Lee Sarkin 6 November 2008

1. Monitoring & EvaluatingAccess to and Effectiveness of HIV and AIDS Treatment in the Private Sector Lee Sarkin 6 November 2008

2. Agenda • Aims • Why M&E? • Progress towards 2010 Universal Access • South African M&E implementation gap • Resource gap • Inaugural Private Sector M&E seminar • Closing remarks: Universal Access

3. Aims • Communicate an M&E implementation gap • Propose a solution to: • Replace a duplicated & fragmented M&E response with a unified response • Promote evidence-based decision-making • Review progress towards meeting targets • Honour international & national commitments

4. Why M&E? • Global commitments: global crisis – global action

5. 2000 UN Millennium Declaration • UN Millennium Summit took place in September 2000. World leaders agreed to reduce poverty and improve lives and issued the eight Millennium Development Goals (MDGs). • As a precursor to the Declaration of Commitment, MDG 6 calls for combating AIDS, and beginning to reverse the spread of HIV/AIDS by 2015. • "We will have time to reach the Millennium Development Goals – worldwide and in most, or even all, individual countries – but only if we break with business as usual. We cannot win overnight. Success will require sustained action across the entire decade between now and the deadline. It takes time to train the teachers, nurses and engineers; to build the roads, schools and hospitals; to grow the small and large businesses able to create the jobs and income needed. So we must start now. And we must more than double global development assistance over the next few years. Nothing less will help to achieve the Goals." - Former United Nations Secretary-General, Kofi A. Annan

6. 189 UN member states signed the 2001 Declaration of Commitment on HIV/AIDS

7. 2001 Declaration of Commitment on HIV/AIDS • In June 2001, Heads of State and Representatives of Governments met at the United Nations General Assembly Special Session dedicated to HIV/AIDS. • The meeting was a major milestone in the AIDS response. It was recognized that the AIDS epidemic had caused untold suffering and death worldwide. The UN Special Session also served to remind the world that there was hope. With sufficient will and resources, communities and countries could change the epidemic’s deadly course. The theme global crisis requiring global action served to underline the need for urgent attention. • At the meeting, Heads of State and Representatives of Governments issued the Declaration of Commitment on HIV/AIDS. The Declaration remains a powerful tool that is helping to guide and secure action, commitment, support and resources for the AIDS response.

8. Why M&E? • Global commitments: global crisis – global action • 2000: Millennium Declaration (8 MDG Goals & 2015 target) • 2001: Declaration of Commitment on HIV/AIDS (25 UNGASS indicators)

9. The ‘Three Ones’ Key Principles – making the money work for people • ONENational Strategic Framework • ONENational AIDS Coordinating Authority • ONENational Monitoring and Evaluation System. (NSP, 2007-2011) (SANAC) (NSP-M&E framework)

10. The “Three Ones” – Principles for the coordination of national AIDS responses • 25 April 2004: UNAIDS, the United Kingdom and the United States co-hosted a high-level meeting at which key donors reaffirmed their commitment to strengthening national AIDS responses led by the affected countries themselves. • Endorsed the "Three Ones" principles, to achieve the most effective and efficient use of resources, and to ensure rapid action and results-based management: • One agreed HIV/AIDS Action Framework that provides the basis for coordinating the work of all partners. • One National AIDS Coordinating Authority, with a broad-based multi-sectoral mandate. • One agreed country-level Monitoring and Evaluation System.

11. Why M&E? • Global commitments: global crisis – global action • 2000: Millennium Declaration (8 MDG Goals & 2015 target) • 2001: Declaration of Commitment on HIV/AIDS (25 UNGASS indicators) • 2004: “Three ones” guiding principles for coordination & collaboration

12. 2006 Political Declaration on HIV/AIDS • A new and forward-looking Political Declaration on HIV/AIDS was adopted unanimously by UN Member States on 2 June 2006 at the close of the United Nations General Assembly 2006 High Level Meeting on AIDS. • Following intense negotiations on the text among Member States, the final 2006 Declaration provides a strong mandate that will help move the AIDS response forward, particularly with regards to scaling up towards universal access to HIV prevention, treatment, care and support. • It reaffirms the 2001 Declaration of Commitment on HIV/AIDS and the Millennium Development Goals, in particular the goal to halt and begin to reverse the spread of AIDS by 2015.

