HIV/TB Stakeholder Meeting

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HIV/TB Stakeholder Meeting. Dr Hans Kluge Director Health Systems and Public Health Special Representative of the Regional Director on MXDR-TB Kiev, Ukraine 06 May 2014. From policy to action: HSS operational approach. Removal of health system bottlenecks. Expected results. Core - PowerPoint PPT Presentation

Transcript of HIV/TB Stakeholder Meeting

Slide 1HIV/TB Stakeholder Meeting
Dr Hans Kluge
Special Representative of the Regional Director on MXDR-TB
Kiev, Ukraine
06 May 2014
I wish to speak to you today briefly on what the WHO Regional Office for Europe is doing in respect of enhancing the resilience and sustainability of health systems in our Member States.
This is an important theme, and important for not just governmental policy-makers but so too health professionals, patients and citizens alike.
For we see that sustaining the health gains made across European countries in recent decades are under threat.
Challenged immediately by the global financial crisis where we have seen an increase in infectious disease, a growing mental health burden (suicide rates in particular have risen sharply), and a negative impact on health determinants and risk factors, for example by adversely affecting income, employment, education, nutrition, among others.
Austerity measures to help stem the crisis appear to have exacerbated the situation in some countries e.g., preventive programmes and early treatment services have been scaled back, generic medicines have been substituted for proprietary ones, health workers’ salaries have been reduced, and some of the costs of health care have been shifted from the state to the general public.
But health gains are also under challenge from longer-terms issues around increasing healthcare costs and expectations around health systems; sustainability challenges which are in fact being exacerbated by the crisis.
But beyond the financial crisis, for which the WHO Regional Office for Europe in partnership with the European Observatory on Health Systems and Policies, has provided a great deal of support to countries affected, what needs to be done, and what is WHO doing, in respect of strengthening health systems in the region to deal with crises and shocks, and more generally towards ensuring more resilient and sustainable health systems?
Cardiovascular health outcomes
WHO Regional Office for Europe
Health systems in times of global economic crisis: an update, 17-18 April, Oslo, Norway
Aligned health workforce
Aligned health workforce
Financial Protection
In April 2009 the Government of Norway generously hosted a WHO high-level meeting on “Health in times of global economic crisis: implications for the WHO European Region”.
Since then, the crisis has deepened across the Region, with a damaging impact on the public finances of many Member States and consequent health outcomes.
Given the fast-moving economic and political environment, the WHO Regional Office for Europe convened a follow-up meeting, again held in Oslo on 17–18 April 2013.
The objectives of the meeting were severalfold:
to review the impact of the ongoing economic crisis on health and health systems in the WHO European Region;
to draw policy lessons around three broad themes: maintaining and reinforcing equity, solidarity and universal coverage; coping mechanisms, with a focus on improving efficiency; improving health system preparedness and resilience; and
to identify policy recommendations for consideration by Member States and possible future political commitments.
Policy responses to economic crisis in the EU
WHO Regional Office for Europe
All people have access to needed health services (incl. prevention) of good quality
Derived from World Health Report 2010, p.6 &
World Health Assembly Resolution 58.33, 2005
What is Universal Health Coverage?
The use of services does not expose any user (or family members) to undue financial hardship
World Health Organization
Ref: World Health Report 2010, Chapter 4
Medicines: under-use of generics and higher than necessary prices
Medicines: use of sub-standard and counterfeit medicines
Medicines: in appropriate and ineffective use
Services: inappropriate hospital size (low use of infrastructure)
Services: medical errors and sub-optimal quality of care
Services: inappropriate hospital admissions and length of stay
Services & products: oversupply and overuse of equipment, investigations and procedures
Health workers: inappropriate or costly staff mix, unmotivated workers
Interventions: inefficient mix / inappropriate level of strategies
Leakages: waste, corruption, fraud
Continual focus on improving efficiency
All health systems must continually seek to improve efficiency, whether health budgets are growing, declining, or constant, for example through the reform of service delivery networks and investment in efficient infrastructure.
Such continual attention to removing waste from health systems can strengthen the resilience of health systems in the face of budget cuts.
