Geneva Health Forum Archive

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Vulnerable Populations and Inequalities in Health: The Case of Marginalized Women with Substance Abuse Problems

Author(s): M. P. Romero1
Affiliation(s): 1Researcher on medical sciences E. Direction of epidemiological and psychosocial research, National Institute of Psychiatry, Mexico city, Mexico

Vulnerable population, women, substance abuse, equity

Background: Interest in health inequalities has grown in recent years. The World Health Organization (WHO) defines them as health variations that are unnecessary, avoidable and unfair (Whitehead M, Dahall G, 2007). These inequalities are also gendered. Gender is a concept that incorporates the social factors associated with men and women’s different patterns of socialization, which in turn has to do with family roles, work expectations, types of occupation and social culture which also affect the process of health and illness. In this work we use the concept of gender quoting Ettore (2002): ‘gender is a process and an institution…As a process, gender is a part of all human interactions. Gender shapes the meaning of “female” and “male” and “masculinity” and “femininity” on cultural, political and economical levels. As an institution, gender is a part of culture just like other components of culture such as symbols, language, mores, norms, values and so on. Gender is a “stable” form of structured inequality and it is embedded in culture’ (p. 329). When women experience the damaging effects of gender whether as a social process or an institution, women are at a greater disadvantage because ‘masculinist’ (male privileging) more than gender-sensitive structures and paternalistic epistemologies predominate. In addition to gender inequalities, there are also social and economic inequalities that give rise to marginalized groups. Therefore, for vulnerable populations, ensuring healthcare coverage an access to good-quality, appropriate public and private sector services is an ongoing a challenging proposition (Ferguson 2007). Type of study: A non-experimental, descriptive, ex-post facto cross sectional study was undertaken in two women’s prison in Mexico city. A non probabilistic sample of 213 women was selected, with the following inclusion criteria: current or sometime consumers of alcohol, tobacco and drugs, aged between 18 and 65 who can read and write.

The aim of this paper is to discuss from the theoretical framework of gender perspective and vulnerable population’s literature, the burden of disease of substance abuse in vulnerable women, specifically data from a research with minor delinquents and women in prison.


Among the interviewed women 14.6% have lived in a shelter or NGO before the prison and 39.5% have lived in the street. The third part (30.5%) ran away from home at least once while being children and 21.6% live with persons different from their parents. On the day they committed the offence 41.8% were under the effects of drugs and 18.8% on alcohol. Among the drugs they used while or before committing the crime, 26.85 % had used cocaine. The most commonly reported crime among the interviewees was theft (51.6%) in different forms (non-specific/simple, qualified, aggravated, non-specified, burglary) followed by drug related offences (possession, traffic) 23.5 % and the third crime was homicide (8.5%). According to their response 43.7% reported having been in a correctional facility before.

Lessons learned:

Prison is an environment with special difficulty in the promotion of health. At the individual level, prison takes away autonomy and may inhibit or damage self-esteem. Common problems include bullying, mobbing and boredom, and social exclusion on discharge may be worsened as family ties are stressed by separation. However, imprisonment is also a unique opportunity for all aspects of health promotion, health education and disease prevention. Vulnerable groups as the women in prison and minor offenders are disadvantaged groups who would normally be hard to reach. It is the prison, therefore a prime opportunity to address inequality in health by means of specific health interventions as well as measures that influence the wider determinants of health (Haton P., 2007).

Mothers’ Use and Perceptions of Artemisinin-Based Combination Therapy for Treating Malaria among Under-Five Children in Nigeria

Author(s): K. O. Odor*1, O. O. Adekunle1, F. O. Oshiname1
Affiliation(s): 1Health Promotion and Education, University of Ibadan, Nigeria, Ibadan, Nigeria
Keywords: Artemisinin-based Combination Therapy (ACT), malaria, under-five children, perception and knowledge

The adoption and promotion of Artemisinin-based Combination Therapy (ACT) in Nigeria is influenced by the increasing prevalence of Chloroquine resistant malaria. However, little is known about the adoption and perceptions of nursing mothers regarding ACT. The study therefore assessed the perceptions and pattern of use of ACT among mothers of under-five children in Oyo State, Nigeria.


The study was a cross sectional survey involving the use of a 5-stage random sampling technique to select 720 participants from households. A validated questionnaire with a 6-point knowledge scale was used for data collection. Descriptive and Chi-square statistics were used to analyze the data using Epidemiology Package Information software.


