Country ownership and the turning point for HIV/AIDS

October 2013  TheLancetGlobalHealth; There is no substitute for either local knowledge or national leadership as the world moves towards the endgame in the HIV/AIDS epidemic. Increased country engagement, or so-called country ownership, in HIV and health programming is central to achieve adequate scale in service delivery, improve the acceptability of interventions, increase domestic investments in health, and advance integration of HIV programming with national health goals and systems. The concept of country ownership was established as a cornerstone of international assistance by the 2005 Paris Declaration on Aid Effectiveness,1 and was reaffirmed by the 2008 Accra Agenda for Action. Nowadays, major global health donors, including the US Government, identify country ownership as a main goal of their programming. Definitions of country ownership vary,2 but the term generally refers to an expanded role by the affected country in planning, implementation, and financing of health programming.

Increased country ownership is fundamental to long-term progress in global health, but too rapid a transition runs the very real risk of undercutting access to services and squandering the potential to accelerate progress in HIV/AIDS. Not all partners are ready; countries heavily affected by HIV include some middle-income countries with substantial internal resources, and some UN least-developed nations that will probably need sustained donor support and building of technical capacity for years to come. Four areas raise particular concern and deserve close attention.
First, rapid transitions could decelerate scale-up of effective HIV services, including antiretroviral treatment, prevention of mother-to-child transmission services, and voluntary medical male circumcision. We now know that speed is an important element in success. Recent assessment of UNAIDS data shows that faster decreases in incidence took place in countries that rapidly increased coverage of HIV treatment than in those that were slower.3 Major shifts in support for treatment and other services could slow the pace of scale up, and, thus, the effectiveness of these programmes. The US Institute of Medicine, in its assessment4 of the President’s Emergency Plan for AIDS Relief (PEPFAR) in February of this year, warned that transition to new models of PEPFAR support, including less direct support for service delivery, has the inherent risk, at least in the short run, that programme and data quality, and access to services, might suffer.4 Both the US Government Accountability Office5 and UNAIDS2 have raised concerns about the readiness of some implementing countries to implement effective data and monitoring systems. An assessment6 by the Center for Strategic and International Studies of PEPFAR in South Africa noted “legitimate fears” that a rushed transition could disrupt the HIV treatment programme in that country. These issues are all the more relevant now that the PEPFAR Stewardship and Oversight Act has been introduced in the US Congress to strengthen the programme.
Second, in many settings, country ownership could undermine the nascent response to HIV in many of the most vulnerable populations, including marginalised groups such as men who have sex with men, transgender people, people who inject drugs, and sex workers. In many of the countries with high burdens of HIV/AIDS, these marginalised groups are criminalised and can be the subject of severe social stigma and police harassment. UNAIDS has reported7 that more than 90% of funding to address the HIV-related needs of these groups in low-income and middle-income countries comes from external donors, not the implementing government. Outside of sub-Saharan Africa, HIV is mostly an epidemic of key populations, and these groups are at an elevated risk of HIV, including in larger, generalised epidemics. Key populations and their sex partners account for 33% of new HIV infections in Kenya and 51% in Nigeria.8 PEPFAR and the Global Fund have placed increasing emphasis on key populations, but in many countries, social and political barriers mean that support for HIV services to these marginalised groups might need external financing for the foreseeable future.
Third, the transition to increased country ownership will require attention to the participation of various stakeholders in health decision making. As many have reported, country ownership must not come to mean simply government ownership; if it does, the voices of affected communities might not be heard and accountability will suffer. A report9 from a 2012 international consultation on country ownership and civil society’s involvement in HIV and family planning programming noted that in many countries the notion of civil society engagement remains ill-defined and unsupported. The report raised the concern that “without careful and thoughtful implementation [of transitions to greater country ownership] there is the risk of undermining the civil society engagement that has proved so critical to global health responses.”9
Finally, adequate financing remains a crucial challenge as countries assume a greater role in their AIDS responses. An often-heard argument for increased country ownership is to achieve greater sustainability for AIDS and other health services. But in view of the fragile financial realities of many countries heavily affected by HIV, quick transitions could seriously undermine sustainability. Findings from an analysis of domestic financing for HIV in lower-income and middle-income countries10 showed an increase of three times in country spending from 2000 to 2010, with greater spending associated with increased economic growth and higher burden of HIV. Yet growth of domestic resources in sub-Saharan Africa was mostly in upper-middle-income countries. The investigators noted that poor countries with high HIV prevalence, such as Zimbabwe, Kenya, Uganda, Ethiopia, and Malawi, are especially vulnerable and are probably unable to attain adequate resources for their HIV response in the near future.10 As the Institute of Medicine reported,4 “it is not realistic to expect that partner countries would be able to independently finance the entirety of HIV programming as it is currently implemented…” Vietnam is a case in point, where steep cutbacks in PEPFAR funding imperil sustainability of that country’s HIV programming.11
Each country is unique, but the transition to country ownership can be considered as having three tiers: (1) countries with well-established health infrastructure that can monitor and implement a substantial share of HIV programming, such as South Africa; (2) countries that can assume substantial expanded ownership in the next 5 years, such as Kenya; and (3) countries where the severity of the HIV epidemic and insufficient domestic resources mean that greatly increased financial ownership is farther off, including Ethiopia, the Democratic Republic of Congo, Malawi, and South Sudan. In each type of setting, implementing countries should take an increased role in planning, but they will require varying degrees of external funding for services, and ongoing technical and other support. A clear transition plan (with metrics to gauge progress in each of four areas above) is needed in each country, as is continued external commitment and careful monitoring to ensure external donors fill gaps to maintain scale-up of strategic services.
An assessment12 of the transition of the Avahan programme from the the Bill & Melinda Gates Foundation to the Government of India found that success is possible but requires thoughtfulness and patience. Avahan was designed with existing national and state-level health systems in mind to facilitate an eventual hand off. Achievement of that level of integration and sustainability in national programming will take many HIV/AIDS programmes years. At this pivotal point in tackling the epidemic, we need to advance nationally owned decision making while acting decisively on the evidence of what works to accelerate the end of AIDS.
 
