Turkana county health leaders pledged to reinstate budget lines for HIV (Ksh 500,000), as well as restore subprogram budget lines for reproductive, maternal, neonatal, child and adolescent health care (RMNCAH) (Ksh 6.4 million) interventions. As HP+ supported the Turkana County Department of Health to hold consultative discussions with the County Treasury, it presented data to illustrate how the county historically underfunded these programs and over-relied on donor support. It advocated for the county to not only finance these critical interventions, but also realign the county budget to a program-based budget approach and ensure they receive the money budgeted to them. These funds, once implemented, will support community-based interventions such as psychosocial support and adherence counseling, as well as nutrition, immunization, and reproductive health services. By improving service delivery and institutionalizing the funds for these interventions, the county aims to improve health outcomes across HIV and RMNCAH. Moving forward, HP+ will continue training county teams to monitor fund absorption and generate evidence to advocate for subsequent increased budget allocations. In doing so, it will strengthen the county’s capacity to efficiently allocate and execute its budgets as well as generate and use evidence to advocate for and promote sustainable financing of the key disease programs.
With HP+ support, the Lagos State Health Scheme in Nigeria has successfully integrated HIV services into the scheme’s benefit package with effective testing, referral, and reporting systems in place. Since June 2021, about 52 percent of the 213 empanelled health facilities enrolled in the scheme have begun to provide HIV services, with 2,850 tests conducted and positive cases linked to care. HP+ supported the Lagos State Health Management Agency to develop appropriate referral and monitoring frameworks, to train empanelled facilities on quality HIV service provision and reporting, and to disburse capitation payment to providers. HIV services through the insurance scheme will reduce out-of-pocket payment for HIV services by persons living with HIV, who spend an average of US$528 on such care every year. The insurance coverage also will expand access to quality HIV services and increase the number of HIV-positive persons who know their status and are promptly linked to treatment, thus contributing to HIV epidemiological control.
With HP+ support, the Nigerian National Agency for the Control of AIDS (NACA) developed and disseminated a Domestic Resource Mobilization and Sustainability Strategy, which can mobilize up to US$662 million for Nigeria’s HIV program by 2025. HP+ worked with NACA through a multisectoral and collaborative process to assess the health financing landscape for HIV in Nigeria and develop feasible strategies to raise tangible resources for the HIV program. Implementation of the strategy across all states will reduce Nigeria’s dependence on donors, increase access to quality HIV services, improve HIV outcomes, and ensure the sustainability of the HIV response.
The government of Kenya and the Global Fund to Fight AIDS, Tuberculosis and Malaria recently kicked off a three-year, US$440-million project to combat these diseases over the next three years. The Global Fund grant, executed in July, will enable Kenya to implement activities in HIV, tuberculosis, and malaria, as well as cross-cutting areas such as integrated service delivery and quality improvement, human resources for health, financial management systems, and health sector governance and planning. HP+ developed and implemented methodologies to cost the proposed interventions and identify counties that meet the co-financing requirement. HP+ also conducted the HIV funding landscape analyses and developed the malaria program’s plans for sustainability, transitioning, and health financing. With the Global Fund grant, Kenya will bring more HIV-positive clients into antiretroviral treatment with a goal of reaching 90 percent coverage by June 2025 and expand distribution of insecticide-treated nets, benefitting 21.6 million people. It will increase intermittent preventive treatment of malaria in pregnancy, and enhance community-based systems for service delivery, among other interventions. The government of Kenya and partners AMREF Health and Kenya Red Cross will implement grant activities and pursue a transition to sustainable financing.
Tanzania recently launched its fifth five-year health plan, a TSh 47 trillion roadmap for saving more than 200,000 lives and reducing HIV incidence by 50 percent. The Five-Year Health Sector Strategic Plan (HSSP V) also lays out strategies for averting more than 400,000 disability-adjusted life years and reducing infant, neonatal, and maternal mortality. To estimate the cost of the strategy, equivalent to US$20.3 billion, HP+ used the OneHealth tool. HP+ also estimated the resources available for the health sector from all sources. The mission of the plan, which covers 2021 to 2026, is to provide sustainable health services with standards that are acceptable to all citizens without financial constraints, based on geographical and gender equity. In her address during the June 24 launch, Honorable Minister for Health, Community Development, Gender, Elderly and Children, Dr. Dorothy Gwajima said the plan will expand reach of primary health services and address the prevention and treatment of both communicable and non-communicable diseases.
HIV services for men and boys are getting a boost in Malawi through the efforts of teen clubs and a church-based support group. With the support of HP+, the Evangelical Association of Malawi is reaching out to teens in Phalombe and Nkhotakota districts with psychosocial counseling, nutritional support, assistance with treatment adherence, and viral load monitoring. Since July 2020, the Faith and Communities Initiative effort has reached 662 men and boys and 82 teen members with nutritional support. The teen clubs have promoted access to early viral load testing among boys living with HIV at Kapiri Health Centre, where 148 members have accessed viral load monitoring services.
Malawi religious leaders are using dance to reach men and boys with messages of hope on HIV testing, treatment, and adherence. In May, the Quadria Muslim Association of Malawi (QMAM), with support from the U.S. President’s Emergency Plan for AIDS Relief and HP+, organized a dance event at Traditional Authority Chamba that attracted 2,500 people and distributed 197 HIV self-test kits. The traditional dances, called Zikiri dances, are performed as a competition by young men in praise of Allah. As part of their grant activities, QMAM integrated HIV messages of hope into their praise songs to help create demand for HIV services.
