Leveraging HIV, TB, and Malaria control programs to address NCDs – December 14-15, 2017

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Q1: How have you integrated services for NCDs into infectious disease programming?

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    • #16013

      Megan Kearns

      Good morning, afternoon, evening, wherever you are. Welcome to the Leveraging HIV, TB, and Malaria Control Programs to Address NCDs seminar. We hope you enjoyed learning about the three examples of integrated services from Ethiopia, Nigeria, and Malawi. We know that many of you have similar experience and important lessons to share. I am looking forward to spirited exchanges to advance our collective knowledge on strategic integration to address the growing burden of NCDs. Please share your questions, thoughts, and recommendations.

    • #16021

      Maggie Aliber

      During the webinar Q&A we discussed this question from Yared:

      At what level is integration of NCD/TB/Other infectious diseases coordinated at the Ministry of Health level? Any lessons learned from your experiences to facilitate program integration at all levels?

      What do you think? Do you have any insights to share from your programming?

    • #16031

      John Munthali

      Integration in the Ministry of Health in Malawi is largely driven by the various departments within the Ministry of Health. They agree mostly on policy and how to build capacity of health workers who offer services. This then translates into building capacity of health workers who provide services. This is largely in the form of training and supervisions. Newly integrated services are normally provided on existing platforms like FANC, CBMNC and others.

      The most important lessons we have learnt is are;
      1.Coordination and integration among partners is key in updating policy, building capacity and then delivering services
      2. Trainings and equipment distribution alone do not directly translate into improved service delivery-supervision is key
      3. Community mobilization plays a role in increasing demand for MiP services
      4. If data recording tools are not updated along with policies and guidelines progress cannot be documented and measured

      • #16032

        Megan Kearns

        Thank you, John, for sharing your experience from Malawi and the lessons you have learned in the implementation of the project.

        Do any others have experience from your programs or projects that provides insight into how MOHs are, or are not, coordinating this integration of NCDs into infectious disease program platforms at the community, facility, state or national levels?

    • #16048

      Megan Kearns

      Are prevention, diagnosis, and treatment for NCDs being prioritized by the governments in countries where you work? Please share examples of where this is happening and how it is working.

    • #16051

      Murtala Rabiu

      Well for my facility and to be more specific that’s Laboratory Services are actually integrated since both NCD and CD have a common pathways ie preanalytic,analytic and post analytic and also uses thesame tools for data collection

      • #16079

        Megan Kearns

        Thanks for sharing your experience in the lab, Murtala – from the discussion on the forum, it seems that screening for some NCD may be relatively easily integrated into the intake form or process when people come for HIV or TB services, and into the training for providers or counselors. And as you note, the integration at the lab level is not difficult.

        The harder part is providing referrals for treatment, as there are often limited resources in terms of providers or facilities to see the client, and funding to provide treatment. And even if the MOH is committed to the idea of integrating services, there are always limits on resources. Another person on the forum mentioned that in light of this, it’s important to integrate prevention for NCDs as part of the infectious disease service delivery.

    • #16058

      I want to share the below experiences on :
      1- Integrating gestational diabetes services into antenatal care at Health centers in Tigray, Ethiopia : 2013-2014
      2- Experiences on Mental Health integration to HIV clinics, ENHAT CS project Tigray, Ethiopia: 2013-2014

      Diabetes: a hidden factor of maternal mortality in Ethiopia? – A low cost solution for integrating gestational diabetes services into antenatal care at health centers in Tigray, Ethiopia

