barriers to antiretroviral therapy in malawi: an assessment of socio-economic inequalities

Inaugural Conference of the African Health Economics and Policy Association (AfHEA)Accra - Ghana, 10th - 12th March 2009

Barriers to Antiretroviral Therapy in Malawi: An assessment of socio-economic

inequalities

Talumba Banda, Eyob Zere, Bertha Simwaka, Erik Schouten, Ireen Namakhoma

REACH TRUST in collaboration with WHO Geneva, WHO Malawi and MoH


Background to the study

In Malawi, access to health services free at the point of delivery,

The poor benefit less from these interventions, yet high disease burden, [Zere E.,et al.,2007].

Other studies – the poor in Mw wait longer, receive fewer drugs and pay more than the non-poor, [MoHP.,2002b, Kapulula et al.,2001,Kabwazi et al.,2001].


Background to the study cont…

the situation would be worse for patients on ARV Qualitative studies - costs, long distances and

waiting times are some of the barriers

Lack of adherence to ART remains a major challenge to AIDS care with serious public health consequences;

treatment failure, development of viral mutations, emergence of drug resistance strains.


Malawi- Brief country profile

Mw, small landlocked country in south East of Southern Africa,

Shares its borders with three countries namely the United Rep. of Tanzania, Mozambique, and Zambia,

Population is about 12 million-1998 NSO population census

Health systems context; provision of both preventive and curative health services is free at the point of delivery,

However, health care resources are unevenly and inadequately distributed.


Malawi- Brief country profile cont…

Only 46% of the population has access to a formal health facility within a 5 km radius,

and only 20% lives within 25 km of a hospital.

Access is worse in rural- 85% live with higher incidences of poverty as compared to urban.

Significantly, there is mal-distribution of the health personnel which favours the urban areas


Malawi- Brief country profile cont…

Despite that 85% of Malawians are in rural areas 50% of doctors and 25% nurses are working in the

4 tertiary hospitals based in the 4 cities in Mw, 97% of government employed Clinical Officers and

82% of nurses are in urban areas (MoHP,2003a) . Implicitly,

health care resources in many rural could be as little as 10-20%

of that required to provide essential health package services Mc Coy, et al.,(2004).


Malawi- HIV and AIDS Situation

HIV prevalence rate estimated at 14% (2004, MDHS).

Over one million PLWAs and over 500,000 children orphaned because of the epidemic.

There are spatial, gender, age, and regional disparities in the prevalence rate of HIV/AIDS;

The southern region has a higher prevalence rate than the Central and Northern regions.

prevalence rates in urban areas are higher than in rural areas (17% against 11% respectively)


Malawi- HIV/AIDS situation cont…

Also, prevalence among the age group of 15-49 is higher in women than men (13% against 10%).

Overall, around 60% of adults living with HIV are females and that women are more vulnerable than men.

Furthermore, there are more girls infected than boys. Girls in the15-19 age group are 4 times more

susceptible to infection than are boys. Similarly, prevalence in the 15-24 age group is 4

times higher in girls than in boys.


Malawi-HIV/AIDS situation cont…

It is estimated that about 170,000 people are in need of ART any point in time

Currently, the number of people ever started on ART increased from 4000 in 2004 to over 140,000 –2007

Of these 61% are females against 39% males. A 12 month survival analysis for the ART programme

show that ; of the patients that initiated treatment in 2007,

78% were still alive and on treatment, indicating the success of the programme,

MoH(2007a).


Study Objectives

Overall, the study aimed at; analyzing whether any groups of people

experience more barriers based on their socio-economic status.

Specifically assess inequalities in access to HIV

treatment, assess the influence of rural- urban

differences in accessing ART.


Study Objectives

Policy formulations that attempt to address inequalities in access to ART would ensure sustainability of the ART programme, bring in health interventions that would

allocate resources according to worst health status more successful in universal access

LIMITATION Data is obtained from those who are already accessing

the ART. Those who are not currently accessing are excluded As such, not possible to understand the barriers that they

face to access ART.


Study Methods

Study setting: Carried out in two districts of Malawi,

Lilongwe and Rumphi 947 ART patients interviewed in almost all

public ART sites Data collection

ART patients interviewed using a structured questionnaire

All ART patients who visited the clinic on a randomly selected day were recruited - sample size reached.


