Tackling the Decline in HIV Resources: Lessons Learned from HAPSAT Itamar Katz, PhD, MPhil Wendy Wong, BS John Osika, MD,MPH,MHMPP,CCST,FFPH December 2011 Abt Associates Inc. In collaboration with: I Aga Khan Foundation I Bitrán y Asociados I BRAC University I Broad Branch Associates I Deloitte Consulting, LLP I Forum One Communications I RTI International I Training Resources Group I Tulane Universitys School of Public Health

2 Health Systems 20/20 Health Systems 20/20 is the USAID flagship project for strengthening health systems worldwide 55 countries, US$125 million Health Systems 20/20 developed the HIV/AIDS Program Sustainability Analysis Tool (HAPSAT) in 2008

Outline Decline in financial resources Sustainability analysis HAPSAT-Plus Three lessons learned Capacity building Summary

HIV Funding: Donor and Estimated Need 4 Source: UNAIDS and Kaiser Foundation, 2011; Schwartländer, et al, 2011 Figures are rounded

Sustainability Analysis What goals can be achieved with the current and potential capacity of the program?

Sustainability Analysis: Example

7 HIV/AIDS Program Sustainability Tool (HAPSAT) is … Sustainability study/tool Provides evidence for decision-making and target setting Comprehensive and flexible costing approach

8 Evolution of HAPSAT Original HAPSAT: Gap analysis Recommendations for efficiency The plus in HAPSAT-Plus: Recommendations also on prioritization Based on stakeholder priorities HAPSAT 2.0 software - simplified, flexible, user-friendly Knowledge hub for sustainability

HAPSAT 2.0 Workflow Defining HIV interventions Quantifying unit costs and human resources unit cost of HIV interventions Understanding need for HIV services in the country Defining policy scenarios (target setting) Quantifying financial and human resources policy scenarios Gap analysis: Comparing resources required to resources available Resource Mobilizations EfficiencyPrioritizing

HAPSAT Experience HRH solutions Domestic resource mobilization Prioritization of services Benin Cote dIvoire DR Congo Ethiopia Guyana Haiti Kenya Nigeria Sierra Leone South Sudan Vietnam Zambia

Lesson Learned 1: Efficient Use of Existing Resources 11 Guyana: Interim, efficient solution for data flow Revisiting belief of shortage in health workers South Sudan: Avoiding costly HIV-prevention facilities

Integration, Integration, Integration Extent of integration of HIV services varies by country, yet need to examine: Integration into the wider health services Integration into social services Integration for resource mobilization 12 Lesson Learned 2:

Unit Cost of ART 13

Lesson learned 3: Prioritize and Set Realistic Targets Need to prioritize interventions 14

Billboard vs. Radio for HIV Awareness in South Sudan Cost per exposure Context Priority Radio ads and talk- shows US$ Major information source for Southern Sudanese High BillboardsUS$ 0.05 Low literacy levels limit its use, potentially useful in urban areas Low

Lesson Learned 3: Prioritize and Set Realistic Targets Need to prioritize interventions Frequently unrealistic targets are formulated: Commitment to reach international targets Mobilizing more resources: Over-ambitious targets to justify more resources Under-ambitious targets to ensure achieving targets in performance-based mechanisms Lack of data prevents setting ambitious, yet feasible, targets 16

Target Setting Reaching universal coverage requires efforts beyond apparent capacity Both are costed for stakeholders to decide on their scale-up

Target Setting in HAPSAT 2.0 Software 18

Target Setting in HAPSAT 2.0 Software 19

Capacity Building Country level: Engaging implementers in sustainability approach Training on the HAPSAT 2.0 software Regional level: Training two regional research institutions 20

Capacity Building of Regional Institutions Advantages Regional capacity building Increased scalability of HAPSAT Potential cost reduction Challenges Teaching a flexible approach Ensuring standardization Building capacity: Technical Managerial 21

HAPSAT Take-aways Targets need to be realistic Resource mobilization strategy needs to be aligned to targets Participatory approach promotes country ownership Helps policymakers to think through sustainability issues 22