The government of Nigeria has advanced its efforts to identify sustainable financing mechanisms for the control of HIV with the publication in June of a national strategy document, National Domestic Resource Mobilization and Sustainability Strategy for HIV, 2021–2025. The document was developed with support from the Health Policy Plus (HP+) project with inputs from HIV stakeholders at both the federal and state level. Nigeria seeks to raise up to US$662 million for the 2021–2025 period with a focus on state and national domestic sources. The strategy is a call to urgent action to mobilize domestic funds to sustain treatment for patients in care, and to identify and treat the additional 20 percent of people living with HIV who have not yet commenced treatment. Between 2005 and 2018, a total of US$6.2 billion was spent on the HIV response in Nigeria, with more than 81 percent from international donors.
Several local media outlets in Malawi have reported on evidence-based HIV programming implemented by faith-based organizations. HP+ is providing these organizations funding from the U.S. President’s Emergency Plan on AIDS Relief as well as technical and organizational development assistance. The project conducts outreach, provides counseling, and carries out advocacy around HIV, with a focus on reaching men and boys with messages of hope and information about HIV. The religious organizations are shifting social norms by reducing stigma and increasing acceptance of discussing HIV in faith settings. They are providing HIV self-test kits and linking individuals to health facilities to support them to know their status and, if positive, to start and stay on treatment. Media coverage of the role of faith communities in HIV programming in Malawi will increase awareness of the important role the faith community plays in the HIV response. This coverage is expected to increase local confidence in the ability of faith leaders to contribute to the HIV response, bolstering strong collaboration between faith communities and the health system.
The Kyrgyz Republic this month requested bids for US$57,000 in HIV services, increasing its HIV social contracting commitment by 35 percent over the previous tender in 2019. The Republican AIDS Center within the Kyrgyz government will secure grants with nongovernmental organizations for services to expand access to HIV treatment and retention in care, directly addressing the Joint United Nations Program on HIV/AIDS’ 95-95-95 goals. HP+ conducted a critical needs assessment in support of the project, collecting and analyzing NGO proposals and supplied technical assistance on the design of the new program. The Kyrgyz Republic Ministry of Health launched the initiative in December and HP+ will provide ongoing mentoring and technical assistance to the Republican AIDS Center in support of the program. Engaging local organizations to provide this critical work—and financing it—demonstrates the Kyrgyz Republic’s progress toward a sustainable and responsive HIV program.
Civil society organizations in West Africa are reporting progress in reducing stigma toward persons living with HIV and increasing access to HIV care after receiving organizational support and training from HP+. During fiscal years 2020 and 2021, HP+ supported the development of data collection tools and trained data collectors to use the tools to ensure PEPFAR-funded facilities provided a supportive environment for quality and barrier-free HIV services in 17 facilities in Burkina Faso and 25 in Togo. In initial feedback received so far, the trained organizations have seen a reduction in reports of stigma and an increase in access, specifically fewer instances of informal fees and earlier access to antiretroviral therapy. HP+ will continue to support the organizations in their efforts to secure funding and expand their monitoring objectives to better quantify the impact of HP+’s technical assistance.
HP+ has helped the Kenya Ministry of Health retain its current allocations for national HIV, malaria, and reproductive health programs into the next fiscal year even in the face of economic constraints due to COVID-19. HP+ provided technical assistance to the Ministry of Health program teams to develop budget justification memos that supported the need to continue to fund these programs. The memos were used during the sector performance review and resource sharing process, helping to ensure that each program is able to continue supporting its respective critical disease area. In preserving budget allocations despite a tightened fiscal space, the health programs established their continued importance among the nation’s priorities, allowing Kenya to maintain stewardship and accountability for funding these programs. The FY 2021/22 funding for HIV, malaria, and reproductive, maternal, newborn, adolescent, and child health programs is US$12 million, $8 million, and $8.63 million, respectively.
Field, Kenya, Health
Domestic Resource Mobilization
HP+ has helped Nigeria increase the availability of HIV services offered to enrollees in its insurance scheme in Lagos State, home to 12 million people and the nation’s capital city. Between September 2020 and February 2021, the Lagos State Health Management Agency (LASHMA) brought 119 new HIV facilities into the Lagos State Health Scheme. With these HIV facilities now active in the state health insurance scheme, HP+ estimates that more than 3,836 enrollees living with HIV can now access HIV services through the scheme. HP+ worked with LASHMA to simplify requirements that facilities must meet to become contracted into the state scheme and helped LASHMA approve a four-month grace period for facilities to submit the necessary documentation. By the end of 2021, assuming LASHMA meets its current target of enrolling 3.5 million people, HP+ estimates that these facilities will serve around 49,000 people living with HIV. In the upcoming months, HP+ will train contracted facilities on how to provide HIV services to clients through the state scheme, how to procure test kits, and how to submit claims.
Using skills gained in HP+-led training sessions, a Malawi sheik is among the 30 religious leaders active in their communities promoting HIV treatment and prevention. The two-day sessions in Dwangwa and Nkhotakota.in August 2020 focused on the promotion of HIV testing and counselling, HIV treatment services, and treatment adherence. Sheiks have been promoting these messages among their faith community, with a particular emphasis on reaching men and boys. Sheik Muhamad Abdul from Dwangwa’s main mosque has referred 30 men and boys for HIV testing and supported three people in restarting antiretroviral therapy (ART) after one year of discontinuing. The messages promote HIV testing, ART initiation and ART adherence. This work is being supported by PEPFAR’s Faith and Communities Initiative (FCI) and implemented by HP+ with six local faith organizations in Malawi.
HP+ Kenya has helped the Kenya Ministry of Health develop budget proposals that align with its health sector priorities and craft advocacy materials in support of these proposals. The MOH requested an additional US$12 million for HIV commodities, an additional US$8 million to procure first line anti-malarial drugs and to settle tax obligations arising from donor-procured malaria commodities, and an additional US$8.6 million for family planning. HP+ Kenya supported national performance reviews of HIV, malaria, and reproductive, maternal, newborn, child, and adolescent health programs to develop sector working group reports that inform the MOH and Treasury budget allocations.
