Journal Article > EditorialFull Text
BMJ Opinion (blog). 2023 September 25; Volume 382; 2205.; DOI:10.1136/bmj.p2205
Bhardwaj V, Philips M
BMJ Opinion (blog). 2023 September 25; Volume 382; 2205.; DOI:10.1136/bmj.p2205
Technical Report > Evidence Brief
Philips M, Bhardwaj V
2023 September 14
English
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Through providing free medical care to people in conflict settings, natural disasters, pandemics, and among people excluded from the health system, MSF teams see first-hand the challenges in accessing healthcare around the world. Our report draws on this practical experience, identifying specific barriers to accessing healthcare for the most vulnerable. We recognize the UNHLM on Universal Health Coverage (UHC) as a key flashpoint on commitments, but we are concerned that the current UHC agenda and most UHC country plans fall short of the ‘Leave no one behind’ principle.
MSF has previously raised concerns about the way UHC targets are developed, with a lack of attention to important barriers to accessing care. In this report we have collected illustrations of problems in getting access to care for the most vulnerable and people in the most critical health situations, such as those in emergencies and crises; migrants and refugees; and people forced to forego essential care because of financial barriers. Through these examples, augmented by the academic and grey literature on financing for UHC, we highlight the real-life and acute gaps between the declared aspirations of UHC and the lived experiences of millions of people. Without action on critical challenges for those without timely and affordable health care, the UHC agenda and country plans will miss their goal and diminish UHC’s credibility.
MSF has previously raised concerns about the way UHC targets are developed, with a lack of attention to important barriers to accessing care. In this report we have collected illustrations of problems in getting access to care for the most vulnerable and people in the most critical health situations, such as those in emergencies and crises; migrants and refugees; and people forced to forego essential care because of financial barriers. Through these examples, augmented by the academic and grey literature on financing for UHC, we highlight the real-life and acute gaps between the declared aspirations of UHC and the lived experiences of millions of people. Without action on critical challenges for those without timely and affordable health care, the UHC agenda and country plans will miss their goal and diminish UHC’s credibility.
Journal Article > ResearchFull Text
Trop Med Int Health. 2010 December 1; Volume 15 (Issue 12); DOI:10.1111/j.1365-3156.2010.02649.x
Bemelmans M, van den Akker T, Ford NP, Philips M, Zachariah R, et al.
Trop Med Int Health. 2010 December 1; Volume 15 (Issue 12); DOI:10.1111/j.1365-3156.2010.02649.x
Objective To describe how district-wide access to HIV/AIDS care was achieved and maintained in Thyolo District, Malawi. Method In mid-2003, the Ministry of Health and Médecins Sans Frontières developed a model of care for Thyolo district (population 587 455) based on decentralization of care to health centres and community sites and task shifting. Results After delegating HIV testing and counseling to lay counsellors, uptake of testing increased from 1300 tests per month in 2003 to 6500 in 2009. Shifting responsibility for antiretroviral therapy (ART) initiations to non-physician clinicians almost doubled ART enrolment, with a majority of initiations performed in peripheral health centres. By the end 2009, 23 261 people had initiated ART of whom 11 042 received ART care at health-centre level. By the end of 2007, the universal access targets were achieved, with nearly 9000 patients alive and on ART. The average annual cost for achieving these targets was €2.6 per inhabitant/year. Conclusion The Thyolo programme has demonstrated the feasibility of district-wide access to ART in a setting with limited resources for health. Expansion and decentralization of HIV/AIDS service-capacity to the primary care level, combined with task shifting, resulted in increased access to HIV services with good programme outcomes despite staff shortages.
Journal Article > ResearchFull Text
Trans R Soc Trop Med Hyg. 2009 June 1; Volume 103 (Issue 6); DOI:10.1016/j.trstmh.2008.09.019
Zachariah R, Ford NP, Philips M, Lynch S, Massaquoi M, et al.
