1. Global HIV/AIDS Initiatives in Zambia: Issues of Harmonisation, Systems Capacity and Marginalised Groups Scale-up in the context of Systems Capacity Frontiers Development and Research Group Phillimon Ndubani Joseph Simbaya

2. National Context Population 10.7 Million Population 10.7 Million Ranks number 166 HDI Ranks number 166 HDI About 16% of adults aged 15-49 living with HIV/AIDS About 16% of adults aged 15-49 living with HIV/AIDS National Response National Response –2002 National HIV/AIDS Council (NAC) established to lead and coordinate Multi-Sectoral Response –2004 HIV/AIDS declared a national emergency –2005 user charges for public sector ART abolished

3. HIV/AIDS Funding Three GHIs Three GHIs –Global Fund –World Bank (MAP) –PEPFAR Disbursement mechanism Disbursement mechanism –Global Fund- Principal Recipients –World Bank (MAP)- Ministry of FNP –PEPFAR- USAID, CDC, CIDRZ

4. Methods Both quantitative and qualitative data collection techniques. Both quantitative and qualitative data collection techniques. Three districts (2 urban & 1 rural) Three districts (2 urban & 1 rural) –Health facility tool –Managers/section heads –Exit interview tool –Clients/patients –Human Resources tool –Health staff –Semi-structured interviews - Directors and managers of DHMT, DATF, NGOs and CBOs and community-level stakeholder

5. Scale-up of HIV/AIDS services Currently there are about 118,000 people on ART from 24,000 in 2004. Currently there are about 118,000 people on ART from 24,000 in 2004. ART centres have increased from about 110 in 2005 to about 300 in 2007 ART centres have increased from about 110 in 2005 to about 300 in 2007 Our data show that there is scale-up of HIV/AIDS services and uptake Our data show that there is scale-up of HIV/AIDS services and uptake

6. Scale-up and uptake of VCT

7. Scale –up and uptake of ART

8. Scale-up of HIV/AIDS Services There is also evidence of service uptake where communities are now accessing HIV/AIDS services. There is also evidence of service uptake where communities are now accessing HIV/AIDS services. The supply of ARVs was reported to have improved. The supply of ARVs was reported to have improved. …. We have enough ARVs, we have not had any shortages of ARVs ……and hope that continues because without these ARVs it will be very difficult, people cannot afford…. (DHMT-Mumbwa). they are actually scaling up. …We have seen a lot of services being offered now and there are a lot of activities in the community about HIV/AIDS and we have seen the support they are giving. They are scaling up… (EHT – Mumbwa) they are actually scaling up. …We have seen a lot of services being offered now and there are a lot of activities in the community about HIV/AIDS and we have seen the support they are giving. They are scaling up… (EHT – Mumbwa)

9. Challenges to scale-up Despite the scale-up process, some of the challenges include inadequate human resources, infrastructure and equipment. Despite the scale-up process, some of the challenges include inadequate human resources, infrastructure and equipment. … there is only one CD4 count machine and that is at Kabwe General Hospital so everyones specimen has to be taken to Kabwe General hospital. Yes quite alright the drugs are available but the procedure is still too long and inadequate because of unavailability of certain equipment that is needed (NZP+ Kabwe) Despite the scale-up process, some of the challenges include inadequate human resources, infrastructure and equipment. Despite the scale-up process, some of the challenges include inadequate human resources, infrastructure and equipment. … there is only one CD4 count machine and that is at Kabwe General Hospital so everyones specimen has to be taken to Kabwe General hospital. Yes quite alright the drugs are available but the procedure is still too long and inadequate because of unavailability of certain equipment that is needed (NZP+ Kabwe)

10. Staff establishment over the last 12 Months Slight increase in the total number of employees Slight increase in the total number of employees No change in the number of staff providing HIV/AIDS related services No change in the number of staff providing HIV/AIDS related services

11. Challenges to scale-up Lusaka(n=69)Kabwe(n=71)Mumbwa(n=35) There are insufficient numbers of health workers to deliver HIV/AIDS services effectively 52%70%69% There are insufficient numbers of health workers to deliver other services effectively 49%76%83% In the last 12 months, you have not had sufficient equipment and materials to carry out the job properly 54%69%43%

12. Perceptions on whether workload had become manageable in the last 12 months Lusaka (n= 66) Kabwe (n=71) Mumbwa (n=71) Agree23%34%44% Undecided11%0 Disagree66% 44%

13. Conclusions There is evidence of scale-up HIV/AIDS services There is evidence of scale-up HIV/AIDS services Scale-up is less dramatic in the rural site Scale-up is less dramatic in the rural site There is no corresponding increase in the scale-up of services and human resource capacity There is no corresponding increase in the scale-up of services and human resource capacity Infrastracture and equipment still a challenge Infrastracture and equipment still a challenge