Nigeria officially launched the country’s National Blueprint for Integration of HIV into State Health Insurance Schemes on December 1, World AIDS Day. The blueprint—developed by the National Agency for the Control of AIDS, the National Health Insurance Scheme, and other HIV stakeholders with support from the USAID-funded Health Policy Plus project—guides Nigeria’s states on how to integrate HIV services into their state health insurance schemes. It represents a significant milestone toward sustainable HIV financing, a key universal health coverage reform in Nigeria. Implementing the document’s recommendations is expected to increase financial protection and access to care for HIV patients, and ultimately lead to improved HIV outcomes.
Survey results from Kenya’s Busia, Kajiado, and Nairobi counties suggest that 38 percent of HIV clients are interested in collecting antiretroviral drug (ARV) refills from private pharmacies. Ninety-five percent of private pharmacy owners in these counties are also interested in extending current services to include dispensing refill ARVs to stable, adult clients. Clients’ willingness to pay a dispensing fee to collect ARVs from private pharmacies is well-aligned with the pharmacies’ minimum dispensing fee, suggesting that a decentralized distribution model involving a hub antiretroviral therapy site and private pharmacies for ARV pick-up may prove successful. HP+ is using these survey results to design and implement a community pharmacy ARV refill pick-up pilot in each county, intended to eventually transfer more than 1,000 clients to private pharmacies to obtain ARVs.
Last week, in conjunction with World AIDS Day, HP+ published a blog outlining recommendations detailing how Indonesia can accelerate its advancement toward HIV epidemic control. Based on their technical assistance experience, the authors explain how changes to service delivery models, populations targeted, and payment mechanisms can reduce costs while improving HIV-related outcomes. The blog was first published by the Infectious Diseases Society of America’s Science Speaks Blog and later cross-posted on Viewpoints.
On October 7, HP+ and the Lagos State Health Management Agency (LASHMA) engaged key ministries, departments, and agencies to discuss and reach consensus around modalities of the state’s health insurance scheme’s regulation policy to enable its effective implementation. Discussions helped to determine practical steps for supporting implementation of the scheme at the local level to expand coverage, increase access to HIV services, and reduce out-of-pocket expenditure on health within rural and poor communities and among people living with HIV. To-date, HP+ has supported LASHMA to expand enrollment in the health insurance scheme to over 200,000 people.
In support of the Government of Cambodia’s implementation of a policy to decentralize health sector leadership to subnational and provincial levels, HP+ supported the National AIDS Authority (NAA) to facilitate an advocacy workshop in the province of Kampong Speu on August 31. Fifty participants—hailing from the provincial government, operational districts, NAA, and the National Center for HIV/AIDS, Dermatology, and STIs—reviewed policy measures and discussed implementation plans and roles. Decentralized implementation of this policy will enable the province to directly manage health resources and make decisions with regard to health planning, monitoring, and policy prioritization.
A journal article authored by HP+ project staff in collaboration with local partners was published this month in a special issue of AIDS. The article, which describes the development and implementation of a three-stage approach to reducing HIV stigma in health facilities, features the approach that HP+ implemented in Ghana and Tanzania. It is an evidence-based, adaptable, scalable approach that has proven successful in generalized and concentrated epidemic settings and can be used to address stigma toward any population. Results of endline evaluations in both countries demonstrate the intervention’s effectiveness, showing significant reduction in drivers and manifestations of stigma and discrimination among facility staff.
In August, HP+ facilitated a virtual training for research institutions and government representatives in Kenya, Tanzania, and Uganda on applying the Activity-Based Costing and Management methodological approach to HIV services. HP+ strengthened the capacity of these institutions and participants to implement data collection; conduct analysis; develop research protocols and data collection instruments; secure ethical clearance; facilitate stakeholder consultations; and develop reports using the approach. Findings from the analysis can help policymakers and partners to more effectively allocate resources, improve monitoring efforts, optimize investments, and drive efficiencies through improved delivery of services.
In Malawi’s Chikwawa district, faith healers have been discouraging community members living with HIV from taking antiretroviral therapy (ART). Concerned that this may lead to ART defaults and increased death, religious mother body PECHANOMA facilitated a dialogue with other leaders in July, with HP+ support, to reinforce their role in emphasizing accurate messaging around HIV and COVID-19 and the importance of continuity in ART for people living with HIV. The leaders committed to continue disseminating accurate HIV messaging in their communities by holding meetings with religious and local leaders, disseminating radio and TV messages, and using mobile vans with loudspeaker systems.
With HP+ support, youth journalists in several districts in Malawi air weekly programs on community radio about topical health issues. Recently, Nkhotakota Radio youth reporters noticed that the number of pregnant adolescent girls getting HIV tests at the local district hospital had dropped significantly. In early June, the station aired a radio program urging pregnant teens to get tested for HIV. The District Health Office reported that in the two weeks following the broadcast, testing was higher than ever—about 40 pregnant girls had visited the facility to be tested. Said Nkhotakota District Hospital Nurse Chimwemwe Nyasulu, “This is what community radio is supposed to do.”
A virtual satellite session—"Data Matters: The Role of Local Stakeholders and Data in Influencing HIV Services and Programs”—was held on July 8, as part of AIDS2020. The session showcased how HIV service delivery is improved when stakeholders generate and use local evidence and data to inform community-level programs. Representatives from the International Treatment Preparedness Coalition joined Palladium and HP+ colleagues Ron MacInnis and Ratna Soehoed, who discussed the use of province-level cost and epidemiological data for HIV planning and budgeting in Jakarta, Indonesia. A recording of the session will be available to the general public next week.
