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The movement of people is a fundamental phenomenon in our way of living. People move to seek a better life or out of necessity. In the Southern African region, migration and cross-border activities contribute to economic growth and development. However, mobility also poses exceptional risks to health. It increases difficulties for people to access treatment and information and to receive continuous care. Peaceful borders become deadly borders to many.
When LIN started its mission in Malawi, we observed the growing challenges of tracing HIV patients on treatment who cross country borders. Subsequently, LIN initiated a series of activities to tackle the issue – from research and advocacy to action.
It all started with the simple question: ”What happened to HIV patients on treatment that stopped coming to the clinic?”
Dr. Joseph Yu, LIN’s International Director, helped set up the Rainbow Clinic at Mzuzu Central Hospital when Malawi was scaling up antiretroviral therapy (ART) for HIV/AIDS in 2004. The national program allowed wide access to treatment for HIV-positive patients and changed the tide of the epidemic. While many patients remained on treatment, others defaulted or were “lost to follow-up”. To find out what happened to these patients, Dr. Yu and a group of colleagues conducted a study. When the researchers traced the patients their home, they found that about half of the patients who did not show up for clinic visits had died. Among the patients who were found alive, two thirds had stopped treatment and one third of them had moved to receive treatment from another clinic without informing the staff of the previous clinic. The issue of the patients who moved around caught the researchers’ interest. They observed that in the clinic there were some patients who would travel abroad – those who migrate and work in South Africa, or traders who cross over to the neighboring countries regularly. In towns bordering Tanzania, Mozambique or Zambia, it can be hard to tell if the patients are from the local community or from the town across the border, since most people are without any forms of personal identification cards.
To generate more evidence on the impact of migration and mobility on ART care and treatment outcomes, another study was conducted in five ART clinics in Malawi. The cross-sectional survey found that migrants (non-Malawian patients) were at higher risk to default treatment, compared to non-migrants, and mobile populations (Malawian ART clients that would travel within the region and abroad) were more likely to default and had poorer adherence to treatment.
Inadequate harmonization and coordination in disease management guidelines, port health services, cross-border referral, and disease control all represent particular problems for member states in the Southern African Development Community.
LIN and its partners started the Cross-Border Patients (CBP) Forums in 2009, recognizing the need for a knowledge-sharing platform on mobile population issues. The issue of migrant health was presented at the International Conference on AIDS and Sexually Transmitted Infections in Africa (ICASA) in Satellite Sessions, which LIN co-hosted for many years. In 2014 LIN called an international meeting in Oslo attended by the SADC Secretariat, Norwegian authorities, and Embassy of South Africa to discuss needs and strategy for the work on cross-border patients.
Through the advocacy and discussions, LIN built contacts and partnerships with National AIDS Councils, Ministries of Health, and international organizations working in the SADC region. The network advocated for the need to test out IT innovations to improve service delivery and continuum of care for migrants and mobile populations.
After many years of discussions, there was finally an opportunity for action. From October 2018 to March 2020, LIN worked with the International Organization of Migration (IOM) to pilot a mobile application in the border towns of Mchinji, Malawi and Chipata, Zambia. The application was used by “change agents” that offers health education, consultation and referral services for sexual and reproductive health and HIV at the community level. The change agents specifically reached out to the migrants, youths and adolescents, sex workers, and people living the community.
One of the challenges was that once the clients were referred, it was difficult to know whether they had actually reached the health facility. At the facility, there was also limited information available on what kind of services the client had received before. The solution served as a job-aide that guided the change agent during service delivery and facilitated data exchange to the nearby facility. The application was built on DHIS2 mobile tracker and allowed easy integration with the district level health information systems.
LIN successfully trained 58 users, including community change agents, program managers and implementing partners in Malawi and Zambia. Since the application was rolled out, change agents had provided services to over 2,000 of clients. From the 795 clients referred, 115 completed the referral, representing a 14.4% referral rate. This is the first time the service providers were able to easily track how many of the clients they referred were able to reach higher level facilities.
WATCH THE VIDEO: Encounter of a Change Agent and Youth in the Community.
“Alright, all your data is entered and registered in the hospital database.”
“You already sent?”
“Yes, what remains is for you to go to the hospital. They will be expecting you.”
The program managers also felt the benefit. Before they had the tool, they could not measure individual performance of the change agents. At the program level, indicators could be compiled and disaggregated by age, sex, migration status (whether they were coming from another district within the country, or coming from outside the country) and profession – which are important for program planning in the health system.
The pilot was hosted under the SRHR-HIV Knows No Borders project- a project focusing on Sexual and Reproductive Health Rights (SRHR) and HIV. The project is supported by the Government of the Netherlands and implemented by IOM, Save the Children International and the University of Wits School of Public Health. LIN is undertaking an end-line assessment for the digital application and hopes to mobilize more resource to continue the work.
Read more on the research conducted: True outcomes for patients on antiretroviral therapy who are “lost to follow-up” in Malawi
Read the report from the 2014 LIN Oslo Conference:
Read more on the advocacy papers and relevant documents from the Cross-Border Patient Forums: https://lukeinternational.no/reduce-inequity/regional-forum-of-cross-border-patient-challenges/