1. PEPFAR Pivot Strategy: Effect of Geographical Prioritization Assessment on Health Systems and Health Outcomes
NACC Webinar – 19 January 2017

2. Outline Background Goal, Objectives, Conceptual framework etc.
MEASURE Evaluation: Study specifics
Project SOAR: Study specifics
Q&A

3. Background
President’s Emergency Plan for AIDS Relief (PEPFAR) strategy:
Coordination of the strategy outlined by UNAIDS
Doing the right things, in the right places, and at the right time to achieve sustained epidemic control  known as the Pivot
Little is known how this pivot will affect client care and health system performance
USAID commissioned and provided substantial input in two studies to assess these issues and inform US Government (USG) efforts
PEPFAR was really coordinating the strategy outlined by UNAIDS and maximizing resources by focusing our most effective interventions in the highest burden geographic areas to achieve epidemic control in certain SNUs.
Right thing: improving M&E, program quality, and scaling up core interventions
Right place: focus on geographic areas at sub-national levels with highest disease burden
Right time: scaling up interventions now to decrease costs over time

4. Goal of assessments
To better understand what the ongoing effect of USG’s changing HIV/AIDS investment strategy has on county health system function and select health outcomes, and provide timely guidance to USG and country stakeholders*
MEASURE Evaluation will focus on county level effects
Project SOAR will focus on the facility level effects
*These studies are also being conducted in Uganda using the same objectives and design.

5. Conceptual framework Service Utilization & Coverage Broader Health
PEPFAR
Geographical
Prioritization
Strategy
HIV service delivery
Non-HIV service delivery
Health workforce
Financing
Drug Supply
Information
Service Utilization
& Coverage
Broader Health
System
HIV service
coverage
Non-HIV service

6. Outcome Indicators - Examples
Service delivery
Hss
HIV
Numbers tested, on ART, retained in treatment, suppression of viral load
Non-HIV
Delivery with skilled attendant, vaccination coverage, unmet need for family planning
Commodities
Number and duration of stock outs of key commodities (HIV test kits, FP methods, etc.)
Health Workforce
Turnover rate, vacancies, % trained in HIV testing and counseling

7. Expected Contribution
Increased understanding of the potential effects of the implementation of geographical prioritization on health systems and health outcomes on counties and facilities
Lessons learned for how to sustain past PEPFAR investments in health systems while implementing transitions
Lessons useful to countries that are slower in implementing full transitions or to implementation of future pivots resulting in geographic prioritization

8. Strengths and limitations
Focus on concrete HSS performance indicators
Retrospective and prospective in nature which allows for an examination of the change over time
HSS is complex and disentangling factor contribution difficult
Assessing data quality and using same data to assess trends

9. Geographic Prioritization in Kenya
Investment Categories
Counties
Saturation and Scale-up
(20 counties)
80% of national PLHIV burden
Bomet, Busia, Homa Bay, Kakamega, Kiambu, Kilifi, Kisumu, Kisii, Machakos, Makueni, Migori, Mombasa, Murang’a, Nairobi, Nakuru, Narok, Nyamira, Siaya, Turkana, UasinGishi
Sustained
Baringo, Bungoma, Embu, Elgeyo Marakwet, Kaijado, Kericho, Kitui, Kirinyaga, Kwale, Laikipia, Meru, Nandi, Nyandarua, Nyeri, Samburu, Taita-Taveta, Tharaka Nithi, Trans Nzoia,, Vihiga, West Pokot
Central Support
(7 counties)
Garissa, Isiolo, Lamu, Mandera, Marsabit, Tana River, Wajir
Saturation and scale up: Intensified demand creation, targeted HTC and linkage to treatment. Enhanced monitoring for better tracking and retention, PLHIV peer networks, convenient working hours, and training of public health personnel in KP services.
Sustained: No demand generation for HTC. Current patients on treatment and newly enrolled patients will be provided a minimum package of care.
Central support: Limited support for laboratory services, supply chain and county-level planning. No service delivery support

10. How the studies are organized
Documentation of Pivot Implementation
National level
Joint Collaboration
Effects of Pivot on Service Delivery Outcomes
(HIV & non-HIV)
Effects of Pivot on Health Systems Components
(HR, supply chain, financing)
County level
(All Counties)
MEASURE
Evaluation
Effects of Pivot on Service Delivery Outcomes
(HIV & non-HIV)
Effects of Pivot on Health Systems Components
(HR, supply chain, financing)
Facility level
(Centrally
Managed & Sustained)
Project SOAR
Summative Evaluation
Joint Collaboration
How the studies are organized

11. Geographic prioritization process documentation
Purpose: To document the strategy implementation process
Approach:
Desk review to include:
USG documents for Kenya: Country Operating Plans, annual reports and work plans from implementing partners, reports on health systems strengthening (HSS), etc.
GOK documents: national health strategies/plans, HIV/AIDS policies and plans, etc.
Qualitative interviews to augment the information from desk review and fill information gaps, incl.
USAID Washington and Kenya
National MOH staff, incl. NACC, NASCOP
Implementing partners (e.g. Jhpiego, Intrahealth, Pathfinder Int’l)
Other development partners (e.g. Global Fund)
Other identified and available key informants.