HP+ is strengthening relationships between communities of faith, health facilities, and district governments in Malawi to support the country’s HIV response. The project is supporting six Religious Mother Bodies (RMBs) to implement PEPFAR’s Faith and Community Initiative, which aims to rapidly increase the proportion of men and boys living with HIV to access testing and treatment. The RMBs and PEPFAR clinical partners are working together to establish how faith leaders and health facilities can coordinate to increase male access to services, including coordinating with eight district governments to establish working relationships and obtain buy-in and guidance on geographic targeting for their activities.
On May 6, representatives from Kenya’s health leadership at the county level adopted a prototype of a new County Health Planning Unit (CHPU) for each county, created to address gaps in planning and advocating for budget allocations for strategic programs such as HIV, family planning, and malaria. HP+ supported the establishment of the CHPU through multisectoral collaboration with individual counties, the Ministry of Health, the Council of Governors, and the National Treasury. Moving forward, HP+ will support CHPU capacity strengthening and mentorship to institutionalize planning and budgeting at the county level, underscoring long-term sustainability on Kenya’s journey to self-reliance.
HP+ supported Cambodia’s National AIDS Authority to conduct a legal and regulatory assessment of private sector provision of HIV services. The assessment concluded that, while the private sector can legally provide HIV services, these services are insufficiently regulated and reported. Findings informed private sector engagement strategies for the five-year National Health Sector Strategic Plan for HIV. If these strategies are adopted, Cambodia can expect to see higher-quality HIV services provided by the private sector, and the government will be able to use more reliable data to program resources.
This month, a project-authored article on reducing stigma and discrimination in health facilities in Ghana was published in the Journal of the International AIDS Society. The article, which evaluates the impact of a “total facility” stigma‐reduction intervention on the drivers and manifestations of stigma and discrimination among health facility staff, found that respondents at stigma intervention facilities were 19 percent more likely to report that staff behavior towards people living with HIV had improved over the last year, compared to those at non-intervention facilities. These results provide a solid foundation for scaling up health facility stigma‐reduction within national HIV responses.
In the Kyrgyz Republic, HP+ is providing technical support for the implementation of the first social contracting projects in the country. In 2019, the Ministry of Health Republican AIDS Center (RAC) awarded projects for six NGOs to support adherence to HIV treatment and reduction of viral load for a total of 3 million soms (about US$45,000 at the time of the allocation). HP+ provided extensive support to strengthen stewardship and management capacity at all stages of implementation. The NGOs successfully linked 68 people living with HIV to care and initiated antiretroviral therapy. The RAC plans to continue social contracting in 2020 and has committed to increasing the allocated amount to 5 million soms. HP+ is also supporting the MOH Oncology and Psychiatry departments to launch social contracting.
In Malawi, youth trained in policy communication have successfully advocated for policy changes at the district level. The training, facilitated by HP+ in coordination with partner Population Reference Bureau (PRB) in July 2019, resulted in the creation of policy advocacy plans by youth advocates. Recent follow-up by PRB revealed multiple successes in the implementation of these plans, including implementation of a differentiated care model for antiretroviral therapy service delivery, expanded clinic hours to target youth, and inclusion of youth leaders in local decision-making committees and district structures. These policy changes improve youth access to health services and family planning information, contributing to improved health outcomes across Malawi.
In January 2020, leadership of a key legislative committee endorsed Ethiopia’s first HIV Domestic Resource Mobilization and Sustainability Strategy, developed with support from HP+. Once approved by the Council of Ministers, the strategy will put in place groundbreaking HIV financing mechanisms, including a US$14 million increase in general government budget allocation to HIV programming and the earmarking of a 0.2 percent tax on the profits of all companies, public and private, with an annual revenue of approximately US$3 million. The strategy is estimated to mobilize US$93 million over five years, increasing from US$15 million in 2021 to US$23 million in 2025.
In recent months, HP+ has supported Cambodia’s National AIDS Authority to identify and budget for HIV-related activities for the coming year in coordination with non-health line ministries. Using the National Strategic Plan for a Multi-Sectoral, Comprehensive HIV/AIDS Response (2019-2023) as guidance—a strategic plan for coordinating the country’s HIV response, produced with HP+ support—the ministries committed approximately US$500,000 to fund HIV-related activities in Cambodia. This commitment supports progress toward achieving the vision of government funding of 50% of the HIV response by 2023 (up from 24% in 2017).
Cambodia took a major policy implementation step in its national HIV/AIDS response this month when the Prime Minister approved a resolution directing operational funding for the response and other key advancements, notably the eligibility of all people living with HIV to receive a Health Equity Card and recognition of the important role played by civil society organizations. The resolution also guides the Ministry of Health to amend policies for health center and hospitals to use their own funds for HIV/AIDS activities, in addition to Ministry’s national budget. This achievement represents the culmination of an extensive effort by HP+ Cambodia and its health advisors, who are embedded at the National AIDS Authority (NAA), to advance health financing policy implementation for people living with HIV. This effort included sensitization and capacity building with the NAA leadership and ongoing support for the entire policy advocacy process including the drafting of the board resolutions and proposal to the Prime Minister’s office. Moving forward, the Prime Minister’s directive calls for the Supreme National Economic Council to further study the fiscal space to ensure implementation of the commitments and to sustainably mainstream the HIV/AIDS response through strengthened human resources, procurement, supply chain management, and health information systems. HP+ will continue to support the NAA in implementation of the new guidance.
As a result of HP+ advocacy support to Cambodia’s National AIDS Authority, the country’s Ministry of Economy and Finance (MEF) agreed to significantly increase funding for antiretroviral drugs (ARVs) over the next three years. The annual increases in funding—from the current allocation of US$1.5 million to US$5 million by 2023—will allow the Global Fund to reallocate resources to critical, underfunded HIV prevention activities. The MEF’s decision supports progress toward achieving the country’s national strategic plan directive that 50 percent of HIV response funding be derived from domestic sources by 2023 and sets a new contribution floor for government ARV funding.
