5th HIVAIDS Management Exchange Workshop

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5th HIV/AIDS ManagementExchange Workshop
Quality of Care
2nd - 3rd April 2008 Sheraton Kampala
HotelKampalaUganda
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Future of funding HIV healthcare are programmes
sustainable

• Prof Joep Lange
• PharmAccess/CPCD/AMC The Netherlands

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A concise history of HIV and its
treatmentearly years

• 1981 emergence of AIDS epidemic in gay men
  East and West Coast US
• 1983/84 discovery of the causative agent HIV
• 1987 first active antiretroviral on the market
  (ZDV)

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Reduction in Mortality Among persons 25-44
years old, USA, 1982-1998
National Center for Health Statistics National
Vital Statistics System Preliminary 1998 data
Introduction of PIs
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Reasons not to introduce HAART in resource-poor
settings in 1996

• Too expensive
• Too complex
• Prevention more important than treatment

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Positive developments (milestones) in bringing
HAART to resource poor settings

• Price reduction of antiretrovirals (Accelerating
  Access Initiative, etc) (2000)
• Declaration of Commitment of the United Nations
  General Asssembly Special Session on HIV/AIDS
  (UNGASS) (2001)

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Positive developments (milestones) in bringing
HAART to resource poor settings

• Establishment of funding mechanisms
• World Bank Multicountry AIDS Program (MAP, 2000)
• Global Fund to fight AIDS, TB and malaria (GFATM,
  2002)
• Presidents Emergency Plan for AIDS Relief
  (PEPFAR, 2003/2004)

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Positive developments (milestones) in bringing
HAART to resource poor settings

• WHO Treatment Guidelines uptake of
  antiretrovirals in WHO Model List of Essential
  Medicines (2002)
• WHOs 3by5 initiative 3 million people in
  resource-poor settings on antiretroviral therapy
  by the end of 2005

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Does the global response to fight AIDS create
islands of excellence in seas of under
provision?

• Kent Buse and Amalia Waxman warned in 2001 that
  the vertical approach adopted by Public-Private
  Partnerships might create islands of excellence
  in seas of under provision.
• Recent attacks on the disease-specific focus of
  the Global Fund to fight AIDS, Tuberculosis and
  Malaria published in Foreign Affairs, the British
  Medical Journal, the Financial Times, the Los
  Angeles Times, and the New York Times, among
  others, echo this warning.
• The global response to fight AIDS is blamed for
  eating an unreasonable share of the global health
  aid pie.
• Gorik Ooms

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Does the global response to fight AIDS create
islands of excellence in seas of under
provision?

• Excellence is a bit strong too many people
  still die because of not having access to AIDS
  treatment.
•  
• Most global health aid to fight AIDS is
  additional global health aid.
• Gorik Ooms
•  

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Nonetheless, the AIDS response did create islands
of sufficiency in a swamp of insufficiency
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How did AIDS activism create islands of
sufficiency?

• 1. Sustainability at national level was replaced
  with sustainability at international level
• 2. Sustainability at international level was
  matched with sustained foreign assistance
• 3. AIDS activists confronted the ceilings on
  health expenditure imposed by the IMF
• 4. The Global Fund included civil society at all
  levels of its decision-making process
• 5. AIDS activists forced the reduction of the
  prices of medicines

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Sustainability at national level was replaced
with sustainability at international level

• Pavignani and Colombo of the World Health
  Organization (WHO)
• Sustainability is continuously invoked as a key
  criterion to assess any aid-induced activity or
  initiative. Sometimes, the concept is given the
  weight of a decisive argument. Thus, to declare
  something unsustainable may sound as equivalent
  of worthless or even harmful, in this way
  overruling any other consideration.
• Gorik Ooms

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Investing in Health for Economic Development
(CMH Nov 2001)

• 2000 WHO Director General Gro Harlem Brundtland
  establishes the Commission of Macroeconomics and
  Health to assess the place of health in global
  economic development
• Chaired by Jeffrey Sachs including many leading
  economists (Manmohan Singh a.o.), public health
  experts, and biomedical researchers (Harold
  Varmus)

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Mortality over four years
Sub-Saharan Africa
Europe North America
CROI 2007 mortality - 31
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And, despite impressive scale-up ,

• Large number still untreated
• Reliance on cheap fixed dose NNRTI-based
  combinations for first line therapy
• Toxicity
• Durability
• High early mortality rates
• Limited availability of second line options
• Limitid monitoring capacity (no pVL)

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Moving to the next stage

• Whereas new disease-specific resources have led
  to some astonishing success stories, much remains
  to be done in moving to the next stage, i.e. the
  building of viable health systems with
  satisfactory medical and administrative capacity
  and functional and reliable supply lines.

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Moving to the next stage

• It is clear that African public systems are too
  weak to accomplish this alone and that we meed to
  rethink the way in which health care is financed
  and delivered.