Health technology assessment also has a critical part to play in the policy response, by allowing budget cuts to be focused on those services identified as ineffective or of clinical low value for money clinically.
Response to the crisis in Latvia
Major cuts with concurrent structural reforms to health system
priority given to primary health care, coverage of essential medicines and outpatient specialist services
reduced hospital capacity and increased day care capacity
pharmaceutical reimbursement budget cut less than in-patient care budget
Significant price reductions of pharmaceuticals
based on cost effectiveness evaluations and international comparisons
enabled treatment for an increasing number of patients for the same amount of money
WB funded Social Safety Net subsidy
provides 100% reimbursement of medicinal products for the poor
Major restructuring in Latvia: 35% reduction of expenditure on hospital in-patient care in two years
2010: 21 emergency care hospital, , 6 care hospitals, 12 specialized hospitals
Number of patients in Day Care
Number of Home Care visits
Data source: The Centre of Health Economics data review, Latvia
WHO Regional Office for Europe
Shifting from hospital to ambulatory care of TB in the Republic of Moldova
Facilitating factors
Significant risks of re-infection and nosocomial transmission of MDR TB
Socio-economic impact related to patients’ long absence from the household
Main obstacles
Resistance of medical personnel due to overburden and lack of proper incentives
Lack of experience of personnel working at PHC care level in monitoring TB treatment
Challenges in ensuring adequate nutrition and additional support in case of adverse effects
Key success factors
Ensuring adequate nutritional and other support
Important role of NGOs and Community TB centres
Rapid diagnostic tools in place
On costs:
In 2013 the National Health Insurance Company has allocated over 80 million MDL for hospital care of TB (this includes just bed/days, as medicines are provided under the National Programme) and over 9 million MDL for ambulatory care (this includes nutritional support and incentives (bonuses) for family doctors) – almost 9 times more is spent for hospital care. It is true that the funds allocated for ambulatory care do not cover all the needs, the real ones being around 30 million (to provide adequate nutritional and social support); anyway the hospital care would still be 2,5-3 times more expensive.
On re-infection:
The previous studies have shown that the rate of re-infection with MDR TB among hospitalized patients was 74%
On socio-economic impact:
Apart from the psycho-social well being of remaining in their families, most of the patients from rural area could also continue work in their households and produce enough food both for themselves and for their families
On resistance of medical personnel and incentives:
There is overall tendency to continuously increase responsibilities of family doctors and they get overwhelmed with them. To be successful the introduction of new responsibilities should be accompanied by specific incentives. Moldova has introduced a performance-based payment at the level of PHC. Out of 26 performance indicators approved initially, 3 were related to TB – screening among risk groups, nr. of TB diagnosed cases and nr. of TB treated cases. It is also important to train personnel at ambulatory care level and to provide them guidelines.
On challenges related to nutrition and addressing the adverse effects:
Most of the patients come from vulnerable families and while they get more or less adequate nutrition when hospitalized, it is challenging to ensure this at ambulatory care level. For the time being the National Health Insurance Company cannot cover with nutritional support all patients under ambulatory treatment. Also the provided support is quite modest.
It is also difficult to deal with adverse effects of treatment at ambulatory care level. Out of 33 patients with MDR TB getting currently ambulatory treatment under the pilot project 7 had to be hospitalized due to adverse effects.
On the role of NGOs and Community Centers:
NGOs play a very important role in ensuring counseling, providing social and nutritional support and promoting adherence to treatment. However according to current legislation they are not allowed to administer the treatment itself. Granting them this possibility might be even more beneficial, especially for the most vulnerable patients.
Moldova has 10 Community TB Centres and they play a very important role in ensuring support to patients and in reducing the number of lost to follow up
On rapid diagnostic tools:
It is essential to have them in place as they permit to initiate a correct treatment from the very start, which is particularly important for the ambulatory management of TB. In Moldova the GeneXpert is successfully used.
Few words about the very preliminary results of the pilot project on ambulatory treatment of MDR TB in Moldova:
Treatment adherence is over 98%
35th Anniversary of Alma-Ata Declaration on PHC,6-7 November 2013
WHO Regional Office for Europe
People-centeredness as a cornerstone of sustainable health systems
The management and delivery of health services such that people receive a continuum of services through the different levels and sites of care within the health system, and according to their needs.
