1. The PHRplus Project is funded by U.S. Agency for International Development and implemented by: Abt Associates Inc. and partners, Development Associates, Inc.; Emory University Rollins School of Public Health; Philoxenia International Travel, Inc. Program for Appropriate Technology in Health; SAG Corp.; Social Sectors Development Strategies, Inc.; Training Resources Group; Tulane University School of Public Health and Tropical Medicine; University Research Co., LLC. URL: http://www.phrplus.orghttp://www.phrplus.org Systems Approaches to HIV/AIDS: Implications, Results, and Lessons Paurvi Bhatt, M.P.H. Senior Associate Abt Associates Informal Discussion: UNESCO April 26, 2004

2. Systems and HIV/AIDS: Why Now?  Rapid increase in resources  Dramatic diversity of sources  Heightened focus on scale and coverage  Increased recognition of multi-sectoral response  Essential need for evidence-based results and financial responsibility

3. Health Systems and HIV/AIDS: The Elephant in the Room  Remarkable attention to constraints of health systems  Lack of clarity on function of health systems related to HIV/AIDS  Key Issues:  Absorptive Capacity  Infrastructure Limitations  Human Resources  Safe, Effective, and Integrated Service Delivery  Sustainability

4. The Health Systems Bridge & HIV: HIV Areas Linked with Health Systems* Policy Reform Workers Commodities Financing Information Health Systems Bridge STI VCT OI & PAL ART Community: NGO/CBO Interventions, Mobilization, & Referral * Slide adapted from USAID

5. Systems Approach to HIV: Key Policy and Financing Questions  What are we trying to accomplish?  What resources are needed?  How will policy and financing options be implemented?  Where did the resources go? Who ended up paying for what?  What can be adapted to be more effective? What policy decisions can lead to sustainability?

6. The Systems Toolbox:  Resource Estimation Models  Resource Source and Flow Tracking  Costing Techniques  Economic Analysis

7. Question 1: What are we trying to accomplish?  Impact through scale, coverage and quality  Policy Reform  Infrastructure Strengthening  Skills Building  Community Mobilization  Service Delivery

8. Question 2: What resources are needed?  Interest in scaling up programs at international and national levels  Accurate cost and resource information critical to guide policy decisions on financial sustainability, resource mobilization, targeting

9. Systems Tool: AIDST REAT C OST (ATC) What is it?  Estimates total resources required to support policy decisions, program planning, and budgeting for a national ARV treatment program.  Prioritizes a systems perspective to consider all costs involved to implement ART- using data on  Demography and epidemiology  Human resources  Commodity and facility requirements etc.  Draws on national experience, is easily adaptable, and generates results quickly

10. Key Results and Lessons  Annual per patient costs involve more than drugs alone  VCT costs are substantial  Opportunistic infection costs will remain  Key human resources are limited  Environment is very dynamic  Financial sustainability and absorptive capacity are critical  Need for extension of model to estimate resources for complex multisectoral programs  Home-based care  Orphans and Vulnerable Children

11. Question 3: Where did the resources go?  Understand absorptive capacity  Demonstrate allocation of funds  Strengthen integrity of resource flow and improve accountability  Monitor changes in policy and resource allocation  Determine equity of service reach

14. Systems Tool: Economic Analysis  Equity Issues: Large divide in use of services and expenditures  Rich spend 13x more than the poor  Men spend 2x more than women  Urban more than rural  Households rely on local resources to minimize impact  Grant assistance from church or family  Loans from family and friends  Sale of household assets

15. Question 4: What can be adapted to be more effective?  Use of tools to answer key HIV questions critical in policy dialogue and resource mobilization  Systems Tool: Cost Analysis  Generates reliable cost and coverage data  Improves dialogue across Ministries  Clarifies intervention areas  Home-based care

16. Future Considerations:  Applying Systems Approach to Multisectoral Programs  Estimating Resource Needs and Flows for Complex Programs  OVC  Adapting Methods from Diverse Mix of Disciplines to Leverage Sustainable Impact