      Authors: Abraha Mebrahtu G.1, Elke Konings1, Ahmed Reja2, Hagos Godifay3, Bud Crandall1
      1 USAID Ethiopia Network for HIV/AIDS Treatment, Care and Support (ENHAT-CS) Program, Management Sciences for Health; 2 Ethiopian Diabetes Association, Medical Faculty of Addis Ababa, Black Lion Hospital; 3 Tigray Regional Health Bureau
      Keywords: diabetes, gestational diabetes, antenatal care, HIV & AIDS, Ethiopia
      Diabetes during pregnancy significantly increases the risk of the primary causes of maternal mortality in Ethiopia. However, diabetes screening is rarely offered as part of routine antenatal care (ANC), partly because Ethiopia-specific guidelines do not exist and partly because diabetes is not recognized as a major health issue. Data on the prevalence of gestational diabetes mellitus (GDM) in Ethiopia are scant and outdated.
      We conducted a pilot study to determine the burden of GDM and related factors among pregnant women and assess the feasibility of integrating diabetes services into ANC at three public health centers in Ethiopia. The health centers were already supported by the President’s Emergency Fund for AIDS Relief (PEPFAR) to provide HIV testing and other services to all pregnant women seen at ANC clinics. We integrated GDM services into antenatal care services. We adapted international diabetes guidelines to the Ethiopia context and trained nurses and health officers in data collection and GDM screening and management. Data on 1,417 ANC clients seen during a three-month period in 2014 were collected using a pilot-tested checklist.
      The study found a prevalence of GDM of 11.3%, with obesity and urban residence being the only statistically significant predictors of GDM. Among women with GDM, 79% responded well to simple behavioral interventions. Using locally adapted guidelines, job aids, and existing training materials was also effective.
      Our results indicate that GDM is an overlooked problem of major public health importance in the study population yet can be addressed at low cost through systematic screening, early detection, and proper management. Integrating GDM services into ANC presents a feasible and effective opportunity to improve maternal and child health in Ethiopia. Adding GDM services to ANC services was a cost-effective way to integrate services that benefit both HIV-positive and HIV-negative pregnant women.
      This study was funded by Management Sciences for Health through its Innovation Challenge Fund. Misrak Tarekegn of the Ethiopia Diabetes Association; and Kahsu Tsegazeab, Hagos Tesfalem, Tewelde Yohannes, Fred Hartman, and Gloria Sangiwa of Management Sciences for Health contributed to and supported the project implementation. Barbara K. Timmons edited the paper.

      Experiences on Mental Health integration to HIV clinics, ENHAT CS project Tigray, Ethiopia: 2013-2014
      ENHAT-CS narrative on Mental Health integration to HIV clinics performance data :
      1.Nov 2013 to January 2014
      • The program was supporting 30 HCs to provide mental health services integrated within the HIV clinic. This includes screening and referral by the case manager (trained lay providers) and diagnosis and treatment or referral by the HIV clinic Health care providers (HCPs).
      • Data from 28 HCs, 22 from Tigray and 6 from west Amhara, has been reported on, covering the period between Nov 2013 to January 2014.
       By HIV clinic case managers: The case managers screened a total of 7,486 clients, of whom 414 (5.5%) were identified with suspected mental health problems. Of these 414 suspected cases, 277 (67%) were referred to the HCP for further assessment.
       By HIV clinic Health care providers/HCPs: Total of 344 patients (4.5%) were diagnosed for mental health problems. Of these 344, a total of 205 (60%) were either treated at the HC by same HCP or referred to another health facility i.e. hospital, with 165 (80%) treated at the HC and 40 (20%) referred.
      Of the 344 with a diagnosed mental health problem, these encompassed:
       Depression: 114 (33%)
       Anxiety: 90 (26%)
       Memory loss/dementia: 73 (21%)
       Psychosis: 38 (11%)
       Epilepsy/seizure: 18 (5%)
       Substance abuse: 11 (3%)
      Of the 205 either treated at the HC or referred, specifics are as follows:
       Depression: 83 (73%) were treated or referred
      o 69 (83%) at HC
      o 14 (17%) referred
       Anxiety: 49 (54%) were treated or referred
      o 38 (78%) at HC
      o 11 (22%) referred
       Memory loss/dementia: 13 (18%) were treated or referred
      o 13 (100%) at HC
       Psychosis: 35 (92%) were treated or referred
      o 22 (63%) at HC
      o 13 (37%) referred
       Epilepsy/seizure: 18 (100%) were treated at HC or referred
      o 17 (94%) at HC
      o 1 (6%) referred
       Substance abuse: 7 (64%) were treated at HC or referred
      o 6 (86%) at HC
      o 1 (14%) referred

