HIV and Health System Sustainability

Prof. Olive Shisana, Sc.DHuman Sciences Research Council South Africa

20th International AIDS ConferenceMelbourne, Australia

22 July 2014

Outline• Key interventions for creating sustainable

health systems:

(1) Strengthen health systems

(2) Integrate services

(3) Increase domestic funding

(4) Ensure universal health coverage

(1) Strengtheninghealth systems

Adults and children living with HIV (millions) around the world

30

35.3

21.725

3.7 3.91.3 1.50.86 1.3

0

5

10

15

20

25

30

35

40

2001 2012

World

Sub‐SaharanAfricaSouth and SouthEast AsiaLatin America

Eastern Europeand Central Asia

Source: UNAIDS 2013

Key: Expanding Trend Declining Trend No change

HIV and AIDS Profile in Asia and the Pacific countries, 2012

Epidemic Pattern HIV Incidence

AIDSDeaths

HIVPrevalence

Countries

Profile 1: Declining Cambodia,India, Myanmar, Nepal, Thailand

Profile 2: Maturingor varies

Malaysia, PNG, Viet Nam

Profile 3: Expanding.

Indonesia, Pakistan, Philippines

Profile 4: Latentor <500

Afghanistan,Bangladesh,Lao PDR, Sri Lanka

Profile 5: Low prevalence <500 low <1 000

Bhutan, Fiji, Maldives, Mongolia

Source: UNAIDS Regional Support Team Asia and the Pacific- HIV and AIDS Data Hub 2013

HIV Prevalence in Key PopulationsSex Workers• Sub-Saharan Africa: 36.9%• Eastern Europe: 10.9%• Latin America: 6.1%

Source: Kerrigan, D. et al. (2010).

IDU• Europe and Central Asia: 3%

to 52%• South and South-East Asia:

1% to 36%• Sub-Saharan Africa: 51.6% in

MauritiusSource: UNAIDS 2013

MSM• Median prevalence across

24 countries is 14% since 2006Source: UNAIDS, 2013

Current distribution of Tuberculosis (TB) worldwide

Source: WHO 2014

The growing burden of NCDs

ECOSOC/UNESCWA/WHO Western Asia Ministerial MeetingAddressing noncommunicable diseases and injuries (Doha, Qatar, 10-11 May 2009)

0

2

4

6

8

10

12

2000 2005 2010 2015 2020 2025 203

Dea

ths

(mill

ions

)

Cancers

Stroke

Road trafficaccidents

HIV/AIDSTBMalaria

Acute respiratoryinfections

Ischaemic heart disease

Perinatal

ww

w.w

ho.int/healthinfo/global_burden_disease/2004_report_update/en/index.html

Projected global deaths from NCDs and injuries (2030)

0

Health System Challenges• For PLWHIV on ART, co-morbidities such as

cardiovascular disease and cancers as well as HAART-associated complications have emerged as the biggest threat.

• With more patients seeking care for HIV and TB in the era of rapidly growing NCDs, the health system is likely to be challenged beyond its capacity.

Opportunities not to be missed• Massive challenges in high HIV and TB burden

countries present opportunities to improve and sustain the health care system, calling for:• Evidence-based approaches to health service

delivery.• Reviews of all programs to weed out those

that outlived their usefulness and replace them with newer and more effective interventions.

• Service integration.

(2) Service Integration

Integrated health services

• Cost-effective (Sweeney et al. 2012).

• Provide a more nuanced approach to co-morbidities (e.g. earlier uptake of ART will lead to fewer TB cases).

• Increase HIV case findings.• Reduce stigma (Topp et al. 2010).

Integration successes & opportunities

• Enhanced capacity of health workers, able to manage other chronic diseases including TB (Dereks et al. 2013).

• Innovate mechanisms of decentralizing treatment –e.g. through task-shifting (Kredo et al. 2013).

• Renew emphasis on mid-level workers to augment human resource capacity (e.g. pharmacist technicians, clinical offices, lab technicians) (Callaghan et al. 2010).

• Develop community-centered systems, engage community health workers and communities (LeBan 2011).

Case study: Integrating HIV into Public

Health Services in Morocco• Expanded the no. of people receiving

HIV counselling and testing,

• 2010: 46 000 2012: 222 620

• Coverage of services for HIV-positive pregnant women to prevent MTCT

• 2010: 29% 2012: 48%

UNAIDS Global Report, 2013

Service Integration: International progress

Services No. of Countries

HIV C&T, +ARV + TB 56

HIV C&T, +ARV  + Outpatient Care 37

HIV C&T, +Sexual + Reproductive Health 34

HIV C&T, +ARV + NCD 27

HIV C&T, +PMTCT +ANC or MCH 31

Sustaining health systems• Today we live in an era where HIV, TB and

NCDs occur in the same population and individuals – integrated care is a necessity.

• Increasing resources must be devoted to these high burden diseases, and new financing mechanisms must be found.

• Organisations including PEPFAR, GFATM, and GAVI have started funding health systems strengthening.

