Learning from the Past and Envisioning the Future

Bridging the Divide: Interdisciplinary Partnerships for HIV and Health Systems

AIDS 2010, 16-17 July 2010, Vienna

Professor Rifat AtunDirector, Strategy, performance and Evaluation ClusterThe Global Fund to Fight AIDS, Tuberculosis and Malaria

The past

HIV and Health Systems

• Underfunded• Huge unmet need• Weak health systems• Political commitment weak

The debate

• Reductionist approach• Binary debate• Polarisation• False dichotomy on

targeted vs health system investments

The current context

HIV and Health Systems

• Substantial financing• Unprecedented scale up of

prevention, treatment and care

• 5 million receiving ARVs but still huge unmet need

• Weak health systems hindering scale up

• Political commitment waning

The debate

• Progressing beyond the reductionist approach

• Exploring synergies• Understanding that MDGs

are inextricably linked• Spirit of collaboration

HIV and Health Systems: bridging the divide

Global Fund experience

The Global Fund and Health System Strengthening

RoundType of request for funding

2-Year Amount*

For HSS

2-Year Round Total*

% of Total

5 HSS proposals 43 726 6

7HSS strategic actions in disease specific funding

186 1,117 17

8 Separate HSS cross cutting actions 283 3,059 9

*The amounts are in million USD – for 2 year period ** HR, Infrastructure, M&E

1-8HSS investments in disease

specific grants** 2,689 8,203 33

The Global Fund and Health System Strengthening

Health financing and social protection have not featured stronglyin the HSS demand from countries.

Budget categories Round 7 Round 8Human Resources 33% 42%

Infrastructure 17% 26%

Monitoring and Evaluation 14% 7%

Community & Client Involv. 11%  

TA & Mgmt Assistance   6%

Health Financing < 1% 1%

HSS Total for each round USD 186 million USD 283 million

Investments in HIV control have strengthened health systems

Country Examples Results

Human resources

Infrastructure

Service Delivery

Ethiopia expanded primary care infrastructure and workforce

Malawi expanded primary care workforce from 4,000 (2003) to 10,000 (2008)

Rwanda used innovative incentives to scale up primary care and IMCI

Between 2005 and 2008, • DPT3 immunization grew from 70 to 82%Between 2002-2007,• AIDS mortality declined by 50%

In 2009, • 77% of facilities provided basic emergency, obstetric and neonatal care

• Between 2005-2007, deliveries assisted by trained attendant increased from 39% to 52%

Investment in Health Systems Strengthening: Malawi (1/2)

Malawi: USD 196.8 million

10,000 Health Surveillance Assistants deployed by 2009, entirely supported by the Global Fund, to provide:

• HIV, TB and malaria services

• supervision of traditional birth attendants

• community-based maternal & newborn care

• family planning advice

• disease surveillance

Global Fund’s contribution to expanding the health workforce in Malawi

Availability Human Resource 2003 2008

Percent Supported by GF in 2008

Doctors 90 177 90% Nurses 1,932 3,185 95% Lab Technicians 76 143 100% Health Surveillance Assistants 4,324 10,127 100% Total 6,422 13,632

0

2000

4000

6000

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10000

12000

2003 2004 2005 2006 2007 2008

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RU5MR Linear (Health Surv. Assistants)

Expansion of HSA and decline in U5MR: 2003-08

Investment in Health Systems Strengthening: Malawi (2/2)

Ethiopia: USD 330.5 million

Service Delivery Indicator 2005 2008

Immunization rate (DPT3) 70 % 82 %

Births attended by health professionals

13 % 24.9%

People on ART (% women and children)

20,000 (25 %)

132,000(35 %)

Indoor residual spraying coverage

7.3 % 51.4 %

Insecticide treated nets coverage

15.8 % 71.3 %

Over 30,000 Health Extension Workers trained and deployed between 2004 - 2009.

Investment in Health Systems Strengthening: Ethiopia

Investment in Health Systems Strengthening: Rwanda

Trends in Deliveries* 2005 2007

% Deliveries assisted by trained personnel

39 % 52 %

% Deliveries at a health facility

28 % 45 %

USD 141.2 million

Contributing to demand and supply of health services.

*Based on DHS

Haiti

• an integrated package of PHC services including HIV counseling, AIDS care, prenatal care, nutritional support, and management of TB and STI to 250 000 people

• supported expansion of community health worker network to provide HIV and TB services The workers instrumental in increased

uptake of PHC services among most vulnerable households

USD 160 million R1 HIV grant (PIH)

Ending the false dichotomyBridging the divide

Is there a divide? Key Questions

• What are the extent and nature of integration of targeted interventions and health systems to achieve synergies in varied contexts?

• Which factors influence the extent and nature of integration?• How do varied health system designs and delivery models

influence outcomes?

Atun, Ohiri, Adeyi, 2008

Key variables affecting the nature and extent of integration

1. The Problem being addressed

2. The Intervention

3. The Adoption System

4. The Health System characteristics

5. The Broad Context

A framework for analysing adoption, diffusion and integration of targeted health interventions

InterventionAdoption

System

Broad Context

Broad Context

Health System Characteristics

Problem

The Problem

Necessity and Urgency• Burden

– health, economic and social

• Perceived and real• Social Narrative

• Transmission dynamics

The Intervention

Complexity • Simpler to complex

Scalability• Replicability

Factors influencing diffusion and integration

The Adoption System

Receptivity• Individual &

organisational• Incentives• Legitimacy

Factors influencing diffusion and integration

Health System Characteristics

Feasibility• Governance• Structure and organization• Financing• Service delivery• M&E system

The Context

Sustainability• Fiscal space

– Overall and health sector specific• Frailty

Opportunity• Critical events

– Visibility• Synergy• Technology / innovation

Desirability• Political economy• Socio-cultural factors

Analysing the extent and nature of integration

Analysis of critical health system functions for targeted health interventions in a health system context

8,274

1,551

118

88

26

6,723 excluded

1,046 excluded

387i.e. program evaluations, descriptions, reviews, uncontrolled studies 30 not available*

18 excluded

44

I. Title scanning

II. Abstract scanning

III. Full text scanning

IV. Quality assessment

12

14

Conclusions from antecedent research

1. Reductionist approaches counterproductive

2. No vertical or horizontal approach– A rich mosaic – Extent and nature of integration varies

3. Context matters– Complex adaptive systems at play– Local solutions for local problems

4. Positive synergies evident

Looking ahead

The evolving context

A Challenging Economic Environment

Broadening the Global Health Agenda1

2

3

The evolving HIV response: managing AIDS as a long term illness in the rapidly increasing cohort

on treatment

Focus on value for money

Create syn

ergies b

etween

H

IV an

d H

SS

investm

ents to

imp

rove

health

ou

tcom

es

Paradigm shift in the way we think about HIV/AIDS and health systems

Low

High

Emergency Long term care

Position in early 2000

2010 onwards

Numbers receiving treatment

Nature of the response

Managing the transition

Upstream Harmonization and alignment of existing supportJoined up analysis, planning, investment and monitoring

Downstream

Structural and operational integrationLong term care modelsFocus on value for money to ensure sustainability

Challenges (1)

Weak evidence base

What works in practice and what has worked less well

Why and how?

Optimal delivery models

Scale effects

1

2

3

4

Methodological challenges in

generating evidence

Challenges (2)

Mounting an effective response

Resistance to policy translation

Incrementalism

Inadequate focus on delivering value

Lack of innovations to achieve step change

1

2

3

4

Strategic and transformational

change