Nudges such as mobile airtime or membership in a health insurance scheme might be helpful in motivating someone to get tested for HIV, suggest the results of a USAID-funded analysis carried out in Tanzania by Health Policy Plus (HP+). HP+ staff met February 5 with officials from the Tanzania health ministry, PEPFAR, implementing partners, and other stakeholders in Dar es Salaam to discuss the study results. Patients and health providers in the study found the incentives attractive and easy to administer. Only 61 percent of the country’s estimated 1.5 million HIV-positive individuals know their status, and Tanzania is looking for cost-effective ways to increase testing uptake.
Representatives from HP+ Cambodia and Indonesia teams participated in the Prince Mahidol Award Conference 2020, adding to discussions on universal health coverage with case studies on HIV financing, social protection, and private sector engagement. HP+ collaborated with USAID to host a well-attended satellite session entitled Harnessing the Private Sector for UHC through Smart Policy, with participation by Elaine Menotti and Pellavi Sharma of the Office of Population and Reproductive Health.
HP+ led a webinar on January 30th to discuss how countries -- with examples from Botswana, Nigeria, Tanzania, Kenya and Indonesia -- have met PEPFAR’s minimum program requirements for policies and practices essential for success. With special guest Sylvain Bowra of the State Department in Botswana, HP+ contributors shared a new resource illustrating the status of each of the minimum requirements across all PEFPAR countries.
The HP+ “total facility approach” to reducing stigma and discrimination in health facility settings is being featured on the PEPFAR solutions website. This showcases the work carried out by HP+ in Tanzania and Ghana as an important solution for the HIV response. PEPFAR Solutions are impactful, data-proven approaches intended to guide others in program design and implementation. U.S. government staff and partners around the world use the solutions website as a resource for HIV program design. Having the stigma-reduction approach featured also makes it accessible to mission staff around the world as they embark on their COP20 planning processes.
Since 2011, Malawi’s HIV clinical guidelines have recommended that providers proactively offer family planning to all clients at each ART visit to ensure no missed opportunity to support PLHIV’s reproductive intentions. This approach, called Provider-Initiated Family Planning (PFIP), calls for condoms and injectables to be available at the ART clinic, and referrals for other methods as needed. In 2015, the USAID-funded Health Policy Project assessed the extent of PFIP implementation in Malawi by collecting data at 41 health facilities (both public and NGO) through facility audits, provider interviews, client exit interviews, and mystery client visits. This study – discussed in a new article in Global Health Science and Practice Provider-Initiated Family Planning within HIV Services in Malawi: Did Policy Make It into Practice? – found that contrary to clinical protocols, only 14% of clients at the ART clinic reported being offered family planning during their visit that day. Furthermore, only 24% of providers had received training in FP-HIV integration, 21% had no family planning training at all, and only half of providers had information on where to refer clients for family planning. Only 24% of sites had both condoms and injectables on hand, and only 15% of ART clinics had a full range of FP available. Overwhelmingly most ART clients relied on condoms for FP, yet there was significant demand for family planning among the female ART clients, with about half wanting no more children. These findings suggest that although Malawi has been an early adopter of PFIP, this innovative policy is not being implemented in practice. The authors, Erin K. McGinn (Palladium) and Laili Irani (Population Council), conclude that the demand for integrated services and high unmet need for FP among PLHIV underscores the need for more focused efforts to fully implement PIFP in Malawi’s HIV services.
HP+ has demonstrated its value to USAID Eswatini in facilitating the transitioning of two local organizations from subs to primes. During March and April 2019, HP+ supported USAID Eswatini to assess the landscape of local organizations working in the HIV sector with regard to their institutional and technical capacity. HP+ conducted organizational capacity assessments (OCAs) with 11 local non-governmental organizations (NGOs) and faith-based organizations (FBOs) and provided recommendations to USAID on organizations exhibiting strong capacity that could be transitioned to primes with some further preparation. HP+ was recently notified of USAID Eswatini’s desire to transition two of the more highly ranked organizations to primes and will be drawing on HP+’s assessment findings and materials in lieu of doing NUPAS with the current subs. World Vision Eswatini is a current sub to Pact and has HIV expertise in OVC, economic strengthening, youth, key populations, and the HIV care continuum. Young Heroes is also a sub to Pact and is known for its work in OVC and youth, although it has expanded into additional HIV sub-areas as the organization has grown.
Health Policy Plus Cambodia received an appreciation award from Cambodia’s National AIDS Authority at its Annual Congress Meeting on November 6, 2019, in Phnom Penh. HP+ Cambodia engaged with the National AIDS Authority on evidence generation, capacity building, policy advocacy, and technical dialogue to drive policy change for a more sustainable and domestically financed HIV response. A success of the engagement has culminated in the prime minister approving a policy circular to increase allocation of resources for HIV. Read our brief for more information.
A new blog -- Integrating Services Means Thinking Outside Silos -- published on Science Speaks, the global health blog of the Infectious Disease Society of America, addresses the need for greater integration of family planning and HIV service delivery. The commentary, by Health Policy Plus deputy director for family planning and reproductive health, Jay Gribble, and the project’s technical lead on stewardship, RTI’s Alyson Lipsky, discusses the complexity of integration and explores three policy approaches to support it. They conclude that, “To move forward, health system actors must identify the problem that integration is trying to fix and which approach to integration best addresses that underlying problem. Often, the biggest challenge is breaking down the health system silos and being open to finding new ways to respond to people’s health needs.”