13. Why M&E? • Global commitments: global crisis – global action • 2000: Millennium Declaration (8 MDG Goals & 2015 target) • 2001: Declaration of Commitment on HIV/AIDS (25 UNGASS indicators) • 2004: “Three ones” guiding principles for coordination & collaboration • 2006: Political Declaration on HIV/AIDS & 2010 Universal Access • National commitments: • 1992: NACOSA plan • 2000: National HIV/AIDS Strategic Plan (NSP) 2000-2005 • 2003: Operational Plan for CCMT • 2007: NSP 2007-2011 & NSP-M&E framework • 2008: UNGASS country reporting on implementing the 2001 Declaration • Evidence-based decision-making • Time-bound targets: need to assess progress towards meeting targets of international & national commitments

14. Selected events in the response

15. What is Universal Access? • Universal access signifies both a concrete commitment and a renewed resolve among the world over to reverse the course of the epidemic. It is a process that builds on past initiatives and infuses existing efforts with greater momentum. • Universal access does not imply that there will be, or should be, 100% coverage of HIV prevention, treatment, care, and support services. • Even in high-income countries where health care is universally available, some patients who are medically eligible for ART are not receiving them for various reasons (e.g. a deliberate decision not to undergo testing or a decision to initiate therapy at a later time). • Rather, by moving towards nationally set targets for universal access, the world has committed to make concrete, sustained advances towards a high level of coverage. • The basic principles for scaling up towards universal access emphasize that services must be equitable, accessible, affordable, comprehensive, and sustainable over the long-term. • By setting national targets, countries are holding themselves accountable to reach universal access within a time frame that is both urgent— galvanizing support and momentum around this goal—and feasible, and that will set them on the way to reach the 2015 Millennium Development Goals.

16. Progress towards 2010 Universal Access • Reaching the MDG on HIV/AIDS – to halt and reverse the spread of the epidemic by 2015 – requires far greater access to HIV prevention services and AIDS treatment, care and support than is currently available. • As per the commitments made in the 2006 Political Declaration on HIV and AIDS, countries around the world are currently in the process of revising their national AIDS plans and targets so as to significantly scale up their response towards universal access to HIV prevention, treatment, care and support by 2010. • Participation and country focus is what makes this effort special. The other critical elements of the process are: • It occurs within and builds upon existing processes at all levels. • Countries drive the process, supported by international and bilateral institutions and donors, in line with the “Three Ones” principles. • It covers the scale up of a comprehensive and integrated response, including prevention, treatment, care and support. • It focuses on finding practical solutions to the main obstacles to scaling up, building on decisions already made. • The participation of a wide range of stakeholders—especially civil society and people living with HIV—is critical to its elaboration and success. • It encourages countries to set their own roadmaps – including midpoint targets and milestones - for themselves in order to advance toward universal access and to achieve the Millennium Development Goal on HIV/AIDS.

17. Access to ART

18. Access to ART

19. 3 by 5 • Launched in December 2003, the “3 by 5” initiative proposed a massive scale-up of ART, sufficient to ensure that 3 million people would be on ART by the end of 2005. • Although the goal of 3 million people on treatment was not reached until two years after the 2005 deadline, “3 by 5” was critical in catalysing unprecedented action to expand treatment access in resource-limited settings.

20. NSP, 2007-2011 • The NSP flows from the NSP of 2000-2005, the Operational Plan for CCMT as well as other HIV and AIDS strategic frameworks developed for government and sectors of civil society in the past • In 2006, the Department of Health was mandated by SANAC, under the leadership of South Africa’s Deputy President, to lead a process of developing a new 5-year plan for the years 2007-2011 • Represents South Africa’s multi-sectoral response to the HIV/AIDS epidemic • The primary aims of the NSP are to: • Reduce the rate of new HIV infections by 50% by 2011. • Reduce the impact of HIV and AIDS on individuals, families, communities and society by expanding access to appropriate treatment, care and support to 80% of all HIV positive people and their families by 2011. • The interventions needed to reach the NSP’s goals are structured under four key priority areas: • Prevention; • Treatment, care and support; • Research, monitoring, and surveillance; and • Human rights and access to justice

21. What is M&E? • M&E provides a way of assessing the ongoing progress of a plan/programme in achieving its goals and objectives and informing key stakeholders about the results. • An effective M&E system is essential for a co-ordinated national response. • The M&E system must provide timely and reliable data that can be used by stakeholders to inform decisions on whether any changes to the response are needed. • This in turn requires the development of annual M&E work plans in order to guide the design of M&E, highlight what information or data need to be collected, describe how best to collect it, and specify how to disseminate and use the results. • Monitoring: • Monitoring is the routine assessment of ongoing activities and progress. • Evaluation: • In contrast, evaluation is the episodic assessment of overall achievements. • Thus monitoring looks at what is being done, whereas evaluation examines what has been achieved or what impact has been made.

22. South African M&E implementation gap • Extract from the NSP M&E framework: • It is expected that each of the sectors would develop their own operational plans on implementing the NSP. The activities and interventions from the sector operational plans would follow that of the NSP. It is important for each sector to develop processes on how to collect information to submit to the SANAC sector M&E coordinating unit.

