1. An Assessment of the Interactions between health systems and Global Health Initiatives Tim Evans Assistant Director-General Information, Evidence and Research World Health Organization

2. Overview 1.Rationale 2.Concepts and Methods 3.Findings 4.Learning to do better

3. Common challenges to scale up services for HIV, TB, malaria, and immunization HIV/UA assessment report Global Plan to stop TB World Malaria report GAVI/Norad report Inadequate financing HR crisis Affordable commodities Stigma, discrimination… Accountability Partnership alignment Inadequate financing Laboratory capacity HR crisis Quality drugs Drug efficacy Information system Inadequate financing HRH and Community services M&E HR crisis Inadequate financing Leadership and management Inter-agency coordination

4. World Health Report 2006 Critical shortage of health workers in 57 countries; 4.3 million more health workers needed to provide essential interventions.

5. T h e L a n c e t 2 0 0 6 ; 3 6 8 : 9 6 4 D O I : 1 0. 1 0 1 6 / S 0 1 4 0 - 6 7 3 6 ( 0 6 ) 6 9 3 9 1 - 4 X D R - T B a g l o b a l t h r e a t S e e C o m m e n t S e e A r t i c l e s C o m e n t A r t i c l e s F o l l o w i n g a n e m e r g e n c y c o n s u l t a t i o n i n J o h a n n e s b u r g o n S e p t 7 a n d 8, g l o b a l h e a l t h a g e n c i e s h a v e d e v e l o p e d a s e v e n - p o i n t p l a n t o c o m b a t e x t e n s i v e l y ( o r e x t r e m e l y ) d r u g - r e s i s t a n t t u b e r c u l o s i s ( X D R - T B ). R e p r e s e n t a t i v e s f r o m s e v e r a l s o u t h e r n A f r i c a n c o u n t r i e s h a v e a g r e e d t o i m p l e m e n t t h e p l a n w i t h i n 3 m o n t h s. M u l t i d r u g - r e s i s t a n t T B ( M D R - T B ), d e f i n e d a s r e s i s t a n c e t o a t l e a s t i s o n i a z i d a n d r i f a m p i c i n, r e q u i r e s t h e u s e o f s e c o n d - l i n e d r u g s t h a t a r e l e s s e f f e c t i v e, m o r e e x p e n s i v e, a n d m o r e t o x i c t h a n f i r s t - l i n e r e g i m e n s b a s e d o n i s o n i a z i d a n d r i f a m p i c i n. R e c o g n i s e d e a r l i e r t h i s y e a r, X D R - T B i s M D R - T B t h a t i s a l s o r e s i s t a n t t o t h r e e o r m o r e o f t h e s i x c l a s s e s o f s e c o n d - l i n e d r u g s. O f 1 7 6 9 0 T B i s o l a t e s t a k e n b e t w e e n 2 0 0 0 a n d 2 0 0 4, 2 0 % w e r e M D R a n d 2 % w e r e X D R. X D R - T B h a s n o w b e e n i d e n t i f i e d i n a l l r e g i o n s o f t h e w o r l d b u t i s m o s t p r e v a l e n t i n A s i a a n d i n e a s t e r n E u r o p e. S i n c e W H O g u i d e l i n e s r e c o m m e n d t h e u s e o f a t l e a s t f o u r d r u g s f o r t h o s e w i t h M D R - T B, X D R - T B i s u n t r e a t a b l e t o i n t e r n a t i o n a l s t a n d a r d s. D a t a p r e s e n t e d a t t h e X V I I n t e r n a t i o n a l A I D S C o n f e r e n c e i n T o r o n t o l a s t m o n t h i n d i c a t e t h e h i g h m o r t a l i t y a s s o c i a t e d w i t h X D R - T B o f 5 3 6 p a t i e n t s w i t h T B i n a r u r a l d i s t r i c t i n K w a Z u l u N a t a l, S o u t h A f r i c a, 2 2 1 h a d M D R - T B, a n d 5 3 o f t h e s e w e r e d e f i n e d a s X D R - T B, m o s t o f w h o m w e r e c o i n f e c t e d w i t h H I V ; 5 2 o f t h e s e 5 3 p a t i e n t s h a v e d i e d. T h e S o u t h A f r i c a n M e d i c a l R e s e a r c h C o u n c i l, W H O, a n d t h e U S C e n t e r s f o r D i s e a s e C o n t r o l a n d P r e v e n t i o n p l a n c a l l s f o r : r a p i d s u r v e y s t o a s s e s s t h e c u r r e n t p r e v a l e n c e o f X D R - T B g l o b a l l y ; e n h a n c e d l o c a l l a b o r a t o r y c a p a c i t y t o c a r r y o u t c u l t u r e a n d d r u g - r e s i s t a n c e t e s t i n g ; i n c r e a s e d t r a i n i n g f o r p u b l i c - h e a l t h s t a f f t o i d e n t i f y, i n v e s t i g a t e, a n d t r e a t X D R - T B o u t b r e a k s ; i m p l e m e n t a t i o n o f i n f e c t i o n c o n t r o l p r e c a u t i o n s ; i n c r e a s e d r e s e a r c h s u p p o r t f o r d r u g s t o t r e a t X D R - T B a n d f o r d e v e l o p m e n t o f r a p i d d i a g n o s t i c t e s t s f o r T B ; a n d a c c e s s t o a n t i r e t r o v i r a l d r u g s. F a i l u r e t o a c t n o w t o c o n t a i n t h e t h r e a t p o s e d b y X D R - T B w i l l h a v e d e v a s t a t i n g c o n s e q u e n c e s f o r p a t i e n t s w i t h T B, p a r t i c u l a r l y t h o s e c o - i n f e c t e d w i t h H I V / A I D S. P r o m p t e n a c t i n g o f t h e s e v e n - p o i n t p l a n a g r e e d i n J o h a n n e s b u r g i s c r u c i a l f o r t h e f u t u r e o f T B a n d H I V / A I D S c o n t r o l e f f o r t s a n d f o r t h e p r e v e n t i o n o f X D R - T B r e l a t e d d e a t h s. T h e L a n c e t "poor TB services" deemed the underlying reason for emergence of XDR-TB. Insufficient vehicles Inadequate supervision of patients beyond hospital Interruption in supply chains Unacceptable rates of "first line" treatment failure No response to evidence of "first line" failure Sloppy "second line" treatment practices Poor infection control in hospitals (over-crowding) Missing laboratory support structures (resistance monitoring)

