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HIV and Health System Sustainability
Prof. Olive Shisana, Sc.DHuman Sciences Research Council South Africa
20th International AIDS ConferenceMelbourne, Australia
22 July 2014
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Outline• Key interventions for creating sustainable
health systems:
(1) Strengthen health systems
(2) Integrate services
(3) Increase domestic funding
(4) Ensure universal health coverage
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(1) Strengtheninghealth systems
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Adults and children living with HIV (millions) around the world
30
35.3
21.725
3.7 3.91.3 1.50.86 1.3
0
5
10
15
20
25
30
35
40
2001 2012
World
Sub‐SaharanAfricaSouth and SouthEast AsiaLatin America
Eastern Europeand Central Asia
Source: UNAIDS 2013
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Key: Expanding Trend Declining Trend No change
HIV and AIDS Profile in Asia and the Pacific countries, 2012
Epidemic Pattern HIV Incidence
AIDSDeaths
HIVPrevalence
Countries
Profile 1: Declining Cambodia,India, Myanmar, Nepal, Thailand
Profile 2: Maturingor varies
Malaysia, PNG, Viet Nam
Profile 3: Expanding.
Indonesia, Pakistan, Philippines
Profile 4: Latentor <500
Afghanistan,Bangladesh,Lao PDR, Sri Lanka
Profile 5: Low prevalence <500 low <1 000
Bhutan, Fiji, Maldives, Mongolia
Source: UNAIDS Regional Support Team Asia and the Pacific- HIV and AIDS Data Hub 2013
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HIV Prevalence in Key PopulationsSex Workers• Sub-Saharan Africa: 36.9%• Eastern Europe: 10.9%• Latin America: 6.1%
Source: Kerrigan, D. et al. (2010).
IDU• Europe and Central Asia: 3%
to 52%• South and South-East Asia:
1% to 36%• Sub-Saharan Africa: 51.6% in
MauritiusSource: UNAIDS 2013
MSM• Median prevalence across
24 countries is 14% since 2006Source: UNAIDS, 2013
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Current distribution of Tuberculosis (TB) worldwide
Source: WHO 2014
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The growing burden of NCDs
ECOSOC/UNESCWA/WHO Western Asia Ministerial MeetingAddressing noncommunicable diseases and injuries (Doha, Qatar, 10-11 May 2009)
0
2
4
6
8
10
12
2000 2005 2010 2015 2020 2025 203
Dea
ths
(mill
ions
)
Cancers
Stroke
Road trafficaccidents
HIV/AIDSTBMalaria
Acute respiratoryinfections
Ischaemic heart disease
Perinatal
ww
w.w
ho.int/healthinfo/global_burden_disease/2004_report_update/en/index.html
Projected global deaths from NCDs and injuries (2030)
0
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Health System Challenges• For PLWHIV on ART, co-morbidities such as
cardiovascular disease and cancers as well as HAART-associated complications have emerged as the biggest threat.
• With more patients seeking care for HIV and TB in the era of rapidly growing NCDs, the health system is likely to be challenged beyond its capacity.
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Opportunities not to be missed• Massive challenges in high HIV and TB burden
countries present opportunities to improve and sustain the health care system, calling for:• Evidence-based approaches to health service
delivery.• Reviews of all programs to weed out those
that outlived their usefulness and replace them with newer and more effective interventions.
• Service integration.
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(2) Service Integration
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Integrated health services
• Cost-effective (Sweeney et al. 2012).
• Provide a more nuanced approach to co-morbidities (e.g. earlier uptake of ART will lead to fewer TB cases).
• Increase HIV case findings.• Reduce stigma (Topp et al. 2010).
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Integration successes & opportunities
• Enhanced capacity of health workers, able to manage other chronic diseases including TB (Dereks et al. 2013).
• Innovate mechanisms of decentralizing treatment –e.g. through task-shifting (Kredo et al. 2013).
• Renew emphasis on mid-level workers to augment human resource capacity (e.g. pharmacist technicians, clinical offices, lab technicians) (Callaghan et al. 2010).
• Develop community-centered systems, engage community health workers and communities (LeBan 2011).
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Case study: Integrating HIV into Public
Health Services in Morocco• Expanded the no. of people receiving
HIV counselling and testing,
• 2010: 46 000 2012: 222 620
• Coverage of services for HIV-positive pregnant women to prevent MTCT
• 2010: 29% 2012: 48%
UNAIDS Global Report, 2013
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Service Integration: International progress
Services No. of Countries
HIV C&T, +ARV + TB 56
HIV C&T, +ARV + Outpatient Care 37
HIV C&T, +Sexual + Reproductive Health 34
HIV C&T, +ARV + NCD 27
HIV C&T, +PMTCT +ANC or MCH 31
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Sustaining health systems• Today we live in an era where HIV, TB and
NCDs occur in the same population and individuals – integrated care is a necessity.
• Increasing resources must be devoted to these high burden diseases, and new financing mechanisms must be found.
• Organisations including PEPFAR, GFATM, and GAVI have started funding health systems strengthening.