The participants’ mean age was 29±5.3 years. Their levels of education were as follows: No formal education (26.0%), Primary (50.7%), Secondary (18.2%) and Higher Institution (4.9%). Thirty percent (30%) of participants had ever heard of ACT and their main sources of information include health facility (69.0%), Physician (11.0%), Nurses (11.0%) and Pharmacy (4.0%). Participants mean knowledge score relating to ACT related drugs was 1.2±2.0. Out of the maximum of 6 points, the mean scores based on their level of education were as follow: no formal education (0.8±1.7), primary (1.2±2.0), secondary (1.5±2.2) and polytechnic (1.5±2.2), p<0.05. Twenty-seven percent of participants had ever used ACT drugs, while 10.0% are current users of coartem which is the most popularly used (24.2%) among the ACT drugs. The level of education of the current users were as follows: no formal education (17.1%), primary (49.7%), secondary (22.5%), higher institutions (10.7%), p<0.05. Majority (90.6%) obtained the drugs from government hospitals where they are distributed free to under five children. These participants were of the opinion that the ACT drugs are not expensive. Only 27.0% of the participants were of the view that ACT was more effective than Chloroquine while 80% of the current users share the same opinion. Fifty –nine percent (59%) of the current users which represents 18.0% of the total participants stated that the drugs were readily available, while 78.0% of the current users could correctly state how they are used for treating under five children. Seventy-five percent of the current users are of the opinion that ACT drugs have lesser side effects compared to chloroquine. Nonetheless, Chloroquine was still the first line drug of choice for treating children with uncomplicated malaria among majority (59.0%) of the current users of coartem in the home management of malaria. The reasons adduced for this included the following: Ready availability (30.2%), they are commonly prescribed by doctors and other health workers (27.8%), chloroquine taste suits my children (17.0%) and chloroquine is very cheap (12.4%). Despite the positive attitude of the population that are aware of ACT and its effectiveness, the awareness and accessibility as well as its use for the management of malaria in under five children are still low among nursing mothers. Advocacy, social marketing and subsidization of ACT drugs especially in the private sector are needed to address the problem.

GHF2006 – PS20 – Gender, Sexual & Reproductive Health: Access Issues

Session outline

Parallel session 20, Friday, September 1 2006, 14:00-15:30
Chair(s): Mary Anne Burke, Switzerland, Priscilla Daniel, India
Microfinance and Health Intermediation 
K. Narendar, Chief Executive, DHAN Foundation, Madurai, India
Micro-credit Financing and Impact on Female Genital Mutilation
Berhane Ras-Work, NGO, Inter-African Committee on Traditional Practices Affecting the Health of Women and Children, Geneva, Switzerland
Mainstreaming Gender-Based Analysis of the Women's Hospital of Costa Rica
Zully Moreno Chacón, Hospital of Costa Rica, San José, Costa Rica

Session Report

submitted by: Anne May (ICVolunteers)
Sudan, Garsila, Western Darfur. Preparations for a distribution of basic household items with support from Sudanese Red Crescent volunteers. Image: © ICRC/ T. Gassmann / 2004

The session addressed the various manners in which gender and social inequalities may negatively impact on population health and general wellbeing. It further looked at ways in which women can be empowered to allow them to develop a holistic approach to their specific health and other related needs. Examples showed that implementing gender-based analysis can produce profound changes in the treatment of women's specific problems.

Mr. K. Narendar, Chief Executive of the Development of Humane Action Foundation (DHAN), Madurai, India, presented the activities of his organization, which promotes improved health outcomes through microfinance intervention. To put his foundation's work into perspective, Mr. Narendar first reminded the audience that population health is strongly correlated with poverty. Microfinance programmes have emerged as one of the significant mechanisms to address the deep-rooted causes of poverty. There is a growing body of evidence showing that access to microfinance services is positively correlated with factors that have a positive impact on health, such as nutritional intake or contraceptive usage, he said.

The microfinance programme of the DHAN, through savings, credit and insurance, is aimed at developing appropriate savings that can be devoted to health care. Specifically targeted at women, it enables poor women to increase expenditure on the well-being of themselves and their children, which ultimately affects the health outcome at the family level. Mr. Narendar cautioned that such schemes are not appropriate to address higher health care needs, for which social security measures such as health insurance must be in place.

