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Rachel Chapman, Ph.D. University of Washington, Seattle Department of Anthropology A Piece of the Action: Winning the Fight for Access to Women in the.

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Presentation on theme: "Rachel Chapman, Ph.D. University of Washington, Seattle Department of Anthropology A Piece of the Action: Winning the Fight for Access to Women in the."— Presentation transcript:

1 Rachel Chapman, Ph.D. University of Washington, Seattle Department of Anthropology A Piece of the Action: Winning the Fight for Access to Women in the HIV/AIDS Epidemic in Africa

2 2013: Conferência Género e Pluralismo Terapêutico Acesso das Mulheres ao Sector de Saúde Privado em África Urgent work in a complex moment… How did we get here? When did public health care get so private?

3 Recent Roots 1960s-1970s: Primary Health Care (PHC) Movement goes GLOBAL 1975: WHO recognizes traditional healing as important and valuable 1978: Alma Ata Conference – Primary Health Care Concept Health For All by 2000

4 Primary Health Care (PHC) Concept Low technology Appropriate technology Rural based Prevention Local providers Health care is a right

5 African Independence Movements Nationalization of Health, Land, Production Health for All as symbol of social transformation

6 1980s – Present Market Fundamentalism and Austerity Neo-Liberal Economic Policies (Reagan, Thatcher) Characterized - Free market, de-regulation Implemented - Economic Restructuring –Structural Adjustment Programs (SAPs) –Debt Repayment/Foreign Investment –Erosion of social safety nets –Privatization (water, oil, education, health…) PHC problems financing

7 1993: World Bank “Investing in Health” 1) Health = commodity International health care = business 2) Justification = Irresponsible debt/consumer responsibility - Cost recovery = FEES - Cost effectiveness = $ saved per intervention, - life measured in work years lost (DALYs) - weighed in relation to GNP 3) Conditions = governance and democracy = global “business managed democracy” (Beder 2004) 4) World Bank surpasses WHO as health policy

8 1980s: Africa, SAPs and Debt Nearly all African countries have unsustainable debt Most of debt caused by global financial policies –Aggressive loans –Changing interest rates (5-7% to 18-22%) –Global subsidies on agriculture decreases value of exports –Increased price of petroleum

9 What follows the gutting, commoditization and privatization of health? Investment in multi-tiered system and growing health inequalities Rollback in primary health care goals and advances Contraction of public services Draining of public resources into private sector (often under the table) Explosion of NGOs, other private providers to fill the gap (civil society discourse)

10 Aid can be a burden: Tanzania, Source: Foreign Policy, Ranking the Rich 2004

11 SAPs weakened national health systems in Africa Ministry of Health budgets slashed causing: Hiring and Salary Caps = Inadequate workforce (numbers, salaries, morale) Poorly maintained and equipped health facilities Inadequate transport, communication Weak procurement and distribution of medicines and supplies, stock ruptures, black market value

12 Global Distribution of Health Workers Selected Countries (WHO minimum 20)

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14 Case Study Privatization, Gender and Health in Mozambique Diverting cash resources in strapped households Need for cash increases micro-exploitation (sex-work, crime) Sapping highest skilled providers fleeing public sector conditions and salary freezes to private practice and NGOs “white follows green”$$$ Unsupervised, unsustainable and uneven care through NGO pet projects, Thriving informal sector “dumba nenge” for drugs, treatments, providers (markets, traveling vendors, moonlighters)

15 Other forms of private care? Professionalization of Indigenous Healers through AMETRAMO and Monetization of services Proliferation of Pentecostal and Zionist churches offering healing without official “fees”, majority of converts poor women

16 AMETRAMO Prices and Treatment List price women out Scanned Ametramo list

17 How does HIV/AIDS “gender” poverty and vulnerability ? Extended families (women) expected to provide care through “economy of affection” and “hidden health care system” Neither can fill in for eroded social welfare institutions. Both give way under pressure of poverty and disease. Zimbabwe

18 Economy of Affection 1.social protection 2. direct face-to-face reciprocities to get things done among family and neighbors 3.informal and largely invisible political economy 4.informal parallel institutions that buffer from the whims of the market and protect from falling into the wide gap left by the weakened and fettered arms of the state under neoliberal economic policy (Hydén 2006) Churches Fostering Rotating labor parties Tithing Collective farms Food sharing Any others?

