Transcript the status of affairs ppt, 13.16Mb

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!