Bridging the Divide

Wafaa El-Sadr, MD, MPHColumbia University and Harlem Hospital

Vienna, July 20, 2010

Bridging the Divide: Interdisciplinary Partnerships for HIV and Health Systems Strengthening

Vienna, July 16-17

• Background: HIV scale-up and health systems• Meeting objectives and agenda

www.worldmapper.org

HIV PrevalencePersons Living with HIV/AIDS, 2008

33.2 million (30.6-36.1 million) worldwide

Health Systems in Crisis: Infrastructure

Health Systems in Crisis: Human Resources

Health Systems in Crisis: Laboratory and Pharmacy Systems

Antiretroviral Therapy by Region, 2001

Unique Characteristics of HIV and its Treatment Drive Programmatic Innovation

Characteristics of HIV Disease Shaping the Response

Impact throughout lifecycle Programs for adults and children (including pregnant women, infants, children, adolescents)

Asymptomatic periods, acute illness, chronic symptoms

Chronic disease model (prevention, health maintenance, continuity care, linkages)

Multiplicity of clinical & psychosocial needs

Multidisciplinary teams (teamwork, referral systems, community resources)

Importance of adherence & retention Outreach & trackingProvider-patient relationship

Need for clinical & laboratory monitoring, secure supply of medications

Medical records and data systems, secure procurement systems

Transmissible infection Counseling, prevention methods (antenatal care, family planning and prevention methods)

Innovations: Multidisciplinary Teams, Health Workforce

• Task-shifting • Changing role of nurses• Linkages with pharmacy• Linkages with laboratory• New cadres (from peer educators to data clerks)• Involvement of PLWHA• Mentorship and supportive supervision > formal didactic training• Enhanced stewardship and supervision by regional health bureaus

Innovations: Family-Focused Services

• Co-located and co-scheduled appointments• Family enrollment forms• Linkages• Community outreach• Couples counseling• Prevention counseling• Integration with primary care, reproductive health, TB, and malaria services

Innovations: Transparent Target-setting, Record Keeping, Data Use

• Appointment systems• On-site medical records• File rooms• Data clerks• Charting tools• Enrollment forms• Electronic medical records / databases• Supportive supervision• Data-based clinical systems mentorship• Use of data to guide quality initiatives

Innovations: Tiered Laboratory Systems, Linkages, Specimen Transport

• Support for national laboratory plans & guidelines• Tiered system strategy• Infrastructure • Equipment/supplies• Training• Standardized approach to patient monitoring• Decentralization of services• Enhanced quality

Innovations: Community Participation and Support

• Mapping of community resources

• Support of and for community-based organizations

• Outreach to community leaders and key stakeholders

• Establishment of organizations of PLWA

• New models for governance

Innovations: Substantial Financing and Financing & Payment Schemes

• Performance-based payment • Inclusion of HIV services in

workplace plans, some national health insurance schemes

• Leveraging the private sector• Use of “vertical” funds to

support broader efforts (mutuelles in Rwanda, health workforce in Malawi)

Total Health

HIV/AIDS0

5000

1000

015

000

OD

A c

omm

ittm

ents

, cur

rent

US

$

1995 1997 1999 2001 2003 2005 2007Year

Total Health

Health Systems Strengthening

050

0010

000

1500

0O

DA

com

mitt

men

ts, c

urre

nt U

S$

1995 1997 1999 2001 2003 2005 2007Year

Source: OECD DAC

ODA commitments for health, 1995-2007

Number of people receiving antiretroviral therapy in low- & middle-income countries, by region, 2002–2008

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

4.5

End 2002 End 2003 End 2004 End 2005 End 2006 End 2007 End 2008

Mill

ion

s

North Africa and the Middle East

Europe and Central Asia

East, South and South-East Asia

Latin America and the Caribbean

Sub-Saharan Africa

WHO, Towards Universal Access, 2009

Bridging the Divide: Interdisciplinary Partnerships for HIV and Health Systems Strengthening

Vienna, July 16-17

• What is the impact of HIV scale-up?

