WHO Consultation on Positive Synergies between Health Systems and Global Health Initiatives Jim Yong Kim M.D., Ph.D. Jim Yong Kim M.D., Ph.D. Fran Franç ois Xavier Bagnoud Center for Health and Human Rights ois Xavier Bagnoud Center for Health and Human Rights Brigham and Women’s Hospital Brigham and Women’s Hospital Harvard Medical School Harvard Medical School Harvard School of Public Health Harvard School of Public Health Partners In Health Partners In Health May 29 May 29 th th , 2008 , 2008
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WHO Consultation on Positive Synergies between Health Systems and Global Health Initiatives
WHO Consultation on Positive Synergies between Health Systems and Global Health Initiatives. Jim Yong Kim M.D., Ph.D. Fran ç ois Xavier Bagnoud Center for Health and Human Rights Brigham and Women’s Hospital Harvard Medical School Harvard School of Public Health Partners In Health. - PowerPoint PPT Presentation
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WHO Consultation on Positive Synergies between Health Systems and
Global Health Initiatives
Jim Yong Kim M.D., Ph.D.Jim Yong Kim M.D., Ph.D.FranFranççois Xavier Bagnoud Center for Health and Human Rightsois Xavier Bagnoud Center for Health and Human Rights
Brigham and Women’s HospitalBrigham and Women’s HospitalHarvard Medical School Harvard Medical School
Harvard School of Public HealthHarvard School of Public HealthPartners In HealthPartners In Health
May 29May 29thth, 2008, 2008
Key Questions
• Health systems and Global Health Initiatives- the state of affairs
•Are there positive synergies between GHIs and HSS?
•Are these synergies being vigorously exploited to assure maximum, mutual added value?
• The need for systematic evidence
• Are there knowledge gaps and, if so, can they be identified?
• How best can current experience be mapped using existing evidence?
• What research is needed to develop the evidence base?
• The search for a logical framework for investigation
• Can we develop appropriate research methodology?
• Can we construct a logical framework for investigation ?
ii. Required to attend adherence counseling sessions
iii. Free Medication; $0.30 user fee
• Focuses on keeping patients on treatment
• Supported by PEPFAR
• US Partner: USAID- development focused
• Medical center-based model
• Distribution of ARVs is the key
• Results:
i. 19,000 patients in ~18 months
ii. Expanded to >30 clinics in public health facilities
iii. Cost of treatment: $16/ month
iv. Free ARVs to ~2000 orphans and pregnant women
• Now- Expanding strategies such as home visits to address adherence
• Focuses on Financial independence
Global Health “Strategy” To Date
• Countries and even districts working in isolation• Project-based
– Donor preference driven– Experimental pilots that never scale
• Competition among implementers• Cottage-industry approach• Fragmentation of services• Ineffective and not results oriented• Absence of technology and measurement
orientation• Resources diverted for overhead and consultants
Clear need for a better approach
“Maximum, mutual added value”
• The need for holistic framework that incorporates all activities and actors contributing to global health outcomes at individual patient and health system level
Value: Patient outcomes per dollar spent
The Care Delivery Value Chain
• The care delivery value chain captures:– Interaction between interventions and
infrastructure– The configuration, sequence and
interdependence of interventions– Value is created across the activities during the
“care cycle”
Allows careful examination of all activities of a care delivery system and more thoughtful deployment of resources
DELAYING PROGRESSION
DIAGNOSING & STAGING
INITIATING ARV THERAPY
PREVENTION & SCREENING
ONGOING DISEASE MANAGEMENT
MANAGEMENT OF CLINICAL DETERIORATION
INFORMING & ENGAGING
ACCESSING
MEASURING
PATIENT VALUE
(Health outcomes per unit of cost)
• Prevention counseling on modes of transmission on risk factors
• Explaining approach to forestalling progression
• Explaining diagnosis and implications
• Explaining course and prognosis of HIV
• Explaining medical instructions and side effects
• Counseling about adherence; understanding factors for non-adherence
• Explaining co-morbid diagnoses
•End-of-life counseling
• HIV testing
• TB, STI screening
• Collecting baseline demographics
• HIV testing for others at risk
• CD4+ count, clinical exam, labs
• Monitoring CD4+
• Continuously assessing co-morbidities
• Regular primary care assessments
• Lab evaluations for initiating drugs
• HIV staging, response to drugs
• Managing complications
• HIV staging, response to drugs
• Regular primary care assessments
• Meeting patients in high-risk settings
• Primary care clinics
• Testing centers
• Primary care clinics
• Clinic labs
• Testing centers
• Primary care clinics
• Food centers
• Home visits
• Primary care clinics
• Pharmacy
• Support groups
• Primary care clinics
• Pharmacy
• Support groups
• Primary care clinics
• Pharmacy
• Hospitals, hospices
• Connecting patient with primary care
• Identifying high-risk individuals
• Testing at-risk individuals
• Promoting appropriate risk reduction strategies
• Modifying behavioral risk factors
• Creating medical records
• Formal diagnosis, staging
• Determining method of transmission
• Identifying others at risk
• TB, STI screening
• Pregnancy testing, contraceptive counseling
• Creating treatment plans
• Initiating therapies that can delay onset, including vitamins and food
• Treating co-morbidities that affect disease progression, especially TB
• Improving patient awareness of disease progression, prognosis, transmission