      We also assessed, at the 22 HCs in Tigray, the availability of at least one psychotropic medication for each mental health disorder, with the findings as follows:
       Depression: 14 HCs (64%)
       Anxiety: 19 HCs (86%)
       Psychosis: 12 HCs (55%)
       Memory loss/dementia: N/A
       Epilepsy/seizure: 20 HCs (91%)
       Substance abuse: N/A
      2. February-Sep 2014
      • The program supported the Gov’ of Ethiopia’s decision to greatly expand provision of mental health services by task shifting service delivery to Health Centers/HCs. The key element of the program’s support to pilot mental health service delivery at HCs level and has provided the below lessons learned from the program’s initiative.
       Demonstrated that HCPs can provide basic mental health service provision
       Demonstrated that HCs can obtain and maintain a regular supply of psychotropic drugs
       Facilitated RHB to assign psychiatric specialists from catchment hospitals to supportive supervision to the health centers/HCs/
       Sharing of the program tools, which are simplified to be appropriate for HCs, used as models for the FMOH’s national program
      • The program’s pilot initiative has integrated mental health services into HIV clinic service delivery at 28 HCs. The program developed a training curriculum and trained HCPs from both HIV and OPD clinics, a guideline, job aids, M&E tools and a mentorship checklist to support this pilot.
      • During this reporting period (Feb – Sep 2014), program technical staff mentored the pilot 28 HCs in Tigray region, including assessing status of implementation and introducing program developed M&E tools. During this reporting period, the logbooks for recording service provision by both the case managers and HCPs were continued to be utilized.
      • The progress of mental health integration into HIV/AIDS services based on the clinical mentors findings, using the mentorship checklist summary, was shared with the Tigray RHB, and especially to the focal person of their Curative and Rehabilitative Core Process and THB head.
      • The program was supporting 28 HCs to provide mental health services integrated within the HIV clinic. This includes screening and referral by the case manager and diagnosis and treatment or referral by the HIV clinic HCP. The mental health data collected using the facility based mental health reporting form from 28 HCs has been reported on, covering the period between Feb – Sep’14.
      • Data from 28 HCs of Tigray has been reported on covering the period between February-Sep 2014 :
       By HIV case managers: the case managers screened a total of 17,780 clients, of whom 508 (2.9%) were identified with suspected mental health problems and referred to trained health care providers for further assessment.
       In the HIV clinic by HCPs: of the suspected cases by the case managers 388(76%) patients were diagnosed for mental health problems by the trained ART providers. Of these 388 diagnosed with mental health problems,
       A total of 266 (69%) were either treated at the HC by prescribing psychotropic drugs or referred to another health facility i.e. hospital, with 235 (88%) treated at the HC and 33 (12%) referred.
       122 (29 %) were managed through only counseling at the HCs.
       these encompassed:
       Depression: 164 (42%)
       Anxiety: 118 (30%)
       Psychosis: 57 (15%)
       Memory loss/dementia: 15 (9%)
       Epilepsy/seizure: 24 (6%)
       Substance abuse: 10 (3%)

      Of the 266 either treated at the HC or referred, specifics are as follows:
       Depression: 45 (79%) were treated or referred
      o 37 (82%) at HC
      o 8 (18%) referred
       Anxiety: 68 (58%) were treated or referred
      o 58 (85%) at HC
      o 10 (15%) referred
       Psychosis: 45 (79%) were treated or referred
      o 37 (82%) at HC
      o 8 (18%) referred
       Memory loss/dementia: 14 (93%) were treated or referred
      o 13 (93%) at HC
      o 1 (7%) referred
       Epilepsy/seizure: 24 (100%) were treated at HC or referred
      o 23 (96%) at HC
      o 1 (4%) referred
       Substance abuse: 6 (100%) were treated at HC or referred
      o 6 (100%) at HC

