and

laboratory staging

Woman does not need ART

Woman starts ART

Dueling Hypotheses:Why high loss to follow up rates?

Inadequate counseling Authorized and unauthorized

fees Poor quality, rude staff Slow or lost tests Too many appointments Poor linkages within programs

at the health facility Cost of transport and

inaccessibility of clinics Drug stock ruptures

Stigma, and discrimination,

Gender conflict, violence

Lack of basic resources, food, social support

Distance and transport fees

Religious, cultural healing beliefs and practices

Health Systems contributing factors

Structural/Social / Cultural contributing factors

BOTH INADEQUATE: WHY?Depoliticize, Individualize, Medicalize

High Cost of Austerity Economics

• Cutting public sector• Privatization• Cutting services• Lay-offs, salary cuts and

freezes• Selective and vertical

interventions

• Remove price subsidies• Fees for services• Erodes social safety nets• Abolish social security

Ignore failed structural adjustment programs (SAPS)

Overlook free market fundamentalist cost-shifting to women

Costs of Austerity to Women’s Health

• Macro: Erosion of health system budget, facilities, staff, salaries, basic resources, services, morale

• Meso: Institution of vertical,selective health programs silo-ing focus and resources fromIntegrated primary care

• Micro: destroys social fabric as people eek out survival from overburdened household

resources, especially social-reproductive labor of women, violence, crime, corruption as individuals seek to resist impoverishment

HIV care and treatment scale up exposes costs of Austerity Economics

• AIDS-related maternal mortality

• Health systems failures• AIDS-related stigma

= tangible consequences of “trickle-down” politics which have immiserated African

households and public sectors that serve them

New Research Question:

• What accounts for loss to follow-up?

• Where are all the pregnant HIV+ women going after they test positive?

Preliminary Findings1. Stigma and fear

2. Domestic violence surrounds negotiation of disclosure, loss of social support

3. food and drug insecurity = new hungers, new conflicts and new markets, new resistances

4. Confusion regarding pregnancy and seropositive status, multiple testing, changing clinics, ghost patients

5. Shock, memory, negotiating identity post-test, failure of counseling

• HIV testing and treatment complicates women’s access to clinical care.

♀g arrives for 1ra pre-natal visit with

SMI nurse

Day 1

HIVRapi

d Test

Blood is sent to lab for CD4 test

Reception activista opens a chart for

♀g+

Day 1

SMI activista accompanies ♀g+ to reception

SMI nurse evaluates the urgency of treatment and determines WHO clinical

stage (I-IV)

Day 1

Reception activista accompanies ♀g+ back to SMI nurse

CD4 count

♀g+ returns to meet with SMI nurse to get CD4 results

≥ Day 3

I-IIStag

e

III-IV

♀g+ receives AZT & duNVP > 250

+

SMI nurse prescribes CTZ and biochemical blood

tests

≥ Day 3

Day 4 or 5TARV

committee reviews

case to determin

e eligibility

TARV ?

Evaluation with a MD or

TM (on Fridays

only)

~1-4 weeks after diagnosis

Social worker gives ♀g+ the

TARV prescription

~1-4 weeks after diagnosis

≤ 250

DOT for the first 14 days of treatment

PTV

Day 1

Day 1

no

yes

Health Center Munhava ♀g+ PTV Flow

At 28 weeks

♀g+ takes sdNVPContractions start

Labor Starts At Home

Duovir (AZT+3TC)DuringlLabor

At Hospital Maternity

AZTFor one week postpartum

In The Home

Children get: sdNVP & AZT

Postpartum

Picks up medicines in the pharmacy

~ 1- 5 weeks later ♀g+ starts 3 phases of

adherence counseling with a social worker (takes

1-3 weeks)

Phase 3

Phase 2

Phase 1

New collaboration:Option B+ (2012 WHO Guidelines)

1. Starting triple therapy ART directly after testing rather than waiting (test and treat)

Option A vs. Option B+

Pregnant woman comes to ANC visit

Woman tested for HIV

HIV chart opened in HIV

clinic

Draw CD4

CD4 <350

CD4 >350

Counseling visits, clinician

visits

Counseling visits, clinician

visits

Start ART

StartAZT+sdN

VP

Draw CD4CD4 <350

CD4 >350 Stop ART 1 week after breastfeeding

Continue ART lifelongStart ART

Woman HIV+

Benefits of Option B+1. simplification of regimen and

service delivery and harmonization with ART programs,

2. protection against mother-to-child transmission in future pregnancies,

3. continuing prevention benefit against sexual transmission to serodiscordant partners,

4. avoids stopping and starting

of ARV drugs

Not enough!Trojan Horse of ART Scale-Up

• Quality HIV care and services are only possible within context of building strong, sustainable, public sector health systems

and securing householdability to generate basic health

action agenda: impeded by the conditions of austerity and clears path for privatization

• “The is clear. To get Millennium Development Goal 5 on track by reducing the contribution of AIDS to maternal mortality,

• we must prevent HIV infection in women and girls, prevent unwanted pregnancies, expand HIV testing and counseling,

• accelerate initiation of antiretroviral treatment in pregnant women who are HIV-positive, and strengthen service delivery and integration of HIV care and obstetric services, along with data collection to track progress.” (Motley, et al. 2011)

Why do we need a public system to scale-up ART treatment to pregnant women?

1. If health care is a right and should be affordable it cannot also be for profit.

2. The organization, integration and sustainability needed for scale-up cannot be achieved through a patchwork system with different protocols and drug regimes.

3. The majority of impoverished people use the public sector in some capacity despite quality.

4. If health care is a right, a public system has some mechanisms for accountability.

Is privatization a risk to the scale-up of ART for pregnant women in Mozambique?

1. Increasing health inequalities in a many - tiered system

2. Demobilization of support from enfranchised and resourced for the disenfranchised and impoverished

3. Resources sapped often under the table from public to private sector (moonlighting, brain drain, informal markets for drugs and services, unauthorized fees)

4. Naturalizes cost shifting from public to domestic sphere through household labor and erosion of labor rights (fees for service, insurance schemes, for-profit NGOs, performance based financing)

5. Blames failure to produce health on consumers and providers

Maybe women are not “lost” to follow-up

New Commons Women join Pentecostal and African

Independent Churches• lively worship communities,• women’s social and business groups, • tithing, • visits and prayer for those who are sick at home, • communal gardens• a range of healing approaches for which they are not asked to pay a fee,• Therapy for infertility or multiple infants deaths and chronic illness (HIV?)• On site birthing facilities• mulheres d’espiritos (wives of spirits) escape the endless cycle of fees and

indebtedness acquired while seeking treatment with curandeiros

• solace and succor

• Decommodification of healing

Global Burden of Absolute HIV Deathsworld mapper (2007)

Global Public Health Spending – enough said!

Worldmapper

Action Research Agenda Medical Anthropologists• Study Up to Track Cultures of Abandonment and

“Zombie Economic Policies”, Who Calls the Shots? • Evaluate Alternative Health Resources• Track patterns of resort in shifting plural health systems

with eye to resistance, human and drug• Seek out and advocate for the politics and practices of

new commons, social movements, resistance outside the formal economic system revealing global connections for action

• Pay attention to micro shifting household economies under austerity, and find new measures for the cost of cost shifting

• Make links between the dehumanizing politics, processes of austerity in Europe, Americas and Africa

BASTA!

Muita Obrigada!University of Washington

Mozambique Ministry of HealthManica and Sofala Provincial DPSHealth Alliance International

Beatrice ThomeJames PfeifferWendy Johnson

Javelina AguiarLucia LazaroVictoria Porthe