6th International AIDS Society Conference

Non-communicable diseases and chronic care models: Can the MCH platform deliver?

Chewe LuoSenior AdviserTeam Leader, Program Scale upHIV/AIDS

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 .

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

Duration, timing ART regimen within the continuum

of care: Can the MCH platform deliver

Maternal ARV prophylaxis

Sd-NVP

sc AZT + Sd-NVP Daily Infant NVP

Maternal therapeutic ART

WORLD HEALTH ORGANIZATION

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).

Antenatal Care Performance for effective delivery of interventions: 77% >1 visit, 47% at least 4 visits

, State of the Worlds’ Children Report 2009

Delivery Care Performance 62% skilled attendant; 54%

institutional State of the Worlds’ Children Report 2009

Intervention uptake variable across the care continuum

Source: Lancet Countdown Coverage writing group, Lancet Countdown special issue, 2008

9

0

20

40

60

80

100

120

140

Receive Results

HIV+ infants

Enrolled in counseling &

treatment

Infants still active after

1 year

76%

48% of HIV+ infants never received results. Several died prior to receiving results. Not

all infants were on CTX.

Of those who enroll in HIV services, almost

1/3 are no longer tracked at the site.

Without investment through the entire follow-

up continuum, the maximum impact of Early Infant Diagnosis (EID) will

not be realized.

Early Infant Diagnosis Cascade

Follow up of infants testing HIV+ Jinia Regional Hospital, Uganda Jan 1, 2008 – December 1, 2009

BOTTLENECK: Less than 1/3 of infants tested for HIV at birth receiving treatment after one year

48%

68

34%

29%45

32

131

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

WCA regional averages (Source: DHS data)

56%

40%

37%

23%

19%

17%

12%

0% 10% 20% 30% 40% 50% 60% 70%

Cost (money)

Distance

Transport problems

Not wanting to go alone

No female provider

Don't know where to go

No permission to go

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

Composition of national health expenditure, 2006

Govern-ment

35.5%

Private64.5%

Composition of private health expenditure, 2006

Pre-paid , 4.5%

Other, 3.0%

OPPs, 92.2%

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

Macro-Level: Policies and

Financing

Meso-level:Health system & other

sectors

Framework and Production Functions for Health MDG’s

MDGs :MalnutritionU5MRMMRMalariaHIV/TBWASH

MDGoutcomes

Micro-level:Households/ Communities

Family/

Community

based Care

Population

Oriented

schedulable

services

Individual

oriented

non schedulable

services

Family

behaviors

availability

access

utilisation

compliance

quality

Efficacy

SWAP

Protection of Household Revenue

Com

mu

nity

S

up

port Budget

Support

Medium Term Expenditure Framework

PRSP

National Health- Nutrition Policy

MDG focused + Child friendly:

Comparison of Expected Impacts & Costs between Intervention Packages

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

Estimated Impacts & Costs to scale up high impact intervention packages and reduce bottlenecks

$4.95

$15.83

$31.43

0%

20%

40%

60%

80%

100%

Phase I Phase II Phase II I

-$2

$2

$6

$10

$14

$18

$22

$26

$30

$34

$38

$42

$46

$50

Anaemia Reduction of Low Birth weight Estimated reduction in stunting

U5MR reduction IMR reduction NNMR reduction

MMR reduction 1 in Lifetime Risk of Dying % total demand for Family P lanning met

Reduction of Malaria Mortality Reduction in AIDS mortality Reduction in TB Mortality

Quality of drinking water Use of sanitary latrine Supply of safe drinking water

Cost per capita per year in US$

MDG 1 MDG4 MDG7MDG 6MDG5

ZZ-Africa TF all countries

Bottlenecks: Skilled human resources

Physical accessQuality

Cost

Individual Oriented non-schedulable

services

High asymmetry of informationTransaction intensive

High discretion

Levers:Direct control of users

Self RegulationSophisticated purchasing

capacity

Providers:

Hospitals

Clinics

Individual practitioners (licensed or not…)

Bottlenecks: Low demand

Poor continuityOpportunity Cost

Population Oriented Schedulable Services

Lower Asymmetry of informationLess Transaction intensiveLow discretion: standards

Public good nature or network externality

Levers:Collective action:

Government Primarily

Providers

•Integrated in clinical services (clinics, GP)

•Integrated in schools, workplace•Outreach health post

•Mobile Activities

•Home visits, door to door activities

Bottlenecks: Knowledge

Availability and cost of commodities

Family/Community based Care

Low asymmetry of informationTransaction light

High discretion in taste/ values

Levers:Imitate the market

Direct control of users

Providers

Retail

Community based organizations/ associations

Cooperatives

Social marketing, media,

Women’s groups, associations etc