Learn from scale-up of HIV services

In the past decade, Kenya’s health indicators have improved significantly following reversals associated with the negative impact of the economic challenges and subsequent health sector reforms in the 1980s and ’90s structural adjustment programmes and the concurrent HIV epidemic.

Overall life expectancy increased from 53 years in 2003 to 67.5 in 2018, mainly attributable to improvement in management of critical infectious diseases such as malaria, tuberculosis, HIV and maternal, newborn and child health services.

With over a million Kenyans receiving high-quality antiretroviral therapy (ART), the success in HIV prevention and treatment has seen a total reversal of the catastrophic impact of the disease on families and communities experienced in the mid- to late 2000s.

The universal health coverage (UHC) agenda is under Goal 3 of the Sustainable Development Goals — ensuring healthy lives and promoting well-being for all. Target 3.8.1 emphasises access to quality health services without risking financial hardship.

The breathtaking scale of ambition to provide high-quality preventive, promotive, curative and rehabilitative health services to all is, perhaps, only comparable to the successful concerted global efforts in addressing the daunting challenge posed by the HIV pandemic.

It is only natural that that informs national and county government policies and processes to bring UHC to scale.

Critical to the success and sustainability of UHC is a functional and responsive health system — defined broadly as the people, institutions and resources required to improve, maintain or restore the health of a population.

An increasingly resilient and sustainable health system that is largely independent of external funding, prioritises local population health needs, is co-ordinated and aligned with national priorities, and can maintain and build on current successes while evolving to accommodate growing expectations and health needs of the Kenyan population, is necessary.

Globally funded local health programmes have largely succeeded despite significant and persistent challenges.

But they spent significant resources on strengthening components of the health system, leading to parallel disease-specific silos to bypass real or perceived bottlenecks.

This continues, with, for instance, significant resources spent on hiring thousands of frontline HIV service providers and in providing HIV-specific laboratory services in Kenya.

National and county health governance structures should coordinate and harmonise these processes.

Secondly, standardisation of service delivery systems has been critical for successful population coverage of HIV services.

Prioritising evidence-based interventions has been crucial in achieving population coverage of cost-effective and impactful HIV services.

Evidence-based, disease-specific guidelines and policies are important, as such clarity will help to improve trust, minimise differences in quality of disease management and increasing capacity to provide quality services across both private and public spheres.

Thirdly, setting goals and monitoring progress was important in defining measures of success and providing milestones that spurred early HIV control efforts.

The World Health Organisation’s “3 by 5” initiative in 2003 aimed at starting three million people in low- and middle-income countries on life-prolonging ART by 2005, an ambitious target with virtually no systems to deliver chronic care services necessary for long-term treatment.

In Kenya’s UHC journey, setting targets and measures of progress will ensure effective prioritisation of interventions, resource mobilisation, demand creation and management of expectations.

Finally, one of the great lessons of the scale-up of HIV services has been the role of patient populations in advocacy and ensuring accountability.

Community engagement in UHC is desirable, particularly because of the weaknesses of the health system.

Active and systematic engagement of the population will drive demand for improvements of the system and increased uptake of services.

The UHC is both a process and an end in itself, with many steps on the way which could be transformative for population health and developmental impact.

The 2019 Maisha HIV/Aids Conference, to be held Thursday and Friday at the Kenya School of Monetary Studies, Nairobi, with the theme “Leveraging the HIV response to accelerate impact for UHC”, will allow us to take stock of lessons learnt in our being part of what has been one of the most remarkably successful public health interventions in history.

Prof Ojoo is a former Kenya country director for the Centre for International Health, Education and Biosecurity (CIHEB) at the University of Maryland, Baltimore, USA. Dr Mochache is a programme director at CIHEB Kenya.