“When they change my physician that means that something is going wrong. The first thing I thought was that I wasn’t doing so well anymore”
“I have a disease that is called COPD (…) no one told me, I found out over time by myself, reading the package inserts of the drugs they prescribe me.”
“We feel like there are people who really care about us here”
[Patient receiving integrated HIV/injection drug services, Ukraine]
It is clear that in addition to investing upstream, transforming how services are delivered is going to be pivotal in both responding to the context of health and persisting shortcomings in the delivery of care – including fragmentation and breaks in communication – and in longer-term thinking.
Innovating and changing the models of care delivery is clearly crucial to health system sustainability in future.
For, despite the disease burden and epidemiological shifts we have seen over the past 100 years or so, the structure of health care delivery and services has not followed suit.
In this regard, rethinking coordinated / integrated care is a priority for the Regional Office
And when we discuss this, we considering care across the full spectrum, with ‘services’ cutting across this continuum at the varied levels and ‘settings’, from the central coordination of primary care, referrals to secondary and specialist care as well as the continuous support of community, home and social care settings, and with linkages across these to local pharmacies and the broad scope of public health at the population and individual level.
People-centred services is therefore the delivery of services whereby care received is organized according to an individual’s needs, overtime and according to their individual preferences.
Attention is due to ensure the conditions are in place for patients to be meaningfully engaged in their care for people-centred care to be realized.
The role of patients is central to increasing self-management – of particular relevance given the continuous attention demanded of chronic diseases.
There is strong evidence that efforts to empower patients to be engaged in responding to their health needs improves health outcomes, adherence to treatment, and has the potential for patients to make more informed decisions regarding their health.
In terms of patients’ own experience, ensuring people-centred services challenges us to consider the delivery of care from the perspective not only of a policy maker, regional or local managers, and across the health providers, but also that of the individual, their carer and the community at large.
A growing literature base has allowed some insight into the preferences of patients and their perceptions of services delivery.
*CLICK* For example, a study on integrated health care networks from Catalonia, describes importantly the perceptions of patients with the continuity in the delivery of care. As one patient describes: READ QUOTE
*CLICK* We see the implications of fragmentation in information described here by another patient, stating: READ QUOTE
In contrast to these experiences, we do also have evidence from patients on the benefits of integrated services, describing improvements in the ease at which they move through the system, their relationships with providers and their general satisfaction with the services received.
BMJ, 314, 24May1997
WHO Regional Office for Europe
120 000 lives and US$ 12 billion saved by implementing the Consolidated Action Plan
The goal is to contain the spread of drug-resistant TB by:
decreasing M/XDR-TB cases among previously treated cases by 20 percentage points;
detecting 85% (or 225 000) M/XDR-TB patients;
successfully treating at least 75% (127 000) of them.
Let’s check the figures:
Is it correct – the percentage point? Baseline 37% target 29%. Percentage point to be removed or baseline changed 49%.
75% of 225,000 is 168,750
WHO Regional Office for Europe
(HLC HIA Dec 2013)
Harvard change mgt steps
Eight Steps to Transforming Your Organization
Institutionalizing New Approaches
Articulating the connections between the new behaviors and corporate success
Developing the means to ensure leadership development and succession
Forming A Powerful Guiding Coalition
Assembling a group with enough power to lead the change effort
Encouraging the group to work together as a team
Creating a Vision
Developing strategies for achieving that vision
Communicating that Vision
Using every vehicle possible to communicate the new vision and strategies
Teaching new behaviors by the example of the guiding coalition
Empowering Other to Act on the Vision
Getting rid of obstacles to change
Changing systems or structures that seriously undermine the vision
Encouraging risk taking and nontraditional ideas, activities, and actions
Planning for and Creating Short Term Wins
Planning for visible performance improvements
Creating those improvements
Consolidating Improvement and Producing Still More Change
Using increased credibility to change systems, structures, and policies that don’t fit that vision
Hiring, promoting , and developing employees who can implement the vision
Reinvigorating the process with new changes, themes, and change agents
Establishing a Sense of Urgency
Examining market and competitive realities
Identifying and discussing crises, potential crises, or major opportunities