Across two USAID priority states—Lagos and Kano—and at the national level, HP+ is supporting the implementation of a series of activities aimed at achieving sustainable financing for HIV and tuberculosis (TB) programs in Nigeria. At a workshop on September 3, organized by the Kano State Ministry of Health in collaboration with HP+, the Kano State TB Domestic resource mobilization (Domestic resource mobilization) Committee was reactivated following a gap in donor funding and HIV/AIDS programming integrated into the committee’s mandate. The Domestic resource mobilization Committee’s aim is to improve local domestic resource funding for TB and HIV/AIDS control programs in the state, promote public-private partnerships, and ensure effective and efficient appropriation, release, utilization, and management of funds for TB and HIV. The workshop was attended by members of the Kano State Domestic resource mobilization Committee for TB/HIV, including representatives of development partners such as USAID’s Sustaining Health Outcomes through the Private Sector (SHOPS) Plus project, KNCV Tuberculosis Foundation, and FHI360. The workshop resulted in commitments made to develop a roadmap for integration of TB/HIV into national programs, advocacy kits for stakeholder engagement, and improved awareness efforts.
The Kyrgyz Republic has been advancing efforts to ensure sustainability of its HIV programming by developing mechanisms to provide government funding to NGOs to deliver services, or social contracting. HP+ is supporting the Ministry of Health and Republican AIDS Center to develop the regulations and mechanisms required to implement social contracting across the health sector. On September 2-3, in Bishkek, HP+ supported the Republican AIDS Center to conduct a grant launch meeting for the first round of social contracting in the health sector. The meeting, which brought together the grantor and organizations awarded approximately $43,000 to deliver services to people living with HIV – the Republican AIDS Center and six NGOs, respectively – focused on the processes and procedures of social contracting, as well as programmatic and financial reporting requirements. With HP+ facilitation, the participants developed tools and forms required for implementation of social contracting, such as an indicator matrix, an implementation action plan, a draft memorandum on interaction between regional AIDS centers and awarded NGOs, and draft reporting forms. Looking forward, HP+ will continue to support the process of implementation of social contracting in the Kyrgyz Republic through direct technical assistance and mentoring to the Republican AIDS Centers, the Ministry of Health, and grant recipients. HP+ is also supporting the national TB, oncology, and psychiatry program to advocate for funding and establish required regulatory documents for social contracting.
In late June, HP+ held a three-day training workshop in Mbabane on the oral pre-exposure prophylaxis implementation, planning, monitoring, and evaluation tool (PrEP-it) for 33 Ministry of Health officials, representatives of implementing partners, USAID, and other stakeholders including the World Health Organization and UNAIDS. The pilot workshop, which took place from June 24-27, gave participants hands-on experience in the five modules of the tool: PrEP cascade, capacity, target-setting, costing, and impact. Meanwhile, the development team garnered valuable feedback on the usability and functionality of the tool. The Ministry of Health utilized the segment on target-setting to set their actual national targets for PrEP scale-up based on desired coverage of eSwatini’s PrEP priority populations. As a result of the workshop, the eSwatini government was able to establish and set PrEP targets for the next five years—the first country to do so—by capitalizing on the participation and concurrence of stakeholders at the training. Version 1.0 of PrEP-it is scheduled for release in September 2019.
Mali's National Network of Key Population Associations (RENAPOC), which advocates for its members to seek health services, prioritized addressing the barrier of stigma and discrimination to increase health access to HIV prevention and treatment services. All 36 members from Bamako, Kayes, Koulikoro, Sikasso, Ségou and Mopti came together to discuss and approve the contents of the strategic plan and on March 2, 2019, with technical and financial support from HP+ Mali, finalized and adopted a strategic plan. The RENAPOC strategic plan is now accepted as the validated strategic plan of the various key population associations and will allow RENAPOC to operate with a stronger structure and strengthened autonomy. This strategic plan will serve as a reference tool, both for internal and external partners, for the next 5 years.
In 2017 and 2018, HP+ began developing tools and approaches to advance public financing for non-governmental organizations working in HIV and other health related areas. HP+ supported the Global Fund for AIDS, Tuberculosis and Malaria (the Global Fund) efforts to prioritize public financing to civil society organizations (CSOs) and non-governmental organizations (NGOs) as a critical factor in all countries’ paths to sustaining and financing their HIV, TB and Malaria programs. This included support to develop the social contracting diagnostic tool, and setting standards for analyzing the legal/regulatory factors inhibiting or enabling this government health system reform. The tools and approaches are now being used around the world by the Global Fund, HP+, and other technical assistance providers to support the uptake of social contracting. HP+ developed a policy brief to summarize the importance of advancing public financing for NGOs/CSOs/private sector as critical to HIV services and epidemic control. The brief outlines the key competencies and capacities needed to advance social contracting into government health systems. In Guyana, HP+ worked with government and other country stakeholders to identify the legal and regulatory barriers for public financing of CSO-led HIV services. In Kyrgyzstan, HP+ supported the Ministry of Health to develop regulations and protocols to implement public financing contracts to non-governmental organizations. In 2018, the government allocated funding to the mechanism.
On October 10, in Jakarta, HP+ disseminated cost results from its subnational HIV activity to an audience of more than 50, composed of attendees from the Indonesian government, civil society, and development partners. HP+ collected primary cost data from 19 civil society organizations and “puskesmas” (community health clinics) in Jakarta to identify the unit costs of delivering critical HIV interventions, disaggregated by key population reached and service delivery model. Detailed, updated unit costs are needed to improve estimates of the total resources required to meet provincial HIV targets and to explore the feasibility of increased financing of the HIV response through local government and greater integration into the Jaminan Kesehatan Nasional benefits package—the country's single-payer national health insurance scheme. As a result, the Provincial Health Office for Jakarta, which presented at the dissemination event, committed to using HP+ cost results in its annual budgeting and planning for HIV activities.
The fifth Global Symposium on Health Systems Research (HSR2018) was held recently in Liverpool, England. PEPFAR’s Sustainable Financing Initiative (SFI), supported HP+ to co-host an independent side session on October 10, with panelists from HP+, SHOPS Plus, UNAIDS, and USAID. The well-received session, “Beyond Vertical: Sustaining HIV Service Delivery Through Health Insurance,” was moderated by USAID’s Susanna Baker with HP+’s Arin Dutta. Also at HSR2018, HP+ presented two posters at the main conference: one on total market approach and another on women’s leadership and accountability. The latter poster, presented by HP+/RTI’s Christin Stewart, was awarded a “high scorer” prize and was featured on the conference website.