23. Selected Indicators of Treatment Access & Effectiveness MDG Goal 6: Target 6B:Achieve, by 2010, universal access to treatment for HIV/AIDS for all those who need it Indicator 6.5% of population with advanced HIV infection with access to ART • NSP Indicators • Priority area 2, goal 6:Enable people living with HIV and AIDS to lead healthy and productive lives. • % of women, men and children with advanced HIV infection who are receiving ART relative to projected new stage IV (2011 target 80%) • % of patients at start of ART with CD4< 50 • Percentage of adults and children on ART who are still alive and in care 12 months after initiation of ART (2011 target 85%) • Viral load suppression 12 months (target 80%) UNGASS Indicators: 4.% of adults and children with advanced HIV infection receiving ART. 24.% of adults and children with HIV known to be on treatment 12 months after initiation of ART 6.% of estimated HIV-positive incident Tuberculosis cases that received treatment for Tuberculosis and HIV 2000 UN Millennium Declaration • 2001 UN Declaration of Commitment on HIV/AIDS • 2006 UN Political Declaration on HIV/AIDS 2000 2001 2006 2007 2008 2009 2010 2011 2015

24. Retention once initiated on ART • Extract from the SA UNGASS 2008 report:

25. Resource gap?Total annual resources available for AIDS, 1986–2007

26. Resource gap: US$ 8 Billion in 2007 Statement at the UN General Assembly High Level Meeting on AIDS New York, 10 June 2008. Dr Peter Piot, UNAIDS Executive Director: “And it is time to increase funding. Sometimes I hear that there is “too much money for AIDS”. Nothing could be further from the truth. Since the creation of the Global Fund to Fight AIDS,Tuberculosis and Malaria and the US President’s Emergency Programme for AIDS Relief, there’s been a tremendous increase in resources for AIDS. But the sobering reality is that the AIDS response remains under funded: last year there was an $8 billion shortfall. If we’re going to sustain the gains we’ve made already – if we’re to get anywhere near Universal Access to HIV prevention, treatment, care and support, the world will need to significantly increase investment in AIDS.” Global annual resources available 2000–2007 and funding gap between projected financial resources if current scale-up continues and a phased scale-up scenario to reach universal access between 2010 and 2015. Source: 2008 Report on the Global AIDS Epidemic, UNAIDS

27. Closing an M&E implementation gap • Currently no routine monitoring on a sector-level of numbers accessing ART via private sector nor retention once initiated • International & national commitments necessitate implementation of M&E frameworks • Progress to date: 2008 - Joint workshop by Actuarial and HIV Clinician’s Societies resulting in a patient level data specification currently under peer-review • Next step: early 2009 - Inaugural seminar for South African Private Sector providers of HIV disease management, treatment and care

28. Inaugural Private Sector M&E Seminar: “the Storm to end the ART Data Drought” • Objectives: • Convey the findings of a data specification jointly developed by the Actuarial and Southern African HIV Clinicians Societies to participating stakeholders, in particular the providers. • Discuss the role of providers as a vital source of data in relation to the NSP, particularly in regard to monitoring and evaluating access to and effectiveness of treatment through the Private Sector (including certain non-state programmes) of South Africa. • Lay a foundation for sustained collaboration amongst the participating stakeholders. • To obtain the support of providers to provide the requested data on an ongoing basis and thereby support Pillar 3 of the NSP, 2007 – 2011 and UNGASS reporting requirements • Potential delegates: • HIV disease management providers • Corporate HIV workplace programmes • Pharmaceutical manufacturers and distributors • Health care professionals (e.g. clinician’s and case managers) • Research institutions (e.g. Medical Research Council (MRC), the Human Sciences Research Council (HSRC), University researchers) • Other (SANAC, the Council for Medical Schemes (CMS), the Board of Healthcare Funders (BHF) and database design and software/technology development companies).

29. A message from the UNGA President • H.E. Srgjan Kerim, President of the UN General Assembly in his closing statement of the 2008 High Level meeting on AIDS, New York: • “History will judge how effectively we rose to the challenge of AIDS; • Our global response must continue to be a collective effort; • No state or individual organisation can succeed alone; • Our renewed determinationmust be matched with accelerated implementationof commitments to achieveuniversal access to HIV/AIDS prevention, treatment, care and support by 2010; • We must not lose momentum of our global response; • For every 2 people that begin treatment there are 5 new HIV infections; and • The implications of HIV prevention failures are clear: unless we act now, treatment queues will get longer and longer and it will become more and more difficult to get anywhere near universal access to ART.”

30. Brad Mears Lee Sarkin lsarkin@mweb.co.za Mobile: +27 (0) 83 242 4381 Dr Francois Venter Fatima Hassan / Mark Heywood