Study Methods cont…

Data collected on; patient’s socioeconomic characteristics Costs incurred per single visit to the ART

facility, distance traveled, Time taken as well as transport mode used

Data analysis Analysis done using STATA SE 10.1 PCA was used to determine;

the socio-economic status of the patients and classify them into wealth quintiles


Study Methods cont…

PCA useful when there exist data on too many variables;

want to develop a smaller number of artificial variables (principal components)

The first Principle component (PC) has the largest amount of information common to all variables.

The first PC was used to develop the asset index based on the following formula:


Study methods cont…

n

njnn

jj s

aaf

s

aafA ...

1

111

Where:- Aj is the asset index of the jth household;-f1 is the scoring factor for the first asset determined by by the procedure - aj1 is the jth household’s value for the first asset; and-a1 and s1 are the mean and standard deviation of the first asset variable over all households.



The scoring factor for each variable is the weight that the variable contributed to the welfare of the household.

The PC indicates that assets likely to be owned by better- off households have +ve values e.g. cement floor.

Thus a household’s asset index is improved with that asset.

Contrary , assets that were owned by poor households had -ve values e.g. unprotected well

Thus a household’s asset index decreases by that asset.



The choice of variables used in the PCA model was based on the Coefficient of Variations (CoF) obtained.

Where a CoF <1, the variable was taken not to explain

much variation among the households, hence was excluded.

Where a CoF > 1, the variable was taken to explain much variation hence included.

The asset index was used to categorize the patients into wealth quintiles.



To achieve the above obectives, the following variables were analysed across wealth quintiles;

transport costs incurred, distance traveled, travel time taken, Mode of transport used.


Result 1-Costs and distance to get to the ART facility

Wealth quintile

Mean distance travelled (Km)

Mean cost of transport (US$)

Poorest 21.8 4.00

Second 22.0 2.51

Middle 20.0 2.50

Fourth 17.9 2.26

Richest 14.1 1.50


Result 2:The influence of rural-Urban residence in access to ART

The poorest 20% from the rural, mean distance -23km compared to the poorest 20% urban, mean distance-8km

The poorest 20% from rural mean cost of $3.04

compared to the poorest 20% urban mean cost of $1.14

A comparison of the richest 20% from rural and the richest 20% from urban shows;

that the costs and distance are higher for those from the rural to those from the urban.


Result 3: Travel time taken to get to the ART facility

20

40

60

80

100

120

Male

Fem

ale

Urb

an

Rura

l

Poore

st 2

0%

Q2

Q3

Q4

Ric

hest

20%

No e

ducation

Pri

mary

JCE

MSC

E

Tert

iary

Sin

gle

never

marr

ied

Marr

ied-m

onogam

y

Marr

ied-p

oly

gam

y

Div

orc

ed

Wid

ow

ed

Avera

ge tra

vel tim

e to A

RT faci

lity

(in m

inute

s)

Sample median


Result 4: Mode of transport used to get to the ART facility

0%

10%

20%

30%

40%

50%

60%

Walk Public bus Bicycle Car

Poorest 20%

Q2

Q3

Q4

Richest 20%


Discussion and Conclusion

The study findings show that; access to ART services is more costly for the poor

particularly the poorest rural populations. ART scale up in Mw has been more favourable

towards the better off populations and those urbanized.

The current ART scale up system for Mw is a phased ART expansion process ART provision started at tertiary level to primary

level but also on a “first come, first served” basis.


Discussion and conclusion cont…

However, provision of treatment a tertiary level without strong links at primary level; Favours the higher educated who are not poor

(Lowenson and Mc Coy ,2004).

This is exacerbated by provision of treatment on a “first come, first served” system.

ART being a lifetime treatment; Provision should ensure that patients experience

less barriers to treatment to promote treatment adherence


Discussion and Conclusion cont…

Mw needs to expand the ART program more at primary level if access to the services is to be more equitable.

The more services are provided at primary level , the more equitable the services

wider provision of services at the primary level ensures that the services are made within reach for the rural people.


Discussion and Conclusion cont…

For example, increase the number of clinics that operate in rural areas through mobile clinics.

Furthermore, explore on the provision of transport vouchers to patients who can hardily

afford transport costs This would minimize costs incurred by

patients Expanding ART access more at primary level

would increase the effectiveness of the ART program in Malawi


End of Presentation

Thank you for your attention!!!!

Special thanks to; WHO Geneva – financial support WHO Malawi- Technical support Ministry of Health Malawi- Technical support

barriers to antiretroviral therapy in malawi: an assessment of socio-economic inequalities

Documents