Trans R Soc Trop Med Hyg. 2009 June 1; Volume 103 (Issue 6); DOI:10.1016/j.trstmh.2008.09.019
Sub-Saharan Africa is facing a crisis in human health resources due to a critical shortage of health workers. The shortage is compounded by a high burden of infectious diseases; emigration of trained professionals; difficult working conditions and low motivation. In particular, the burden of HIV/AIDS has led to the concept of task shifting being increasingly promoted as a way of rapidly expanding human resource capacity. This refers to the delegation of medical and health service responsibilities from higher to lower cadres of health staff, in some cases non-professionals. This paper, drawing on Médecins Sans Frontières' experience of scaling-up antiretroviral treatment in three sub-Saharan African countries (Malawi, South Africa and Lesotho) and supplemented by a review of the literature, highlights the main opportunities and challenges posed by task shifting and proposes specific actions to tackle the challenges. The opportunities include: increasing access to life-saving treatment; improving the workforce skills mix and health-system efficiency; enhancing the role of the community; cost advantages and reducing attrition and international 'brain drain'. The challenges include: maintaining quality and safety; addressing professional and institutional resistance; sustaining motivation and performance and preventing deaths of health workers from HIV/AIDS. Task shifting should not undermine the primary objective of improving patient benefits and public health outcomes.
Journal Article > CommentaryFull Text
Lancet. 2007 January 6; Volume 369 (Issue 9555); 10-11.; DOI:10.1016/S0140-6736(07)60008-7
Brikci N, Philips M
Lancet. 2007 January 6; Volume 369 (Issue 9555); 10-11.; DOI:10.1016/S0140-6736(07)60008-7
Journal Article > ResearchFull Text
AIDS Care. 2008 September 1; Volume 20 (Issue 8); DOI:10.1080/09540120701768446
Moon S, Van Leemput L, Durier N, Jambert E, Dahmane A, et al.
AIDS Care. 2008 September 1; Volume 20 (Issue 8); DOI:10.1080/09540120701768446
Financial access to HIV care and treatment can be difficult for many people in China, where the government provides free antiretroviral drugs but does not cover the cost of other medically necessary components, such as lab tests and drugs for opportunistic infections. This article estimates out-of-pocket costs for treatment and care that a person living with HIV/AIDS in China might face over the course of one year. Data comes from two treatment projects run by Médecins Sans Frontières in Nanning, Guangxi Province and Xiangfan, Hubei Province. Based on the national treatment guidelines, we estimated costs for seven different patient profiles ranging from WHO Clinical Stages I through IV. We found that patients face significant financial barriers to even qualify for the free ARV program. For those who do, HIV care and treatment can be a catastrophic health expenditure, with cumulative patient contributions ranging from approximately US$200-3939/year in Nanning and US$13-1179/year in Xiangfan, depending on the patient's clinical stage of HIV infection. In Nanning, these expenses translate as up to 340% of an urban resident's annual income or 1200% for rural residents; in Xiangfan, expenses rise to 116% of annual income for city dwellers and 295% in rural areas. While providing ARV drugs free of charge is an important step, the costs of other components of care constitute important financial barriers that may exclude patients from accessing appropriate care. Such barriers can also lead to undesirable outcomes in the future, such as impoverishment of AIDS-affected households, higher ARV drug-resistance rates and greater need for complex, expensive second-line antiretroviral drugs.
Journal Article > ResearchFull Text
J Int AIDS Soc. 2011 January 5; Volume 14 (Issue 1); DOI:10.1186/1758-2652-14-1
Bemelmans M, van den Akker T, Pasulani O, Saddiq Tayub N, Hermann K, et al.
J Int AIDS Soc. 2011 January 5; Volume 14 (Issue 1); DOI:10.1186/1758-2652-14-1
ABSTRACT: BACKGROUND: In Malawi, the dramatic shortage of human resources for health is negatively impacted by HIV-related morbidity and mortality among health workers and their relatives. Many staff find it difficult to access HIV care through regular channels due to fear of stigma and discrimination. In 2006, two workplace initiatives were implemented in Thyolo District: a clinic at the district hospital dedicated to all district health staff and their first-degree relatives, providing medical services, including HIV care; and a support group for HIV-positive staff. METHODS: Using routine programme data, we evaluated the following outcomes up to the end of 2009: uptake and outcomes of HIV testing and counselling among health staff and their dependents; uptake and outcomes of antiretroviral therapy (ART) among health staff; and membership and activities of the support group. In addition, we included information from staff interviews and a job satisfaction survey to describe health workers' opinions of the initiatives. RESULTS: Almost two-thirds (91 of 144, 63%) of health workers and their dependents undergoing HIV testing and counselling at the staff clinic tested HIV positive. Sixty-four health workers had accessed ART through the staff clinic, approximately the number of health workers estimated to be in need of ART. Of these, 60 had joined the support group. Cumulative ART outcomes were satisfactory, with more than 90% alive on treatment as of June 2009 (the end of the study observation period). The availability, confidentiality and quality of care in the staff clinic were considered adequate by beneficiaries. CONCLUSIONS: Staff clinic and support group services successfully provided care and support to HIV-positive health workers. Similar initiatives should be considered in other settings with a high HIV prevalence.