19 How is austerity gendered? counter-geographies of survival: micro 1.“regrouping …around the pooled resources of households and, especially, the survival skills and desperate ingenuity of women” 2.Hyper-masculinity and the rise of “nightmarish crime and predatory gangs” 3.explosion of male and female sex-work in urban and rural settings

20 UNAIDS 2010 Report on the global AIDS epidemic Despite overall MMR decreases: HIV Played a Major Role in Increasing MMR mostly Sub-Saharan Africa NO SURPRISE …

21 Overlapping Global Shadows Global Maternal Mortality (WHO) Global HIV Infection (UNAIDS)

22 Overlapping Shadows? Global Maternal Mortality (WHO) Global HIV Infection (UNAIDS)

23 HIV and Maternal Mortality (UNICEF Interagency Estimates of Maternal Mortality Levels and Trends: ) Direct: associated increase in pregnancy complications –anemia, –post-partum hemorrhage –puerperal sepsis Indirect : increased susceptibility to opportunistic infections –Pneumocystis carinii – pneumonia, –tuberculosis – malaria.(McIntyre. 2003) Maternal HIV in Sub- Saharan Africa HIV accounts for an estimated 10X increased risk of maternal death, esp. symptomatic women (Moodley, et al. 2011)

24 Early Response: Prevention of Mother to Child Transmission (PMTCT) pregnant women living with HIV in sub- Saharan Africa who received antiretroviral drugs to prevent transmission of HIV to their children: 2005: 15% 2009: 54% Bias: women as Reproducers and Fetal environments

25 Around the world to Mozambique with HAI

26 My Research Project 1.Why don’t women with access to prenatal care get prenatal care? 2.What is the cause of underutilization of public prenatal clinic services? 3.What are all reproductive health options for women in post-war Mozambique? 4.How does inequality get into Mozambican women’s bodies? 5.What are the unexamined costs of Western policies of economic austerity and privatization? 6.What can be done about it?

27 Guro Tambara Chemba Maringue Macossa Sussundenga Machaze Machanga Muanza Cheringoma Chibabava HF Providing HAART (new) 1 (1) PLWHA Registered (%) 2,000 (1) Eligible in HAART (%) 94 (0) HAI/MOH HIV Treatment Expansion Plan through NGO/public sector collaboration

28 Guro Tambara Chemba Maringue Macossa Sussundenga Machaze Machanga Muanza Cheringoma Chibabava HF Providing HAART (new) 2 (1) PLWHA Registered (%) 7,300 (2) Eligible in HAART (%) 600 (1) HIV Treatment Expansion Plan

29 Guro Tambara Chemba Maringue Macossa Sussundenga Machaze Machanga Muanza Cheringoma Chibabava HF Providing HAART (new) 5 (3) PLWHA Registered (%) 18,600 (5) Eligible in HAART (%) 2,500 (4) HIV Treatment Expansion Plan

30 Guro Tambara Chemba Maringue Macossa Sussundenga Machaze Machanga Muanza Cheringoma Chibabava HF Providing HAART (new) 17 (13) PLWHA Registered (%) 36,270 (9) Eligible in HAART (%) 5,250 (9) Children <15 y in HAART (% of those in HAART) 420 (8) HIV Treatment Expansion Plan

31 Guro Tambara Chemba Maringue Macossa Sussundenga Machaze Machanga Muanza Cheringoma Chibabava HF Providing HAART (new) 47 (30) PLWHA Registered (%) 63,390 (16) Eligible in HAART (%) 13,225 (22) Children <15 y in HAART (% of those in HAART) 1,323 (10) HIV Treatment Expansion Plan

32 Guro Tambara Chemba Maringue Macossa Sussundenga Machaze Machanga Muanza Cheringoma Chibabava HF Providing HAART (new) 53 (7) PLWHA Registered (%) 100,490 (25) Eligible in HAART (%) 23,903 (40) Children <15 y in HAART (% of those in HAART) 3,585 (15) HIV Treatment Expansion Plan

