Edwin Bolastig, Yoko Laurence and Karen Pierre Centre for Health Sciences

1. Case Study on the Integration of HIV/AIDS Services in Trinidad and Tobago into Maternal, Newborn & Child Health Services, as well as Sexual and Reproductive Health Services, including Family Planning Edwin Bolastig, Yoko Laurence and Karen Pierre Centre for Health Sciences University of Trinidad and Tobago Funded by: Pan American Health Organization/ World Health Organization

2. OBJECTIVES OF CASE STUDY • To contribute to the body of work on health services integration • To determine: “how vertical programs and Global Health Initiatives have impacted on the health system, and affected segmentation/fragmentation”

3. TRINIDAD AND TOBAGO: • Southernmost Caribbean country • Independence 1962; Republic 1976 • Parliamentary democracy • Multi-ethnic population: 1.3M • Oil and gas-based economy • GNI per capita (09):US$ 17,884 • 10-year GDP growth(99-08): 7.7% • Epidemiologic shift: CNCDs over 60% of deaths

4. CONTEXT • First HIV case diagnosed in 1983 • 8th leading cause of death in 2004 • STI-HIV co-infection prevalence rate: 42% (60% M ; 40% F) (Buensuceso, 2008) • HIV/AIDS cause enjoys strong political support • World Bank loan, EU grant, CARICOM PANCAP, government, private sector funding • SOCIAL DRIVERS: • Poverty and unemployment • Gender inequality/domestic violence • High mobility: Caribbean diaspora • Stigma and discrimination • Multiple sex partners/Early initiation • Substance abuse/unprotected sex • (UNAIDS , 2005) • ECONOMIC DRIVERS: • Inequitable income distribution • Sex work due to poverty • Rapid urbanisation • Limited skills and poor socialisation • Sex-oriented tourism • (Camara, CAREC, 2002)

5. BROAD SECTORAL CONTEXT • 1986 – National AIDS Programme • 1993 – Caribbean Charter on Health Promotion • 1996 – Health Sector Reform Programme (HSRP) National Health Promotion Plan • 2001 – Health Promotion Council; Directorate of Health Promotion and Public Health • 2004 – National AIDS Coordinating Committee (NACC) • 2005 – Vision 2020 • 2006 – MOH Corporate Plan (2006-2009)

6. SEGMENTATION/FRAGMENTATION • Decentralisation of health service delivery to RHAs with the exception of Vertical Programmes and Services • Fragmented human resource management • Dual employment system • Information and medical records management largely manual • Unstructured referral system

7. HIV INTEGRATION INITIATIVES • Integration with Maternal and Child Health - PMTCT • Integration with STI and Family Planning - VCT • Integration with Population Programme - PITC • Integration with Chronic Disease Care • Tobago Health Promotion Clinic (THPC) • Integration of Treatment with Prevention – San Fernando General Hospital • Integration of Information Systems for HIV/AIDS • TERIDA Project

8. EMERGING MODELS Three (3) Emerging Models of Integration: • Standalone outpatient HIV/AIDS clinic integrated with chronic disease care (Tobago Health Promotion Clinic) • Hospital-based HIV/AIDS testing and treatment centres – adult & paediatric (San Fernando General Hospital) • Satellite network of multi-tiered hospital based and outpatient health facilities

9. MODEL 1 – Stand Alone

10. MODEL 2 – Hospital Based Testing and Treatment

11. MODEL 3 – Multi-tiered Satellite Network

12. FINANCING – Total TTD 253.5 million 1 USD = 6.29 TTD

13. BENEFITS • Programmes – institutionalisation of PMTCT; integration of VCT with SRH; free ARVs • Resources - high levels of funding for HIV/AIDS also used for MCH, STIs and FP • Processes - shift from a programme approach to institutionalisation of interventions • Intermediate products – build capacity of committed health personnel • Outcomes – increased HIV testing among mothers; improved efficiency in some areas; community outreach

14. TWO SCHOOLS OF THOUGHT ON INTEGRATION: Strengthening of services as pre-requisite to integration vs. Integration as means to improve services

15. LESSONS LEARNT Facilitating factors: • Role of advocates and champions in the health system • Perception of strong political support from government • Health promotion (high risk groups and wider population) • Service delivery decentralisation (RHAs) • Increased resources for HIV/AIDS • Expanded role of civil society – “knowledge broker”

16. LESSONS LEARNT Hindering Factors: • Structural and support services – inadequate infrastructure, human resource shortages, weak reporting and referral systems • Socio-cultural – breach of confidentiality, S&D, territorialism, lack of accountability • Policy and legal environment – lacks policy framework for zero tolerance to S&D, non-adherence to protocols/SOPs

17. AREAS FOR IMPROVEMENT • Socio-cultural • Health workforce • Service delivery • Systems interventions • Policy and legal environment

18. CONCLUSIONS • Resources for HIV/AIDS supported integration of HIV services with other health programmes such as Maternal and Child Health • GHIs did not seem to have undermined national planning and policy development process • Integration process aligned with national priorities, along existing mechanisms for coordination