Strengthening Community and Health Systems for Quality PMTCT: Applications in Kenya, Nigeria, South Africa, and Ethiopia

This 12-page report by Pathfinder discusses experiences as well as recommendations based on programmes for prevention of mother-to-child transmission (PMTCT) of HIV. According to the report, barriers to implementing programmes for PMTCT in resource-limited settings fall into common biomedical, behavioral, and structural categories. In addition to a lack of access to quality PMTCT services at the clinic level, community-level factors such as stigma, adverse gender dynamics, low support for HIV testing, antenatal care (ANC), and skilled birth attendance, and poor linkages between communities and their facilities all pose challenges to improving PMTCT outcomes. Since 2002, Pathfinder has implemented PMTCT programming globally, using lessons learned to inform implementation of their global PMTCT strategy. This technical brief discusses implementation experience in four African countries, providing recommendations for future efforts to more holistically advance improved PMTCT outcomes in resource-limited settings.

Pathfinder's PMTCT programmes are designed to work from a systems perspective to see the larger picture in which mother-to-child transmission occurs, while allowing flexibility for adaptation at the implementation level. To support long-term positive health outcomes, the strategy addresses health system and community factors that drive poor HIV and maternal and newborn health (MNH) health outcomes. At the health systems level, the global strategy works to reduce stigma within facilities and institutionalise rights-based care through quality service standards that emphasise full integration with MNH services, provider-initiated opt-out testing, risk reduction, male involvement, on-going care for mother and infant, and support for safe breastfeeding. At the community level, the strategy places particular emphasis on mitigation of the drivers of HIV vulnerability and barriers to PMTCT service uptake. This includes working to empower women, supporting them to create enabling environments for their and their families’ health and security throughout the PMTCT continuum. In Africa this has included community and health system collaboration in Nigeria, addressing adverse gender dynamics in Kenya, improving quality through dedicated service delivery models for youth in South Africa, and expanding coverage through engagement of frontline workers in Ethiopia.

Some communication related highlights from the report related to implementation include the following.

• In Nigeria, the programme first reached out to local community leaders via existing community-facility co-management committees to establish links to women in the community. Religious leaders, facility managers, and project staff developed an approach to bring skilled care to women at venues already deemed safe by the community - in the religious leaders' homes. Across the catchment areas of the projects' 79 facilities, religious leaders called community meetings in which male community members and facility managers collaboratively discussed known challenges to desired MNH and PMTCT outcomes, allowing both parties to gain a deeper understanding of the social and epidemiological factors in their community. Maternal and child health (MCH) nurses began routine service days twice a month in leaders’ homes, enabling women to receive HIV rapid testing and counseling, ANC, and birth planning, as well as offering a chance to learn and discuss together how best to care for themselves and their children.
• In Kenya, the project began by working at the community level to improve men’s support of women’s clinic attendance. Male peer educators (called "male champions") were first organised to conduct targeted outreach to community leaders. During regular gatherings and specialised events throughout facility catchment areas, leaders began to emphasise the need for families to learn their HIV status together, discuss and plan for pregnancy together, and adhere to MNH and HIV treatment services. This community-level messaging was accompanied at the clinic level by proactive outreach to female clients. Women received invitation cards from their providers, to help them with proposing that their partners become more involved. At the community level, the project approached HIV-positive women in the community for training as peer mothers. Once prepared, these mothers began outreach within their communities to bring women with HIV together for dialogue, education, and resource networking.
• In South Africa, Pathfinder expanded its programmatic portfolio to include capacity building for youth-friendly PMTCT services within public clinics. To ensure the intervention addressed the wide range of life experiences of the facilities' youth populations, the effort began at the community level with the recruitment of peer educators, training them to address a broad spectrum of SRH needs, from prevention of HIV and unintended pregnancy, to birth preparedness, treatment adherence, exclusive breastfeeding, and social support. At the facility level, Pathfinder prioritised capacity building. To address needs for quality improvement, the project provided technical assistance to improve facilities' data collection, monitoring, and analysis skills. Through trainings and supportive supervision, staff established routine performance reviews to institute regular, collaborative data analysis to monitor quality and identify areas for improvement.
• In Ethiopia, the programme's first priority was to leverage its existing community-facility linkages for immediate improvement in identification and coverage of pregnant women’s needs. As part of this initiative, the project supported providers at the health centre level to conduct routine backstopping visits to health posts, ensuring service quality through supportive supervision, commodities maintenance, and provision of other services as needed. To generate sufficient community demand for services leading up to these days, Health Extension Workers (HEWs) and community health workers conducted targeted outreach, identifying pregnant women and encouraging all women of reproductive age to attend. The project also supported health centres to address cultural barriers to institutional delivery. Traditional rites and ceremonies were an important part of birth for many families in Ethiopia, and were exclusively administered by traditional birth attendants (TBAs) at the community level. To support facilities' integration of these rites, the project facilitated collaboration between facility staff and TBAs, training providers to safely integrate TBAs into delivery ward procedures and conducting outreach to TBAs to build their awareness of pregnancy risk signs and support for HIV-positive women's institutional deliveries.