 
he issue of universal health coverage (UHC) is a hot topic these days. The WHO director general Margaret Chan calls it: “the – See more at: http://blogs.adb.org/blog/why-universal-health-coverage-needs-better-measurements?utm_content=buffera07f4&utm_source=buffer&utm_medium=twitter&utm_campaign=Buffer#sthash.VHll177A.dpuf

The issue of universal health coverage (UHC) is a hot topic these days. The WHO director general Margaret Chan calls it: “the single most powerful concept that public health has to offer”. A report from the UN-established High Level Panel of Eminent Persons says it is the best hope for achieving better health outcomes in future. 

But what does universal health coverage actually mean? The WHO defines it as a system which ensures that all people can access the health services they need and in sufficient quality for them to be effective, while ensuring that the use of services does not expose the user to financial hardship. 

This definition embodies three related objectives: 

  • equity in access to health services – those who need the services should get them, not just those who can pay for them; 
  • that the quality of health services is good enough to improve the health of those receiving them; 
  • financial-risk protection – ensuring that the cost of using care does not put people at risk of financial hardship.

That’s a lot of ground to cover especially in Asia and the Pacific, where equity in access to health services is low, the quality of health services varies, and out-of pocket expenditures are the highest in the world.

The region, though, is looking to confront these challenges. ASEAN governments, for example stated in 2012 that they want to provide UHC for the more than 2 billion people in their sub- region.

So is their one common model for providing UHC that all countries in the region look to follow? 

The answer is no. Countries have neither simply adopted a National Health Service model, which relies on general taxes, one national risk pool, and publicly provided services available to all, nor a social health insurance model which relies on household premiums and payroll taxes, many risk pools, and services purchased largely from private providers available to those who have enrolled.

Instead many countries have created hybrid systems to meet their own specific needs. In short, there is no one size fits all model for successfully delivering UHC.  

A paper published in Lancet last year suggests looking at three dimensions when assessing progress towards UHC. They are:

  • Who is covered?
  • What services are covered?
  • What proportion of cost is covered?

The paper also suggests that common, comparable indicators of progress are needed to allow countries carrying out reforms to assess outcomes, and to make midcourse corrections in policy and implementation. Such a set of indicators would also allow development partners to design effective country specific investments in UHC.

At the moment progress towards UHC is driven by policy decisions which prioritize one dimension over the other and are affected by how successful a country has been in revenue generation and pooling and delivery ―  which depends on many factors.  

Indicators like coverage for example are often meaningless when we consider the weak Civil Registration and Vital Statistics systems and the low proportion of costs covered. Ultimately, this can send wrong signals about progress made towards UHC and create proclamatory UHC systems without much development impact.

For ADB, getting involved in developing common indicators to assess progress towards UHC, and assisting developing member countries to design and implement cost-effective hybrid systems is a challenging but rewarding task. 

– See more at: http://blogs.adb.org/blog/why-universal-health-coverage-needs-better-measurements?utm_content=buffera07f4&utm_source=buffer&utm_medium=twitter&utm_campaign=Buffer#sthash.VHll177A.dpuf

The issue of universal health coverage (UHC) is a hot topic these days. The WHO director general Margaret Chan calls it: “the single most powerful concept that public health has to offer”. A report from the UN-established High Level Panel of Eminent Persons says it is the best hope for achieving better health outcomes in future. 

But what does universal health coverage actually mean? The WHO defines it as a system which ensures that all people can access the health services they need and in sufficient quality for them to be effective, while ensuring that the use of services does not expose the user to financial hardship. 

