International Treatment Preparedness Coalition (ITPC) Treatment Monitoring & Advocacy Project

Why monitoring through Missing the Target (MTT)? Started with need to track 3 by 5 initiative from a civil society perspective Recognition: scale up dependent on politics, money and implementation issues Need to make governments and global agencies accountable for progress Focus on outcomes, identify specific barriers & be solution-oriented Inform advocacy with objective research

Research Approach and Methods Civil society teams based in countries Standardized research template Research based on confidential interviews with diverse informants: civil society, local and national government, health workers, policy makers Centralized editing, coordination, global and domestic media Focus on recommendations to change national policies and response of global agencies

MTT 1, 2 & 3: Findings November 2005, May 2006, November 2006 –Reports cover: Dominican Republic, India, Kenya, Nigeria, Russia, South Africa –Lack of urgent, global strategic plan driving HIV treatment scale up –Inadequate national leadership in response to ARV treatment access gap –Specific barriers (and solutions) –Technical support needs of government and civil society unmet –Pervasive HIV-related stigma –Very limited or no connections between HIV and TB responses

Findings: MTT 4 & 5 July 2007, November 2007 –New countries join: Morocco, Pakistan, Uganda, China, Belize, Cameroon, Kenya, Cambodia, Argentina, Zambia, Zimbabwe, Malawi, Philippines –Need for increased attention to marginalized populations, supportive services including nutrition, human resources, free access to medications and testing, integration of prevention and treatment services –MTT 5 documents that treatment regimens in many countries do not meet new WHO standards for 1st and 2nd line care

MTT Outcomes The report ignited a debate with policy makers. The reporting process strengthened the network of PLWHA and focused the efforts of treatment advocates. The scrapping of user fees for ARVs followed recommendations we made in the report. The report has opened up dialogue with the AIDS and TB program in the Ministry of Health. Informs domestic and international media coverage and dialogue on AIDS –Recommendations endorsed by The Lancet; covered in The New York Times, FT, IHT as well as national media in the countries studied

MTT 6: AIDS and Health Systems Six civil society country research teams in Zambia, Zimbabwe, Uganda, Dominican Republic, Argentina, Brazil Country teams selected through competitive process based on demonstrated capacity, expertise Project coordinators also strive for geographic representation

MTT 6: Methodology Interviews and focus groups using standardized questionnaires Questionnaire template developed in collaborative process with all country teams participating Respondents: People with HIV, grassroots level key informants, hospital administrators, government officials (disease specific and health in general), caregivers, health workers, national heads of multilateral agencies, national civil society, etc. Literature review, including of key national health documents (eg Ugandas HSSP II)

MTT 6: Main findings AIDS response has far-reaching positive impacts on health care service access: building infrastructure, raising quality, and extending the reach of health care to socially marginalized groups (eg sexual minorities, drug users, migrants, poorest) AIDS response has revealed existing fragilities in health systems in some cases has increased burdens on systems because AIDS response has not yet been used to create additional capacity (eg GHIs rarely used to fund additional health workers)

MTT 6: Main findings Engaging advocates and health consumers has increased accountability and urgency of response Expansion of resources requires simultaneous work to increase on human resources, transparency, and strengthen infrastructure Untapped opportunities to improve broader delivery of comprehensive primary health care services using GHI funding Scaling up coverage in rural/peri urban/remote areas extremely challenging: must use GHIs to strengthen health systems in order to extend impact of AIDS programs

MTT 6: Main findings Civil society plays a vital role in helping service users demand their health rights and in providing HIV and health care services External funding for HIV can result in a country viewing HIV treatment programs as separate from health system, undermining integration--no requirement by GHIs to do so

Positive Synergies Civil society involvement in monitoring, governance and implementation at the country level Civil society identifies existing opportunities that are not being used to leverage positive synergies, using funding to fight AIDS while improving health outcomes for the larger communities In particular, health worker shortages: critical barrier in countries studied, while GHI funding not used to address problem

MTT 7 to be released Oct. 6

Where to next? Budget monitoring training for all teams in Cape Town and Bangkok in 2008 One minute audio comments by all CCM Advocacy report researchers on itpcglobal.org MTT 7 on PMTCT+ (6 countries) – March 09 Goals for the future: Closer tie to advocacy – all teams to implement advocacy plans Fully integrated research and monitoring, advocacy, and ongoing capacity building, mentoring and training for country teams Integration of budget monitoring and other skills Advocate on access to health services while keeping AIDS focus

MTT 6: Uganda AIDS claims the biggest share of health financing of any single disease in the country Massive inflow of funds from foreign donors for AIDS programs has resulted in broader improvements to public health but significant additional funding is needed to meet health care needs AIDS programs have improved community mobilization, including TB and village health teams Limited successful examples of integrating AIDS care into primary health care services

MTT 6: Uganda AIDS has placed increased workload and strain on medical personnelwhose numbers have not increased proportionally to the demand and on existing weak infrastructure Personnel working in often AIDS are better paid, and their facilities better equipped leading to further attrition An increase in AIDS funding has not led to the efficient delivery of services and commodities (eg stock-outs persist)

MTT 6: Uganda Urgent need to train and equip health workers and devolve ARV treatment to lower-tier health facilities, engaging communities in health service delivery and planning

MTT 6: Zambia Ongoing ART roll out has reduced HIV related hospital admissions, reducing workloads Basic health services and supplies still not available in public system, forcing poor patients to go without Serious health worker shortage exacerbated by IMF-imposed conditionalities

MTT 6: Zambia High reliance on donor support, often conditional, but donor funds not being used to increase capacity of local health workers and implementers, or increase overall number of health workers Donors should train additional health workers to compensate for those hired from the public system to work in their projects Low levels of community mobilization to demand better access to comprehensive health care services