Public health issues in Asia

Bangkok’s transgender community finally gets the health services it wants

At a HIV conference a while ago I was chatting to one of the other participants, a transgender woman, about why in the HIV world, transgender people are typically lumped in with men who have sex with men. This makes little sense. As my coffee break companion said, with a ‘look at this’ gesture from her high heels, to her fitted dress, all the way up to her long, wavy hair: “In what way does this say I am a man, having sex with men?”

Whilst both gay men and transgender people are known to be at especially high risk of acquiring HIV, for transgender people the risk is far more extreme: 49 times higher than for the general population, in fact. Moreover, they face a degree of marginalization and exclusion from the educational and employment opportunities that men who have sex with men rarely have to grapple with. The lack of a separate ‘key population at increased risk of HIV’ category for transgender people also does nothing to address the lack of data on the HIV epidemic, and what services the transgender community needs, making it difficult to get dedicated funding for HIV programmes for transgender people.

The highly restricted work options for transgender people in many countries see a disproportionate number entering into sex work .What sexual health and HIV prevention services there are tend to focus on transgender sex workers, while stigma and discrimination make the transgender community often extremely difficult to reach with HIV testing, treatment and care services.

Until recently, folding transgender people in with men who sex with men, despite the fact that the two communities have very different needs, was what was happening in Bangkok.

In 2008 the Thai Red Cross AIDS Research Center changed its approach from offering HIV testing to offering anal cancer screening, as a way to get gay men and other men who have sex through the door, and then offer them HIV testing too. It worked: client numbers went up and 80% who came in for anal cancer screening also accepted the offer of HIV testing. Five years on, it was clear that this approach was highly successful in increasing demand for the clinic’s services, but the number of transgender people accessing the clinic remained unchanged. The clinic was missing something if it wanted to appeal to transgender people.

“Through extensive consultations with the transgender community we understood the barriers they face when accessing health services,” Nittaya Phanuphak, Chief, Prevention Department, Thai Red Cross AIDS Research Centre told me. These extensive consultations were with diverse members of the transgender community – including those working as advocates, healthcare providers, within the fashion industry, as well as those working with transgender sex workers – revealed that transgender people face obstacles in accessing hormone level testing and therapy, the most basic health services that they regularly require to affirm their gender identity. What services there are typically are not from transgender-friendly providers, or even worse are provided outside the medical profession entirely.

Hormone therapy services were identified as the entry point to make the clinic attractive to its target population. The Tangerine Community Health Centre opened in late November 2015 and became the first clinic catering specifically to the needs of transgender people in Bangkok. The name was carefully chosen. “We knew the clinic’s name should be one that makes everyone feel comfortable, with nothing that can be considered stigmatizing, Tangerine is a play on transgender, and was chosen because it a fruit that is not too sweet not too sour, just the right blend.

Most of the clients have since come seeking hormone level testing and injections, but they are also offered a package of services including anal and neo-vaginal pap smears, cervical smear tests for transgender men, testing for sexually transmitted infections and a free HIV test (all Thai nationals are entitled to two free HIV tests a year). The centre provides both pre and post-exposure HIV prophylaxis and harm reduction interventions for safe injection.

Funding from USAID covered the costs of the community consultation, start-up, and sensitization training for staff, but services are fee-based, with the cost set at a level that makes them affordable to most clients. As the clinic becomes established, should the fees prove to be prohibitive to some, one option is to introduce a co-pay mechanism, but the aim of the clinic is to be self-financing. A clinic that covers its own costs is a sustainable and replicable role model for other cities trying to close the gap between their transgender communities and HIV services.

Tangerine’s catchment area is Bangkok and it surrounding four provinces, although approximately a fifth of its clients so far have travelled from other provinces to access services and a handful were from overseas. The clinic has a target to see over 400 clients in the first year of operation, with at least 600 consultations. From November 27 2015 to February 23 2016, it had seen 84 male-to-female clients, of whom 61 had received HIV testing, with 11% testing positive. Of the 25 female-to-male clients, 16 had been tested for HIV. Most clients also received testing for syphilis, over half of the transgender women requested hormone level measurement, as did four out of five transgender men.

The Tangerine Community Health Center’s key strengths are its foundations built on extensive community engagement, and its model of integrated health services with a self-sustaining funding model. The clinic’s two transgender staff have also proven essential to ensuring that the clinic continues to offer accessible, transgender-friendly services and remains in close contact with the needs of the community it serves. In time, its usage data will also become an invaluable database of the transgender community’s health profile, overcoming the current invisibility of transgender people in the national AIDS database, and this community’s unique HIV and other health-related needs will be better understood.