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(3) Increase domestic funding
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Domestic public spending as a percentage of total HIV spending by
region
Source: UNAIDS 2013
81%
54%
19% 21%
69%
21%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
EasternEurope
South andSouth‐East
Asia
CentralAfrica
East Africa SouthernAfrica
West Africa
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Source: World Bank 2014
Government expenditure as a percentage of total health expenditure in high HIV burden countries
0
10
20
30
40
50
60
70
2004 2006 2008 2010 2012
WorldSouth AfricaNigeriaKenyaMozambiqueTanzaniaUgandaZambiaEthiopia
Source: World Development Indicators, World Bank 2014
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0
5 000
10 000
15 000
20 000
25 000
30 000
35 000R m
illion
Total HIV spending in South Africa 2007/8 – 2016/17
• Treatment accounts for 75% of the National Department of Health’s conditional grant expenditure.
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HIV expenditure from domestic sources, Asia and the Pacific, latest available year, 2009-2012
Source: Prepared by www.aidsdatahub.org based on www.aidsinfoonline.org, country reported data for UNAIDS regional management meeting 2013 from India and Fiji, and Kumar, U. A. (13 February, 2014). Azad Launches Rs 14,295 CrorePhase IV of NACP, The New Indian Express. Retrieved from http://www.newindianexpress.com/nation/Azad-Launches-Rs-14295-Crore-Phase-IV-of-NACP/2014/02/13/article2053712.ece
Countries in Asia and the Pacific contribute 59% of the funds for the regional HIV response
63% Committed for NACP IV
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Innovative funding mechanisms: AIDS Levy in Zimbabwe
• Only country that started using a levy to raise additional funding given dwindling donor support (National AIDS Trust Fund, 2000).
• Levy is 3% of the amount of income tax assessed.
• 50% of the revenue is allocated to treatment and the rest to prevention, M&E and coordination, logistics, etc.
• Although revenues generated remain inadequate ($52.7 m between 2009 & 2011) vs. need, such mechanisms can assist in sustaining health systems for countries in various forms of distress or conflict.
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(4) Universal health coverage
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Health System Challenges
• Many countries are struggling to finance and provide comprehensive quality health care to all.
• With the growing number of people on ART the health care budget is increasingly inadequate.
• Furthermore, the welcome demands of communities to increase access to care pushes the resource envelope to its limit.
• The WHO has urged countries to provide universal health coverage as a means to sustain health systems.
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Elements of universal health coverage• Prepayment mechanisms • Free services at the point of care• Health care as a legal right• Equity – the system must be fair and just for all• Health services should not be treated as a commodity• Financial risk protection and equity for the entire
population with cross-subsidation between the rich and the poor, the healthy and sick
• Single payer fund (vs multi payer) – cuts costs (OECD 2014)
• Start at the community level
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Single payer-model of funding health care
Source: (Hsiao, 2012).
Universal effective coverage
One reasonable benefit
package for everyone
One fund; one uniform
policy framework;
one payment system
One pruchaser that uses its monopsony power in
negotiations
Can allow supplemen‐tary private insurance
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Health care use by coverage system in 1981 and use of the SUS (Brazil) by 2012
Sources: IBGE (PNAD 1981); Pesquisa CNI and IBOPE (2012) from Gragnolati et al. (2012).
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Benefits of introducing single payer models for sustaining health systems• Increases the resource envelope for prevention,
treatment and care for the double burden of CDs and NCDs.
• Ensure sustainability of health care funding.
• Staff retention in the public health system.
• Equity in access to quality health care.
• Universal access to quality health care will ensure the right to health is realised.
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Moving forward• Smarter spending – appropriate technologies, emphasis
PHC, establish local manufacturing of drugs, reject protection extensions for expired patents.
• Quick fixes are not the solution – need concerted and coordinated health systems reforms.
• Investing in keeping people active, healthier and for longer through health promotion and prevention activities.
• Reducing avoidable inequalities in accessing quality health care and health outcomes through various mechanisms (financing, delivery, governance regulation, etc.) – targeting the most vulnerable.
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Pertinent research questions• How will we address the growing burden of NCDs
without letting HIV fall by the wayside?
• What forms of integrated care are feasible, acceptable and cost-effective under what contextual circumstances?
• How can health systems resilience and adaptability be enhanced to deal with both current and emerging pandemics?
• Surely, the focus ought to be on developing capable delivery systems, financing systems, procurement systems etc., that are adaptable
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Concluding remarks• The global response to epidemics including
HIV/AIDS, TB, NCDs and others must be undergirded by resilient health systems.
• Health system must be adaptive as new models of delivery, financing mechanisms, procurement mechanisms, governance arrangements, and technologies emerge.
• Key question: how can all this be achieved?
Step up the pace
• A deliberate focus on building sustainable and effective health systems through evidence based approaches.
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Acknowledgements
• Sai Subhasree Raghavan, Ph.D(SAATHII, India and IAS Governing Council Member)• Meredith Evans, MA (HSRC)• Charles Hongoro, PhD (HSRC)• Thomas Rehle, MD, PhD (HSRC)• Yogan Pillay, PhD (South African
Department of Health)
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1918 - 2013
THANK YOU