      By Dr Mebrahtu Abraha – current Challenge TB regional Manager , Tigray-Ethiopia ,
      previously : Regional Technical Manager for ENAHT CS Tigray.
      I am an MSHer for 8+ years ( Sep 4, 2008 till present )
      My Achievements at MSH – to mention some:

      • I was MSH’s Candidate for APHA’s 2014 young professional Award ( selected by Bud Crandall – ENAHT CS COP, Ethiopia & Elke Konnings – M&E/OR director, ENHAT CS Ethiopia and approved by Jonathan Quick – MSH CEO/President)
      • I lead the team – was winner of MSH INCH 2014 fund for GDM project ( Integration of GDM screening in to ANC)
      • Some of my abstracts as PI – had been accepted for presentations at 7th International AIDS Society Conference on HIV Pathogenesis, Treatment and Prevention, Malaysia (30 June – 3 July 2013), STI & AIDS World Congress 2013, Vienna, Austria, (14-17 July 2013), and American Public Health Association (APHA) Annual Meeting, Boston, USA, (2-6 November 2013) on:
      – impact of different ARV regimens infants and mother pair in reduction of MTCT– Tigray , Ethiopia : monitoring data 2008-2014 – which was appreciated by Dr Kesete, FMOH Ethiopia at National Health festival
      – Impact of Mother support Group members on Prevention of MTCT – Tigray, Ethiopia : monitoring data 2008-2014
      • My biography posted in MSH NCD web page at 2014 selected as NCD expert- ( selected by Sara Holtz & her team ) – as member and for my active participation at MSH NCD technical exchange networks (TENs), prepare NCD talent assessment –survey questions for MSH global staffs and my abstracts posted in MSH blogs
      • At first years of MSH experience – As regional senior clinical mentor and Regional pediatrics/PMTCT advisor during 2008-2009: My field reports : on Health centers experience on improving the ART and pre-ART services, and PMTCT interventions has been shared to different regional offices in Ethiopia ( by Muluken Melese- HCSP country Technical Director Ethiopia and Haile Wubneh – HCSP COP-Ethiopia )

      • #16082

        Megan Kearns

        Thanks, Mebrahtu, for sharing the abstracts and summary findings from the papers on integrating diabetes care into ANC clinics and on integrating mental health services into HIV clinics. They show that this can be done successfully and are examples of where this integration is in support of the MOH plans for improving health service provision.

        Do any other participants have any examples to share from other settings?

      • #16094


        Dear Dr. Mebrhatu,

        Thank you for sharing your excellent experience of ENHAT-CS. It is an excellent experience you shared us and I know it was a model by then. What is the situation after ENHAT-CS phased out. I hope these experiences are integrated and continued in the HIV/AIDS program of the country and the region.

        • #16095

          Dear Dr Muluken, I would like to appreciate on your remarks to know’’ situation mental health integration and GDM screening after ENHAT-CS phased out since Jan 2015’’.
          At the time of phase out ENAHT CS – had conducted different transition workshops and shared a well transition document to the RHB – including the performance and way forwards of the all projects including the mental health integration. Additionally the Mental health integration has been coordinated by RHB curative and rehabilitative core process focal person and HIV case team.

          Today I also visited to one of the high load HCs with ART Service, Kasech HC (with 930 PLHIV currently on ART)– located in Mekelle and the HC was also the INCH site- GDM integration to ANC/PMTCT clinics. Below are some of my findings on document review and discussion with HC director, ART provider, case manager, Mental Health focal person, ANC provider and Lab staffs.

          1. Mental health screintegration in to ART clinic :
          • In the HFs routine mental health screening to PLHIV by case managers and ART providers, and mental health screening at OPD continued to be practiced. I have observed the case manager and ART provider registers, monthly reporting templates – all introduced by ENHAT CS are continued to be utilized.
          • Additionally a health officer /HO working at OPD is assigned as mental health focal person. Accordingly mental health is reported from ART clinic and OPDs.
          • In the HFs which includes OPDs, ART clinics : a total of 27 cases reported to have mental disorder in the last quarter – of which
           18 (67%) were newly diagnosed
           By type : Epilepsy-seizure =17(63%) , Moderate-Severe depression=6(), Psychosis=1, Alcohol use disorder=1, behavioral disorder=1, and other MNS conditions=1 cases
           Currently there 6 PLHIV are under drug treatment for mental disorder ( 2 of which under psychiatrist follow up in Ayder referral hospital).

