Health Sector Strengthening and the Response to AIDS

Arletty Pinel, MD Geneva, 22 February 2008

o  Appropriate and effective service delivery depends on strong health systems

o  Weak health systems are a central obstacle to scaling-up and sustaining AIDS programs

o  Health outcome related targets cannot be achieved without adequate investment in health systems

o  Investment in health needs to be embedded in broader social and economic development planning

Health systems strengthening includes: o  Policy development and implementation o  Effective governance and coordination o  Efficient and reliable financing mechanisms o  Increased information on health expenditures and

costs o  Improved quality of health service delivery o  Surveillance and reporting of disease impact within

communities o  Implementation of sustainable health information

systems

Strengthening the health system: For what? For whom? o  For a particular disease or system-wide to

address a range of health priorities? Vertical or integrated? Or should it focus on promoting and enhancing health rather than combating disease? Either/or or both?

o  Are health system strengthening plans based on equity? Do they ensure that disenfranchised or particularly at-risk populations are proactively reached?

Response to AIDS has contributed to strengthening health systems: o  Blood safety o  Laboratory services o  Clinical care and treatment o  Procurement and supply management o  VCT o  Human resources o  Data management o  Policies and coordination mechanisms o  Targeted strategies to reach vulnerable and at-risk populations o  Prevention/care/treatment continuum, demand creation o  Community participation and GO/NGO synergies o  Unprecedented funding levels

But there have been some challenges o  National health systems struggling to provide adequate basic

health care while facing additional resource allocation and system management requirements for AIDS

o  AIDS created a greater demand for services while at the same time caused attrition of the limited health workforce

o  The sharp increase of resources for HIV/AIDS has brought about a need to address new critical components, such as: n  Absorptive capacity n  Planning for rapid scale up and human resource planning n  System capacity for effective and safe delivery of treatment

o  Limited understanding of the links between the provision of AIDS services and the broader health systems required to ensure a sustainable, effective response in the long-term

Health system strengthening needed to make progress in the response to AIDS o  Pandemic has reached an unprecedented scale and

although the it touches all aspects of society, health systems are and will remain at the forefront of the response to AIDS

o  Areas that have slow progress can only be addressed within a health system strengthening frame (e.g., achievements of health objectives for AIDS met the decline in African health standards in the maternal and child health sector – what’s the effect over PMTCT?)

o  “Movement fatigue” – can health system strengthening revitalize the response to AIDS?

A recent example: The Global Campaign for the Health MDGs o  International Health Partnerships (IHP+) areas for

action: n  Enabling countries to identify, plan and address health

systems constraints to improve health related outcomes in a sustainable, equitable and effective manner

n  Generating and disseminating knowledge, guidance and tools in specific technical areas

n  Enhancing coordination and efficiency in aid delivery and strengthening health systems

n  Accountability and monitoring performance

Inputs Outputs Outcomes Impact

FundingDomestic sourcesInternational sources

PlanCoherent, prioritised and funded

HarmonizationAligned international efforts with national planWell coordinated and harmonized support

National plan implementationSystems strengtheningPriority interventions scale -up

Capacity buildingProgrammesInstitutionsPeople

AccountabilityPerformance monitoringResults focus and evaluationUse for better practices and results

Health system

strengthenedG

overnance, HR

, medical products, inform

ation

Increased service utilization and intervention coverage

Reduced inequity (e.g. gender, socio -economic position)

Responsiveness

No drop -off non -health sector interventions (e.g. water & sanitation)

Improved survivalChild mortalityMaternal mortalityAdult mortality due to infectious diseases

Improved nutritionChildrenPregnant women

Reduced morbidityHIV, TB, malaria, repr . health

Improved equity

Social and financial risk protectionReduced impoverishment due to health expenditures

Framework for monitoring performance and evaluation of the scale-up for better health

Improved services

Access, safety, quality, efficiency

Process

Aid process monitoring

Resource tracking Strengthen country health information systems

Evaluation: process, health systems strengthening, impact

M &

E action

Health system monitoring Coverage monitoring Impact monitoringImplementationMonitoring

But is it all about numbers, technical soundness, scaling up, services, commodities, funding, alignment, harmonization and coordination?

A little bit of history of health systems… o  1945 – 75: universal, comprehensive public services to meet basic health needs o  60’s and 70’s: Primary Health Strategy to address unsolved problems of basic health

care, to reinforce health infrastructures especially in rural areas o  1978: International Conference on Primary Health Care – Alma Ata. Health care

for all; health as wellbeing and a fundamental human right o  1979: Selective Primary Care: WB challenges Alma Ata (“too expensive” 5.4 to 9

billion by year 2000) and proposes few interventions to fight against a limited number of diseases. UNICEF develops GOBI.

o  1985: Good Health at Low Cost recommends equitable distribution of income, access to public health care services to all, and primary health care reinforced by secondary and tertiary services but loses to the vertical approach/sectoral interventions

o  1987: WB’s structural adjustment policy (enforce fee payment for health services; encourage privatization of health services; promote (private) insurance programs.

o  WHO crisis; appeals to extra-budgetary funds of vertical interventions. o  1993: WB becomes a major financial institution in health – essential package and new

indicator Disability Adjusted Life Years (DALYs) o  1998: Public-Private-Partnerships (Gates, UNAIDS, GAVI, Stop TB….) o  2001: ARVs, UNGASS… Jan 2002 GFATM… 2003: 3 by 5… PEPFAR o  2007: Global Campaign for the Health MDGs; Health 8… health system strengthening

Preparing for the 4th decade of AIDS

o  The first decade of AIDS was about losses o  The second decade of AIDS was about hope:

hope for a cure, a vaccine o  Money dominated the third decade of AIDS

believing that resources would do the trick o  How do we want the fourth decade of AIDS

to be known for?

The 4th decade of AIDS: back to basics? o  Health system strengthening starts at securing

primary health care for all (PHC is the litmus test of HSS)

o  We have gone through Primary Health Care and Selective Primary Care, can we think of a Primary Health Care – PLUS where access to basic and comprehensive health care can include specificity?

o  The spirit of Alma Ata should be rescued since “Health for All” – based on social justice and human rights – is achievable

o  We can start by infusing to the MDG rhetoric the sense of optimism, moral vision and inspiration that led to Alma Ata

The 4th decade of AIDS: back to basics! o  Like in the past, the response to AIDS

can lead the way since its core has always been fueled by the principles of inclusion, rights and personal and collective self-determination

o  The world needs an infusion of optimism and the response to AIDS is inspirational because it’s essentially about commitment to life and conviction that change can happen

The 4th decade of AIDS: back to the human element

Hu Health system strengthening is only possible when you go

back to the basics: putting the human being at the center of the analysis and the response

Thank you