Mrs. Berhane Ras-Work, from the Inter-African Committee on Traditional Practices Affecting the Health of Women and Children (IAC) addressed the problem of female genital mutilation (FGM) in Africa. FGM is a widespread problem on the continent, affecting at least 28 countries. It is rooted in and nurtured by tradition, culture, religion, far-reaching misconceptions and socio-economic circumstances. All members of the community are participants in the continuation of this most brutal form of violence and governments tend to be silent, thereby justifying this violation of Human Rights, she said.

NGOs have played a key role in giving international recognition to gender inequality and violence. The IAC has initiated action and shown that it is possible to impact positive changes of attitude through the empowerment of women along two lines. First, by offering them micro-credits aimed at curbing their economic vulnerability. Indeed, women accept gender-based violence to ensure the security of their marriage and the survival it provides. Second, by giving them education and information to erase the misconceptions perpetuating the practice of FGM and to develop women's valuation of their bodies and health. In parallel, the IAC has embarked on a micro-credit scheme with excisers themselves, to help their conversion to other income-generating activities. Such schemes have already been successful in persuading excisers to stop their traditional practices.

Mrs. Berhane noted finally that such strategies should be further developed but that their success depended on accompanying, additional measures starting with strong political commitment and investment.

Mr. Manuel Carballo, from the International Centre for Migration and Health, Vernier, Switzerland, focused on the problems faced by migrants, an ever growing population worldwide. The migrant population was officially 195 million in 1995, but certainly amounted to three times that number when illegal migrants were taken into account. The health problems of migrants are a complex issue, combining pre-migration health profiles, diseases and health problems acquired during transit and newer ones acquired in the host country. Hence, care should be specifically tailored to the migrants' health profiles, a course which is undermined in times of increased socio-political resistance to migrants.

The nature of their health problems is only one element in all those undermining migrants' health, Mr. Carballo said. Access to health care for migrants is dependent on the availability of specific services adapted to their different psychosocial, cultural and linguistic backgrounds. The availability of such existing services should be known to the migrants, but this has been shown not to be the case in almost half of those migrants surveyed in Geneva. Such services should also be legally available, for example through a scheme of health insurance, and they should be affordable, taking into consideration the overall low income of migrants.

As migration continues to increase, Mr. Carballo concluded, medical insurance coverage which includes migrants, specific training of health personnel to handle multicultural differences and outreach to the migrant population for health promotion and disease prevention is more critical than ever.

Mrs. Zully Moreno Chacon, from the Hospital of Costa Rica in San José came with a concrete example of how gender-based analysis helped the transformation of the Women's hospital in Costa Rica from a traditional one to one working with women themselves to design tailor-made strategies addressing specific needs. The transformation was a far-reaching process involving strategic planning; revision of physical infrastructure, working processes and administration; space distribution; challenge of management structures; allocation of budgets; new practices and methodologies.

The key to the success of this initiative was to empower women in the process and to develop a holistic approach to their specific health and other related needs. Active participation was fostered by the creation of associations and a health network. Employees' training was carried out to improve the sensitivity of care for women.

Mrs. Moreno noted that implementing gender-based analysis produced profound changes in the treatment of women's specific problems and that female patients demonstrated a real appreciation of the new approaches and resources that were developed.

Mainstreaming Gender-Based Analysis of the Women’s Hospital of Costa Rica

Author(s): Zully Moreno Chacón1, L. Ledesma1
Affiliation(s): 1Hospital of Costa Rica, San José, Costa Rica
Purpose: Explain how Gender-Based Analysis (GBA) helped the transformation of the Women’s Hospital in Costa Rica through the implementation of the Women’s Health Integral Attention Model Process developed since 1999.

A descriptive type investigation with a quantitative methodology was followed to build and understand learning about the Hospital’s transformation process. Also, an evaluation of three programmes directed to the attention of women’s health was conducted with a retrospective vision through GBA. This analysis was completed with a reflexive revision of the process documentation.


A transformation process of the hospital was achieved, from a traditional one to a strategic planning hospital which works with communities and women to make decisions regarding health, with the creation of programmes and projects through GBA. In relation to Sexual and Reproductive Health, new forms of attention were directed to: childbirth, abortion, integral attention to the adolescent mothers, women of the medium age, cervical-uterine health, intra-family violence, HIV/AIDS, drugs, maternal nursing and healthy lifestyles. Nine interdisciplinary teams were developed for the formulation and execution of a women’s integral health model. A base of active citizenship was created, formed by three women’s health associations and a board for women’s health. A health network was developed, composed of eleven areas that developed the Access Plan for the pathology of the uterus neck with the support of women. Evaluation and monitoring of the qualitative and quantitative attention was set up. As a result of the project, decreases were noted for delays for colposcopy consultation from six to one and a half months, and for menopause consultations from nine to three months. Training of 517 employees from the health network was carried out to improve the sensitivity of care for women, also reaching 95% of hospital members.

