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

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Presentation transcript:

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

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

Background President’s Emergency Plan for AIDS Relief (PEPFAR) 3.0 strategy: Coordination of the 90-90-90 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 90-90-90 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

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.

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

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

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

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

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

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

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.

MEASURE Evaluation

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

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

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.

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 2017

Timeline 2016 2017 2018

Project SOAR

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

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

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

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.

Timeline 2016 2017

Karibu…Thank you…

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-14-00004. 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. www.measureevaluation.org Project SOAR (Cooperative Agreement AID-OAA-14-00026) 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.