2.3 Health care systems

A programme of voluntary counselling and testing, antiretroviral drugs and replacement feeding can only be set up where there is an efficiently functioning health system with certain key services.

Mother-and-child health services, including widely available and acceptable antenatal, delivery and postnatal services, are essential.

And counselling services, family planning services and medical care for HIV-positive women and their children should also be part of the basic health care provision. These services need to be carefully prepared for the integration of the new programme. In particular, steps are required to ensure:

a) easy access and privacy for clients attending services. This will require assessment of the physical environment of clinics, and perhaps rearrangement of activities;

b) continuity of care and a good flow of information between the various units involved in the management of HIV-positive clients;

c) technical supervision of services to enhance quality;

d) opportunities for clients to express their needs and their views.

Where the basic services are already in place and operating efficiently, the cost of providing counselling and testing, antiretroviral drugs and replacement feeding is likely to be well distributed across the health system and relatively easy to absorb. However, in places where the health infrastructure needs considerable strengthening and perhaps even building from scratch to support the new programme, the additional cost will assume greater significance. Since expansion and improvement of the health system benefit the whole of society, it is important that the MTCT programme is not expected to bear an undue and perhaps crippling proportion of the costs and responsibility. If the provision of antiretroviral drugs and replacement feeding is to be sustainable over the long term, the financial burden must be fairly distributed across the health services. Policy-makers should take account, also, of the fact that improvements in access and quality of services have a tendency to increase public expectations of health and therefore the demands on the health services.