Exploring a diagonal approach - Integrating antiretroviral treatment into primary health care

Exploring a diagonal approach - Integrating antiretroviral treatment into primary health care

Programmes aimed at fighting single diseases have helped many, but they have also weakened public health systems. This does not have to be the case. According to Thomas Gass who published an article in individual disease programmes can help to develop the capacity of primary health care systems.

ART has had a huge impact on African families, communities and society as a whole. Now that treatment is available, more and more people are ready to learn more, to talk about HIV, to protect themselves better and to show up for testing and counselling.

In parallel with this good news, a controversial debate has emerged on the drawbacks of the MDG approach and on global health policy in general. Yet critics argue that HIV/AIDS interventions absorb too big a share of the resources allocated for improving health. According to a report jointly published by the World Health Organization (WHO), the Organisation for Economic Co-operation and Development (OECD) and the World Bank, 32% of all official development assistance for health since 2000 has been spent on HIV/AIDS intervention. Some countries in sub-Saharan Africa, including Kenya and Uganda, spend more than half their health budgets on alleviating HIV/AIDS.

In 2005, SolidarMed started running an HIV/AIDS treatment and prevention programme called SMART in ten district sites in Tanzania, Mozambique, Lesotho and Zimbabwe. The organisation learned that the key to fighting HIV/AIDS was to build the capacities of local health systems -– it does not work the other way round. Certainly, managing HIV/AIDS requires money for drugs, but what’ is much more important is a strong health workforce, reliable health services that reach out to rural communities and adequate district health management capacities.

In an effort to mitigate the drawbacks of vertical health programmes, SolidarMed pursued three strategies:

  • It integrated SMART into existing SolidarMed primary health care programmes and long-standing hospital partnerships.
  • It harmonised SMART with existing HIV/AIDS programmes and brought it in line with national health policy. From the beginning, SMART was designed to complement government ART programmes and to be in line with national policy on HIV/AIDS. In memorandums of understanding, SolidarMed and district health authorities defined the terms of a harmonised and multi-stakeholder approach.
  • It used some of SMART’s budget lines to strengthen capacity. A number of budget lines are earmarked for general capacity building interventions, such as infrastructure and salary top-ups, that are not specifically related to HIV/AIDS services.

As a result, SMART pursues a ‘diagonal’ programme approach – one where ART-specific interventions are embedded in wider primary health care support. However, as the following examples show, the SMART project has been a learning experience for SolidarMed, and there have been adverse as well as positive effects on local health systems. (, 28 Mai 2011)

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