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Blogs posted for Asian Development Bank (ADB)

The art of interactive conference for knowledge sharing

 

Published on ADB website on Thursday, 12 November 2015

Written by Susann Roth and Jane Parry

Conferences are a great way to bring like-minded people together in one venue to learn from each other and share ideas. But they can also be deadly dull if they don’t break away sufficiently from the traditional plenary format. Fortunately, the recentConference on Measurement and Accountability for Universal Health Coverage in Asia-Pacific gave participants a multitude of innovative ways to engage with their peers.

ADB jointly organized the event, held in Bali in late October, together with the Government of Indonesia, BPJS Kesehatan (Indonesia’s largest social health insurance provider), the World Health Organization, UNICEF, the Asia eHealth Information Network (AeHIN) and other development partners such as NORAD, the Joint Learning Network, and PATH. During the conference, participants reviewed the current evidence on cost, benefit and impact of ICT-enabled solutions in the health sector, and then set about developing their own set of concrete priority actions to work on in the coming year at the country and regional levels.

A number of plenary sessions brought together high-profile speakers from around the region and beyond. The sessions became interactive with the help of the forum app Pigeonhole, through which the audience posted questions as they arose, and others could then vote on them. As questions bubbled up to the top of the list, the speakers were able to address the issues that most concerned their audience.

There were the usual breakout sessions, with feedback presented to the whole conference, and each group was tasked with a practical goal to achieve. In these smaller groups, national peers decided on the next steps appropriate to their unique circumstances that will help their country use ICT-enabled solutions to reach the goal of universal health coverage and transition their countries health sector M&E frameworks from the Millennium Development Goals (MDGs) to the new Sustainable Development Goals (SDGs).

By using a marketplace format—which is our personal favorite—the conference was able to present 22 different digital health architecture tools and solutions, with participants choosing the ones that interested them the most. Presenters engaged with smaller and strongly interested audiences, showcasing a wide range of innovations, including those for electronic health records, civil registration and vital statistics, geographical information systems, and open-source software solutions for health information systems.

Hearing about how ICT can be harnessed to make health systems interconnected and serve patients better is interesting, but the conference went a big step further.

A live demonstration showed in real time how even fairly basic computers and mobile phones can support existing open-source digital health solutions to deliver better care. Using a scenario of maternal/child health and malaria to illustrate the role for interoperable HIS in continuity of care, the live demo showed how a barcode-based unique health identifier can be created at any point of care. Information can then be shared not only with national databases, but also with other points of care in different locations and over time. Check out this video to learn more about digital health infrastructure.

The conference also got participants out of the meeting rooms with four site visits to a BPJS regional division office; a district hospital that had deployed integrated HIS and BPJS information systems, and two primary care clinics at different stages of implementing ICT-enabled HIS.

As the week drew to a close, it was clear that the transition from the MDGs to the SDGs was an over-arching theme. Whereas the MDGs fostered a silo-ed approach to specific health issues, the health-related SDGs have a clear focus on equity and they demand measurement and accountability for achieving specific targets. Both these factors put the role of ICT at the forefront.

This event was an excellent forum to build a regional response to the global call to action made at the Measurement and Accountability for Results in Health Conference held in Washington, DC earlier this year. Participants left Bali knowing that there was a thriving community of practice that they could draw on for advice and support, and ADB is proudly part of that.

 

 

 

 

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Blogs posted for Asian Development Bank (ADB)

Malaria elimination – a public health best buy

 

Published on ADB website on Monday, 12 October 2015

Written by Susann Roth and Jane Parry

Despite the many successes across Asia and the Pacific in reducing the incidence of malaria, the disease continues to be a heavy burden for many countries, with an estimated 2.2 billion people at risk in the region. Growing resistance to simple-to-use, effective malaria drugs and sub-optimal delivery of malaria treatment, in particular for mobile and migrant populations, are both widespread throughout the Greater Mekong Subregion (GMS). Lack of timely and comprehensive disease surveillance and inadequate cross-border and multi-sectoral cooperation are also serious obstacles to malaria elimination. Together, they threaten to undo all the progress to date toward elimination of this public health menace. Any serious effort to tackle malaria and other communicable diseases must thus start from this understanding: these diseases thrive in the face of weak health systems, and they do not respect national boundaries. Malaria has long been on ADB’s radar as a threat to regional prosperity and security, and our efforts to support countries striving to eliminate malaria received a significant boost when the Regional Malaria and Other Communicable Diseases Threats Trust Fund (RMTF) was set up in December 2013 to support developing member countries create multi-country, cross-border and multi-sector responses. To date, the RMTF has pooled over $28 million in resources from multiple donors, among them Australia, Canada, and the United Kingdom. Over $19.5 million in technical assistance has already been approved, including support to countries to reduce the risk of drug-resistant malaria and work toward elimination of the disease; malaria and dengue risk mapping in the GMS; and support for the Asia-Pacific Leaders Malaria Alliance. Expectations of solid results by the end of 2017—when the first round of financing expires—are high, with ambitious targets set for each of its six components: strengthened regional leadership; increased financing for malaria; better access to drugs and commodities; better use of surveillance technologies; improved capacity to detect drug resistant malaria and other disease threats; and inclusion of malaria and communicable disease prevention in large commercial and development projects. The focus of the RMTF tells us that five changes to the business-as-usual approach are needed if we are to get serious about malaria control and elimination:

