bridging the divide
DESCRIPTION
Bridging the Divide. Wafaa El-Sadr, MD, MPH Columbia 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. - PowerPoint PPT PresentationTRANSCRIPT
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
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
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 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
√√√√√√√√√
√√√√√√√√√
√√√√√√√√√
√√√√√√√√√
√√√√√√√√√
Adapted from Travis, Bennett, et al. Lancet 2004
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
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)
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