Through on-going efforts to advance health outcomes for women, babies, and families, several key lessons have emerged. Recommendations based on these lessons are outlined below:

• Integration of PMTCT within MNH means value for women and donors: In Ethiopia and Northern Nigeria, where HIV prevalence is low, but population is high it has allowed for improvements in critical service uptake for women and children with and without HIV. In South Africa, youth-friendly PMTCT that addresses SRH and MNH has provided youth with a host of needed services delivered in an integrated, non-stigmatising manner. Strengthening this package of interrelated services bolsters health systems’ ability to apply limited resources to quality improvement for women and girls, mothers, babies, dads, and families overall.
• Community-facility collaboration mechanisms are building blocks for improvement: Structured communication between facilities and communities is a key ingredient for PMTCT improvement, whether through formal governance bodies, as in Nigeria’s co-management committees, or linked operations, as in Ethiopia’s PMTCT backstopping system and Kenya's peer mother support groups. Beyond improving services, dialogue between communities and facilities enables the development of relevant, sustainable solutions to the myriad barriers blocking women's access and adherence—solutions that are particularly important when funds are low. Pathfinder’s programmatic experience indicates that this is an important area for further donor and government attention. By restricting funding coverage to primarily clinic-based interventions, many governments and donors have limited PMTCT programmes' ability to implement components that are essential to effective community-facility collaboration. National policies and donor guidelines must support and expand community-facility linkages if PMTCT efforts are to overcome local barriers to improvement.
• Women's empowerment is a foundational component of PMTCT: The barriers women experience at the community level lie fundamentally in ill perceptions of their right to understand and act in their own self-interest. From community leaders to male partners and mothers-in-law, the perception of women's lack of power translates to very real structural and even physical barriers to positive health outcomes. Perhaps most importantly, women’s own belief in their lack of power creates formidable barriers not only to their health, but to their overall security and the security of their children. By helping women to organise, creating supportive peer networks for women’s collective sense of agency, and engaging community stakeholders to understand the relationship between women’s self-determination and family health outcomes, PMTCT programmes can address this critical gender dynamic.
• Data systems must be capable of tracking the full PMTCT care cycle: PMTCT programmes require data systems capable of individual tracking to make meaningful, mid-course corrections within a project lifecycle. This is particularly important given the nature of PMTCT programming — where a woman’s adherence is critical not only from the antenatal to immediate postpartum periods, but up to 18 months following birth to ensure the health of the mother and baby. As the majority of national health information systems are currently unable to track individual client service uptake, the responsibility falls on facilities to devise means of tracking, or risk inability to ensure adherence. Pathfinder projects have innovated to address this need, through individual follow-up by peer educators and improved inter-facility processes. However, limited resources preclude a comprehensive strategy to address this challenge. Donors and policymakers can play a decisive role in addressing this situation, by supporting monitoring systems capable of capturing this critical information.