F. Rasschaert et al


Reviewed by Josefien Van Olmen
This paper tries to evaluate to what extend the scale-up of anti-retroviral treatment (ART) in two Sub-Saharan African countries has also contributed to positive change in the wider health systems. The authors used routine data, collected from 2004-2009 in both countries and looked at the effect of ART scale-up on human resources (availability, new cadres), service delivery (utilization rates of health facilities for specific services such as immunization, antenatal care, ART) and health outcomes (under-five mortality, maternal mortality, TB treatment success rate).
The indicators assessed show a positive trend: health outcomes have improved, utilization of health facilities has increased and the numbers and different cadres of health workers expanded exponentially. In the discussion, the authors themselves are the first to acknowledge the limitations of their analysis, especially the lack of direct link between ART scale-up and the results found. They state that their analysis indicates no documented evidence of substantial changes in other factors, programmes or patient user fees for health services in this time period. In my opinion, there they bypass the greatest potential of their article. The fact that all indicators improved was in itself not very surprising, other papers have shown similar effects. However, a closer look at the tables show remarkable differences between the pre-existing situations in Malawi and Ethiopia and in the differences over time. Malawi has a much larger burden of HIV patients, 12% prevalence versus 2.5% in Ethiopia. The pre-existing state of the health system in Malawi seems to have been appalling, looking at the figures of immunisation coverage (9%) and availability of basic obstetric services (2%). This has improved enormously. In general, the improvement of health service indicators in Ethiopia appears less steep, although also impressive. Nevertheless, the overall improvement in health outcomes has been greater in Ethiopia than in Malawi. A possible explanation of this difference could be that the overall burden of HIV AIDS still puts a heavy mark on the health of the Malawian population.
This short reflection raises the appetite for more in-depth analysis. Both Malawi and have performed exceptionally well in response to the HIV epidemic. But it are not the parallels, but the differences between the countries that contain most valuable lessons for others.

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