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Media Contacts
Chris Collins: +1 845 701 0158; ChrisCSF@aol.com
Gregg Gonsalves: gregg.gonsalves@gmail.com
Kay Marshall: +1 347-249-6375; nkmarshall@gmail.com
Previous Reports
December 2007 -- Missing the Target #5 [PDF]
Missing the Target #5 Media Release 11-27-07 [PDF]
July 2007 ---ITPC AIDS Treatment Access materials
November, 2006 ---ITPC AIDS Treatment Access materials
May, 2006 -- ITPC AIDS Treatment Access Update [PDF]
November 2005 -- ITPC AIDS Treatment Access Report [PDF]
May 2006 ITPC Press call transcript [RTF]
May 2006 ITPC Press Release [RTF]
November 2005 Archive
Executive Summary
Abandoning the United Nations (UN) and Group of Eight (G8)
commitments to universal access to HIV/AIDS services, as rich nations
of the world have begun to do, is not a strategy to accomplish better
health care for anyone. For this sixth edition of Missing the Target, civil
society research teams in six countries - Argentina, Brazil, the Dominican
Republic, Uganda, Zambia, and Zimbabwe - investigated the impact of
the significant scale-up of HIV/AIDS services on broader health systems.
The results were distinct in each country but point to several broad
conclusions.
First, the HIV/AIDS response to date has had far-reaching positive impacts
on health care in many settings: building infrastructure and systems,
raising the bar on quality, extending the reach of health care to socially
marginalized groups, and engaging consumers.
Second, significant new investments in HIV/AIDS services have revealed
existing fragilities in health systems, and in some cases have placed
increasing burdens on these systems by expanding demand and stretching
already overextended human resources.
Third, the push for HIV/AIDS treatment access has not been just about the
money. Although these efforts have brought considerable new financing,
the mobilization of activists and health care consumers themselves has
also forced global and national leaders toward a more vigorous sense of
accountability and urgency.
If the UN' s health-related Millennium Development Goals (MDGs) are
to have any chance of being realized, we need to do for health systems
what we have done for AIDS while increasing the momentum of AIDS
service scale-up. With increased resources, accountability for outcomes,
and consumer engagement, the move toward broader health systems
strengthening will have enormous benefits for communities as a
whole, including people living with HIV. But if the business-as-usual,
bureaucratic approach to health systems prevails, the world risks failing
communities and leaving the millions living with HIV without desperately
needed care.
On-the-ground realities and today's global health debate
Our research found that in Argentina and Uganda, scale-up of HIV/
AIDS services has led to improvements in several aspects of health care,
including how services are delivered and who receives care. In Brazil,
HIV/AIDS services have been scaled-up in conjunction with the expansion
of general public health care, though clear and distinct benefits for
maintaining dedicated HIV-related services continue to be identified. In
the Dominican Republic and Zambia, HIV/AIDS services have established
models of care that with adequate resources could be applied more
broadly. In Zimbabwe, HIV/AIDS funding has become a "lifeline” for a
health system on the verge of collapse.
Some voices in the health care debate are claiming that the international
response to HIV/AIDS is weakening primary care in many countries,
diverting funding and health care personnel and distorting health systems.
Our investigation suggests that the global mobilization on HIV has not
"diverted” resources but instead greatly expanded total health financing.
It has "distorted” health systems to the degree that it has increased the
accessibility and quality of services for one devastating disease. In most
countries with serious HIV epidemics, health systems were not healthy
prior to HIV' s arrival: they were suffering from decades of disinvestment
due to structural adjustment policies and chronic underfunding. AIDS
has opened up a sense of possibility for change, for progress in providing
health care to all who need it.
Research process and major findings
Missing the Target civil society research teams used a standardized research
template to interview key informants in their countries, including
government officials, UN and other global agency staff, and program
managers, as well as health care workers and consumers. Research teams
asked a range of questions about: how the response to HIV/AIDS had
affected different aspects of health care, both positively and negatively;
lessons learned from scale-up of HIV/AIDS services; and priorities for
improving prevention of parent-to-child transmission services. Key
findings are listed below.
Impact of HIV/AIDS services on health systems
Research teams found that the response to HIV/AIDS has had notable
positive impacts in several areas, though this impact has been distinct
in each country. Frequently noted positive effects of HIV/AIDS service
scale-up included:
* promoting integration of HIV, TB, and other health services;
* relieving demand for hospital beds, emergency room services, and
antibiotics that the AIDS crisis had created;
* motivating and expanding the capacity of health care workers;
* increasing access by marginalized populations and the poor to
health services;
* raising community awareness about health, sexuality, and human
rights issues;
* making AIDS-financed clinics, laboratories, and equipment available
for other health services; and
* improving commodity procurement and negotiation skills with
suppliers.
