bridging the hiv implementation gap: a path to health systems strengthening

Number of people receiving ARV therapy in low- and middle-income countries, 20022007Source: WHO, UNAIDS, UNICEF; 2008

Boucan Carre June 03:VCT withStaffEssential MedsCommunity outreachHIV Prevention and Treatment Integration into Primary Health CareBoucan Carre March 03

Success story: Central Plateau, HaitiIntegrated HIV/TB programme strengthens primary health care including immunization coverage

20080221 Wharton GHD DRAFT 20080221.ppt

Implementation bottleneckVaccinesPrimary Health CareDrug TherapiesMaternal and Child Health CareBasic Surgery


Bill and Melinda Gates Foundation $6.5 B

The Global Fund $8.6 B

Presidents Emergency Plan for AIDS $15 B

International Finance Facility $4 B

Multi-Country HIV/AIDS Program $1.1 B

Global Alliance $3 B

Public-private partnerships $1.2 B

Anti-Malaria Initiative in Africa (proposed) $1.2 B

United Nations Fund $360 M*Funds pledged, committed, or spent. Overlap exists between organizations (e.g., PEPFAR money supports the Global Fund).Adapted from Jon Cohen, The new world of global health. Science 2006;311(5758):162-167.TOTAL $40.7 BWarren Buffet $37 B TOTAL $77.7 B


Gates grantsGATES GRANTS$448M - new health technologies $413M - HIV/AIDS vaccine $258M - malaria vaccine $165M - new malaria drugs $124M - anti-HIV microbicides $115M - diarrhea/nutrition $106M - TB vaccines/diagnostics


Implementation bottleneck +VaccinesPrimary Health CareDrug therapiesMaternal Child Health CareBasic SurgeryGates Foundation develops:Microbicides and other preventive tools New malaria and TB drugs, diagnosticsNew combination therapiesDrugs for neglected diseases>10 new vaccines


GLOBAL HEALTH STRATEGY TO DATECountries and even districts working in isolationProject-basedDonor preference drivenExperimental pilots that never scaleCompetition among implementersCottage industry approachFragmentation of servicesIneffective and Non-results orientedAbsence of technology and measurement orientationResources diverted for overhead and consultants

Clear need for a better approach

Condom DistributionAntiretroviralTherapyEducationalCampaignsClinicConstructionHIV/AIDSFieldworkersCorporateInvolvement

EconomicsQuality ImprovementAnthropologyManagement ScienceMedicineSystems DesignStrategySociologyOperations ResearchHealth Services ResearchNeed for an Interdisciplinary ApproachGlobal Health Delivery

Framework for Investigating Health Systems DynamicsDisciplinesBaseline Analysis: Clinic and System-LevelCase StudiesSimulation ModelHypothesisDesign Delivery ModelEpidemiology, Anthropology, EconomicsStrategySystems DynamicsOperations ResearchSystem Optimization and EngineeringImplementManagement SciencesEvaluationQuality Improvement


The AIDS Support Organization (TASO)Joint Clinical Research Center (JCRC)Uganda


TASOJoint Clinical Research Center Supported by PEPFARUS Partner: CDC- public health focused Community-based modelAddn Services: Counseling, Home-based follow up, Food support, Vocational trainingResults: 2500 patients in ~18 months Required to attend adherence counseling sessions Free Medication; $0.30 user feeFocuses on keeping patients on treatmentSupported by PEPFAR US Partner: USAID- development focused Medical center-based model Distribution of ARVs is the key Results: 19,000 patients in ~18 monthsExpanded to >30 clinics in public health facilities Cost of treatment: $16/ month Free ARVs to ~2000 orphans and pregnant women Now- Expanding strategies such as home visits to address adherence Focuses on Financial independence


Global Health Delivery CasesAMPATH, KenyaCIDRZ, ZambiaZamne Lasante, HaitiTASO, Uganda


WHO Positive Synergies InitiativeWHO-led initiative for G8, Italy 20093 consortia: Academic, civil society, and implementersFourteen academic partners from Africa, Asia, Europe, and the U.S.