Conclusion (max 400 words):

GBA implementation produced profound changes in the treatment of problems and women’s health needs and enhanced: strategic planning, revision of physical infrastructure, revision of working processes and administration, distribution of spaces, challenge of management structures, allocation of budgets, new obstetrical practices, and methodologies and processes of work. GBA is beneficial for the care of women’s health.

Micro-credit Financing and Impact on Female Genital Mutilation

Author(s): Berhane Ras-Work1
Affiliation(s): 1NGO, Inter-African Committee on Traditional Practices Affecting the Health of Women and Children, Geneva, Switzerland
Key issues:

Gender is a cross-cutting issue that determines the health and lives of women and men in different ways and at different levels. The health of the majority of women, in particular their reproductive health, is impacted by the role and status attributed to them by the society in which they live. Systematically women are affected negatively by social attitudes and practices. Gender-based violence with all its variations is a strong health determinant across the life cycle of women. The unequal power relationship between men and women both socially and economically render women vulnerable, forcing them to accept in silence and with apathy even the most gruesome forms of violence. The most brutal form of violence is perpetrated on African women in the name of preserving cultural values. Female genital mutilation is practised in at least 28 African countries. Reasons advanced for the persistence of the female genital mutilation include: religious, e.g. misconceptions; family honour, e.g. virginity; economic, e.g. bride price; aesthetic; social integration; prevention of child mortality. The benefits received by those who carry out the excision and ignorance on the part of the women are also important reasons to be considered. Although the cost of such forms of violence is high to the nations, governments tend to be silent, thus justifying this violation of Human Rights as an inevitable tradition and integral par of culture. In recent times, gender inequality and violence have been gaining international recognition. NGOs have played a crucial role in bringing the issue of violence on the agenda of the relevant bodies of the UN. A very important outcome of this lobbing is the appointment of the Special Reporter on Violence against Women. The experience of the Inter-African Committee on Traditional Practices Affecting the Health of Women and Children (IAC) shows that with intensive education and information tailored to respond to the varying cultural contexts, it is possible to impact positive changes of attitudes. IAC has realized the underlying factor for gender-based violence proves to be the economic vulnerability of women as well as their ignorance. Women subject themselves and their daughters to practices such as FGM to ensure the security of marriage and the survival it provides. Empowering women through education, skills training and micro-credits can change the status of women for a better life. IAC has embarked on a micro-credit scheme with excisers to enhance alternative income generating activities. Through this experience it has been proven that excisers, once reoriented and supported, can stop their traditional practice and engage themselves in productive activities. They can also act as agents of change. Although a sufficient number of protective international and national instruments exist, the political will to fully protect women and girls is still lagging. The responsibility of civil society lies in holding governments accountable for compliance.

Meeting challenges: Changing deep-seated traditional attitudes and practices in favour of promoting the health and status of women.
Conclusion (max 400 words): Women themselves have to be continuously informed and made aware in order for them to be empowered to value themselves, including their body, and to protect their rights. The socializing system of boys and girls should be gender sensitive with built in values for equality.

