in India
Supporting Community Action on AIDS in India
Mythri Mainstreaming Model
A New Initiative for Delivery of STI Services
Intoduction The Avahan Focused Prevention Program for Key Populations or KPs (female sex workers, men who have sex with men, transgenders and drug users) has been providing free treatment and counseling services for Sexually Transmitted Infections (STIs) since 2004 in Andhra Pradesh. Working through 36 NGO partners, Avahan set up Mythri Clinics in thirteen districts of Telangana and Rayalaseema. From 2003--2008, during Phase I, services were provided through program-owned static clinics, mobile clinics, or outreach clinics.
What is a Mythri Clinic? The Mythri Clinic offers STI clinical services critical for HIV prevention among female sex workers, men who have sex with men, and transgenders. Care is taken to ensure that Mythri Clinics remain stigma-free, are user-friendly and provide quality services. All the clinics were standardized by implementing Family Health International (FHI) developed Clinic Operating Guidelines and Systems (COGS).
What services does a Mythri Clinic provide? A Mythri clinic provides an essential package of STI services: l
Regular monthly check-ups for STIs
l
Treatment for symptomatic and asymptomatic STIs
l
Screening for syphilis bi-annually
l
Counseling on risk reduction
l
Condom promotion and distribution, and
l
Referral for HIV and TB services.
Emergence of Mythri Mainstreaming Model In the run up to Avahan Phase II, the HIV
program-owned STI clinics. It was expected
prevention program moved toward greater
that, in the long-run, the chosen model would
community-participation
help achieve the following:
and
ownership.
There was need to ensure sustainability of
l KP-friendly
STI/HIV services would be
clinical services on long-term basis which
provided, especially in areas with low and
meant looking at ways and means to provide
scattered populations
the same quality services at lower operating costs. (i)
Two
working
options through
were
considered:
existing
public
healthcare institutions and (ii) working through private practitioners. After some
l The
public healthcare system would be
strengthened, the communities sensitized and demand for these facilities generated, thereby improving their utilization; and l The
stigma perceived in accessing STI
deliberation, the first option was chosen
services from public healthcare facilities
as it provided a sustainable alternative to
would be reduced.
MYTHRI MAINSTREAMING MODEL: How it Works
In other words, it is the responsibility of the local
treatment, syphilis screening, TB screening
NGO to ensure that the key population groups
and referrals for HIV, TB and care and
are made aware of the services and accept
support services.
the new location. It is also its responsibility to
In 2007,
India HIV/AIDS Alliance, Andhra
Pradesh, initiated the Mythri Mainstreaming
ensure sensitization of both service providers
India HIV/AIDS Alliance:
and users.
l
Training of:
a. Medical officers and Auxiliary-Nurse
The roles and responsibilities of different partners
The Government Healthcare Facility:
Midwives (ANMs) on syndrome case
under the Mainstreaming Model are as follows:
l
Providing space and basic infrastructure
management of STI, clinic operational
l
Ensuring the availability of a medical officer
guidelines and positive prevention; and
Model based on public-private partnership, providing STI services in partnership with the
The NGO:
for STI clinics on a fixed day and at fixed
Andhra Pradesh State AIDS Control Society
l
times
(APSACS).
Mythri Mainstreaming Model Clinics: A Public-Private Partnership The Model uses infrastructure and personnel of existing public healthcare facilities. The services are provided to the KPs after regular outpatient hours.
Carries out community mobilisation through peer outreach l Ensures that the new clinic is at a location acceptable to the community and that it is KP- friendly l Works on condom promotion and provides risk-reduction counseling l Sets up community monitoring systems l Handles documentation, collection and maintenance of patient records and reporting l Manages the clinics, including provision and management of drug stocks and condoms, and l
Networking and linkage establishment.
Figure 1
STI Clinic Model at Public Healthcare facility – Mythri Mainstreaming Model
l Provision
b. The NGO staff on peer outreach and follow-ups.
of
STI
services
including
l
syndromic case management, presumptive
Regular supportive supervision to the clinics and mentoring for doctors and ANMs.
The Process... Realizing the need for following sustainable
The Mainstreaming Model was then extended
approaches for providing STI services to the key
to 60 mandals in another seven districts ―
populations, Mythri Mainstreaming Model was
Chittoor, Cuddapah, Khammam, Warangal,
conceptualized by the Alliance in collaboration
Ranga Reddy, Medak and Kurnool, wherever
with APSACS and Avahan.
the HIV-prevention programme was being scaled up.
In 2007, when Alliance was scaling up its India HIV/AIDS Alliance, Andhra Pradesh
Training of clinic staff and Supportive Supervision
intervention in 70 new mandals, it was decided to
Existing government healthcare facilities were
use Mythri Mainstreaming Model for STI service
assessed for suitability before making the choice
delivery in all scale-up sites. The model was first
regarding location of the Mythri Mainstreaming
rolled out in Anantapur district in September 2007
Model clinics.
for two NGOs (CERA and MEOS) at five sites
UHC/PHC/AH 1. KP-friendly STI services 2. Delivery of essential sex worker package 3. Provision of free STI and OI drugs (supplied by NGO) 4. Quality standards (COGS) followed 5. Availability of doctor (from hospital), and ANM (by NGO) during agreed clinic time 6. Maintenance of STI records, clinic register and drug stock register 7. Risk reduction counseling 8. Syphilis screening.