          2. Integrating gestational diabetes services into antenatal care at Health centers
          The routine symptom screening and FBS testing for all pregnant mothers at ANC has been continued. FYI- we had procured and distributed Glucometer and strips which has been approved by RHB PFSA – so that strips are sustainably received from the market through the PFSA hub.

          Unfortunately, currently the HC has no adequate test strips and can’t provide free service to ANC. The HC director agreed to review the cost the test strips in terms the ANC client load. I will further discuss with TRHB and the PFSA hub.

    • #16061

      Degu Jerene

      In settings with scarce resources and high disease burden, integrating services at health facility and community is a necessity, not a choice. Integration sometimes happens even when the Ministries of Health are not prepared to lead the process. For example, in a primary health care setting where there is only one clinical officer, it is the responsibility of this single person to do everything.

      However, sustainable integration of services requires strategic guidance and deliberate planning from top down. In Ethiopia, integration is a core guiding principle in all disease programming activities. In fact Ethiopia was once criticized for eliminating disease specific departmentalization of its structures, putting all disease prevention and control activities under one Core Process (adopting a business process re-engineering approach).Although there has now been some specialization of various coordinating units, all disease prevention and control activities are put under one directorate. Specific disease prevention and control activities are delineated by case teams which are led by case team leaders (not NTP coordinator, HIV Department Head, etc.).

      The NCDs are thus fully integrated within the Disease Prevention and Control Directorate, together with communicable diseases and neglected tropical disease. As a result, processes are better streamlined and there is frequent inter-case team coordination between NCDs and communicable diseases.

      The country now has clear strategies and guidelines for delivering integrated services for NCDs and other diseases, especially at community and primary health facility levels.

      • #16063

        Thanks Dr Degu for the explicit explanation of the past and current Ethiopian FMOH and health system context in addressing and the implementing NCDs.

    • #16065

      Amaechi Okafor

      In Nigeria, at the ministry of health level, policies on the integration of NCD are in existence. But the level of implementation, monitoring, evaluation and reporting is below average. Integration of NCDs are mostly championed by Implementing Partners with funding from external donors. Government need to emphasize and show more commitment through increased budget allocation, fund release, implementation, monitoring, evaluation and reporting.

      From implementation experience, active engagement and involvement of stakeholders at various levels – ministry of health at the national level, ministry of health at the regional level, heads of health facilities and service providers at the health facility level is key to a successful integration.

    • #16087

      Murtala Rabiu

      Thanks a lot for your imput Megan Kearns and I quite agree with you to integrate prevention of NCD into current communicable disease

    • #16090

      Qader, Ghulam

      Hi every body. The CTB project has increased collaboration and coordination with Diabetes, Mental health and Drug demand reduction programs. During 2017, the CTB project assisted provincial health offices in five major cities of Herat, Kandahar, Balkh, Nangerhar and Kabul. The CTB project helped PHO team to screen 20,000 of drug addicts and 8,000 of patients with mental disorders for signs and symptoms of TB. Also, during 2016, the CTB projected assisted NTP to screen the Diabetic patients attending public and private health facilities. Moreover, during 2017, the CTB project helped to screen diagnosed TB patients for their mental health status.

      We can conclude that strengthening coordination and collaboration of both communicable and non-communicable diseases could resulted in mutual benefits and will led to early diagnosis and treatment of both of diseases. The synergy between these programs assists diagnosis in initial phase of disease and led to avoid deaths and morbidity.

    • #16092


      I remember in a very striking experience in Haiti. During 2012 after the earthquake, the people were having a difficult time, because of lack of medical service, lack of professional person in the health system, me and my institution worked in collaboration with the people who were affected.

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