WHO Consultation on Positive Synergies between Health Systems and Global Health Initiatives

1. 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

2. 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 ?

3. Kenya(AMPATH)

4. The Peruvian National TB Program Peru (TB Control)

5. SCALE-UP THE PROGRAMMATIC MANAGEMENT OF MDR TB AND XDR TB 2001-2004 2005-2007 85.2 % 97.0 % Lima and Callao 2008 98.7 % Expecting inclusion of 5 more regions Global Fund Government Resources Partners in Health • GEOGRAPHICAL EXPANSION OF MDR TB TREATMENT Lima and Callao + 7 regions • FINANCIAL SUPPORT FOR MDR TB TREATMENT EVOLUTION Source: NTP Ministry Of Health Peru

6. 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 • HIV/AIDS prevention and care linked via opt out testing to comprehensive primary health care • TB diagnosis and treatment linked with HIV case finding • STD case finding and treatment linked with HIV prevention and testing • Women’s Health Services linked to providing pMTCT and care for women with HIV

7. Rwanda District Health System Strengthening Framework … Province District Leaders & Partners Briefing Session …, .. April 2008 7

8. Uganda The AIDS Support Organization (TASO) Joint Clinical Research Center (JCRC)

9. TASO Joint Clinical Research Center • Supported by PEPFAR • US Partner: CDC- public health focused • Community-based model • Add’n Services: Counseling, Home-based follow up, Food support, Vocational training • Results: • 2500 patients in ~18 months • Required to attend adherence counseling sessions • Free Medication; $0.30 user fee • Focuses on keeping patients on treatment • Supported by PEPFAR • US Partner: USAID- development focused • Medical center-based model • Distribution of ARVs is the key • Results: • 19,000 patients in ~18 months • Expanded to >30 clinics in public health facilities • Cost of treatment: $16/ month • Free ARVs to ~2000 orphans and pregnant women • Now- Expanding strategies such as home visits to address adherence • Focuses on Financial independence

10. 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

11. “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

12. 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

13. HIV/AIDS CARE DELIVERY VALUE CHAIN • Prevention counseling on modes of transmission on risk factors • Explaining diagnosis and implications • Explaining course and prognosis of HIV • Explaining approach to forestalling progression • Explaining medical instructions and side effects • Counseling about adherence; understanding factors for non-adherence • Explaining co-morbid diagnoses • End-of-life counseling INFORMING & ENGAGING PATIENT VALUE (Health outcomes per unit of cost) • HIV testing • TB, STI screening • Collecting baseline demographics • HIV testing for others at risk • CD4+ count, clinical exam, labs • Monitoring CD4+ • Continuously assessing co-morbidities • Regular primary care assessments • Lab evaluations for initiating drugs • HIV staging, response to drugs • Managing complications • HIV staging, response to drugs • Regular primary care assessments MEASURING • Meeting patients in high-risk settings • Primary care clinics • Testing centers • Primary care clinics • Clinic labs • Testing centers • Primary care clinics • Food centers • Home visits • Primary care clinics • Pharmacy • Support groups • Primary care clinics • Pharmacy • Support groups • Primary care clinics • Pharmacy • Hospitals, hospices ACCESSING ONGOING DISEASE MANAGEMENT PREVENTION & SCREENING DELAYING PROGRESSION INITIATING ARV THERAPY MANAGEMENT OF CLINICAL DETERIORATION DIAGNOSING & STAGING • Initiating therapies that can delay onset, including vitamins and food • Treating co-morbidities that affect disease progression, especially TB • Improving patient awareness of disease progression, prognosis, transmission • Connecting patient with care team • Connecting patient with primary care • Identifying high-risk individuals • Testing at-risk individuals • Promoting appropriate risk reduction strategies • Modifying behavioral risk factors • Creating medical records • Formal diagnosis, staging • Determining method of transmission • Identifying others at risk • TB, STI screening • Pregnancy testing, contraceptive counseling • Creating treatment plans • Initiating comprehensive ARV therapy, assessing drug readiness • Preparing patient for disease progression, treatment side effects • Managing secondary infections, associated illnesses • Managing effects of associated illnesses • Managing side effects • Determining supporting nutritional modifications • Preparing patient for end-of-life management • Primary care, health maintenance • 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

14. INTEGRATING DELIVERY SYSTEM AND CONTEXT Environmental Factors Nutrition HOUSING ECONOMIC DEVELOPMENT Education Water & Sanitation TECHNOLOGY TRANSPORT Access to Care Facilities

16. Next Round of Cases • MDR-TB/DOTS Plus in Peru • Malawi National ART Program • ABE: Artemisinin Producers • ACTs in Senegal • CHAI Pediatric HIV Drug Program • Novartis Coartem Program • ARV Logistics in Zambia (CIDRZ) • Brazil National HIV Program (A&B) • Thailand and Quality Improvement • Zambia National Malaria Program • Bangladesh: BRAC Urban TB • Bangladesh: BRAC Rural TB • HR and Task Shifting in Swaziland: Male Circumcision • PMTCT in Botswana • Open MRS • Tobacco Control in South Africa • Rwanda Mutuelle Program • PEPFAR Authorization • Tanzania Bed Nets • TASO/Uganda’s National HIV Program and the Global Fund • XDR-TB in South Africa • Plumpy’nut

18. 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 System Dynamics Systems Engineering Analytic Frameworks for HS building blocks Simulation Model Delivery Models and Supply Chains Epidemiology Anthropology Economics Value Chain Analysis Monitoring Implement Operations Research, System Optimization Strategy Operations Management Evaluation

19. 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 Communities of Practice

20. 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 ?

22. 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 investigationof 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!