6th International AIDS Society Conference

1. 6th International AIDS Society Conference Non-communicable diseases and chronic care models: Can the MCH platform deliver? CheweLuo Senior Adviser Team Leader, Program Scale up HIV/AIDS

2. Increasing leadership and commitments - 1 • UN Secretary General Global Strategy for Women’s and Children’s Health • Reinforce commitments and collective efforts to accelerate progress toward reaching MDG 4 , 5 and 6 • United States government (USG)’s Global Health Initiative: • $US 63 billion over six years focusing on improving maternal, newborn and child health • Heads of Agencies June 2010 DC meeting: • Endorsement of the MTCT elimination goal - recognized the importance of PMTCT as a natural platform for bridging and integrating responses for MNCH and HSS .

3. Leadership and commitments - 2 • PMTCT prioritized for major and implementation by PEPFAR, the Global Fund, CIDA and UNITAID • CEE/CIS, TACRO, Asia and Africa have all developed regional frameworks on elimination of MTCT • Development of a Global Action Framework for MTCT elimination (IATT) • Launch of Global Plan towards elimination new HIV infection among children by 2015 and keeping their mothers alive

4. Duration, timing ART regimen within the continuum of care: Can the MCH platform deliver Sd-NVP sc AZT + Sd-NVP Daily Infant NVP Maternal therapeutic ART Maternal ARV prophylaxis

5. Two continuums of care at the centre of maternal and child Survival agenda • A continuum that spans life's beginnings: • …from before conception to childhood through pregnancy, childbirth, and infancy. • A continuum that goes from: • …the home (empowering families); • …through the health centre (bringing care closer to home); • …and, when needed, to the hospital (facilitating referral).

6. Antenatal Care Performance for effective delivery of interventions: 77% >1 visit, 47% at least 4 visits , State of the Worlds’ Children Report 2009

7. Delivery Care Performance 62% skilled attendant; 54% institutional State of the Worlds’ Children Report 2009

8. Intervention uptake variable across the care continuum Source: Lancet Countdown Coverage writing group, Lancet Countdown special issue, 2008

9. Early Infant Diagnosis Cascade BOTTLENECK: Less than 1/3 of infants tested for HIV at birth receiving treatment after one year Without investment through the entire follow-up continuum, the maximum impact of Early Infant Diagnosis (EID) will not be realized. 48% 131 76% 34% 68 29% 45 32 Receive Results HIV+ infants Enrolled in counseling & treatment Infants still active after 1 year Of those who enroll in HIV services, almost 1/3 are no longer tracked at the site. 48% of HIV+ infants never received results. Several died prior to receiving results. Not all infants were on CTX. Follow up of infants testing HIV+ Jinia Regional Hospital, Uganda Jan 1, 2008 – December 1, 2009

10. The poorest women are substantially less likely than the richest women to deliver with assistance of a doctor, nurse or midwifePMTCT delivery is dependent upon ANC and skilled birth attendants

11. Why women do not access health services Sources: Anthony Hodges. Presentation at the ACSD meeting, Dakar, 22-26 June 2009

12. Importance of out-of-pocket payments in health expenditure in WCA Sources: Anthony Hodges. Presentation at the ACSD meeting, Dakar, 22-26 June 2009

13. Countries with critical shortage of health services providers

14. HR crisis • Estimated shortage of almost 4.3 million doctors, midwives, nurses and support health workers worldwide • 57 countries mostly in Sub-Saharan Africa have critical shortages

15. Macro-Level: Policies and Financing Meso-level: Health system & other sectors Micro-level: Households/ Communities Framework and Production Functions for Health MDG’s MDGoutcomes Family/ Community based Care MDG focused + Child friendly: MDGs : Malnutrition U5MR MMR Malaria HIV/TB WASH National Health- Nutrition Policy Efficacy Family behaviors Population Oriented schedulable services PRSP quality SWAP compliance Community Support Budget Support utilisation access Medium Term Expenditure Framework Protection of Household Revenue availability Individual oriented non schedulable services

16. Comparison of Expected Impacts & Costs between Intervention Packages

17. Expected Impacts & Costs of phased scaling up of all Intervention Packages

18. Individual Oriented non-schedulable services Providers: Hospitals Clinics Individual practitioners (licensed or not…) High asymmetry of information Transaction intensive High discretion Bottlenecks: Skilled human resources Physical access Quality Cost Levers: Direct control of users Self Regulation Sophisticated purchasing capacity

19. Population Oriented Schedulable Services • Providers • Integrated in clinical services (clinics, GP) • Integrated in schools, workplace • Outreach health post • Mobile Activities • Home visits, door to door activities Lower Asymmetry of information Less Transaction intensive Low discretion: standards Public good nature or network externality Bottlenecks: Low demand Poor continuity Opportunity Cost Levers: Collective action: Government Primarily

20. Providers Retail Community based organizations/ associations Cooperatives Social marketing, media, Women’s groups, associations etc Family/Community based Care Low asymmetry of information Transaction light High discretion in taste/ values Bottlenecks: Knowledge Availability and cost of commodities Levers: Imitate the market Direct control of users