Reversing the AIDS Epidemic through Third-Generation Health Systems: A Call to Action

This 69-page position paper from the international nonprofit organisation Management Sciences for Health (MSH) makes the claim that permanent reversal of the AIDS epidemic is only possible by health systems strengthening in the countries most affected by HIV and AIDS.

To meet the Millennium Development Goal (MDG) of reversing the epidemic by 2015, MSH argues, donors, policymakers, and programme managers in the public, private, and nongovernmental (NGO) sectors must change how services are designed and delivered. This is because, as MSH argues, it became clear during the earlier "generations" (1990s and 2000s) of the AIDS response, "a host of separate activities cannot be scaled up in a sustainable way..."

MSH offers the following analysis of the evolution of AIDS programmes:

• Zero Generation (1980s): No Effective Response
• First Generation (1990s): Early Prevention Response: "limited funding, a focus on prevention, continued denial in many quarters, and - as before - essentially no treatment in low- and middle-income countries."
• Second Generation (2000s): Emergency Response: massive expansion of political and financial support (e.g. the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) and the United States (US) President's Emergency Plan for AIDS Relief, or PEPFAR). Despite the many successful programmes supported through these mechanisms, "prevention efforts still lag, and only 42 percent of people eligible for antiretroviral therapy (ART) in low- and middle-income countries can access it. Second-Generation interventions have been fragmented; lacked integration across the continuum of prevention, care, and treatment with other health services; and have not been focused on effectiveness or sustainability. Local ownership has been undermined by the huge number of actors operating independently, whereas local capacity has not developed enough to sustain interventions."
• Third Generation (2010s): Health Systems Response: a fundamental shift from a fragmented approach to an approach based on a vision of a holistic, high-performing system. MSH indicates that this shift will need to build on 6 fundamental components; these are listed below, with communication-related explanations selectively gleaned from the report:
  1. Leadership, governance, and management - clear vision, sound implementation strategy, inspiring leadership, and systems that hold people accountable. "Processes such as...[MSH's] Leading and Managing for Results Model and the Social Mobilization Process will help governments, communities, and civil society take charge and improve the sustainability of interventions."
  2. Health service delivery - MSH suggests that a decentralised and restructured health service delivery will allow marginalised populations, including the most-at-risk populations, to use prevention, care, and treatment services closer to where they live. "A bottom-up approach is likely to achieve coordinated action faster than the reverse, but the role of national governments in providing stewardship to orchestrate evidence-based planning and implementation cannot be overemphasized. Mechanisms for public-private partnerships must also change so that nongovernmental actors can participate fully..." Because "ART is rapidly transforming HIV infection into a chronic condition...strengthening the participation of individuals and communities in prevention, care, and treatment [is required]."
  3. Human resources for health - "...A larger and better health workforce will be required to support accelerated prevention efforts and expanded access to treatment. In addition, managing scarce resources better is an immediate priority to improve the performance of the health workforce....Expanding the capacity of national health training institutions to train more health workers and adopting new curricula that incorporate skills in HIV & AIDS prevention, care, and treatment should be planned and adequately financed..."
  4. Pharmaceutical and laboratory management - "...As more patients move into their second decade of AIDS treatment and many new patients are recruited into treatment, treatment 'literacy' and adherence will become more important..."
  5. Health care financing and financial management - "...Improved financing and financial management will help programs meet increasing demand for HIV & AIDS services at a time when resources are expected to be stable or diminished....Creatively packaging and targeting HIV & AIDS services will increase effectiveness and efficiency in using resources..."
  6. Health information - ..."Instead of multiple databases focused on short-term processes and outputs...HIV & AIDS information should be part of an integrated health information system (HIS) that effectively combines prevention, treatment, pharmaceutical supply, laboratory support, supervision, and program management with a holistic system of primary health care reaching into the community. New HIS must enable comprehensive decisionmaking and performance improvement at the local level. HIS, including surveillance, should be decentralized, integrated, and designed to paint a picture of the local epidemic in the context of the overall health system, thereby enabling coordinated action..."

MSH stresses that these components must strengthened "not as six separate parts, but as one vehicle moving forward with communities and clients on board." The resulting holistic health system would:

• work toward universal access to essential health services as its long-term goal;
• operate at all levels: from households, to communities, to health facilities, to municipal, regional, and national authorities;
• harness the strengths of all sectors: public, private, and civil society;
• work as a unified whole with all levels and sectors and many stakeholders for a common purpose; and
• use evidence to guide policies, choice of interventions, and programmatic strategies.
  

AIDS interventions within this envisioned high-performing health system must, according to MSH, demonstrate 3 essential characteristics:

1. Integration: operating comprehensive AIDS programmes across the continuum of prevention, care, treatment, and support; integrating AIDS services with all other health services through revitalised primary health care;
2. Efficiency: achieving the same or higher quality and quantity of services for the same or lower cost and focusing on cost-effective interventions that achieve the greatest impact;
3. Sustainability: building the local capacity of people and organisations as well as strong partnerships that have the potential to expand with need; using available resources wisely.
   

MSH asserts that Third-Generation programmes need both policy and programming modifications to succeed:

• Appropriate policies should be implemented or reformed in the context of human rights to overcome sexual violence and end the stigma and discrimination that push the most at-risk populations and people living with HIV (PLHIV) underground, where they are unable to access services. Discrimination in health care must be stopped. As self-testing technology becomes available, policies that promote self-care and monitoring of HIV status should be put in place.
• In addition to the integration of services described above, MSH makes the following communication-related suggestions related to programming: "Family-focused and community-based programming and behavior change communication that increase the participation of individuals and communities should be hallmarks of Third-Generation programs. Better partnerships with governments that pay attention to developing strong stewardship and coordination frameworks will sustain improvements in overall health systems performance."

The report provides specific examples of Third-Generation approaches for: NGO and programme managers, governments, civil society and the private sector, and donors.

"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."