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MSH Paper Calls for a New Way Forward for Third-Generation AIDS Programs
MSH calls for a dramatic change in strategy to focus on strengthening health systems in the countries most affected by HIV & AIDS. The call for concerted action is urgent: AIDS is the leading cause of death and disease among women ages 15 to 44, according to the World Health Organization in its first study on women’s health (November 2009).
“We can permanently reverse the AIDS epidemic only by strengthening health systems,” says Dr. Daraus Bukenya, global lead for HIV & AIDS at MSH. “We learned in the First Generation of AIDS programming, the 1990s, and the Second Generation, the 2000s, that a host of separate activities cannot be scaled up and that strengthening the health system is essential for long-term sustainability. It is time to take a systems approach to HIV & AIDS programming. This holistic approach will create a strong foundation by focusing all efforts on integration, effectiveness and sustainability.”
Reversing the AIDS Epidemic through Third-Generation Health Systems: A Call to Action incorporates approaches distilled from four decades of MSH experience in working with countries around the world to identify and address gaps in their health systems and 20 years of contributions to advancements in HIV & AIDS programming. The paper argues that to meet the Millennium Development Goal of halting and beginning to reverse the epidemic by 2015, donors, policymakers and program managers in the public, private and NGO sectors must change how they design and deliver services—to strengthen health systems in the countries most affected by HIV & AIDS.
The paper recommends that AIDS programs in the decade 2010–20, the Third Generation, take a longer-term perspective than the emergency response of Second-Generation interventions. Increasing concern about the imbalance between investments in AIDS and other major health needs and about the aftermath of the global financial crisis, which threatens resources for AIDS, makes this transition from an emergency to a long-term approach timely.
“It is critical to the success of future programs that we work toward universal access to essential health services,” states Bukenya. “We need a system that operates at all levels, from households to national authorities; harnesses the strengths of the public, private and civil society sectors; and works as a unified whole with all levels and sectors and many stakeholders for a common purpose.” Bukenya adds, “The health system must use evidence to guide policies, choice of interventions, and programmatic strategies.”
Most members of the global AIDS community also agree that a focus on human rights is critical. The theme of the 21st World AIDS Day on December 1, 2009, is universal access and human rights.
“Good health is not only a matter of human rights and social justice. It is also fundamental to the economic growth and political stability of all nations, rich and poor,” says Dr. Jonathan D. Quick, President and CEO of MSH.
MSH advocates that crucial policies be put in place, including policies to overcome sexual violence and end the stigma and discrimination that push the most at-risk populations and people living with HIV underground, where they are unable to access services. The paper also advocates policies that promote self-care and self-monitoring of HIV status.
Proven practices such as targeting high-impact services for the most vulnerable and those most at risk will have a multiplier effect. Combination prevention—in which prevention components are integrated with care and treatment, packaged on the basis of knowledge about local epidemiology, and delivered through multiple channels—will also help achieve high impact on a large scale. An access-to-prevention campaign similar to earlier activism to expand treatment is needed.
A revitalized primary health care framework will accelerate the impact of interventions. Family-focused and community-based programming should be a hallmark of Third-Generation programs, to increase the participation of individuals and communities. Households and communities are part of high-performing health systems whose ultimate goal is to improve health.
Integration requires that HIV & AIDS services become part of other health services, such as family planning/reproductive health and maternal-child health care, which increases effectiveness and sustainability. The paper recommends a shift from clinic-based care to a model of interlinked services delivered in a variety of settings, and providing HIV & AIDS prevention, care and treatment as part of primary health care.
In practice, strengthening health systems in the Third Generation requires a basic shift, from a fragmented approach to a holistic, high-performing system that builds on six components: leadership, governance and management; health service delivery; human resources for health; medicines and health technologies; health care financing and financial management; and health information.
MSH advocates strengthening leadership, governance, and management and changing mechanisms for public-private partnerships so that nongovernmental actors can participate fully
in the delivery of integrated, effective and sustainable interventions. Better partnerships with governments that pay attention to developing strong stewardship and coordination frameworks will sustain improvements in overall health systems performance.
“Little of lasting value will be achieved without inspiring leadership, a clear vision, a sound implementation strategy and systems that hold people accountable,” states Quick. “Strong stewardship will allow those in charge to manage scarce health resources sustainably and bolster leaders’ and communities’ ability to support movements that address the social factors that drive the AIDS epidemic.”
The paper calls for investment in the health workforce, strengthened pharmaceutical and laboratory management, health care financing from multiple sources and improved financial management, and integrated health information systems to help programs meet increasing demand for HIV & AIDS services at a time when resources are expected to be stable or diminished.
“Emphasis on efficiency of AIDS programs will reduce the waste of resources, produce services at least cost, and ensure that they are of the type and amount that people affected by HIV and their communities value most,” says Quick.
For Third-Generation programs to reverse the AIDS epidemic with the resources likely to be available over the next decade, every intervention must demonstrate the three essential characteristics that were often lacking in the Second Generation: integration, effectiveness and sustainability. A coordinated approach to health systems strengthening, with the long-term goal of universal access to prevention, care and treatment, is the most promising way forward.
For the full text of the paper (1.05MB)