Towards integrated, people-centered and efficient health services for impactful response to HIV, TB and malaria

Inter-regional workshop in preparation for transitioning towards domestic financing in TB, HIV and Malaria programmes
17-19 October 2018 -- Tbilisi, Georgia
alexandre.lourenco@icloud.com
Towards
integrated, people-centered and
efficient health services
for impactful response to HIV, TB and malaria
Alexandre Lourenco
Portuguese Association of Hospital Managers & European Association of Hospital Managers
Coimbra Hospital and University Centre, Coimbra
Nova School of Business and Economics, Lisbon
https://www.linkedin.com/in/alexlourenco/

• The current situation
• Integrated people-centred health services
• Examples for moving forward
• Take away messages
Outline
2

Ending the epidemics is not on track,
in spite of a great progress globally
“Even if we mobilise more resources, we must make our
interventions more effective, maximising the impact of
every dollar. [..] We must build people-centred health
systems while maintaining laser-like focus on achieving
results” (1)
(1) The Lancet and IAS Commission on HIV and global health, July 2018;
(2) The Lancet Commission on tuberculosis: building a tuberculosis-free world, March 2018
Lancet
Commissions
on
HIV
and
TB,
2018
Inadequate
service delivery
approaches put
ending the
epidemics at
risk
Need for people-centered, more
effective and more efficient
approaches
3
Peter Sands, Global Fund

Why are services inadequate?
Weak coordination &
integration among
different service
providers
Rigidness of services
Inadequate, unskilled
and staff
Not evidence based
interventions and
procedures
Stigma and
Discrimination
environment
4

"Streamline service delivery“
“Implement an integrated package of services to people who inject drugs
and other key affected populations”
“Develop funding procedures to contract NGOs to deliver services”
"Coordination across different levels of care needs to be improved“
“... Revising and enforcing protocols ensuring the decrease of inpatient stay
and increased responsibility of primary health centers for treatment“
“Increase the integration of TB and HIV Programs”, “Limited or no
integration of TB/HIV services”
“TB and HIV are not integrated [in general health system]”
* Quotes from TRAs and EHRN case studies
TRAs highlight challenges with service delivery
approaches in (your) transitioning countries
5

Transition exposes
additional risks to service access
6
ARGENTINA BRAZIL ECUADOR MEXICO ROMANIA CROATIA ESTONIA URUGUAY
Service Continuation • Less priority given to prevention interventions following transition
• Countries increasingly recognise importance of integrated service delivery
Governance • Importance of National Strategic Plan to drive and guide public investment
• Coordination function (CCM) deterioration
• Political commitment may weaken when leadership changes
Programmatic Risks • Investments in human resource trainings were mostly not institutionalized
• Persistence of stigma and punitive legal environment limited access to
services for vulnerable and criminalized populations, leading to reduced
coverage
Data risks • Epidemic information, generated through grant support tended to become
limited or lost after transition
• Failure to monitor the quality of treatment outcomes following transition
Financial Dependency • Significant dependence of the national disease responses on external
financing (>25%) at the time of transition

Country setting
& development status
Other sectors:
education,
sanitation,
social assistance,
labour, housing,
environment
& others
Conceptual framework of integrated people-centred
health services
Health
sector:
governance,
financing &
resources
<
Service delivery:
Networks,
Facilities &
practitioners
7
PERSON

The five strategies
8

Examples for moving forward
9

Coordination across diseases and
services around people’s needs
Ambulatory
Care
Coordination
Home
Services
Community
Services
Health
Posts
Primary
Care
Doctors
Social
Support
Outpatient
Specialized
Services
Inpatient
Ambulatory coordination services
Prevention, diagnostic (including contact
tracing) and treatment
Integration of diagnostics and care for
different diseases
Involving primary care in addressing HIV,
TB and malaria
Differentiated packages for different
populations (e.g. on prevention)
Differentiated care (stable vs patients with
more complex needs)
Coordination with social support
Differentiated care & co-design
10

• Engaging community (non-health) workers to
reach communities
• Improving patient treatment literacy including
patient schools and peer educators/
counselors
• Asking clients about services including their
quality
Reaching unreached communities and
empowering clients/communities
11

Think human resources
The case of community and peer workers
1) Paintain LS, et al. Review Article: Community Health Workers and Stand Alone or Integrated Case Management of Malaria: A Systematic Literature Review, Am.J. Trop. Med. Hyg 91(3), 2014
A strong evidence base
on the effectiveness of
community health
workers providing good
quality care
Important facilitating
factors are appropriate
training, clear
guidelines, and regular
supportive supervision
This should be part of
the broader planning of
human resources
during and after the
changes in services or
their funding sources
and elimination of
diseases like malaria
Along with such strengthened health system capacity – systems for health
12

UNAIDS. Invest in HIV Prevention, 2015, : National AIDS Coordinating Agency. 2015 Botswana at the crossroads: investment towards effective HIV prevention health, system strengthening, and the
end of AIDS.
Investment in prevention
* Includes PrEP and a small allocation to cash transfers
Global resource needs for AIDS response 2020
45%
26%
20%
9%
Prevention
Treatment
Critical enablers
Synergies
13

Population(s)
Co-located HIV and SRHR services Women, adolescent girls, sexual minorities
Co-located HIV and antenatal services Pregnant women
Co-located HIV and paediatric health
services
Children living with HIV
Co-located and jointly planned HIV and TB
screening and treatment services
People with or at risk of HIV-TB co-infection
Co-located HIV and HCV screening and
treatment services
People with or at risk of HIV-HCV co-
infection
Co-located drug treatment or
rehabilitation for HIV, NSP, and MAT/OST
People who inject drugs
Screening for HIV and NCDs General population in high-burden settings
Management of NCDs in HIV service
platforms
People living with HIV and people with or
at high risk of NCDs
Lancet-IAS
commission
on
HIV
and
integration,
2018
SRHR=sexual
and
reproductive
health
and
rights.
HCV=hepatitis
C
virus,
NSP=provision
of
clean
needles
and
syringes;
MAT=medication-assisted
therapy
or
opioid
substitution
therapy,
NCDs=non-communicable
diseases
Immediate opportunities for synergies through
co-located services, by service platform: HIV case
14

