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Transcript of Learning from the Past and Envisioning the Future Bridging the Divide: Interdisciplinary...
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
8000
10000
12000
2003 2004 2005 2006 2007 2008
No
. o
f H
SA
su
pp
ort
ed
by G
F
-
20.0
40.0
60.0
80.0
100.0
120.0
140.0
160.0
U5M
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