This definition embodies three related objectives: 

  • equity in access to health services – those who need the services should get them, not just those who can pay for them; 
  • that the quality of health services is good enough to improve the health of those receiving them; 
  • financial-risk protection – ensuring that the cost of using care does not put people at risk of financial hardship.

That’s a lot of ground to cover especially in Asia and the Pacific, where equity in access to health services is low, the quality of health services varies, and out-of pocket expenditures are the highest in the world.

The region, though, is looking to confront these challenges. ASEAN governments, for example stated in 2012 that they want to provide UHC for the more than 2 billion people in their sub- region.

So is their one common model for providing UHC that all countries in the region look to follow? 

The answer is no. Countries have neither simply adopted a National Health Service model, which relies on general taxes, one national risk pool, and publicly provided services available to all, nor a social health insurance model which relies on household premiums and payroll taxes, many risk pools, and services purchased largely from private providers available to those who have enrolled.

Instead many countries have created hybrid systems to meet their own specific needs. In short, there is no one size fits all model for successfully delivering UHC.  

A paper published in Lancet last year suggests looking at three dimensions when assessing progress towards UHC. They are:

  • Who is covered?
  • What services are covered?
  • What proportion of cost is covered?

The paper also suggests that common, comparable indicators of progress are needed to allow countries carrying out reforms to assess outcomes, and to make midcourse corrections in policy and implementation. Such a set of indicators would also allow development partners to design effective country specific investments in UHC.

At the moment progress towards UHC is driven by policy decisions which prioritize one dimension over the other and are affected by how successful a country has been in revenue generation and pooling and delivery ―  which depends on many factors.  

Indicators like coverage for example are often meaningless when we consider the weak Civil Registration and Vital Statistics systems and the low proportion of costs covered. Ultimately, this can send wrong signals about progress made towards UHC and create proclamatory UHC systems without much development impact.

For ADB, getting involved in developing common indicators to assess progress towards UHC, and assisting developing member countries to design and implement cost-effective hybrid systems is a challenging but rewarding task. 

– See more at: http://blogs.adb.org/blog/why-universal-health-coverage-needs-better-measurements?utm_content=buffera07f4&utm_source=buffer&utm_medium=twitter&utm_campaign=Buffer#sthash.VHll177A.dpuf

The issue of universal health coverage (UHC) is a hot topic these days. The WHO director general Margaret Chan calls it: “the single most powerful concept that public health has to offer”. A report from the UN-established High Level Panel of Eminent Persons says it is the best hope for achieving better health outcomes in future. 

But what does universal health coverage actually mean? The WHO defines it as a system which ensures that all people can access the health services they need and in sufficient quality for them to be effective, while ensuring that the use of services does not expose the user to financial hardship. 

This definition embodies three related objectives: 

  • equity in access to health services – those who need the services should get them, not just those who can pay for them; 
  • that the quality of health services is good enough to improve the health of those receiving them; 
  • financial-risk protection – ensuring that the cost of using care does not put people at risk of financial hardship.

That’s a lot of ground to cover especially in Asia and the Pacific, where equity in access to health services is low, the quality of health services varies, and out-of pocket expenditures are the highest in the world.

The region, though, is looking to confront these challenges. ASEAN governments, for example stated in 2012 that they want to provide UHC for the more than 2 billion people in their sub- region.

So is their one common model for providing UHC that all countries in the region look to follow? 

The answer is no. Countries have neither simply adopted a National Health Service model, which relies on general taxes, one national risk pool, and publicly provided services available to all, nor a social health insurance model which relies on household premiums and payroll taxes, many risk pools, and services purchased largely from private providers available to those who have enrolled.

Instead many countries have created hybrid systems to meet their own specific needs. In short, there is no one size fits all model for successfully delivering UHC.  

A paper published in Lancet last year suggests looking at three dimensions when assessing progress towards UHC. They are:

  • Who is covered?
  • What services are covered?
  • What proportion of cost is covered?

The paper also suggests that common, comparable indicators of progress are needed to allow countries carrying out reforms to assess outcomes, and to make midcourse corrections in policy and implementation. Such a set of indicators would also allow development partners to design effective country specific investments in UHC.

At the moment progress towards UHC is driven by policy decisions which prioritize one dimension over the other and are affected by how successful a country has been in revenue generation and pooling and delivery ―  which depends on many factors.  

Indicators like coverage for example are often meaningless when we consider the weak Civil Registration and Vital Statistics systems and the low proportion of costs covered. Ultimately, this can send wrong signals about progress made towards UHC and create proclamatory UHC systems without much development impact.

For ADB, getting involved in developing common indicators to assess progress towards UHC, and assisting developing member countries to design and implement cost-effective hybrid systems is a challenging but rewarding task. 

– See more at: http://blogs.adb.org/blog/why-universal-health-coverage-needs-better-measurements?utm_content=buffera07f4&utm_source=buffer&utm_medium=twitter&utm_campaign=Buffer#sthash.VHll177A.dpuf

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