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Global inequity in health expenditure versus
disease burden

Source WHO data 2003

• Africa carries gt 40 of the global disease burden
  for communicable diseases, it spends lt 1 of
  global total health expenditure
• Highest of HIV/Aids worldwide
• Health in Africa is seriously under-funded

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The problem with Africa

• Moreover, in spite of the billions of dollars of
  international aid dispensed, an astonishing 50
  of sub-Saharan-Africas total health expenditure
  is financed by out of pocket payments from its
  largely impoverished population.
• Health care remains the worst in the world the
  region lacks the infrastructure, facilities, and
  trained personnel to provide even minimal levels
  of health services and goods.

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Global health work force(density per 1000
population)

• Africa 2.3
• Europe 18.9
• Americas 24.8
• There are currently 57 countries with critical
  shortages of hcw, equivalent to a global deficit
  of 2.4 million doctors, midwives and nurses.
• Based on hcw density needed to have 80
  coverage of births by skilled birth attendants
  (approx. 2.5)

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Reasons for health work force shortages Africa

• Insufficient training opportunities
• Attrition due to illness/death (HIV/AIDS)
• Migration
• rural -gt urban
• within Africa
• from Africa to Europe, North America

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The old paradigm and its consequences (1)

• Sub-Saharan African governments, almost without
  exception see their role as the dominant provider
  of health care, aiming for universal access.
• In accordance with this, most donor funding is
  channeled to the public system in the form of
  input-financing to the supply side.

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The old paradigm and its consequences (2)

• Yet, African public systems have been unable to
  deliver health care efficiently.
• As a result, almost 60 of health care, often
  obtained in the private sector, is paid by
  patients out of pocket, causing many to fall into
  a poverty trap.

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Who profits from the public health care systems?
Source Preker, A.S., Langenbrunner, J.C. et al
(2005) Spending Wisely, Buying Health Services
for the Poor. World Bank, Washington DC, p.50
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Private health care in Africa is usedby the
rich, but also by the poor
World Development Indicators, World Bank (2002)
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Private financing is highest in poorer countries
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The role of the private sector (1)

• It fills an important medical need for poor and
  rural populations that are underserved by the
  public sector.
• In addition, it may provide services that might
  otherwise not be available (advanced medical
  equipment, procedures).

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The role of the private sector (2)

• On the other hand, it is diverse and fragmented,
  and quality can be inconsistent and poor.
• These conditions, coupled with the lack of
  accreditation and a largely uninformed population
  have created an environment in which an
  unscrupulous majority can sometimes prevail over
  responsible providers.

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Investments in health sector are very low
In 2004, IFC committed 5.6 billion in direct
loans or guarantees Of these investments, 63
million (1.12) went to the health sector (of
which none to Africa)
Source Annual reports 2004, websites (checked
August 2005)
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Health insurance is almost non-existent in Africa

• Only 3 of total health expenditure (excluding
  South-Africa) is financed through private
  pre-paid risk pooling arrangements
• In most countries (44 out of 47) less than 10 of
  total health expenditure is made through private
  risk pooling
• 33 countries have no private risk pooling at all

Absence of insurance markets deprives the
community from the ability to pool risks
introducing financial shocks
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Historical developmentIntroducing health
insurances to communities was the first critical
step
Typical development of healthcare systems in OECD
countries
National policies
Donor policies
Dominance of out-of-pocket costs
Evidence-based advocacy
Community health insurance/ risk-pooling
Disconnection of contribution from utilization
Capacity-building and technical support
Established insurance pools
Framework for pool management and interactions
Set up funding and reinsurance
Increased regulation
Insurance pool consolidation
Inter-pool subsidies and consolidation policies
Advocacy, consumer protection funding, and
reinsurance
Universal insurance coverage
Optimized subsidy of low income by high-income
households
Group-based, private risk-pooling schemes are
crucial for the development of health systems and
access to quality health care
Including private insurance
Source Arhin-Tenkorang, 2001
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PharmAccess approach
External
PAI ME
funds
3.
Insurers
HMO, TPA
1.
Customers
workplace
programs
4.
Community
2.
Providers
Clinics/labs
ATC

• Communities Public Private Partnerships
  supported by Health Insurance Fund (HIF)