12. MEASURE Evaluation

13. MEASURE Evaluation Team
MEASURE Evaluation research team consists of the following members:
Dr. Elizabeth Sutherland (PI)
Dr. Stephanie Watson-Grant (Kenya lead)
Khou Xiong (Quantitative lead)
HealthStrat is in-country research partner led by Ambrose Agweyu

14. MEASURE Evaluation: Objectives
To assess the data quality for selected indicators over time
To document data use
To assess shifts in selected indicators and associations with the county investment categories
To explore findings from the quantitative data through key informant interviews

15. MEASURE Evaluation: Hypotheses
Key HSS elements (Health Workforce, Commodities and Health Information System Performance) will change in USAID scale up, sustained, and centrally managed counties over time.
Counties experiencing changes in PEPFAR investments (up or down) will see no donor and host government investments in response to increases or decreases in USAID PEPFAR support.

16. MEASURE Evaluation: Methods
Mixed methods design
Secondary analysis of HMIS, TBU and iHRIS data
Data quality assessment (sample: 182 sites)
Associations of trends with PEPFAR investments
Key informant interviews
Data Use
HIV Expenditure
Contextual information about observed trends
Three time periods to be assessed; 2014, 2016 and

17. Timeline
2016
2017
2018

18. Project SOAR

19. Project Supporting Operational Aids Research (SOAR)
Overall purpose is to conduct HIV and AIDS operations research “to identify practical solutions to improve HIV prevention, care and treatment services”
5-year program led by Population Council, funded by USAID
Johns Hopkins School of Public Health (JHSPH) is a Project SOAR partner

20. Project SOAR Team
JHSPH research team consists of the following members:
Dr. Sara Bennett (PI)
Dr. Daniela Rodriguez (Kenya lead)
Dr. Antonio Trujillo (Quantitative lead)
Mary Qiu (Study Coordinator)
Ipsos-Kenya is in-country research partner led by Caroline Mackenzie

21. Project SOAR: Objectives
Document the process of implementing the PEPFAR Geographical Prioritization Strategy
Determine the change in (i) key HIV service indicators and (ii) select non-HIV service indicators over time
Explore changes in health systems components in the centrally- supported facilities (e.g. health workforce, pharmaceutical supply, lab services, supportive supervision) over time and explore how these health system changes have affected service delivery and demand for HIV and non-HIV services
Identify strategies and factors that have either supported or hindered a smooth and sustainable transition of counties and sites to central support

22. Project SOAR: Methods Component of Study Methods Time Points
Documentation of the transition
Document review
Ongoing
Key-informant interviews
Q1 & Q3 2017
Quantitative analysis of health system effects
Analysis of secondary data (DHIS, iHRIS)
Facility survey
Q2 2017
Longitudinal Case Studies of selected facilities
In-depth interviews, focus group discussions
Summative Evaluation
Triangulate data and results
Ongoing  Q4 2017
Quant analysis: Assesses changes associated with the implementation of geographic prioritization on HIV and non-HIV services outcomes 1-2 years prior to implementation and 18 months after.
LCS: Longitudinal case studies of 3-5 purposively selected centrally-supported SNUs in each country to examine how the process of transition, affects health systems and service delivery.

23. Timeline
2016
2017

24. Karibu…Thank you…

25. This presentation was produced with the support of the United States Agency for International Development (USAID) under the terms of MEASURE Evaluation cooperative agreement AID-OAA-L MEASURE Evaluation is implemented by the Carolina Population Center, University of North Carolina at Chapel Hill in partnership with ICF International; John Snow, Inc.; Management Sciences for Health; Palladium; and Tulane University. Views expressed are not necessarily those of USAID or the United States government Project SOAR (Cooperative Agreement AID-OAA ) is made possible by the generous support of the American people through the President’s Emergency Plan for AIDS Relief (PEFPAR) and United States Agency for International Development (USAID). The contents of this presentation are the sole responsibility of Project SOAR and Population Council and do not necessarily reflect the views of USAID or the United States Government. Led by the Population Council, Project SOAR is implemented in collaboration with Avenir Health, Elizabeth Glaser Pediatric AIDS Foundation, Johns Hopkins University, Palladium, and The University of North Carolina.