Agence Nationale de Recherche sur le SidaRoyal College of Surgeons in IrelandInstitute of Tropical Medicine, AntwerpGeorge Washington UniversityKenyatta UniversityUniversity of Yaound Public Health Foundation of IndiaDakar University Teaching HospitalUniversity of Western CapeThe AIDS Support Organization Center for Global DevelopmentGlobal Fund/World BankUniversity of PretoriaHeartfile, Pakistan


Pathways to ImpactHealth OutcomesFairness of FinancingResponsivenessGHI investmentHealth workforce GovernanceInformationMedical productsDELIVERY PrivateexpenditureGovernmentexpenditureFinancingOther externalexpenditure


Country-level mixed methods analysis

Cross-country quantitative analysisProvider-unit level analysisLevels of AnalysisIdentify relationshipsUnderstand relationshipsUnderstand the impact


WHO Positive Synergies Research QuestionsHow do GHI-funded programmes interact with health systems in varied country contexts?


WHO Positive SynergiesMethods Qualitative and quantitative case studies Key informants:

InstitutionsNational AIDS Control CouncilWHOPEPFARGlobal Fund for AIDS, Malaria, and TuberculosisUSAIDCDCUNAIDSAAR Private HealthcareNational NewspaperMinistry of HealthTreasury DepartmentFamily Health InternationalAidspan GFATM watchdogMinistry of Public Health and SanitationAIDS NGO Consortium


WHO Positive Synergies Research QuestionsHow do different health system designs and specific implementation strategies influence the coverage of targeted and non-targeted interventions?


WHO Positive SynergiesMethodsFacility Assessment Tool


Doris Duke AfricanHealth InitiativeFunds implementation, evaluation and operations research of innovative approaches to improve comprehensive primary care in AfricaConsortium of PIH,BWH,HMS and HSPH awarded planning grant to develop 5 year implementation grant3 countries (Rwanda, Lesotho, Malawi)


Doris Duke Primary Health Initiative


BasicScienceClinicalScienceEvaluation ScienceWhat is the pathophysiology?What is the diagnosis and appropriate intervention?Does the intervention and delivery model work?Is there a place for a new field in health research and education?

Is there a place for a new field in health research and education?BasicScienceClinicalScienceEvaluation ScienceWhat is the pathophysiology?What is the diagnosis and appropriate intervention?Does the intervention and delivery model work?HealthcareDeliveryScienceHow do we best deliver the intervention to everyone?


What is to be done?Can these efforts help to build the new field of global health delivery science?Can we move beyond the RCT? Can we begin to illuminate the black box of delivery?Can we build positive synergies and improve outcomes?Where are the opportunities?Positive Synergies, Doris DukeGates "Delivery"IHP Common Monitoring and EvaluationPEPFAR and GFATM

***http://www.whitehouse.gov/news/releases/2003/01/images/20030128-19_speechd128-ed-515h.htmlhttp://www.whitehouse.gov/news/releases/2003/01/20030128-19.html**3by5 is an attempt to use time in the most creative of ways. Bureaucrats who were supposed to lead the battle against this epidemic were simply telling us that it was getting worse and that we should pay more attention. Body counts and meetings, more body counts and more meetings. When PLWHA demanded treatment for everyone, most of them just shrugged their shoulders and said it was too complex and not cost-effective. We knew as we were preparing to announce 3by5 that we needed to use time to light a fire under all of us who have the skills and the resources to do something about this epidemic. I wake up every morning in a cold sweat thinking about how little time left we have to reach our target of 3 million on treatment. But I take comfort in knowing that for even a brief moment, I might share a small fraction of the terror that people waiting for ARV treatment feel every moment of their lives. Gustavo Gutierrez, during a public conversation with Noam Chomsky that was sponsored by Partners in Health, told us that there is a simplicity on this side of complexity and a simplicity on that side of complexity. He told us to try our best to never mistake the former for the latter and to do whatever we can to reach the latter in any great project we take on. 3by5 is often misunderstood as the simplicity on this side of complexity. Nothing could be further from the truth. 3by5 represents an understanding that the mighty battle we are now engaged in to struggle with and ultimately handle the complexities of HIV treatment, may be one of the few chances we have in this life for redemption. All of us, especially the health care workers among us, might be asked someday by our children, what did you do when you knew that AIDS was going to be such a huge problem. My own answer will be that I didn't do enough but we took a good shot at it with 3by5. As you think about what you can do here in Seattle to participate in the great battles for health and social justice like the battle to bring treatment to poor people living with HIV, I would like to leave you with a quote from a particularly distinguished member of my tribe, the tribe of anthropologists. Margaret Mead once said, "never underestimate the ability of a small group of committed souls to change the world. Indeed, they are the only ones who ever have." It is my great, great privilege today to deliver a lecture named after a man who every day of his life, lives in solidarity with the suffering poor who are waiting for so many things, especially treatment for HIV. *****Lighten up photo**-BMG data here represents how much money they have spent on global health thus far, to illustrate annual spending now a more accurate number would be between 2-3 billion**BMG grants to Harvard$44.7 million to develop the program model for the control of MDR-TB $25 million to support AIDS Prevention in Nigeria (APIN)$2.28 million to support the development human papilloma virus (HPV) vaccines $7.57 million to develop a new paradigm for needle-free vaccination technology$18.7 million to develop valid, reliable and comparable measurements of population health**

