TREATMENT MONITORING AND ADVOCACY PROJECT

International Treatment Preparedness Coalition (ITPC)

CCM ADVOCACY REPORT -- October, 2008 [DOWNLOAD PDF]
Making Global Fund Country Coordinating Mechanisms work through full engagement of civil society
On-the-ground research in Argentina, Cambodia, Cameroon, India, Jamaica, Romania, and Uganda


July 2008 -- Missing the Target #6 The HIV/AIDS Response and Health Systems: Building on success to achieve health care for all

en Español : July 2008 -- Missing the Target #6 en Español [doc]

Press Release: July 29, 2008 -- Missing the Target #6 [PDF]

Post Teleconference Press Release: July 29, 2008 -- Missing the Target #6 [PDF]

Audio replay of Teleconference: July 29, 2008 -- Missing the Target #6 [mp3]


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.