Journal Article > LetterFull Text
Trans R Soc Trop Med Hyg. 2009 May 1; Volume 103 (Issue 5); DOI:10.1016/j.trstmh.2009.01.012
Zachariah R, Ford NP, Philips M, Draguez B, Harries AD
Trans R Soc Trop Med Hyg. 2009 May 1; Volume 103 (Issue 5); DOI:10.1016/j.trstmh.2009.01.012
Journal Article > ResearchAbstract
Int Health. 2011 May 19; Volume 3 (Issue 2); 91-100.; DOI:10.1016/j.inhe.2011.01.002
Ponsar F, Tayler-Smith K, Philips M, Gerard S, Van Herp M, et al.
Int Health. 2011 May 19; Volume 3 (Issue 2); 91-100.; DOI:10.1016/j.inhe.2011.01.002
Although user fees are a common form of healthcare financing in resource-poor countries, there is growing consensus that their use compromises health service utilisation and population health. Between 2003 and 2006, Médecins sans Frontières (MSF) conducted population-based surveys in Burundi, Sierra Leone, Democratic Republic of Congo, Chad, Haiti and Mali to determine the impact of user fees on healthcare-seeking behaviour and access. For general and disease-specific conditions, MSF also measured the impact of (i) reduced payment systems in Chad, Mali, Haiti and Burundi and (ii) user fee abolition for certain population groups in Burundi and Mali. User fees were found to result in low utilisation of public health facilities, exclusion from health care and exacerbation of impoverishment, forcing many to seek alternative care. Financial barriers affected 30-60% of people requiring health care. Exemption systems targeting vulnerable individuals proved ineffective, benefiting only 1-3.5% of populations. Alternative payment systems, requiring 'modest' fees from users (e.g. low flat fees), did not adequately improve coverage of essential health needs, especially for the poorest and most vulnerable. Conversely, user fee abolition for large population groups led to rapid increases in utilisation of health services and coverage of essential healthcare needs. Abolition of user fees appears crucial in helping to reduce existing barriers to health care. The challenge for health authorities and donor agencies is around working creatively to remove the fees while addressing the financial consequences of improved access and providing quality care.
Journal Article > ResearchFull Text
PLOS One. 2010 May 4; Volume 5 (Issue 5); DOI:10.1371/journal.pone.0010452
Mwagomba B, Zachariah R, Massaquoi M, Misindi D, Manzi M, et al.
PLOS One. 2010 May 4; Volume 5 (Issue 5); DOI:10.1371/journal.pone.0010452
BACKGROUND: To report on the trend in all-cause mortality in a rural district of Malawi that has successfully scaled-up HIV/AIDS care including antiretroviral treatment (ART) to its population, through corroborative evidence from a) registered deaths at traditional authorities (TAs), b) coffin sales and c) church funerals. METHODS AND FINDINGS: Retrospective study in 5 of 12 TAs (covering approximately 50% of the population) during the period 2000-2007. A total of 210 villages, 24 coffin workshops and 23 churches were included. There were a total of 18,473 registered deaths at TAs, 15781 coffins sold, and 2762 church funerals. Between 2000 and 2007, there was a highly significant linear downward trend in death rates, sale of coffins and church funerals (X(2) for linear trend: 338.4 P<0.0001, 989 P<0.0001 and 197, P<0.0001 respectively). Using data from TAs as the most reliable source of data on deaths, overall death rate reduction was 37% (95% CI:33-40) for the period. The mean annual incremental death rate reduction was 0.52/1000/year. Death rates decreased over time as the percentage of people living with HIV/AIDS enrolled into care and ART increased. Extrapolating these data to the entire district population, an estimated 10,156 (95% CI: 9786-10259) deaths would have been averted during the 8-year period. CONCLUSIONS: Registered deaths at traditional authorities, the sale of coffins and church funerals showed a significant downward trend over a 8-year period which we believe was associated with the scaling up HIV/AIDS care and ART.