Barriers to Antiretroviral Therapy in Malawi: An assessment of socio-economic inequalities

Barriers to Antiretroviral Therapy in Malawi: An assessment of socio-economic inequalities Talumba Banda, Eyob Zere, Bertha Simwaka, Erik Schouten, Ireen NamakhomaREACH TRUST in collaboration with WHO Geneva, WHO Malawi and MoH

Background to the study In Malawi, access to health services free at the point of delivery, The poor benefit less from these interventions, yet high disease burden, [Zere E.,et al.,2007]. Other studies – the poor in Mw wait longer, receive fewer drugs and pay more than the non-poor, [MoHP.,2002b, Kapulula et al.,2001,Kabwazi et al.,2001].

Background to the study cont… the situation would be worse for patients on ARV Qualitative studies - costs, long distances and waiting times are some of the barriers Lack of adherence to ART remains a major challenge to AIDS care with serious public health consequences; treatment failure, development of viral mutations, emergence of drug resistance strains.

Malawi- Brief country profile Mw, small landlocked country in south East of Southern Africa, Shares its borders with three countries namely the United Rep. of Tanzania, Mozambique, and Zambia, Population is about 12 million-1998 NSO population census Health systems context; provision of both preventive and curative health services is free at the point of delivery, However, health care resources are unevenly and inadequately distributed.

Malawi- Brief country profile cont… Only 46% of the population has access to a formal health facility within a 5 km radius, and only 20% lives within 25 km of a hospital. Access is worse in rural- 85% live with higher incidences of poverty as compared to urban. Significantly, there is mal-distribution of the health personnel which favours the urban areas

Malawi- Brief country profile cont… Despite that 85% of Malawians are in rural areas 50% of doctors and 25% nurses are working in the 4 tertiary hospitals based in the 4 cities in Mw, 97% of government employed Clinical Officers and 82% of nurses are in urban areas (MoHP,2003a) . Implicitly, health care resources in many rural could be as little as 10-20% of that required to provide essential health package services Mc Coy, et al.,(2004).

Malawi- HIV and AIDS Situation HIV prevalence rate estimated at 14% (2004, MDHS). Over one million PLWAs and over 500,000 children orphaned because of the epidemic. There are spatial, gender, age, and regional disparities in the prevalence rate of HIV/AIDS; The southern region has a higher prevalence rate than the Central and Northern regions. prevalence rates in urban areas are higher than in rural areas (17% against 11% respectively)

Malawi- HIV/AIDS situation cont… Also, prevalence among the age group of 15-49 is higher in women than men (13% against 10%). Overall, around 60% of adults living with HIV are females and that women are more vulnerable than men. Furthermore, there are more girls infected than boys. Girls in the15-19 age group are 4 times more susceptible to infection than are boys. Similarly, prevalence in the 15-24 age group is 4 times higher in girls than in boys.

Malawi-HIV/AIDS situation cont… It is estimated that about 170,000 people are in need of ART any point in time Currently, the number of people ever started on ART increased from 4000 in 2004 to over 140,000 –2007 Of these 61% are females against 39% males. A 12 month survival analysis for the ART programme show that ; of the patients that initiated treatment in 2007, 78% were still alive and on treatment, indicating the success of the programme, MoH(2007a).

Study Objectives Overall, the study aimed at; analyzing whether any groups of people experience more barriers based on their socio-economic status. Specifically assess inequalities in access to HIV treatment, assess the influence of rural- urban differences in accessing ART.

Study Objectives Policy formulations that attempt to address inequalities in access to ART would ensure sustainability of the ART programme, bring in health interventions that would allocate resources according to worst health status more successful in universal access LIMITATION Data is obtained from those who are already accessing the ART. Those who are not currently accessing are excluded As such, not possible to understand the barriers that they face to access ART.

Study Methods Study setting: Carried out in two districts of Malawi, Lilongwe and Rumphi 947 ART patients interviewed in almost all public ART sites Data collection ART patients interviewed using a structured questionnaire All ART patients who visited the clinic on a randomly selected day were recruited - sample size reached.

Study Methods cont… Data collected on; patient’s socioeconomic characteristics Costs incurred per single visit to the ART facility, distance traveled, Time taken as well as transport mode used Data analysis Analysis done using STATA SE 10.1 PCA was used to determine; the socio-economic status of the patients and classify them into wealth quintiles

Study Methods cont… PCA useful when there exist data on too many variables; want to develop a smaller number of artificial variables (principal components) The first Principle component (PC) has the largest amount of information common to all variables. The first PC was used to develop the asset index based on the following formula:

Study methods cont… • Where: • - Aj is the asset index of the jth household; • f1 is the scoring factor for the first asset determined by • by the procedure • - aj1 is the jth household’s value for the first asset; and • -a1 and s1 are the mean and standard deviation of the first asset variable over all households.

Study methods cont… The scoring factor for each variable is the weight that the variable contributed to the welfare of the household. The PC indicates that assets likely to be owned by better- off households have +ve values e.g. cement floor. Thus a household’s asset index is improved with that asset. Contrary , assets that were owned by poor households had -ve values e.g. unprotected well Thus a household’s asset index decreases by that asset.

Study methods cont… The choice of variables used in the PCA model was based on the Coefficient of Variations (CoF) obtained. Where a CoF <1, the variable was taken not to explain much variation among the households, hence was excluded. Where a CoF > 1, the variable was taken to explain much variation hence included. The asset index was used to categorize the patients into wealth quintiles.

Study methods cont… To achieve the above obectives, the following variables were analysed across wealth quintiles; transport costs incurred, distance traveled, travel time taken, Mode of transport used.

Result 1-Costs and distance to get to the ART facility

Result 2:The influence of rural-Urban residence in access to ART The poorest 20% from the rural, mean distance -23km compared to the poorest 20% urban, mean distance-8km The poorest 20% from rural mean cost of $3.04 compared to the poorest 20% urban mean cost of $1.14 A comparison of the richest 20% from rural and the richest 20% from urban shows; that the costs and distance are higher for those from the rural to those from the urban.

Result 3: Travel time taken to get to the ART facility

Result 4: Mode of transport used to get to the ART facility

Discussion and Conclusion The study findings show that; access to ART services is more costly for the poor particularly the poorest rural populations. ART scale up in Mw has been more favourable towards the better off populations and those urbanized. The current ART scale up system for Mw is a phased ART expansion process ART provision started at tertiary level to primary level but also on a “first come, first served” basis.

Discussion and conclusion cont… However, provision of treatment a tertiary level without strong links at primary level; Favours the higher educated who are not poor (Lowenson and Mc Coy ,2004). This is exacerbated by provision of treatment on a “first come, first served” system. ART being a lifetime treatment; Provision should ensure that patients experience less barriers to treatment to promote treatment adherence

Discussion and Conclusion cont… Mw needs to expand the ART program more at primary level if access to the services is to be more equitable. The more services are provided at primary level , the more equitable the services wider provision of services at the primary level ensures that the services are made within reach for the rural people.

Discussion and Conclusion cont… For example, increase the number of clinics that operate in rural areas through mobile clinics. Furthermore, explore on the provision of transport vouchers to patients who can hardily afford transport costs This would minimize costs incurred by patients Expanding ART access more at primary level would increase the effectiveness of the ART program in Malawi

End of Presentation Thank you for your attention!!!! Special thanks to; WHO Geneva – financial support WHO Malawi- Technical support Ministry of Health Malawi- Technical support

Barriers to Antiretroviral Therapy in Malawi: An assessment of socio-economic inequalities