1. Learning from the Past and Envisioning the Future Bridging the Divide: Interdisciplinary Partnerships for HIV and Health Systems AIDS 2010, 16-17 July 2010, Vienna Professor Rifat Atun Director, Strategy, performance and Evaluation Cluster The Global Fund to Fight AIDS, Tuberculosis and Malaria

2. The past HIV and Health Systems Underfunded Huge unmet need Weak health systems Political commitment weak The debate Reductionist approach Binary debate Polarisation False dichotomy on targeted vs health system investments

3. The current context HIV and Health Systems Substantial financing Unprecedented scale up of prevention, treatment and care 5 million receiving ARVs but still huge unmet need Weak health systems hindering scale up Political commitment waning The debate Progressing beyond the reductionist approach Exploring synergies Understanding that MDGs are inextricably linked Spirit of collaboration

4. HIV and Health Systems: bridging the divide Global Fund experience

5. The Global Fund and Health System Strengthening Round Type of request for funding 2-Year Amount * For HSS 2-Year Round Total* % of Total 5HSS proposals437266 7 HSS strategic actions in disease specific funding 1861,11717 8Separate HSS cross cutting actions2833,0599 *The amounts are in million USD – for 2 year period ** HR, Infrastructure, M&E 1-8 HSS investments in disease specific grants**2,6898,20333

6. The Global Fund and Health System Strengthening Health financing and social protection have not featured strongly in the HSS demand from countries. Budget categoriesRound 7Round 8 Human Resources33%42% Infrastructure17%26% Monitoring and Evaluation14%7% Community & Client Involv.11% TA & Mgmt Assistance 6% Health Financing< 1%1% HSS Total for each roundUSD 186 millionUSD 283 million

7. Investments in HIV control have strengthened health systems Country ExamplesResults Human resources Infrastructure Service Delivery Ethiopia expanded primary care infrastructure and workforce Malawi expanded primary care workforce from 4,000 (2003) to 10,000 (2008) Rwanda used innovative incentives to scale up primary care and IMCI Between 2005 and 2008, DPT3 immunization grew from 70 to 82% Between 2002-2007, AIDS mortality declined by 50% In 2009, 77% of facilities provided basic emergency, obstetric and neonatal care Between 2005-2007, deliveries assisted by trained attendant increased from 39% to 52%

8. Investment in Health Systems Strengthening: Malawi (1/2) Malawi: USD 196.8 million 10,000 Health Surveillance Assistants deployed by 2009, entirely supported by the Global Fund, to provide: HIV, TB and malaria services supervision of traditional birth attendants community-based maternal & newborn care family planning advice disease surveillance

9. Global Fund’s contribution to expanding the health workforce in Malawi Expansion of HSA and decline in U5MR: 2003-08 Investment in Health Systems Strengthening: Malawi (2/2)

10. Ethiopia: USD 330.5 million Service Delivery Indicator 20052008 Immunization rate (DPT3)70 %82 % Births attended by health professionals 13 %24.9% People on ART (% women and children) 20,000 (25 %) 132,000 (35 %) Indoor residual spraying coverage 7.3 %51.4 % Insecticide treated nets coverage 15.8 %71.3 % Over 30,000 Health Extension Workers trained and deployed between 2004 - 2009. Investment in Health Systems Strengthening: Ethiopia

11. Investment in Health Systems Strengthening: Rwanda Trends in Deliveries*20052007 % Deliveries assisted by trained personnel 39 %52 % % Deliveries at a health facility 28 %45 % USD 141.2 million Contributing to demand and supply of health services. *Based on DHS

12. Haiti an integrated package of PHC services including HIV counseling, AIDS care, prenatal care, nutritional support, and management of TB and STI to 250 000 people supported expansion of community health worker network to provide HIV and TB services  The workers instrumental in increased uptake of PHC services among most vulnerable households USD 160 million R1 HIV grant (PIH)

13. Ending the false dichotomy Bridging the divide

14. Is there a divide? Key Questions What are the extent and nature of integration of targeted interventions and health systems to achieve synergies in varied contexts? Which factors influence the extent and nature of integration? How do varied health system designs and delivery models influence outcomes?

15. Atun, Ohiri, Adeyi, 2008 Key variables affecting the nature and extent of integration 1.The Problem being addressed 2.The Intervention 3.The Adoption System 4.The Health System characteristics 5.The Broad Context

16. A framework for analysing adoption, diffusion and integration of targeted health interventions Intervention Adoption System Broad Context Health System Characteristics Problem

17. The Problem Necessity and Urgency Burden –health, economic and social Perceived and real Social Narrative Transmission dynamics The Intervention Complexity Simpler to complex Scalability Replicability Factors influencing diffusion and integration

18. The Adoption System Receptivity Individual & organisational Incentives Legitimacy Factors influencing diffusion and integration Health System Characteristics Feasibility Governance Structure and organization Financing Service delivery M&E system

19. The Context Sustainability Fiscal space –Overall and health sector specific Frailty Opportunity Critical events –Visibility Synergy Technology / innovation Desirability Political economy Socio-cultural factors

20. Analysing the extent and nature of integration

21. Analysis of critical health system functions for targeted health interventions in a health system context

22. 8,274 1,551 118 88 26 6,723 excluded 1,046 excluded 387 i.e. program evaluations, descriptions, reviews, uncontrolled studies 30 not available* 18 excluded 44 I. Title scanning II. Abstract scanning III. Full text scanning IV. Quality assessment 12 14

24. Conclusions from antecedent research 1.Reductionist approaches counterproductive 2.No vertical or horizontal approach –A rich mosaic –Extent and nature of integration varies 3.Context matters –Complex adaptive systems at play –Local solutions for local problems 4.Positive synergies evident

25. Looking ahead

26. The evolving context A Challenging Economic Environment Broadening the Global Health Agenda 1 2 3 The evolving HIV response: managing AIDS as a long term illness in the rapidly increasing cohort on treatment Focus on value for money Create synergies between HIV and HSS investments to improve health outcomes

27. Paradigm shift in the way we think about HIV/AIDS and health systems Low High Emergency Long term care Position in early 2000 2010 onwards Numbers receiving treatment Nature of the response

28. Managing the transition Upstream Harmonization and alignment of existing support Joined up analysis, planning, investment and monitoring Downstream Structural and operational integration Long term care models Focus on value for money to ensure sustainability

29. Challenges (1) Weak evidence base What works in practice and what has worked less well Why and how? Optimal delivery models Scale effects 1 2 3 4 Methodological challenges in generating evidence

30. Challenges (2) Mounting an effective response Resistance to policy translation Incrementalism Inadequate focus on delivering value Lack of innovations to achieve step change 1 2 3 4 Strategic and transformational change