System Wide Effects of the Global Fund with respect to ART Scale-up: Evidence from Ethiopia

1. System Wide Effects of the Global Fund with respect to ART Scale-up:Evidence from Ethiopia Hailom Banteyerga Miz-Hasab Research Center 22 Nov.07 Dublin, Ireland

2. The Research Team Miz-Hasab Research Center Hailom Banteyerga, Ph.D Aklilu Kidanu, PhD PHRplus and Health Systems 20/20 Kate Stillman, MPA Sara Bennett, PhD David Hotchkiss, PhD

3. Country Context • Population: 81 million • HIV Prevalence • Prenatal clinics: 3.5 percent • National prevalence rate: 2.4 percent • PLWHA: 1.3 million • Eligible for ART: 270 thousand • With support from the Global Fund and PEPFAR, Ethiopia has embarked on a massive scale-up of free Antiretroviral Treatment (ART) services, with a target of 100 thousand patients by the end of 2006

4. Study Design and Methods • Facility and health care provider surveys administered in 2006 to a sample of 12 government hospitals in two regions: Addis Ababa and Amhara • Surveys collected quantitative and qualitative information on staffing, training, managerial processes, health worker motivation, and other topics • 269 health care providers were interviewed • Surveys were supplemented by document review

5. Opportunities: Positive response to HIV/AIDS prevention and control by the donor community: HIV/AIDS Spending as of 2006 in USD

6. Scaling up of ServicesinART & PMTCT - 2006

7. Impact: Access to Services 705,519 have tested for HIV. - Number of PLHA ever enrolled for ART services has increased to164,914 - Number of PLHA taking ART currently: 72,884 - Women and vulnerable groups accessed services free of charge ( first line regimen,99.5% and second line regimen,0.5%

8. HIV trends • HIV prevalence in antenatal clinics has declined from 7% in 2002 to 3.5% in 2006. • Number of PLHA has declined from an estimated 1.5 million in 2002 to 1.3 million in 2006. • Death rate caused by HIV/AIDS is reported to have declined by 41% due to ART. • However, new HIV infection rate is expected to rise till 2010. • TB infection is increasing - 32% of TB cases are associated with HIV infection.

9. Challenges: Adherence - Default rate in ART patients is between 20-25%.

10. Human Resource Constraints • ART scale-up made possible primarily through the use of currently employed health workers • Over half of all non-ART providers samples report splitting their time between the HIV/AIDS services and other services • Hospitals have not been able to hire new workers to make up the difference • Responsible for increased work burden among staff; some reports of decreased health worker motivation (80-120 clients per nurse per day) • ART providers were more likely than non-ART providers to cite that a lack of resources at the hospital has undermined their performance (85% vs. 72%) • Study found no evidence that the availability of non-focal service have decreased

11. Concern About Effects on Non-Focal Health Care Services “Health providers are shifted from the medical and surgical departments to the ART clinic. This is creating work burden on health providers, for they have to cover services that used to be offered by the shifted staff”. Regional hospital, head of the ART clinic. “With the scale up of ART services in hospitals, patients with chronic illnesses like diabetes, hypertension, other internal illnesses are not given attention. Hospital staff and facilities are getting engaged with HIV/AIDS related patients especially those seeking ART services”. Associate Professor and Head of Internal Medicine, Gondar University.

12. Other Issues affecting ART Scale-up • Long travel distance: access to services and follow up in ART • Shortage of facility space: dependence on existing facility space • Poor inter and intra facility referral linkage and facility and community linkage • Inadequate care and support • Poor Logistic and storage services • Fear of Stigma and discrimination

13. Challenges: Medicalization of HIV/AIDS due to ART scale up: MAP& GF fund utilization by program (source HAPCO documents)

14. PEPFAR obliged amount by program in USD (Source PEPFAR COP Ethiopia documents)

15. Challenges: Sustainability. HIV/AIDS especially ART is donor dependent—HIV Spending (in Birr) by Source of Funds: Donor Vs Government (source HAPCO documents till 2005)

16. Conclusions • The donor support to ART has given vulnerable groups opportunities to access services. • However, it has made the HIV/AIDS response more medicalized. • It has also weakened the multi-sectoral response to HIV/AIDS control and prevention. • Inadequate infrastructure and human resources constraints are limiting the scale-up of quality ART services, and may be affecting non-focal health services.

17. Research recommendations • Availability and quality of non-focal health services in a ART scale-up setting. • Track the impact of major government human resources strategy • Increase in the volume of service providers • Task shifting • Retention • Incentives for rural placement

18. Reference • SWEF Ethiopia Study Report, 2005 and 2006 (Abt Associates and Miz-Hasab Research center) • Scaling up antiretroviral treatment and health care systems: evidence from Ethiopia (2006) (Abt Associates and Miz-HasabResearch center) • Update as of end of Sene 30,1999 (July8,2007) ( Monthly HIV care and ART report), HAPCO, Addis Ababa, Ethiopia • AIDS in Ethiopia, 6thy Report, HAPCO, FMOH, Meskerem 1999 (September 2007), Addis Ababa, Ethiopia

19. Acknowledgements • Miz-Hasab acknowledges the support received from • Sara Bennett for her immense contribution in making the study move forward • FMOH, HAPCO, CCM and all implementers contacted for their helpful cooperation • USAID, whose financial support made the study possible

20. Thank you Reports related to this presentation are available at www.HS2020.org