A national youth conference on HIV/AIDS and sexual reproductive health and rights, organized by the National Youth Council of Malawi (NYCOM) and supported by the Global Fund, was held June 28, 2018, in Lilongwe. The conference provided a venue for youth, government, and civil society leaders to exchange best practices and recommendations in sexual and reproductive health, HIV, and other issues that impact youth under the theme is “Reflect and Act for Improved Youth Participation and Leadership.” USAID through the Health Policy Plus (HP+), supported the participation of five youth champions and five district Youth Friendly Health Services coordinators and held capacity building and leadership strengthening sessions for the youth leaders. As a result of advocacy led by youth at the conference, the U.S. Embassy revised its criteria for youth organization eligibility for PEPFAR’s Small Grants Program and NYCOM announced on July 1, 2018, its new board of directors, which until then had several vacancies in critical leadership positions.
The US President’s Emergency Plan for AIDS Relief (PEPFAR’s) Annual Report to Congress features the Gender and Sexual Diversity (GSD) blended learning package. The training package is designed to help PEPFAR improve its effectiveness at serving its most vulnerable populations with a focus on staff training. Health Policy Plus and PEPFAR built on the success of a series of in-country trainings to develop the GSD blended learning package, which includes online and in-person training components. All PEPFAR field and headquarters staff are required to spend 90 minutes participating in the online interactive curriculum. All staff must also join an in-person panel discussion with local gender and sexual minority representatives around HIV, human rights, and meaningful engagement of GSD in PEPFAR programming. Thus far, more than 400 PEPFAR field and headquarters staff have taken the online training.
HP+ Jamaica Country Director, Sandra McLeish, and HP+ Senior Associate, Ryan Ubuntu Olson, were recognized by local stakeholders and media for their outstanding contributions to the HIV and AIDS responses. Sandra was presented with an award from Ricky Pascoe, JN+ President, and Dr. Jennifer Knight Johnson, USAID Jamaica. Ryan, who was named to the Clinton Global Initiative University’s Honor Roll in October, received a mention in the Washington Blade. More details are available in our news article.
USAID and PEPFAR, through HP+ is providing technical support to Guyana’s national AIDS program secretariat to plan for the country’s transition from external to domestic financing of HIV programs and services. This support includes the development mechanisms the government can use to directly support civil society through new “social contracting” measures. A meeting held in mid-November resulted in consensus among nearly 50 civil society, private sector, and government stakeholders and donors to move forward with a social contracting model. In addition to implementation of the model, HP+ will provide additional support to Guyana’s mobilization of domestic resources for HIV programs, including developing costing of civil society-led services and programs and technical assistance to Guyana’s high-level HIV Transition and Sustainability Steering Committee.
To raise awareness and promote redress, the Jamaican Network of Seropositives (JN+) re-branded the Jamaica Anti-discrimination System for HIV (JADS), formerly the National HIV-Related Discrimination Reporting and Redress System. Through JADS, Jamaicans can report cases of HIV-related discrimination and potentially receive mediation and/or damages. For the past several years, USAID and PEPFAR through the Health Policy Plus (HP+) project, and its predecessor Health Policy Project, has been supporting JN+ and the Ministry of Health, a JN+ redress partner, to strengthen and evaluate their redress systems and address HIV-related stigma and discrimination.
For World AIDS Day, HP+ participated in PEPFAR’s thunderclap and published an online #EndAIDS photo album, promoted via and e-postcard and on social media. The photos and accompanying quotes answered the question, “How does your work promote transparency, accountability, and partnerships to #EndAIDS?"
Ministry of Health (MoH) Kenya engaged stakeholders’ preparation of the grant for securing Global Fund resources for HIV/AIDS, Tuberculosis and Malaria. The grant making process which took more than a month involved review of program interventions and targets, costs and cash forecast for the next three and half years. As a result, Kenya application of US$ 356 million is expected to go to full GFATM Board for approval in November 2017. HP+ supported MoH to cost the proposed intervention and in realignment of the grant distribution so as to facilitate the absorption capacity of the grant over the 3.5 years for the three diseases.
The Health Policy Project, the predecessor to HP+, with funding from PEPFAR provided Gender and Sexual Diversity trainings for 2,825 participants including PEPFAR staff and program implementers, U.S. government staff, and local stakeholders in 38 countries. Results from the first study to report on GSD attitude change among a global sample of almost 180 individuals from 33 countries were published in PLOS on September 19, 2017. The paper, Changing hearts and minds: Results from a multi-country gender and sexual diversity training, reports that attitudes toward gender and sexual minorities were more positive after the training compared to before the training. Additionally, positive attitudes toward gender and sexual minorities not only persisted 3 – 6 months after that training but improved even further. These changed attitudes were not only sustained for months after the training, but they were also associated with changes in the workplace and, to a lesser extent, HIV programming.
USAID and PEPFAR, through the Health Policy Project’s (HPP) follow-on, Health Policy Plus (HP+), shared best practices, resources, and the project’s current work to reduce HIV-related stigma in health facilities during a recent webinar. The HPP/HP+ stigma-reduction package is comprised of a series of tools (assess, train, and sustain); includes a total-facility approach to reducing stigma and discrimination; and is based on a globally validated measurement tool, participatory training materials, and experiences from Africa, the Caribbean, and South and Southeast Asia. The stigma-reduction package has been implemented globally, with work ongoing in Ghana, Tanzania, and Jamaica. During the webinar, Suzie Jacinthe of USAID/Ghana commented, “We’ve never been able to quantify [stigma-reduction activities] in a way to show that what we’re doing is measurable change. With this activity, the beauty about it is that we…do questionnaires for the health facility as well as questionnaires from the PLHIV perspective of their experiences with those facilities to: gauge both [perspectives], come up with interventions out of the findings of the assessment, pilot them…and measure that change.” Jacinthe went on to say that HP+’s current effort to also cost these interventions, a first, will help governments demonstrate the real costs, alongside the measurable benefits, of implementing and replicating stigma-reduction interventions.