33 87 facilities offering HAART (55 March 2008) 180,000 PLWHA registered for HIV care (49% of the infected) (92,600 March 2008) 45,000 in HAART (64% of eligible) (22,000 Mar. 2008, 31% of eligible) All HUs with TB treatment in Sofala and Manica testing for HIV and strengthening of TB screening in PLWHA 202 CPN with PMTCT (156 March 2008) 2009 Treatment Plan Manica and Sofala scale- up through of existing public network Guro Tambara Chemba Maringue Macossa Sussundenga Machaze Machanga Muanza Cheringoma Chibabava CS HCB HR HPC HG Proj.

34 THE PROBLEM - Major loss to follow-up (LTFU): women and exposed infants drop from programs to treat maternal HIV and prevent maternal to child transmission at any step along the “treatment cascade”

35 pMTCT strategy in Mozambique

36 Dueling Hypotheses : Why high loss to follow up rates?  Inadequate counseling  Authorized and unauthorized fees  Poor quality, rude staff  Slow or lost tests  Too many appointments  Poor linkages within programs at the health facility  Cost of transport and inaccessibility of clinics  Drug stock ruptures  Stigma, and discrimination,  Gender conflict, violence  Lack of basic resources, food, social support  Distance and transport fees  Religious, cultural healing beliefs and practices Health Systems contributing factors Structural/Social / Cultural contributing factors

37 BOTH INADEQUATE: WHY? Depoliticize, Individualize, Medicalize High Cost of Austerity Economics Cutting public sector Privatization Cutting services Lay-offs, salary cuts and freezes Selective and vertical interventions Remove price subsidies Fees for services Erodes social safety nets Abolish social security Ignore failed structural adjustment programs (SAPS) Overlook free market fundamentalist cost- shifting to women

38 Costs of Austerity to Women’s Health Macro: Erosion of health system budget, facilities, staff, salaries, basic resources, services, morale Meso: Institution of vertical, selective health programs silo-ing focus and resources from Integrated primary care Micro: destroys social fabric as people eek out survival from overburdened household resources, especially social-reproductive labor of women, violence, crime, corruption as individuals seek to resist impoverishment

39 HIV care and treatment scale up exposes costs of Austerity Economics AIDS-related maternal mortality Health systems failures AIDS-related stigma = tangible consequences of “trickle-down” politics which have immiserated African households and public sectors that serve them

40 New Research Question: What accounts for loss to follow-up? Where are all the pregnant HIV+ women going after they test positive?

41 Preliminary Findings 1.Stigma and fear 2.Domestic violence surrounds negotiation of disclosure, loss of social support 3.food and drug insecurity = new hungers, new conflicts and new markets, new resistances 4.Confusion regarding pregnancy and seropositive status, multiple testing, changing clinics, ghost patients 5.Shock, memory, negotiating identity post-test, failure of counseling

42 HIV testing and treatment complicates women’s access to clinical care.

43 ♀ g arrives for 1 ra pre-natal visit with SMI nurse Day 1 HIV Rapid Test Blood is sent to lab for CD4 test Reception activista opens a chart for ♀ g+ Day 1 SMI activista accompanies ♀ g+ to reception SMI nurse evaluates the urgency of treatment and determines WHO clinical stage (I-IV) Day 1 Reception activista accompanies ♀ g+ back to SMI nurse CD4 count ♀ g+ returns to meet with SMI nurse to get CD4 results ≥ Day 3 I-II Stage III-IV ♀ g+ receives AZT & duNVP > SMI nurse prescribes CTZ and biochemical blood tests ≥ Day 3 Day 4 or 5 TARV committee reviews case to determine eligibility TARV ? Evaluation with a MD or TM (on Fridays only) ~1-4 weeks after diagnosis Social worker gives ♀ g+ the TARV prescription ~1-4 weeks after diagnosis ≤ 250 DOT for the first 14 days of treatment PTVPTV Day 1 no yes Health Center Munhava ♀ g+ PTV Flow At 28 weeks ♀ g+ takes sdNVP Contractions start Labor Starts At Home Duovir (AZT+3TC) DuringlLabor At Hospital Maternity AZT For one week postpartum In The Home Children get: sdNVP & AZT Postpartum Picks up medicines in the pharmacy ~ 1- 5 weeks later ♀ g+ starts 3 phases of adherence counseling with a social worker (takes 1-3 weeks) Phas e 3 Phas e 2 Phas e 1