In addition, a variety of information, management, monitoring, and
logistics systems implemented to enable HIV/AIDS service scale-up have
helped improve care delivery and could be adapted to advance other
health services.
Missing the Target 6 research also identified areas where the response to
HIV/AIDS has revealed fragilities in health systems and created new
challenges, including:
* increasing demand for services, sometimes leading to drug stock-outs;
* raising new concerns about corruption and lack of transparency as
increasing resources came from outside sources;
* increasing the workload on health care personnel;
* imposing new budget pressures on governments;
* taking government focus away from other aspects of health services
as it strove to meet demands of donors and a growing HIV/AIDS
service system;
* attracting high quality health care personnel away from other health
services; and
* creating an unequal system where some AIDS drugs are free while
other treatments are only available at substantial cost.
Lessons learned for strengthening health services
Country chapters in this report identify a variety of lessons learned in
scale-up of HIV/AIDS services that should inform strengthening of broader
health systems. They include the following:
* investments in hiv services have paid off. All teams found that
the impact of HIV service scale-up has been visible and dramatic.
Yet in most of the countries included in this report there remains
considerable unmet need for HIV treatment and prevention services
and additional resources are required.
* the engagement of health care consumers has been
indispensible to success. The involvement of people living with HIV
in demanding services, helping to design programming, promoting
transparency and accountability, and addressing stigma has been
essential to the success of HIV/AIDS programming - and in some cases
has had spill over effects to other areas of health care.
* Significantly increased financing has been critical to expanding
service capacity and quality, making necessary infrastructure
improvements, and attracting and retaining health care personnel.
* At the same time, significant expansion of resources requires
accompanying efforts to: support increased training opportunities
and financing for human resources generally; improve anti-fraud and
transparency measures as increasing resources enter the system; and
expand infrastructure to accommodate new services.
* The mobilization around HIV/AIDS services has created valuable,
though often untapped, opportunities to improve broader health
delivery, such as more efficient procurement systems, models for
program management and monitoring, and community engagement
in health planning.
Improving delivery of prevention of vertical
transmission services
In several countries, targeted prevention of parent-to-child transmission
(or PPTCT, also known as PMTCT) strategies have been highly successful in
reducing HIV infection among newborns and, in some settings, providing
an entry point for HIV treatment for women. In several cases, however,
uptake of services is impeded by geographic barriers, lack of access to
HIV testing, inadequate education and outreach, fear of stigma, and
high costs of accessing care. There are also concerns about substandard
HIV treatment for pregnant women. To improve the impact of PPTCT
services, report authors make a variety of recommendations, including
to better integrate these services with maternal and child health and
primary care services, expand access in rural areas, raise awareness about
the availability of services, and ensure the health care needs of pregnant
women and new mothers are adequately addressed.
Implications for policymakers
The beneficial factors in the HIV/AIDS response will be essential to the
success of the International Health Partnership (IHP+) and other efforts
that place increasing emphasis on "horizontal” financing to support
health systems. A simple reshuffling of health resources toward more
generalized health functions at the expense of effective disease-specific
programs, such as HIV/AIDS, would jeopardize the remarkable advances
that have been achieved.
The promise of Alma-Ata1 - 30 years old this year - of health care for all
will be belatedly realized by building on (instead of dismantling) those
programs that have produced demonstrable results. The dichotomy
between vertical and horizontal financing and programming is a false
one - outdated and largely theoretical. We can and must do both:
strengthen health systems while fighting HIV/AIDS. We can't be lulled
into thinking that by doing one of these alone, the other goal will be
automatically achieved. That is the lesson of this report.
HIV/AIDS advocates are by definition health systems advocates. The
advent and increasing global availability of antiretroviral treatment
(ART) has made HIV infection a chronic manageable illness for many
people, a condition handled at the level of primary care over a lifetime.
We need strong health systems: our lives depend on them. But the work
of addressing the HIV/AIDS epidemic has just started, and only one in
three have access to urgently needed ART. Today's challenge is not to
unravel the benefits of this extraordinary response or find an excuse to
abandon the 33 million people living with HIV, but to take advantage of
what has been learned and what has been built and make significant new
investments in health services for all.
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