(3) Increase domestic funding

Domestic public spending as a percentage of total HIV spending by

region

Source: UNAIDS 2013

81%

54%

19% 21%

69%

21%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

EasternEurope

South andSouth‐East

Asia

CentralAfrica

East Africa SouthernAfrica

West Africa

Source: World Bank 2014

Government expenditure as a percentage of total health expenditure in high HIV burden countries

0

10

20

30

40

50

60

70

2004 2006 2008 2010 2012

WorldSouth AfricaNigeriaKenyaMozambiqueTanzaniaUgandaZambiaEthiopia

Source: World Development Indicators, World Bank 2014

0

5 000

10 000

15 000

20 000

25 000

30 000

35 000R m

illion

Total HIV spending in South Africa 2007/8 – 2016/17

• Treatment accounts for 75% of the National Department of Health’s conditional grant expenditure.

HIV expenditure from domestic sources, Asia and the Pacific, latest available year, 2009-2012

Source: Prepared by www.aidsdatahub.org based on www.aidsinfoonline.org, country reported data for UNAIDS regional management meeting 2013 from India and Fiji, and Kumar, U. A. (13 February, 2014). Azad Launches Rs 14,295 CrorePhase IV of NACP, The New Indian Express. Retrieved from http://www.newindianexpress.com/nation/Azad-Launches-Rs-14295-Crore-Phase-IV-of-NACP/2014/02/13/article2053712.ece

Countries in Asia and the Pacific contribute 59% of the funds for the regional HIV response

63% Committed for NACP IV

Innovative funding mechanisms: AIDS Levy in Zimbabwe

• Only country that started using a levy to raise additional funding given dwindling donor support (National AIDS Trust Fund, 2000).

• Levy is 3% of the amount of income tax assessed.

• 50% of the revenue is allocated to treatment and the rest to prevention, M&E and coordination, logistics, etc.

• Although revenues generated remain inadequate ($52.7 m between 2009 & 2011) vs. need, such mechanisms can assist in sustaining health systems for countries in various forms of distress or conflict.

(4) Universal health coverage

Health System Challenges

• Many countries are struggling to finance and provide comprehensive quality health care to all.

• With the growing number of people on ART the health care budget is increasingly inadequate.

• Furthermore, the welcome demands of communities to increase access to care pushes the resource envelope to its limit.

• The WHO has urged countries to provide universal health coverage as a means to sustain health systems.

Elements of universal health coverage• Prepayment mechanisms • Free services at the point of care• Health care as a legal right• Equity – the system must be fair and just for all• Health services should not be treated as a commodity• Financial risk protection and equity for the entire

population with cross-subsidation between the rich and the poor, the healthy and sick

• Single payer fund (vs multi payer) – cuts costs (OECD 2014)

• Start at the community level

Single payer-model of funding health care

Source: (Hsiao, 2012). 

Universal effective coverage

One reasonable benefit 

package for everyone

One fund; one uniform 

policy framework; 

one payment system

One pruchaser that uses its monopsony power in 

negotiations

Can allow supplemen‐tary private insurance

Health care use by coverage system in 1981 and use of the SUS (Brazil) by 2012

Sources: IBGE (PNAD 1981); Pesquisa CNI and IBOPE (2012) from Gragnolati et al. (2012). 

Benefits of introducing single payer models for sustaining health systems• Increases the resource envelope for prevention,

treatment and care for the double burden of CDs and NCDs.

• Ensure sustainability of health care funding.

• Staff retention in the public health system.

• Equity in access to quality health care.

• Universal access to quality health care will ensure the right to health is realised.

Moving forward• Smarter spending – appropriate technologies, emphasis

PHC, establish local manufacturing of drugs, reject protection extensions for expired patents.

• Quick fixes are not the solution – need concerted and coordinated health systems reforms.

• Investing in keeping people active, healthier and for longer through health promotion and prevention activities.

• Reducing avoidable inequalities in accessing quality health care and health outcomes through various mechanisms (financing, delivery, governance regulation, etc.) – targeting the most vulnerable.

Pertinent research questions• How will we address the growing burden of NCDs

without letting HIV fall by the wayside?

• What forms of integrated care are feasible, acceptable and cost-effective under what contextual circumstances?

• How can health systems resilience and adaptability be enhanced to deal with both current and emerging pandemics?

• Surely, the focus ought to be on developing capable delivery systems, financing systems, procurement systems etc., that are adaptable

Concluding remarks• The global response to epidemics including

HIV/AIDS, TB, NCDs and others must be undergirded by resilient health systems.

• Health system must be adaptive as new models of delivery, financing mechanisms, procurement mechanisms, governance arrangements, and technologies emerge.

• Key question: how can all this be achieved?

Step up the pace

• A deliberate focus on building sustainable and effective health systems through evidence based approaches.

Acknowledgements

• Sai Subhasree Raghavan, Ph.D(SAATHII, India and IAS Governing Council Member)• Meredith Evans, MA (HSRC)• Charles Hongoro, PhD (HSRC)• Thomas Rehle, MD, PhD (HSRC)• Yogan Pillay, PhD (South African

Department of Health)

1918 - 2013

THANK YOU