Synergetic impact of services
Projected coverage required for each intervention combination to achieve a 30 or
50% decrease in HIV incidence or prevalence in each setting among people who inject
drugs over 10 years
Note:
Tallinn
and
Dushanbe
baselines
include
high
or
moderate
NSP
and
so
their
scale
up
is
not
considered
International
Journal
of
Drug
Policy,
2016
Case of three different interventions and their combination for decreasing
HIV incidence and prevalence among people who inject drugs
15

Inpatient - Hospitals
(input base line item budget or perdiem)
Outpatient – e.g. Dispensaries
(line item budget)
Family doctors
(per capita or salary)
Community
workers
Ambulatory
care
Inpatient
care
TB model of care in EECA
16

Graphical illustration of a possible
TB patient pathway
17
Patient with
TB symptoms
Family Doctor
Referal
TB Cabinet
Clinical
Evaluation
Clinical
Diagnosis Treatment initiation
Protocol Activation
DOT/ VOT plan
Social Support
Contact tracing
Universal
DOT
Contagious
Phase
1
Home Treatment
2
DOT cabinet
Family doctor
Workplace
Non- Contagious
Phase
Treatment Provision
Contact Tracing
X-ray
Sputum
&
Blood
test
Laboratorial
confirmation
Treatment cancelation
Treatment continuation
Drug sensitive TB
GeneXpert
MDR TB
Treatment
revision
Last resource, only considered when the patient health status obliges
Limited to the time needed to stabilize the patient and optimize treatment
Hospitalization
Discharge to the community under DOT

Country Savings per patient Total savings
Drug
susceptible
Drug resistant All types In US$ As % of 2017
costs
Armenia $69 $760 $251 $916,795 10.5%
Azerbaijan $429 $1,723 $685 $3,487,697 26.2%
Belarus $175 $258 $210 $828,371 5.2%
Georgia $155 $803 $223 $721,316 20.8%
Kazakhstan $352 $63 $246 $3,648,191 7.5%
Moldova $69 $760 $251 $916,795 10.5%
Ukraine $258 $2,462 $845 $19,158,590 28.2%
Tajikistan $0 ($54) ($7) ($42,805) -0.3%
Regional $29,634,951 17.0%
Mid-term review of TB Regional EECA Project on Strengthening Health Systems for Effective TB and DR TB Control (TB REP), 2018
No cost savings in Tajikistan as there were limited intervention under TB REP project in 2015-17
Projected reduction in TB care expenditures
in a 2 year progress of reforming TB care model through national work and regional
support (2015-2017)
18

Benefits of people-centered approaches
• Impact on
diseases
• System
efficiency
• Services,
workforce
• People and
communities
More acceptable,
addresses
different
concerns and
less costly to
people and
communities
Better
satisfaction of
staff, integration
and coordination
among service
providers
Better outcomes
and impact on
the diseases
Once
implemented,
costs less to the
system
19

Take away messages
Re-visit services thinking
of them as part of
national systems, not
stand alone or donor
programs
Balance between health
promotion, prevention,
treatment and care
People-centredness is
also community
involvement and
addressing social
determinants
Start early. Involve.
Manage the change
All health system
building blocks need to
support the change
20

• WHO/Europe: Martin Van Den Boom, Ihor Perehinets, Sayohat Hasanova & Szabolcs Szigeti
• WHO Headquarters: Clarisse Mason, Nuria Toro Polanco, Giorgio Cometto
• WHO/EMRO: Hoda Atta
• WHO/WPRO: Kalpeshsinh Rahevar
• WHO/AMRO = PAHO: Freddy Perez & Juan Pagano
• Global Fund: Franziska Fuerst, Roopal Patel, Nicholas Furtado, George Shakarishvili, Erin
Ferenchick, Olga Bornemisza, and Matthew MacGregor
• UNAIDS: Nertila Tavanxhi
• PAS Center & TB REP Project: Stela Bivol
• Evidence to Policy Initiative: Sara Fewer
• Alliance for Public Health & TB Europe Coalition: Yuliya Chorna
• USAID: Sevim Ahmedov
• UNDP: Maisoon Elbukhari
• Conference consultants: Uldis Mitenbergs & Raminta Stuikyte
Acknowledgements
21

More…
22

23
Thank you!

Optima studies can inform choices
• Example of Belarus TB Optima study showing budgets
for models of care required to deliver treatment at
current levels of coverage
The World Bank. 2017. Optimizing Investments in Belarus’ Tuberculosis Response
What Will Be the Impact of Different Program Implementation Scenarios? 35
Figure 5.4 Total cost of TB treatment using three different TB treatment modalities
Source: Populated Optima-TB model for Belarus.
Total cost of TB treatment using three different TB
treatment models , Belarus
29

Towards integrated, people-centered and efficient health services for impactful response to HIV, TB and malaria

Recommended

Recommended

More Related Content

Similar to Towards integrated, people-centered and efficient health services for impactful response to HIV, TB and malaria

Similar to Towards integrated, people-centered and efficient health services for impactful response to HIV, TB and malaria (20)

More from Alexandre Lourenço

More from Alexandre Lourenço (20)

Recently uploaded

Recently uploaded (20)

Towards integrated, people-centered and efficient health services for impactful response to HIV, TB and malaria