Country-level Results Kenya: Developing an innovative financing mechanism South Sudan: Avoiding expensive ineffective prevention activities Guyana: Changing thinking on shortage of health workers 23

24 Thank you For more information…

HAPSAT-Plus Process 25

26 Stakeholder Engagement

Stakeholder Engagement Workshop: Identification of sustainability issues and prioritization by stakeholders Results to Action Workshop: Validating the findings, taking forward approved recommendations, creating action plans 27

Stakeholder Process in Sierra Leone Stakeholders priority: Need to train M&E officers HAPSAT teams solution: Need to strengthen data quality, supervision m-health supportive supervision Stakeholders decision: Excel-based supportive supervision 28

Stakeholder Process in Guyana Stakeholders priority: Lack of HRH HAPSAT team solution: Quantifying HRH need Stakeholders decision: HRH need for HIV services is small Establish appointment system Review number of HIV counselors 29

ActionTimelineLead Assesses suitability of clinic hours to make it adaptable to the needs of the patients 2 monthsNAPS/ Care and treatment coordinator Assess the disparity between the public and private clinics appointment 3 monthsNAPS/ Care and treatment coordinator Training of staff and patients on appointment system 4 monthsNAPS/GHARP Stakeholder Process in Guyana, cont.: Sample Action Plan from Results to Action Workshop Expanding Clinic Opening Hours to Better Utilize HRH

Efficiency: Billboard vs. radio for HIV awareness in Southern Sudan Cost per exposure ContextPriority Radio ads and talkshows US$ Major information source for southern Sudanese High BillboardsUS$ 0.05 Low literacy levels limits its use, potentially useful in urban areas Low

32 Comparison of HAPSAT and HAPSAT-Plus Scopes Original HAPSAT: Assessing current funding resources Assessing current financial and human resources required to maintain and scale-up HIV services Gap analysis Resource generation/innovative financing (optional) The plus in HAPSAT-Plus: Customized analysis according to stakeholder priorities Simplified, flexible, user-friendly software with: Triangulation of costing Target setting for multiple scenarios

Development of HAPSAT: 2008 HAPSAT: HIV/AIDS Programs Sustainability Analysis Tool In 2007/08 Health Systems 20/20 developed the Excel-based HAPSAT to estimate gaps between countries available human and financial resources, and what is needed to implement HIV programs at the national level Donor support for HIV programs was still ramping up Priority was scale-up across the board from donors to countries to programs

Development of HAPSAT-Plus: 2010 Priority is sustainability, particularly at country and program levels HAPSAT has been adapted to address concerns of current context and key players In 2010, paradigm changed significantly and donor support is referred to as constant but likely to fall soon

The moderate scenario was preferred by the government: ambitious, yet feasible within three to five years timeframe Sustainability: Decentralization of HIV treatment services in Kenya

36 HAPSAT-Plus Tool Purpose Program sustainability analysis of financial and human resources Key Features Setting programmatic targets of clinical and non-clinical HIV activities based on different scale-up scenarios and costing them Enhanced bottom-up and top-down costing of non-clinical HIV activities Comparison of different policy scenarios Customized to obtain data from Spectrum and from UNAIDSs Mode of Transmission studies Harmonized with PEPFAR and Global Fund categorization of HIV services Can be downloaded for free from: 36

HAPSAT-Plus Gap analysis: Assessing current funding resources Assessing current financial and human resources required to maintain and scale-up HIV services Planning resource generation/innovative financing (optional) Customized analysis according to stakeholder priorities Tools: Flexible, user-friendly software for quantifying the financial and human resources required for a set of policy scenarios Protocol for the approach

Resource mobilization: Levy tax in Kenya

Health Systems Strengthening: FTE of Medical Doctors Required for pre-ART & ART Calculating FTE medical doctors required for delivering pre-ART and ART Three patients per hour (18 per day) 44 working weeks per year ART patients visits on average 6 times a year Visits evenly distributed during the working hours Need to integrate of ART clinics with less than 600 pre-ART and ART patients