COPD Prevalence among Women due To Indoor Air Pollution: South India

Author(s): Priscilla Johnson1, Padmavathi Ramaswamy2, Kalpana Balakrishnan2, Santu Ghosh2
Affiliation(s): 1Department of Physiology, Sri Ramachandra University, Chennai, India, 2Department of Environmental Health Engineering, Sri Ramachandra University, Chennai, India
1st country of focus: India
Relevant to the conference theme: Non-communicable chronic diseases
Summary (max 100 words): Chronic obstructive pulmonary disease (COPD) is the 4th leading cause of death and 13th leading cause of burden of diseases worldwide. Although smoking remains the predominant risk factor, exposure to solid fuel smoke has also been identified as a risk factor for COPD, with rural women in developing countries bearing most of this disease burden.  Despite the importance of this disease, the fact is that the prevalence of COPD is not well measured due to the uncertainties in the prevalence estimation. Most of the previous studies have focused on prevalence of COPD in men and primarily addressing smoking as a risk factor and relatively few studies have attempted to assess prevalence amongst non-smoking rural women. Moreover, estimates of COPD prevalence were diverse either due to variation in the type of assessment or due to inconsistent physician recognition of COPD. In this study a meticulous diagnostic approach was chosen for identification of the COPD cases, including a complete clinical evaluation with spirometry before and after bronchodilation. Further, a previously developed predicted equation using  a log linear multiple regression model was used for understanding the likely household concentrations experienced by the women dwelling in different type of rural household which may be applied in future to generate exposure response for the development of COPD.
Background (max 200 words): COPD is the 4th leading cause of death and 13th leading cause of burden of diseases worldwide with projected increases in its contributions over the next decade. Active smoking is the major risk factor for COPD. Other risk factors include air pollution, passive smoking, heredity etc., More recently exposure to biomass smoke resulting from household combustion of solid fuels has also been identified as a risk factor for COPD. Solid fuel combustion results in high levels of pollutants like respirable particulate matter, carbon monoxide, oxides of nitrogen and sulphur, formaldehyde, benzo(a)pyrene and benzene which are a  major source of  respiratory irritants in the etiopathogenesis of COPD. Evidence from recent studies which have made contributions to examining temporal, spatial, or multi-pollutant patterns, in addition to day-to-day or seasonal variability in household concentrations,  show that persons in solid fuel using settings experience extremely high levels of noxious pollutants. Moreover, WHO’s Comparative Risk Assessment estimated that about 650,000 premature deaths of women from COPD and lung cancer occurred as a result of these exposures. Despite the importance of this disease, the fact is that the prevalence of COPD is not well measured is due to the uncertainties in the prevalence estimation.
Objectives (max 100 words): The primary aim of this cross sectional study was to estimate the prevalence of COPD among the rural women above 30 years through a primary household level, clinical and spirometric assessment. The secondary objective was to explore the different household level variables that may influence the development of COPD. The additional objective was focused at understanding the likely household concentrations experienced by the women dwelling in different type of rural household which may be applied in future to generate a exposure response for the development of COPD.
Methodology (max 400 words): This cross sectional study was conducted among 900 women from 45 different rural villages in Tiruvallur, a rural district in the state of Tamilnadu in India. The study was approved by the Institutional Ethics committee and was conducted between January and May 2007. The study subjects were selected through cluster sampling using probability proportion to size criteria.  This approach resulted in the selection of 45 out of 612 small villages with populations less than 10,000 in Tiruvallur district. The selection criteria included women aged 30 yrs and above who have been residents of the villages in Tiruvallur District for a minimum period of five years who did not report a history of bronchial asthma, pulmonary tuberculosis, cardiac diseases, pregnancy, diabetes and cancer. Informed written consent was obtained before recruiting any person into the study.  Then, the questionnaire was administered that collected information on known risk factors for COPD, details on type of fuel, duration of cooking etc. A detailed clinical history on respiratory symptoms was also obtained.  All symptomatic women were then subjected to pulmonary function tests. COPD cases were diagnosed based on the three criteria given by the GOLD diagnostic guidelines. Pulmonary function test was performed following American Thoracic Society guidelines using a portable data logging Spiro meter (MIR Spirobank).  This test was performed in a sitting position and the subject was then asked to inhale completely and rapidly and exhale maximally until no more air can be expelled while maintaining an upright posture. The same was repeated for a minimum of three manoeuvres and not more than eight was done for acceptability and repeatability. A complete flow-volume loop was obtained from the Spiro meter. The data were compared with individual predictive values based on age, sex, body weight, standing height and interpreted to arrive at the diagnosis. Spirometry with broncho dilation testing after inhalation of 200 µg of Salbutamol, was carried out in order to confirm COPD. Statistical analysis was performed using “R” Version 2. Prevalence was expressed in terms of percentage. Logistic regression analysis was performed to examine the association between selected risk factors and COPD. The Odds Ratios were calculated. Further, a previously developed predicted equation using  a log linear multiple regression model by Santu Ghosh  et al 2011 that predicts household level concentrations in relation to the household level determinants was assigned to the solid fuel and the clean fuel using households of the study population.
Results (max 400 words): The overall prevalence of COPD in this study was found to be 2.44% (95% CI 1.43- 3.45). COPD prevalence was higher in solid fuel users than the clean fuel users 2.5% vs 2 %, (OR 1.24; 95% CI 0.36 – 6.64) and it was two times higher (3%) in women who spend 2hours/day in the kitchen involved in cooking. Logistic regression analysis was performed to examine the association between COPD and use of solid fuel for cooking. Logistic regression analysis has shown increased risk of COPD in women using solid fuel for cooking, in older women, in women involved in cooking for longer duration, in women living in kutcha houses, and in women with history of passive smoking, though not significant. The concentration of particulate matter (PM2.5 ) of solid fuel using households was found to be 237.4 µg/m3 which was significantly higher than the households using clean fuel (50 µg/m3)
Conclusion (max 400 words): Accurate prevalence information is vital for several reasons such as documentation of COPD’s impact on the morbidity, mortality and economic burden and also for public health planning. This population based cross-sectional study used a meticulous diagnostic approach for the identification of the COPD cases, including a complete clinical evaluation with spirometry before and after bronchodilation, and estimated the COPD prevalence in a non-smoking rural women population primarily using solid fuel. The estimates generated in this study will contribute significantly to the growing database of available information on COPD prevalence and to refine the attributable burden of disease estimates. Besides, this information will help researchers to monitor trends, including the success or failure of control efforts. Moreover, this study has incorporated a previously developed model to assign exposure status in terms of quantitative value for  the categorical variables namely solid fuel and clean fuel using households of the study population which in turn may be applied to generate exposure response relationship with relevant to the development of COPD.