Provision of STI and ICST kits, basic equipments, and reporting forms
(four PHCs and one CHC) with the support of the
Criteria for Selection of Government Healthcare
District Medical Health Officer (DMHO). At the
NGO-Activities
facility for Mythri Mainstreaming Model:
same time, a letter of request to start delivering
l
Fully-functional healthcare facility
1. Peer Outreach activities 2. Condom Distribution 3. Peer-Led Counseling 4. CBO formation 5. Advocacy 6. Community mobilization and follow-up tracking 7. Monthly reports
STI
l
The facility should be within a 5-km radius of
services
from
government
healthcare
facilities in other districts was made to the office
the target community (KPs)
of the Director, Health Services, Andhra Pradesh
l
Acceptability of services by the KPs
through the APSACS. Director-Health Services
l
The doctor must be willing to participate in
issued an office order in May 2008 to all the
the programme and to provide services after
DMHOs to take forward the Mythri public-private
regular outpatient hours.
partnership initiative in healthcare services.
Figure 3
Key population accessing STI services from Mythri Mainstreaming Model Clinics
THE SUCCESSES successes. l
It has successfully brought female sex workers, men who have sex with men and transgenders to the mainstream healthcare services
l
Key Features of Mythri Mainstreaming Model are:
public healthcare facilities. As shown in Figure 2, within the first year of initiating these clinics, more
More efficient use of infrastructure and personnel of the existing public healthcare facilities. It is a new public-private partnership initiative. l The model has resulted in sustainable availability of STI services and healthcare. l The STI services are stigma free. l KPs are less vulnerable to the stigma generally attached to STIspecific clinics. l It has strengthened government facilities in terms of infrastructure and staff capacities.
positive changes: Trained medical officers in Government facilities with improved knowledge and skills in management of STIs. There is considerably greater understanding of the medical staff on issues related to key populations. The community has access to user-friendly services in a stigma-free environment. This model serves as a ‘one-stop’ center for all the healthcare needs of KPs (general aliments, ICTC and DOTS). l
Individual medical records are maintained and available for each key population group, helping to streamline follow-up and tracking of the users.
l
The presence of ANMs supported by Alliance has helped with syphilis screening (over 8O% clients screened),
data
collection,
streamlining
40
40
% KPs screened for syphilis
23
20
11 2008
6 2009
2010
Table 1 and Figure 3 gives a clear picture of the success of the Mythri Mainstreaming Model Clinics.
l
Two years into the programme and one can see many
l
% KPs availed STI services
It compares quite favorably with the earlier program-owned clinics.
than 60% of the KPs had accessed the STI services.
l
% STI symptom visits
72
60
0
system, resulting in improved utilization of the
l
86 75
73
80
The Model has helped change perceptions of key population groups regarding the public healthcare
l
Percentage (%) of KPs
‘Mystery Client’ survey conducted by Alliance in April 2010 revealed that most users were satisfied with the services provided by the new Mythri Mainstreaming Model clinic.
The Mythri Mainstreaming Model has achieved notable
99
100
drug
procurement and supply and most importantly in ensuring that the services are rendered to the key population, as the ANMs are familiar with the group.
Table 1: Clinic Indicator Comparison under New Mythri Mainstreaming Model and Project Owned Models (January -- December 2010) Indicator
Mythri Mainstreaming Model
Project -owned Clinics
13351
33850
Percentage of KPs accessing clinic services every month
31%
29%
Percentage of KPs availing STI consultations every quarter
72%
70%
Percentage of KPs availing RMC every quarter
68%
68%
6%
3%
Percentage of KPs screened for syphilis during the year
86%
81%
Percentage of KPs screened for HIV during the year
68%
66%
Number of total KPs covered
STI rates
Challenges Some of the major challenges faced during
l
the rollout of MMM include: l
Irregular availabilty of medical officer on
Dependence on ANMs for documentation, and
l
Provision of services to key population
the days specified. Since government
groups located in distant ‘hotspots’. Given
doctors have multiple responsibilities, they
that people living in such far-off locations
are often assigned to different jobs on a
find it difficult to access PHCs in any case,
given day leading to postponement of clinic
the situation exacerbates when the doctor
services
is not available on the specified day.
Figure 2
STI services accessed in Mythri Mainstreaming Model clinics in year 2008 STI episodes diagnosed
The Way Ahead
6968
KPs screened for syphilis
Now that the STI service delivery through PHC/UHC/CHC is an acceptable, accessible option for the key population groups, the services can next be mainstreamed in collaboration with the National Rural Health
12030
Mission (NRHM).
KPs accessed STI services
22118
In areas where HIV prevention efforts are being scaled up through the Link Worker Scheme, the Mythri 29889
Total KPs
Mainstreaming Model could be used for provision of quality STI services since the Link Worker Scheme covers key populations that are geographically dispersed.
0
5000
10000
15000
20000
25000
30000
in India
Note: The photographs are being used only for the purpose of illustration.
India HIV/AIDS Alliance, Hyderabad 500 063, Telephone: +91-40-66781161, 66686261 Fax: +91-40-6668-6262 Website: www.allianceindia.org
Acknowledgment Alliance India AP wishes to acknowledge the support received from Sri R. Chandravadan, IAS, Project Director-APSACS; the Director-Public Health and Family Welfare, AP; and the Commissioner-AP Vidya Vidhan Parishad
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