Estimated Impact of ART on AIDS-related deaths, globally, 1996–2008

2.5

2.0

1.5

0.5

1.0

3.0

0

Num

ber

(mill

ions)

Year

1996 1998 2000 2002 2004 2006 20081997 1999 2001 2003 2005 2007

No antiretroviral therapy

At current levels of antiretroviral prophylaxis

UNAIDS 2009 AIDS Epidemic Update

2.9 M lives saved

ART coverage and all-cause mortality in South Africa, 2003–2006

WHO, Towards Universal Access, 2009

Under-two Child Mortality/1000 Live BirthsKwa Zulu Natal, South Africa

Ndirangu et al. AIDS 2010

Impact of HIV Services on Mortality of HIV-uninfected Infants Mortality, Uganda

• Prospective cohort of 1373 HIV-infected adults and 4601 HIV-uninfected household members

• ART and cotrimoxazole associated with– 95% reduction in mortality among HIV-infected– 81% reduction in mortality in uninfected children

< 10 years of age– 93% reduction in orphanhood

Mermin et al, Lancet 2008

Effect of PMTCT Programs on Quality of Overall Antenatal Care and Delivery, Cote D’Ivoire

Delvaux et al, IAS 2009

Effect of ART on Incidence of MalariaUganda & Zimbabwe

Year 1 Year 2 Year 3 Year 40

100

200

300

400

500

600

700591

476

259

153

Incidence of Malaria in HIV patients on ART

Rate

of M

alar

ia p

er 1

,000

pys

Kasirye et al, IAS 2009

Impact of ART on worker absenteeism

Impact of ART as Prevention:Effect on New HIV Infections

Free ART

TaiwanBritish Columbia, Canada

Wood et al. BMJ 2009;338b:1649 Fang et al. JAIDS 2004;190:879-85

Bridging the Divide: Interdisciplinary Partnerships for HIV and Health Systems Strengthening

Vienna, July 16-17

• What about other health threats?

Millennium Development Goals (MDGs)

MDG-1: to eradicate extreme poverty and hunger MDG-2: to achieve universal primary education MDG-3: to promote gender equality and empower women MDG-4: to reduce child mortality MDG-5: to improve maternal health MDG-6: to combat HIV/AIDS, malaria, and other diseases MDG-7: to ensure environmental sustainability; and MDG-8: to develop a global partnership for development

27

Commonalities of Barriers and Challenges

Maternal health Child health TB Diabetes HIV/AIDS

Barriers and challenges:

• Demand-side barriers • Inequitable availability• Human resources• Lack of adherence support• Infrastructure, equipment• Program management• Drug supply / procurement• Referral and linkages• Community involvement

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Adapted from Travis, Bennett, et al. Lancet 2004

Cape Town 2009:Accelerating the Impact of HIV Programming

on Health Systems Strengthening

Bridging the Divide: Interdisciplinary Partnerships for HIV and Health Systems Strengthening

Vienna, July 16-17

Meeting Objectives:• To foster interdisciplinary partnerships across disciplines• To present data and evidence from implementation

research, rigorous evaluation and country case studies addressing impact of HIV programming on health systems

• To discuss options for the future with respect to leveraging HIV programming to improve health systems and other priority health conditions;

• To highlight a priority research agenda re: HIV and health systems

Health Systems Building Blocks

Service DeliveryIntegrated Service Delivery Case StudiesModerator / framing presentation: Rifat AtunCase Study #1: Global Fund Case Study: Kenya – Erin

Sullivan (HSPH)Case Study #2: Global Fund Case Study: Malawi – Thyra

de Jongh (KIT 25)Case Study #3: GF Case Study: Ghana – Daniel Degbotse

(MoH Ghana)Discussant: Yogan Pillay (MOH SA)

HIV Scale-Up and Chronic Disease ServicesModerator/framing presentation: Kevin De Cock The Growing Global Burden of NCDs – Implications for

Health Systems: Joseph-Hubert Perriens (WHO)Integrated Services for HIV, Diabetes, and CVD in

