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WHO Consultation on Positive Synergies between Health Systems and Global Health Initiatives Jim Yong Kim M.D., Ph.D. François Xavier Bagnoud Center for Health and Human Rights Brigham and Women’s Hospital Harvard Medical School Harvard School of Public Health Partners In Health May 29th, 2008 Key Questions • Health systems and Global Health Initiatives- the state of affairs •Are there positive synergies between GHIs and HSS? •Are these synergies being vigorously exploited to assure maximum, mutual added value? • The need for systematic evidence • Are there knowledge gaps and, if so, can they be identified? • How best can current experience be mapped using existing evidence? • What research is needed to develop the evidence base? • The search for a logical framework for investigation • Can we develop appropriate research methodology? • Can we construct a logical framework for investigation ? Kenya (AMPATH) The Peruvian National TB Program Peru (TB Control) SCALE-UP THE PROGRAMMATIC MANAGEMENT OF MDR TB AND XDR TB 1. GEOGRAPHICAL EXPANSION OF MDR TB TREATMENT 2005-2007 2001-2004 97.0 % 85.2 % Lima and Callao Lima and Callao + 7 regions 2. FINANCIAL SUPPORT FOR MDR TB TREATMENT EVOLUTION 100% 2008 80% 98.7 % 60% Expecting inclusion of 5 more regions 40% Source: NTP Ministry Of Health Peru 20% 0% 2001 2002 2003 Partners in Health 2004 2005 Global Fund 2006 2007 2008 Government Resources HIV/AIDS Prevention and Treatment Strengthens Healthcare System Partners In Health’s Experience in Haiti • Because of abandoned health structures, AIDS case detection and treatment impossible without revitalizing health systems. • GFATM money (and later PEPFAR) used to provide primary health services based on linkages to 4 basic areas i. HIV/AIDS prevention and care linked via opt out testing to comprehensive primary health care ii. TB diagnosis and treatment linked with HIV case finding iii. STD case finding and treatment linked with HIV prevention and testing iv. Women’s Health Services linked to providing pMTCT and care for women with HIV Rwanda District Health System Strengthening Framework … Province District Leaders & Partners Briefing Session …, .. April 2008 7 Uganda The AIDS Support Organization (TASO) Joint Clinical Research Center (JCRC) TASO Joint Clinical Research Center • Supported by PEPFAR • Supported by PEPFAR • US Partner: CDC- public health focused • US Partner: USAID- development focused • Community-based model • Medical center-based model • Add’n Services: Counseling, Homebased follow up, Food support, Vocational training • Distribution of ARVs is the key • Results: • Results: 19,000 patients in ~18 months i. 2500 patients in ~18 months ii. Expanded to >30 clinics in public health facilities ii. Required to attend adherence counseling sessions iii. Cost of treatment: $16/ month iv. Free ARVs to ~2000 orphans and pregnant women iii. • i. Free Medication; $0.30 user fee Focuses on keeping patients on treatment • Now- Expanding strategies such as home visits to address adherence • Focuses on Financial independence Global Health “Strategy” To Date • Countries and even districts working in isolation • Project-based – Donor preference driven – Experimental pilots that never scale • Competition among implementers • Cottage-industry approach • Fragmentation of services • Ineffective and not results oriented • Absence of technology and measurement orientation • Resources diverted for overhead and consultants Clear need for a better approach “Maximum, mutual added value” • The need for holistic framework that incorporates all activities and actors contributing to global health outcomes at individual patient and health system level Value: Patient outcomes per dollar spent The Care Delivery Value Chain • The care delivery value chain captures: – Interaction between interventions and infrastructure – The configuration, sequence and interdependence of interventions – Value is created across the activities during the “care cycle” Allows careful examination of all activities of a care delivery system and more thoughtful deployment of resources HIV/AIDS CARE DELIVERY VALUE CHAIN INFORMING & ENGAGING • Prevention counseling on modes of transmission on risk factors ACCESSING • Explaining approach to forestalling progression • Explaining medical instructions and side effects • Counseling about adherence; understanding factors for nonadherence • Explaining co-morbid diagnoses • Regular primary care assessments • HIV staging, response to drugs • HIV staging, response to drugs • Lab evaluations for initiating drugs • Managing complications • Regular primary care assessments • Collecting baseline demographics • Explaining course and prognosis of HIV • HIV testing for • Monitoring CD4+ others at risk • Continuously • CD4+ count, assessing coclinical exam, labs morbidities • Meeting patients in high-risk settings • Primary care clinics • Primary care clinics • Primary care clinics • Primary care clinics • Primary care clinics • Primary care clinics • Clinic labs • Food centers • Pharmacy • Pharmacy • Pharmacy • Testing centers • Testing centers • Home visits • Support groups • Support groups • Hospitals, hospices PREVENTION & SCREENING DIAGNOSING & STAGING DELAYING PROGRESSION MANAGEMENT OF ONGOING INITIATING CLINICAL ARV THERAPY DISEASE MANAGEMENT DETERIORATION • Connecting patient with primary care • Formal diagnosis, staging • Identifying high-risk individuals • Determining method of transmission • Initiating therapies that can delay onset, including vitamins and food • Initiating comprehensive ARV therapy, assessing drug readiness • HIV testing MEASURING • Explaining diagnosis and implications • TB, STI screening • Testing at-risk individuals • Promoting appropriate risk reduction strategies • Identifying others at risk • TB, STI screening • Modifying • Pregnancy behavioral risk factors testing, contraceptive • Creating medical counseling records • Creating treatment plans • Treating comorbidities that affect disease progression, especially TB • Preparing patient for disease progression, treatment side • Improving patient awareness of disease effects progression, • Managing prognosis, secondary transmission infections, associated • Connecting patient illnesses with care team • Managing effects of associated illnesses • Managing side effects • Determining supporting nutritional modifications • Preparing patient for end-of-life management • Primary care, health maintenance •End-of-life counseling PATIENT VALUE • Identifying clinical and laboratory deterioration • Initiating second- and third-line drug therapies • Managing acute illnesses and opportunistic infection through aggressive outpatient management or hospitalization • Providing social support • Access to hospice care (Health outcomes per unit of cost) INTEGRATING DELIVERY SYSTEM AND CONTEXT Environmental Factors Nutrition HOUSING Shared Delivery Infrastructure ECONOMIC DEVELOPMENT HIV/AIDS TUBERCULOSIS Education MATERNAL, PERINATAL CARE TECHNOLOGY MALARIA Malaria Malaria Access to Care Facilities 20080221 Wharton GHD – DRAFT 20080221.ppt Water & Sanitation TRANSPORT Next Round of Cases 1. MDR-TB/DOTS Plus in Peru 11. Bangladesh: BRAC Urban TB 2. Malawi National ART Program 12. Bangladesh: BRAC Rural TB 3. ABE: Artemisinin Producers 13. HR and Task Shifting in Swaziland: Male Circumcision 4. ACTs in Senegal 5. CHAI Pediatric HIV Drug Program 14. PMTCT in Botswana 15. Open MRS 6. Novartis Coartem Program 16. Tobacco Control in South Africa 7. ARV Logistics in Zambia (CIDRZ) 17. Rwanda Mutuelle Program 8. Brazil National HIV Program (A&B) 18. PEPFAR Authorization 9. Thailand and Quality Improvement 10. Zambia National Malaria Program 19. Tanzania Bed Nets 20. TASO/Uganda’s National HIV Program and the Global Fund 21. XDR-TB in South Africa 22. Plumpy’nut Preliminary Framework to Investigate the Interactions between Global Health Initiatives and Health Systems •Gathering clinic and system-level data •Interviewing key constituents •Building costing models Case Studies Systems Engineering Simulation Model Analytic Frameworks for HS building blocks Delivery Models and Supply Chains Value Chain Analysis Monitoring Implement Epidemiology Anthropology Economics Strategy Operations Management Operations Research, System Optimization Evaluation Communities of Practice • Tool to Drive Strategy • World Bank uses COP as knowledge management strategy • Quick Problem Solving • Rapid exchange of information and recommendations • Generate Innovative Ideas • Capitalize on current knowledge and generate new perspectives • Identify and Transfer/Disseminate Best Practices • Create a forum for sharing and spreading best practices • Develop Professional Skills • Willingness to provide and share information and act as mentors Key Questions • Health systems and Global Health Initiatives- the state of affairs •Are there positive synergies between GHIs and HSS? •Are these synergies being vigorously exploited to assure maximum, mutual added value? • The need for systematic evidence • Are there knowledge gaps and, if so, can they be identified? • How best can current experience be mapped using existing evidence? • What research is needed to develop the evidence base? • The search for a logical framework for investigation • Can we develop appropriate research methodology? • Can we construct a logical framework for investigation ? A Path Forward? • Gather all existing data and expertise on GHI and HSS • Build a case library of past and current examples of positive synergies and mutual threats • Collectively study the data to develop frameworks for investigation of positive synergies and mutual threats (e.g. CDVC, systems analysis) • Develop a framework for evaluation of the impact of GHI’s on health systems (DDCF) • Create a community of practice for GHI/HSS • Make our collective work relevant and immediately helpful to practitioners • Health for All, finally!