*****Main question/points: Question: Which model is better? How to maximize the strengths and minimize the weaknesses of the two models? Is either model sustainable? Need to understand how fee structure, home-based care and social services affect ARV delivery Problem: PEPFAR does NOT require data on adherence, morbidity, and mortality from its programs

Background:Uganda has received US$230 million since 2004 (article from 2005) -the money had helped support nearly 40% of the countrys accredited ARV centers and 75% of all Uganda receiving ARVs-speed v. caution; medicalised v. community-based model -without long-term adherence to treatment, many public health experts fear that the benefits of ARV programs could be relatively short-lived

TASO-Partner: CDC- its mandate is public health -first 18 months: 2500 patients -most required to attend a series of adherence couseling sessions- before signing the contract -free medications; $0.3 user fee

Peter Mugyenyi: -Partner: USAID- development agency -Distribution of ARVs more important than infrastructure, adherence, and labs -priority is to put out the fire if treatment is delayed because of quality issues, you are denying life to people. That Is a gross human rights violation This exclusive focus on ARV provision has helped JCRC expand at a remarkable speed. During the first 18months of PEPFAR funding, JCRC enlarged its clientele to over 19000 and expanded nationally to more than 30 clinics, the majority of which are in public health facilities. Most clients purchase generic drugs procured by JCRC, with the cheapest regimen costing roughly $16/month. Around 2000 orphans and pregnant women receive free medications from PEPFAR. Adherence is discussed at clinical appointments, and the program is NOW expanding strategies such as home visits to clients with risk factors for poor adherence

Main difference: JCRC- expand access to treatment at a remarkable speed- SPEED TASO- Free medication- Caution

USAID, CDC, and agencies including the Peace corps and the US department of Defense, are charged with developing a SINGLE-COUNTRY OPERATING plan. Question facing both groups- Sustainability (how to make ARV programs sustainable) -JCRC- focuses on developing durable systems for procurement and distribution; financial independence through fee structure -TASO- aims to keep patients on treatment, even if it means taking potentially unsustainable steps

***** Theirs is a greater need to understand in more detail how fee structures, home-based care, and social services affect ARV delivery. However, there has not been an assessment to evaluate adherence, morbidity, and mortality in various programs (Uganda PEPFAR team planning on developing this). Furthermore, these data are NOT required by PEPFAR; however, these data are vital. Christian Pitter (principal adviser to ARVs fro CDC Uganda), If we do not roll out ARVs in a careful manner we could end up with a situation much worse than where we are today **************

As you click, key lessons that we have learned from each case will appearNote to Jim: This emphasizes that what were adding is a multi level, mixed methods approach. This positions us & distinguishes us from the previous work in the field.

Cross-country: The global cross-country quantitative analysis will look across many countries for the existence of statistical relationships between GHI investment and the inputs into and outputs from country health systems.

Country level studies will look into the black box of delivery and implementation to begin building theories about why these relationships exist. These are mixed methods studies that will use quantitative methods when possible to triangulate with qualitative results.

The provider unit-level data will allow us to begin to consider how different care delivery models lead to variations in health outcomes across disease priorities, as well as how such models affect local health system capacity.

25 countries in Africa, Latin America, Asia constitute varied contextsInsert picture of interview in action

This is a list of some of the main actors weve interviewed in one of our countries for the WHO project

In almost all cases, we interviewed the executive directors, heads, and key actors within each of these institutionsBefore and after GHI involvementThis is Louise Iverss facility assessment tool, in use in Haiti****

bridging the hiv implementation gap: a path to health systems strengthening

Documents

new health technologies

b20080221 wharton ghd

new world of global

pptglobal health strategy

new malaria drugs

malaria vaccine

preventive tools new

bthe global fund