Strengthening Health Systems for Improved Access to Health Services for Pregnant Women in Rural Areas: Nigeria

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Author(s): Chioma Nwuba1, Umoh Mary1, Lawal Salimat2, 3Livinus Ibiang
Affiliation(s): 1Management Sciences for Health, Kwara, Nigeria, 2Kwara State Ministry of Health, Nigeria, 3Management Sciences for Health, Abuja, Nigeria
1st country of focus: Nigeria
Relevant to the conference theme: Redesigning health services
Summary: In Nigeria, the uptake of Prevention of Mother to Child Transmission (PMTCT) services for HIV positive women remains notably low despite significant advances in HIV/AIDS care and treatment. The burden of traveling long distances from their villages and waiting for long hours in order to access treatment has resulted in a most pregnant women opting out and this poses a barrier to the effective implementation of PMTCT programs. Thus, strengthening of health systems is vital in addressing these challenges of limited health service that prevent large numbers of HIV positive pregnant women in rural communities from accessing care and treatment services.
What challenges does your project address and why is it of importance?: Eligibility for antiretroviral therapy (ART) for the over 360,000 children and 1.6 million women living with HIV in rural areas in Nigeria is based on absolute CD4 count. This laboratory investigation is only available once a week on clinic days making it difficult for the vast majority of children and pregnant women who test positive on non clinic days to have access to baseline CD4 estimation. In addition, the burden of travelling long distances to and from clinics for initial blood draw and receipt of test results has led to attrition in the number of pregnant women who test positive to HIV versus the number who eventually commence antiretroviral therapy.. Furthermore, shortage of human resources for health also made it difficult to have enough workers attend to patients promptly. Patients have to wait for the few available doctors who are already overburdened by huge workloads to fill laboratory and pharmacy request forms before accessing laboratory investigations or collecting their antiretroviral drugs.
How have you addressed these challenges? Do you see a solution?: In order to increase uptake of CD4 monitoring for pregnant women attending HIV care and treatment clinics in North Central, Nigeria, the USAID funded PrO ACT project of Management Sciences for Health, strengthened existing systems using the following data driven interventions: 1. Provided hands-on facility based capacity building on HIV rapid testing for antenatal and maternity clinic staff. 2. Established point of service HIV testing in the antenatal clinics (ANC) and maternity units. 3. Introduced point of care CD4 sample collection for clinics where the laboratory is far from the ANC/maternity unit. 4. Task shifting to data clerks to fill laboratory request forms for CD4 investigations instead of the few available doctors. 5. Bridged the gap in human resources for health by task shifting to laboratory technicians on the use of automated CD4 equipments after consistent onsite training and supervision. 6. Adopted a flexible duty roster which ensures that a staff is always available every working day to attend to clients. 7. Task shifting to pharmacy technicians and assistants to assist in dispensing drugs daily. 8. Initiated daily (Monday – Friday) access to CD4 investigations for all pregnant mothers in order to capture women who test positive to HIV on non clinic days and ensure that they have access to baseline investigations on the same day.  9. Establishing daily investigations to provide an opportunity for pregnant women attending clinics from long distances and difficult terrains to have access to laboratory and pharmaceutical services on any day of the week. 10. Instituted 24 hours turnaround time for receipt of CD4 test results for all pregnant women to ensure rapid initiation of eligible clients on ART. 11. Harmonized patient appointments for antiretroviral drug pick up and laboratory monitoring on the same day in order to improve adherence to clinic appointments.  12. Integrated ART laboratory into existing general laboratory ensuring that the same phlebotomy point is used for all clients irrespective of their HIV status.