6. Systems Performance Shortfalls Scale --- safe, proven and cheap interventions not reaching those in need Scope --- comprehensive services responding to needs and expectations are the exception Distribution --- those with unmet needs are disproportionately those with lesser means Protection/Safety --- too many are worse off through encounters with the health system Systems capabilities --- primitive frameworks and responses to dealing with complex challenges

7. 2. Concepts and Methods Global Health Initiatives Country Health Systems Conceptual Framework Methods

8. Global Health Initiatives Address priority health problems of developing countries Focused on specific diseases, selected interventions, or commodities Generate substantial funding (billions!) for these priorities based on strong culture of results Transnational in organization and operations: Invite proposals from countries for support Independent technical review of proposals Make direct investments in countries Dynamic, evolving…

9. Health Systems The main goals are: –Improving health and health equity –Responsiveness, –Financial fairness The intermediate goals are: –Greater access and coverage –Quality and safety A health system consists of all organizations, people and actions whose primary intent is to promote, restore or maintain health

10. Conceptual Framework

11. Methods Inputs: –Literature searches >250 studies from published and grey literatures, –Call for original data 15 new studies (Table 2) Analysis –review of evidence on interactions –more "association" than "causation" –may change with time –what is the point of comparison? No GHIs; Pre/Post-GHI?; between GHIs?

12. Assessing the nature of the interactions Positive, synergistic Equivocal, unclear, mixed Negative, undesired

13. 3. Findings Service delivery Governance Financing Health Workforce Supply management Information systems

14. Findings - service delivery Access Rapid expansion targeted services Expansion of non-targeted services e.g. maternal health Supply-induced demand Equity Services free at point of service Focus on marginalized populations Quality Promoting universal standards of care Rush to meet targets compromising quality

15. Planning and Coordination Demands of GHI planning processes overwhelm national capacities GHIs responsive to country systems needs through new funding windows Community Involvement GHIs have accelerated non-state sector/civil society engagement in health sector planning, delivery and accountability Findings - governance

16. Total Financing GHIs linked to recent surge in health ODA Unclear association between GHI and domestic health financing Aid Effectiveness GHI funding more; "predictable"; "sustainable" e.g. Innovative Financing mechanisms; "responsive" to global burden of disease; GHI funds skew country priorities Out-of-pocket expenditures GHIs have promoted principle of free services and subsidies but have not invested in prepayment systems Findings - financing

17. Findings - health workforce Production and Strengthening Limited investment in expanding the workforce through pre-service training Better productivity of existing workforce through in-service training, task shifting, supervision and material support Distribution Workforce drawn away from non-targeted services Incentives get workers to remote areas Retention Brain drain from public to private sector due to better pay

18. Findings - supply management systems Procurement and Distribution Rapid improvements in availability and affordability of commodities Strong GHI-owned systems duplicate and displace national supply chains Quality Improvements in quality through pre- qualification and agreement on global standards

19. Findings - health information systems Availability and Accuracy Disease surveillance and service coverage data specific to GHIs is improving. Chronic weaknesses of information systems largely ignored esp. vital statistics and measures of health systems performance Use and Demand Dominance of stand-alone info systems is inefficient and burdensome Growing demand and funding for more comprehensive HIS Innovation Electronic records are improving efficiency and quality of care

20. Synergies leading to systems transformation

21. Piecing together the big picture There is ample evidence of: –"strong synergies"; –"serious shortfalls"; –And "uncertainty" Actions need to be developed towards: –Amplifying synergies –Stemming shortfalls –Understanding uncertainty

22. Challenging the way we do business Beyond false dichotomies Necessary but not sufficient conditions: –Universal Access for HIV/AIDS –One M+E for HIV –Global financing mechanisms –Sustainable financing for TB No one size fits all Harnessing innovation systematically

23. Overarching Recommendations 1.High Profile Research Agenda 2.Engage decision-makers 3.Country leadership backed globally 4.Increase finance Learning to do better

24. Thank you