  1. More sustainable financing.
  2. Cooperation to ensure supplies of affordable and effective malaria drugs and commodities.
  3. Improved data for evidence-based decision-making.
  4. Stronger national malaria programs.
  5. Expansion of leadership that looks beyond the health sector.

Under the RMTF, ADB is busy leveraging financing by mobilizing co-financing from other donors, and linking with ADB’s ongoing and planned loan and grant portfolio on communicable diseases control in the GMS. We are acting as both a catalyst and financing body for innovation, bringing together centers of excellence such as the the Harvard School of Public Health, Oxford University, the Mahidol Oxford Tropical Medicine Research Unit and the University of Tokyo to help GMS countries better manage their malaria and dengue surveillance and response planning through call data record and geographical information systems. The benefits of the RMTF stretch beyond malaria and will feed into broader health systems strengthening,  so we are working with the World Health Organization and the Asia eHealth Information Network to improve the regional evidence base for elimination of malaria and control of other communicable disease threats through better data collection, and analysis including accurate data on the costs involved. And since accurate surveillance of malaria relies on being able to identify, track and treat people with the disease, ADB and UNICEF are supporting national efforts on civil registration and vital statistics systems, based on unique identifiers for every member of the population. Finally, we are also teaming up with Singapore’s Center of Regulatory Excellence and other partners to improve regulatory convergence of pharmaceuticals to improve availability of high-quality communicable disease and anti-malaria pharmaceuticals and commodities. For ADB, malaria elimination is an obvious public-health best buy, not just because of the reduction in human suffering that it offers, but also because it can bring substantial economic gains: annual per capita GDP growth in malaria-affected countries is 0.25–1.3% lower than in countries without the disease. Investments in malaria now will yield savings in the longer term through reduced health care costs, more robust and sustainable health systems, increased worker productivity, improved educational outcomes, and a more vibrant tourism sector. Success depends on countries, agencies and sectors working together, being as innovative as possible, and putting our developing member countries in the driving seat.

 

 

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Blogs posted for Asian Development Bank (ADB)

ICT helping countries move toward universal health coverage

 

Published on ADB website on Friday, 12 December 2014

Written by Susann Roth and Jane Parry

When the Conference on Measuring and Achieving Universal Health Coverage with ICT in Asia Pacific wrapped up earlier this month, the 290 participants could head home knowing that it had been time well spent. Not only did they share their experiences as health systems administrators and managers, they also left with a bigger network, and a commitment to taking concrete steps to use information and communications technology (ICT) to help their countries move closer to universal health coverage

It was gratifying, as one of the co-organizers together with colleagues from World Health Organization and the Asian e-Health Information Network to see this process unfold. The conference was designed to get people talking in small groups, actively learning from each other, consulting together to hammer out what needs to happen for health systems to fully harness the benefits of ICT, and it culminated in a vote on what the 10 most important next steps are.

ADB is committed to increasing health investments in the coming five years and those investments have to go where the organization can have the biggest impact. One of ADB’s key strengths is its ability to convene disparate organizations and foster partnerships.

This conference was a prime example of effective collaboration among partners to capitalize on each other’s strengths. The knowledge that was gained in the conference room will not just travel back home with the participants. ADB’s health team learns from this process too.

The 10 next steps agreed to at the meeting will also inform a forthcoming joint ADB/WHO policy brief on using ICT to promote and measure progress towards universal health coverage.

ICT can bridge the gap between existing health systems and universal health coverage, but it’s a complex process and every country has its own challenges. We need to know from the people who are closest to the respective health systems to ensure that ADB’s commitment to supporting the goal of universal health insurance continues to hit the mark.

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Blogs posted for Asian Development Bank (ADB)

Move away from HIV and AIDS? Not quite yet!