How do you know whether you have made a difference?: At the end of 12 months, the number of HIV positive pregnant women who accessed baseline laboratory CD4 investigations at our comprehensive care and treatment clinics increased from 53.8% to 90%. In addition, the number of pregnant women placed on antiretroviral therapy increased from 50% before the initiation of our interventions to 83% after the interventions. Laboratory turnaround time for CD4 result, which used to be 7 days, has reduced to 24 hours resulting in rapid initiation of eligible patients on antiretroviral therapy. Average client waiting time on clinic days reduced from 4 hours to 1 hour 30minutes resulting in more pregnant mothers being willing to access care and treatment services at our clinics. Furthermore, the number of patients lost to follow up reduced from 58.7% to 10.7% at the end of twelve months. More importantly, after the intervention, the number of exposed infants who tested negative to HIV increased from 85% to 100%.
Have you or the project mobilized others and if so, who, why and how?: The successes recorded after strengthening health systems for effective delivery of HIV care and treatment services at our pilot treatment center (Specialist Hospital Offa) prompted us to implement these strategies at two other treatment centers in Kwara state (General Hospital, Omuaran and Children Specialist Hospital, Ilorin).  At each clinic, we held a sensitization meeting with the hospital management committee, community leaders, health workers, community women groups and other relevant stakeholders. At these meetings, we presented data on the prevalence of HIV in each community as well as the number of women who tested positive to HIV since the inception of the program. We went further to highlight the number of HIV positive pregnant women who did not commence ART or were lost to follow up . Data concerning the high rate of under five mortality in these communities were also discussed.  Thereafter, working as a team, participants at the meetings made suggestions as to why most women who are diagnosed with HIV do not access treatment or are lost to follow up. Some of the suggestions made include ignorance about mother to child transmission of HIV, distance and difficult terrains of some communities, long waiting time encountered by most patients at the clinics, stigmatization by health workers, long turnaround time for laboratory results, different appointment days for laboratory investigations and drug pick up etc.  Possible solutions were then proffered by each group present. The women’s group agreed to have community health talks regarding HIV transmission given at their meetings. The hospital management committee introduced the idea of having more than one clinic day in a week. Working in collaboration with the Kwara state Ministry of Health we assisted in building the capacity of available health workers and adopted task shifting approaches to address the shortage of health workers. The capacity of data clerks and nurses were built up to enable them to fill laboratory and pharmacy request forms thereby reducing client waiting time and alleviating the workload on the few available doctors.  The laboratory unit instituted “same day CD4 system” ensuring that CD4 investigations are done five working days of the week for all patients who test positive to HIV. Test results are also released on the same day to ensure rapid initiation of eligible patients on antiretroviral therapy. Appointment days for laboratory investigations and drug pick up were harmonized to improve adherence to clinic appointments.
When your donor funding runs out how will your idea continue to live?: At the inception of this program, we strengthened the capacity of health sector institutions, systems and personnel to plan and manage the delivery of sustainable comprehensive and quality prevention, care and treatment support services. To also ensure that the program continues to survive and succeed even after our donor funding runs out, we instituted the following measures• Each hospital management committee drives the program and makes independent decisions necessary for the delivery of quality services. • On the job trainings facilitated by each unit head is held for incoming new staff on HIV rapid testing, filling of laboratory and drug request forms, use of automated equipments for laboratory investigations, ARV drug dispensing, adherence etc. This will ensure that more trained health workers are available to attend to patients.• At the laboratory unit of each clinic, quality assurance meetings led by the heads of each unit are held to address issues relating to improvement in the quality of services provided.• The idea has a 100% buy in from the state government as we neither employ nor pay the salaries of health workers working in the hospitals. The state government does so.