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Bridging the Divide

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.

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Bridging the Divide

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  1. Bridging the Divide Wafaa El-Sadr, MD, MPHColumbia University and Harlem Hospital Vienna, July 20, 2010

  2. Bridging the Divide: Interdisciplinary Partnerships for HIV and Health Systems StrengtheningVienna, July 16-17 • Background: HIV scale-up and health systems • Meeting objectives and agenda

  3. HIV Prevalence Persons Living with HIV/AIDS, 200833.2 million (30.6-36.1 million) worldwide www.worldmapper.org

  4. Health Systems in Crisis: Infrastructure

  5. Health Systems in Crisis: Human Resources

  6. Health Systems in Crisis: Laboratory and Pharmacy Systems

  7. Antiretroviral Therapy by Region, 2001

  8. Unique Characteristics of HIV and its Treatment Drive Programmatic Innovation

  9. 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

  10. 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

  11. 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

  12. 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

  13. 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

  14. 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)

  15. Number of people receiving antiretroviral therapy in low- & middle-income countries, by region, 2002–2008 WHO, Towards Universal Access, 2009

  16. Bridging the Divide: Interdisciplinary Partnerships for HIV and Health Systems StrengtheningVienna, July 16-17 • What is the impact of HIV scale-up?

  17. Estimated Impact of ART on AIDS-related deaths, globally, 1996–2008 3.0 2.5 2.0 Number (millions) 1.5 1.0 0.5 0 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Year No antiretroviral therapy At current levels of antiretroviral prophylaxis 2.9 M lives saved UNAIDS 2009 AIDS Epidemic Update

  18. ART coverage and all-cause mortality in South Africa, 2003–2006 WHO, Towards Universal Access, 2009

  19. Under-two Child Mortality/1000 Live BirthsKwa Zulu Natal, South Africa Ndirangu et al. AIDS 2010

  20. 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

  21. Effect of PMTCT Programs on Quality of Overall Antenatal Care and Delivery, Cote D’Ivoire Delvaux et al, IAS 2009

  22. Effect of ART on Incidence of MalariaUganda & Zimbabwe Kasirye et al, IAS 2009

  23. Impact of ART on worker absenteeism

  24. Impact of ART as Prevention: Effect on New HIV Infections British Columbia, Canada Taiwan Free ART Fang et al. JAIDS 2004;190:879-85 Wood et al. BMJ 2009;338b:1649

  25. Bridging the Divide: Interdisciplinary Partnerships for HIV and Health Systems StrengtheningVienna, July 16-17 • What about other health threats?

  26. 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

  28. Cape Town 2009:Accelerating the Impact of HIV Programming on Health Systems Strengthening

  29. Bridging the Divide: Interdisciplinary Partnerships for HIV and Health Systems StrengtheningVienna, 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

  30. Health Systems Building Blocks

  31. Service Delivery Integrated Service Delivery Case Studies Moderator / framing presentation: RifatAtun Case 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: YoganPillay (MOH SA) HIV Scale-Up and Chronic Disease Services Moderator/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)

  32. Health Workforce Health Workforce Moderator 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: TamratAssefa(MOH Ethiopia) Leveraging HIV Funding for the Malawi Health Workforce: Frank Chimbwandira (MOH Malawi)

  33. Information and Technology Leveraging HIV Scale-up for Health Information Systems Moderators: Kevin Fenton (CDC) and NosaOrobaton (WHO) Presentation from WHO HIS: John Cutler(WHO) Case Study 1: Charles Nzioka (MoH Kenya) Case Study 2: Michael Graven (Health Metrics Network)

  34. Financing and Payments Leveraging Private Sector for Health Moderator: 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: TesfaiGabre-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)

  35. Leadership and Governance HIV Scale-up and Global Health Moderator: Alan Whiteside, IAS Executive Board Ezekiel Emanuel (USG) Eric Goemaere (MSF) Lynn Freedman (Columbia University) Julian Lob-Levyt (GAVI) Directions For The Future Moderator: Wafaa El-Sadr (ICAP) Key Outcomes: RifatAtun (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: EllyKatabira (IAS)

  36. Vienna 2010:Bridging the Divide: Interdisciplinary Partnerships for HIV and Health Systems

  37. Bridging the Divide: Interdisciplinary Partnerships for HIV and Health Systems StrengtheningVienna, July 16-17 Build the Partnerships Generate the Evidence HIV and Health Systems Strengthening

  38. 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 • NandiniOomman, Center for Global Development • GorikOoms, Yale University • JosPerriens, WHO • Estelle Quain, USAID • Miriam Rabkin, ICAP Columbia University • SubhaRaghavan, SAATHI India

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