Published on ABD website, Monday, 01 December 2014
By Susann Roth, Patricia Moser and Jane Parry
The AIDS response in our region has undoubtedly made impressive gains in the past 15 years. But as we mark today World AIDS Day, we can reflect that there is so much more that remains to be done.
New infections have fallen since 2001, but in 2013 there were 4.8 million people living with HIV in the region, including 350,000 newly infected that year. Worryingly, the number of new infections has flatlined for 5 years. Treatment access has been massively expanded, and 1.56 million people living with HIV were receiving life-saving antiretroviral therapy by 2013. But at that rate only half of those eligible will be on treatment by 2015.
Resources dedicated to the AIDS response in our region come from both domestic and international sources, and ADB has been supporting HIV prevention projects since the early 1990s. From 2005 onwards, much of ADB’s contribution has been through the ADB Cooperation Fund for Fighting HIV/AIDS in Asia and the Pacific, established with a $19.2 million grant from the Government of Sweden.
HIV specialists from ADB and its partner organizations gathered recently to discuss what the fund had achieved as it draws to a close at the end of this year.
The 120 participants from governments, UN agencies, and civil society organizations had a lot of good news to discuss. The fund has supported 17 projects in 12 countries, and had its most notable successes when it focused on ADB’s unique advantages: its key role in the development of the region’s new transport and economic corridors, its convening power and knowledge broker status, and its established relationships with national decision-makers at the most senior level.
The Cooperation Fund’s success stories included projects that capitalized on ADB-supported infrastructure projects to mitigate HIV risk along economic and transport corridors. Projects in Cambodia, the People’s Republic of China, the Lao People’s Democratic Republic, Mongolia, Myanmar, Papua New Guinea, and Viet Nam all used this route to bring HIV prevention interventions to otherwise hard-to-reach vulnerable groups such as migrant workers, mobile populations and people living in border areas; and key populations at higher risk of HIV including sex workers, and people who inject drugs.
The knowledge base on HIV in Asia and the Pacific has been greatly improved thanks to a grant from the Cooperation Fund to set up and manage the HIV and AIDS Data Hub. The Data Hub’s website is now the go-to resource for data on the epidemic and response in the region. Other projects under the fund contributed more than 20 publications and other knowledge products, many of which are routinely used by ADB staff in HIV prevention work as part of infrastructure projects.
Partnerships with specialist HIV agencies, in particular UNAIDS, and grassroots organizations that have strong connections to marginalized groups and target populations, have greatly extended ADB’s reach. They have also enabled resources from the fund to strengthen civil society and nongovernment organizations and build their capacity, notably in the Greater Mekong Subregion.
HIV prevention is not a static target and as the epidemic in this region has evolved, the Cooperation Fund has been able to target resources to areas where there are newly emerging vulnerabilities, e.g., in cities such as Manila, Bangkok, and Chennai; and in border areas throughout the Greater Mekong Subregion.
And thanks to ADB’s established relationships with governments and the private sector in Asia and the Pacific, the fund has been uniquely positioned to convene key players from the private and public sectors, build on their experiences, and foster cross-border collaboration. Some of the most innovative projects are those that have brought on board the private sector, such as the Asian Football Confederation, which was able to use its massive region-wide reach to disseminate HIV prevention messages through the Protect the Goal campaign.
Hearing about the successes of the Cooperation Fund—as well as the lessons learned from those projects that were less successful—was heartening. Based on all this good news, it might be tempting to think that it’s time for HIV to move over and make way for other health and development priorities. What a wrong move this would be.
One only has to look again at the data, and the newly emerging epidemics in hotspots around the region, to see how much more work remains to be done.
HIV/AIDS continues to be a significant threat to economic prosperity and health security in the region. Slowing down efforts now runs the grave risk of unraveling the gains made so far, and missing the opportunity to stop the epidemic in its tracks, reverse its course and get on target for zero AIDS by 2030.
In his opening remarks at the meeting in Bangkok, Myo Thant, an ADB Principal Economist in the Office of Regional Economic Integration, said that we need more resources, but we also need to understand how best to utilize these resources. Specifically, there is a need to increase the knowledge base, not just about the epidemic landscape in the region, but also about what works, and how best to invest previous resources in future interventions.
HIV does not exist in isolation, nor does it respect national boundaries. The strengthening of health systems is crucial to improve access to HIV/AIDS testing, prevention, treatment, care and support, including harmonization of services across the porous national boundaries in border areas. All sectors must be brought onside including, public, private and nongovernment agencies. Moreover, greater domestic responsibility for HIV/AIDS investments notwithstanding, support from regional and international funding sources is still essential.
For its part, ADB must continue to be innovative in its contribution to the HIV/AIDS response, strengthen its partnerships and tirelessly use its influence to ensure that this region does not drop the ball on HIV/AIDS.

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