Ahead of Country Operational Plan reviews, the USAID- and PEPFAR-supported Health Policy Plus project—along with representatives from the Jamaica Ministry of Health, Jamaican civil society, and USAID—presented updates to their Positive, Health, Dignity, and Prevention (PHDP) Training Modules, to USAID staff and missions around the world. The webinar highlighted key changes to the PHDP—a curriculum by and for people living with HIV and key populations to promote personal health and advocate for high-quality HIV services—and its potential application in settings outside of Jamaica. During the February 2017 webinar, Dr. Chevannes, executive director of Jamaica’s National Family Planning Board, Sexual and Reproductive Health Agency Health commented, “…I wish to endorse the critical importance of PHDP in helping the address the structural barriers that result in depressed treatment cascades through loss to follow up among communities of persons living with HIV as well as key populations. As Jamaica moves to Test and Start PHDP is a valuable tool in achieving the 90-90-90 targets.” The revised PHDP will be available later this spring.
The Government of Tanzania has committed 5.5 billion Tanzanian shillings (US $2.42 million) to the country's AIDS Trust Fund (ATF) for fiscal year 2016/17. This injection of funds, alongside the appointment of an independent board of governors to manage the ATF, represent important milestones in the trust fund's development. Once fully operational, the ATF could significantly reduce the country's dependence on external funders and promote the sustainability of Tanzania's HIV response. The ATF’s recent progress is due in part to support from USAID through the Health Policy Project, which provided technical assistance to the Tanzania Commission for AIDS starting in May 2015.
Mali’s Ministry of Health and Public Hygiene signed the Dakar Declaration on Factoring Key Populations in the Response to HIV and AIDS on December 9, 2016, after months of effort by the USAID-funded Health Policy Plus’s West Africa team. The Declaration stems from an April 2015 regional consultation on key populations and HIV and AIDS, held in Dakar, Senegal, and outlines how ECOWAS members will work to increase access to and use of HIV and AIDS services for key populations. Mali’s endorsement clears the path for HP+ to work with government and civil society stakeholders to develop a roadmap outlining how the Declaration will be implemented in Mali.
In 2015/16 health budgets, 12 of Kenya’s counties collectively committed US$2 million to HIV programs, enhancing these programs’ sustainability. These budget commitments come as a result of program-based budgeting (PBB) training provided to county health teams by USAID through the Health Policy Plus (HP+) project. Additionally, in Turkana county, the health department’s budget allocation increased in the 2016/2017 budget by 16 percent. These increases were informed through the PBB training and the USAID-supported county health accounts, which provided evidence to support the request. HP+ is now in the process of training a further 14 counties to improve program-based budgeting.
An article published in the Pacific Standard (Malawi’s Secret Weapon Against HIV: Male Circumcision, September 8, 2016) highlights the impact of USAID's Voluntary Male Medical Circumcision modeling study conducted by the Health Policy Project. The study recommends that Malawi focus on recruiting men and boys between the ages of 10 and 34 and to prioritize urban areas. The recommendation led the government of Malawi to shift its VMMC focus with an aim to have 60 percent of males between the ages of 10 and 34 in 14 of Malawi’s 28 districts circumcised by 2025. If Malawi reaches this goal the study calculates a potential total savings of $344 million.
Palladium’s Catherine (Barker) Cantelmo and Thomas Fagan presented work conducted under the Health Policy Project at an oral session on health financing chaired by Michael Ruffner (PEPFAR) and David Wilson (World Bank) at the International AIDS Conference. One of the presentations was on a study published in Plos Medicine. This 97-country study estimates that the facility-level ART resource needs for test-and-start from 2016 to 2020 exceed the projected funding available, assuming flat external support yet ambitious domestic resource contribution, and that the five-year funding gap could be as large as $21 billion. The results of the study were cited in a Washington Post article that underscores the need for additional donor funding for HIV, including a fully-funded Global Fund, to sustain the progress made over the last 16 years.
A collection of peer-reviewed articles on male circumcision modeling and costing were published in Plos One and released during the International AIDS Conference. Most of the articles are based on work completed under the Health Policy Project and use data generated with an HPP-developed model called DMPPT.2. At the conference, USAID’s Emmanuel Njeuhmeli presented estimates that medical male circumcision performed between 2005 and 2015 in South Africa will save more than $790 million in treatment costs by 2030; and that male circumcisions in South Africa will avert 218,000 HIV infections by 2030. Referencing the research, Ministers of Health from South Africa, Lesotho and Swaziland called on policymakers to maintain high levels of male circumcision coverage and for endemic countries to commit domestic funding in an Op Ed published July 21st on Bhekisisa the health site of South Africa’s Mail & Guardian newspaper.
Supported by USAID's Health Policy Plus project, Kenya's parliamentary health committee adopted an amendment bill to the National Hospital Insurance Fund (NHIF) act. The proposed reforms impact delivery and financing of the mandated benefits package (inclusive of FP and HIV), supporting Kenya's efforts to achieve universal health coverage (UHC). The amendment will facilitate an increase in the number of individuals with health insurance, reducing out-of-pocket expenditure and ultimately reducing catastrophic health expenditure. If adopted, the bill will streamline administration at the NHIF, freeing up resources to be used for service delivery, contributing to domestic resource mobilization for health, and increasing access to essential health services. The bill now moves to the National Assembly for discussion and full adoption by September 2016.