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2005 DHS market position
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High value Low cost
High value High cost
OMNI CARE
DIAMOND
GOLD
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ELITE CARE
PRESTIGE CARE
DHS is low cost medium value product (AIDS
included, but no hospitalisation)
STATUS CARE
SAPPHIRE
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CORPORATE
EXPRESS CARE
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RUBY
ECONO CARE
SILVER
high
low
PROTECTOR HEALTH
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PRICE
550
650
750
1000
1500
2000
2500
250
350
450
1250
1750
2250
POWER PLUS
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TOP OPTION
ECONOMIC
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Low value Low cost
Low value High cost
3
0
low
Diamond Health Services
NMC Products
NHP products
RENAISSANCE Products
Costs are shown per family of 3 Member plus 2
dependents
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2006 DHS provokes 3 new products and improves
itself
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High value Low cost
High value High cost
OMNI CARE
DIAMOND
GOLD
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ELITE CARE
PRESTIGE CARE
STATUS CARE
SAPPHIRE
21
CORPORATE
NHP Blue Diamond
Vitality NetCare
EXPRESS CARE
18
Vitality DayCare
NHP Economic
15
RUBY
ECONO CARE
SILVER
high
low
PROTECTOR HEALTH
POWER PLUS
12
PRICE
550
650
750
1000
1500
2000
2500
250
350
450
1250
1750
2250
9
6
Low value High cost
Low value Low cost
3
0
low
NMC Products
NEW PRODUCTS
NHP products
RENAISSANCE Products
New
Costs are shown per family of 3 Member plus 2
dependents
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2006 Competing insurers establish Risk
Equalistion Fund for AIDS, supported by
PharmAccess
Risk Equalization Fund
PSEMAS
Bankmed
Closed funds
Namdeb
Napotel
RCC
NHP
Nammed
Open funds
HEALTH IS VITAL Day Care / NetCare
NHP BD
Rennaissance
NMC
Administrators
Prosperity
Medscheme
Methealth
Paramount
Prosperity DM
Aids Outreach
Aid for Aids
Disease Mgt
My Health Disease Mgt
Private Service Providers
Doctors
Laboratories
Clinics
Hospitals
Pharmacies
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The way forward a new model -4Risk pooling
spurs a virtuous circle of health care
The way forward
HIGH
(Donor) subsidy injection
Financing Public/Private collective health
insurance schemes
Healthcare revenues are guaranteed, reducing the
investment risk, leading to investments in
quality. Subsidies for quality improvement also
lead to increased quality
Introduce risk pooling and subsidize premiums to
stimulate demand higher capacity to pay
HIGH
HIGH
DEMAND Insurance membership Medical
care usage
SUPPLY Quality health care
Increased quality leads to increased trust in the
system, fuelling the willingness to prepay for
health care
Increased willingness to prepay and higher
capacity to pay lead to increased demand and usage
Delivery Healthcare providers
Private investments
HIGH
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The role of Health Insurance Fund, IFHA and
PharmAccess in breaking the vicious circle
Practical examples

Health Insurance Fund

• Health care revenues are guaranteed, thus
  investments can be made in access and quality

• Introduce risk pooling and subsidize premiums to
  stimulate demand
• higher capacity to pay

Public/Private collective health
insurance system
financing
financing
financing
DEMAND Insurance membership Medical
care usage
SUPPLY Quality
PharmAccess
Health Insurance Fund

• Through investment higher quality, fuelling
  willingness to pay

• Increased willingness to pay leads to increased
  demand and usage

delivery
Investment Fund for Healthcare in
Africa (IFHA)
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How can Government Intervene ?
Inform - promotion campaigns - distribute
health research findings Regulate - quality
control (drug medical personnel) Mandate -
immunization - annual check-ups Finance -
directly (incl. subsidies) - through public
insurance Deliver - public doctors - public
hospitals
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The Millennium Development Goals

• Goal 1 Eradicate extreme poverty and hunger
• Goal 2 Achieve universal primary education
• Goal 3 Promote gender equality and empower
  women
• Goal 4 Reduce child mortality
• Goal 5 Improve maternal health
• Goal 6 Combat HIV/AIDS, malaria and other
  diseases
• Goal 7 Ensure environmental sustainability
• Goal 8 Develop a Global Partnership for
  Development

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Acknowledgements

• PharmAccess
• Onno Schellekens
• Tobias Rinke de Wit
• Michele van Vugt
• And many others

• AIID
• Jacques van der Gaag
• MSF
• Gorik Ooms

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Bringing together scientists involved in HIV
treatment, pathogenesis and prevention research
in resource-poor settings. The location of this
annual workshop will rotate among continents and
focus on issues of particular relevance for that
continent. Admission to this meeting will be
limited to those who have submitted an accepted
abstract or who have been invited by the
Organising Committee. An attendance cap of
approximately 300 intends to guarantee quality
and to enable an interactive environment.
Scientific agenda AMC, Center for
Poverty-related Communicable Diseases, Univ. of
Amsterdam. Logistics Virology Education. The 2nd
Interest Workshop will be held 20 23 May 2008
in Dakar, Senegal
ORGANIZING COMMITTEE Papa Salif Sow
(chair 2008) Dakar University Teaching Hospital,
Senegal Charles Boucher, UMC Utrecht and Erasmus
University Rotterdam, the Netherlands David
Cooper, University of New South Wales,
Australia Elly Katabira, Makerere University
Kampala, Uganda Richard Koup, Vaccine Research
Center, NIAID, NIH, Bethesda, USA Joep Lange,
CPCD, Academic Medical Center, University of
Amsterdam, the Netherlands Timothy Mastro, CDC
Atlanta, USA Praphan Phanuphak, Thai Red Cross
Aids Research Center, Bangkok, Thailand Helen
Rees, University of the Witwatersrand,
Johannesburg, South Africa
Announcement Call for abstracts For
registration, abstract submission, scholarship
application and more information please go to
www.virology-education.com

TIMELINESRegular Registration 16 February 31
March 2008Late Registration from 1 April 2008
Abstract submission 1 January -17 March 2008
Deadline scholarship application 17 March 2008

For more information www.virology-education.com