44 New collaboration: Option B+ (2012 WHO Guidelines) 1.Starting triple therapy ART directly after testing rather than waiting (test and treat)

45 Option A vs. Option B+ Pregnant woman comes to ANC visit Woman tested for HIV HIV chart opened in HIV clinic Draw CD4 CD4 <350 CD4 >350 Counseling visits, clinician visits Start ART Start AZT+sdN VP Draw CD4 CD4 <350 CD4 >350 Stop ART 1 week after breastfeeding Continue ART lifelong Start ART Woman HIV+

46 Benefits of Option B+ 1.simplification of regimen and service delivery and harmonization with ART programs, 2.protection against mother-to- child transmission in future pregnancies, 3.continuing prevention benefit against sexual transmission to serodiscordant partners, 4.avoids stopping and starting of ARV drugs

47 Not enough! Trojan Horse of ART Scale-Up Quality HIV care and services are only possible within context of building strong, sustainable, public sector health systems and securing household ability to generate basic health

48 action agenda: impeded by the conditions of austerity and clears path for privatization “The is clear. To get Millennium Development Goal 5 on track by reducing the contribution of AIDS to maternal mortality, we must prevent HIV infection in women and girls, prevent unwanted pregnancies, expand HIV testing and counseling, accelerate initiation of antiretroviral treatment in pregnant women who are HIV-positive, and strengthen service delivery and integration of HIV care and obstetric services, along with data collection to track progress.” (Motley, et al. 2011)

49 Why do we need a public system to scale-up ART treatment to pregnant women? 1.If health care is a right and should be affordable it cannot also be for profit. 2.The organization, integration and sustainability needed for scale-up cannot be achieved through a patchwork system with different protocols and drug regimes. 3.The majority of impoverished people use the public sector in some capacity despite quality. 4.If health care is a right, a public system has some mechanisms for accountability.

50 Is privatization a risk to the scale-up of ART for pregnant women in Mozambique? 1.Increasing health inequalities in a many - tiered system 2.Demobilization of support from enfranchised and resourced for the disenfranchised and impoverished 3.Resources sapped often under the table from public to private sector (moonlighting, brain drain, informal markets for drugs and services, unauthorized fees) 4.Naturalizes cost shifting from public to domestic sphere through household labor and erosion of labor rights (fees for service, insurance schemes, for-profit NGOs, performance based financing) 5.Blames failure to produce health on consumers and providers

51 Maybe women are not “lost” to follow-up

52 New Commons Women join Pentecostal and African Independent Churches lively worship communities, women’s social and business groups, tithing, visits and prayer for those who are sick at home, communal gardens a range of healing approaches for which they are not asked to pay a fee, Therapy for infertility or multiple infants deaths and chronic illness (HIV?) On site birthing facilities mulheres d’espiritos (wives of spirits) escape the endless cycle of fees and indebtedness acquired while seeking treatment with curandeiros solace and succor Decommodification of healing

53 Global Burden of Absolute HIV Deaths world mapper (2007)

54 Global Public Health Spending – enough said! Worldmapper

55 Action Research Agenda Medical Anthropologists Study Up to Track Cultures of Abandonment and “Zombie Economic Policies”, Who Calls the Shots? Evaluate Alternative Health Resources Track patterns of resort in shifting plural health systems with eye to resistance, human and drug Seek out and advocate for the politics and practices of new commons, social movements, resistance outside the formal economic system revealing global connections for action Pay attention to micro shifting household economies under austerity, and find new measures for the cost of cost shifting Make links between the dehumanizing politics, processes of austerity in Europe, Americas and Africa

56 BASTA!

57 Muita Obrigada! University of Washington Mozambique Ministry of Health Manica and Sofala Provincial DPS Health Alliance International Beatrice Thome James Pfeiffer Wendy Johnson Javelina Aguiar Lucia Lazaro Victoria Porthe


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