Cambodia: Bart Janssens (MSF)Integration of HIV and CVD Services in Kenya: Frank

Mwangemi (FHI)Discussant: Peter Lamptey (FHI)

Health Workforce

Health WorkforceModerator and framing remarks: Wim Van

Damme The Future of the CHW – lessons from HIV

programs: Eric Buch (UP/NEPAD/GHWA)Expanding the Health Workforce in Ethiopia:

Tamrat Assefa (MOH Ethiopia)Leveraging HIV Funding for the Malawi Health

Workforce: Frank Chimbwandira (MOH Malawi)

Information and Technology

Leveraging HIV Scale-up for Health Information Systems

Moderators: Kevin Fenton (CDC) and Nosa Orobaton (WHO)

Presentation from WHO HIS: John Cutler(WHO)

Case Study 1: Charles Nzioka (MoH Kenya)Case Study 2: Michael Graven (Health Metrics

Network)

Financing and Payments Leveraging Private Sector for HealthModerator: Pamela Rao (USAID)Public Stewardship to Optimize the Role of the Private Sector in

Health: Deus Mubangizi (U. of Maryland/Results for Development)

Private Sector Engagement in HIV Service Provision in Ethiopia: Tesfai Gabre-Kidan (Abt Associates Inc.)

Mobilizing the Private Sector for HIV & Social Health Protection: Joep Lange (Pharm Access)

From “Universal Access” to Universal Health Coverage Moderator: Robert Hecht (Results for Development)Financing for Universal Coverage: Are There Generalizable Lessons

from Experience? David Evans (WHO)HIV & Social Health Insurance: Overview of Country Experiences: Erik

Lamontagne (UNAIDS)HIV Integration and Health Systems Strengthening: Performance-

based Financing in Rwanda: Jean Kagubare (MSH) Health Investment and Expenditure Data to assess the

Financial Impact of HIV Scale-up Moderator: Charles Holmes (OGAC)Where are the data on health spending and HIV? Understanding the

evidence: Anna Vassall (LSHTM)What can we learn from NHA and HIV spending accounts? Jose

Antonio Izazola (UNAIDS)HIV and Health Spending Surveys: Jean-Paul Moatti (INSERM-France)Discussant : Susna De (USAID)

Leadership and Governance HIV Scale-up and Global HealthModerator: Alan Whiteside, IAS Executive Board Ezekiel Emanuel (USG)Eric Goemaere (MSF)Lynn Freedman (Columbia University)Julian Lob-Levyt (GAVI)

Directions For The FutureModerator: Wafaa El-Sadr (ICAP)Key Outcomes: Rifat Atun (Global Fund)Taking Forward Key Outcomes: Eric Goosby

(PEPFAR) Taking Forward Key Outcomes: Carissa Etienne

(WHO)Taking Forward Key Outcomes: Paul DeLay

(UNAIDS) Closing Remarks: Elly Katabira (IAS)

Vienna 2010:Bridging the Divide: Interdisciplinary Partnerships for

HIV and Health Systems

Bridging the Divide: Interdisciplinary Partnerships for HIV and Health Systems Strengthening

Vienna, July 16-17

Build the Partnerships Generate the Evidence

HIV and Health Systems Strengthening

Acknowledgements

Steering Committee• Sam Adjei, CHeSS Ghana• Rifat Atun, The Global Fund• Jacqueline Bataringaya, The Global Fund• Karl-Lorenz Dehne, UNAIDS• Wafaa El-Sadr, ICAP Columbia University• Charles Holmes, OGAC• Harrison Kiambati, MOH Kenya• Jeffrey Lazarus, The Global Fund• Sharonann Lynch, MSF• Robert Oelrichs, The World Bank• Sam Okuonzi, ACHEST Uganda• Nandini Oomman, Center for Global Development• Gorik Ooms, Yale University• Jos Perriens, WHO• Estelle Quain, USAID• Miriam Rabkin, ICAP Columbia University• Subha Raghavan, SAATHI India