Global Health Delivery

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Global Health Delivery Matthew H. Bonds The
François-Xavier Bagnoud Center for Health and
Human Rights Harvard School of Public
Health Partners in Health
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Outline of Presentation

• Introduction to Partners in Health in Rwanda
• Principles of Global Health Delivery
• Community Health Workers System
• Outcomes
• Further Economic Epidemiology Research Relevant
  to Global Health Delivery

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www.pih.org
(Insert PIH Website)
http//www.pih.org/inforesources/news/60_Minutes_M
ay_2008.html
Introduction to Partners in Health
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Rwanda
Introduction to Partners in Health
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Introduction to Partners in Health
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Regional Health Indicators
Leading Diseases Malaria, Respiratory
Infections, Diarrhea,
HIV/AIDS, TB, Hookworm, Malnutrition
Introduction to Partners in Health
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Rwanda
Introduction to Partners in Health
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Introduction to Partners in Health
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Guiding Principles

• Focus on the most vulnerable groups as a means to
  improve health outcomes in the overall population
  
• Community health worker outreach to those not in
  care or fallen out of care, including the most
  vulnerable (e.g., child-run households, HIV/TB
  households, others)

CHWs with their patients
Introduction to Partners in Health
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Guiding Principles

• Ensuring sustainability through capacity-building
• Transferring skills and innovative tools while
  meeting the immediate needs of the population

Introduction to Partners in Health
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Strengthening the Delivery of an Integrated
Primary Healthcare and Health System
Health Center
District Hospital
Community
District-wide cohort of CHWs trained in health
promotion, referrals and treatment
Strengthen district hospitals and health centers
to provide comprehensive primary care coordinated
with community-based work
Develop strong district network of primary care
including prevention, case finding, care,
treatment and outreach
Introduction to Partners in Health
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Strengthening the Delivery of an Integrated
Primary Healthcare and Health System
Health Center
District Hospital
Community
4 (8) Health Centers
3 district hospitals
4000 CHWs
Total Catchment Population 1 Million People Cost
per Person per Year to PIH 13 Cost per Person
per Year for total health system in PIH Catchment
area 32
Introduction to Partners in Health
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Accompagnateur Program

• All patients initiating ART have the option of an
  accompagnateur.
• Accompagnateurs provide social support and at
  least once-daily home-based directly observed
  therapy.
• Accompagnateurs attend regular trainings in HIV
  prevention, treatment, adherence, and recognition
  of opportunistic infections and adverse effects.

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Accompagnateur Program

• The PIH/Rwanda MoH CHW model is based on
• Adequate number of CHWs One for every 6
  households with a patient on ART.
• Community involvement and CHW integration into
  the health system Elected by the community, CHWs
  participate in meetings and advocacy, build
  solidarity and establish a community link to the
  healthcare system.
• Standardization of training CHWs receive
  standardized training (including modules on TB,
  HIV/AIDS, chronic diseases, IMCI, nutrition,
  sanitation, reproductive health, and family
  planning) with consistent supervision from health
  center personnel.
• Adequate compensation For CHWs to be held fully
  accountable and be a sustainable part of the
  system, they need to be compensated adequately.
  Performance based financing can be used.

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Accompagnateur Program Collateral Benefits

• Neighbors helping neighbors
• Job creation, economic growth
• Kids in school
• Prenatal care
• Family planning uptake
• Earlier presentations of illness
• Advocacy and disease awareness
• Adherence and solidarity

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Role of Economic and Epidemiological Modeling for
Global Health Delivery
Objective Build a broader global coalition to
combat poverty and disease based on scientific
understanding of their interactions and their
response to healthcare interventions.

• Monitoring and evaluating impacts of programs
• Miscellaneous programmatic questions e.g., user
  fees cost-effectiveness analysis of proposed
  investments, cost-effectiveness analysis of
  Community Health Worker Model, etc.
• Development of epidemiological and economic model
  frameworks to contribute to basic knowledge of
  disease patterns in areas of extreme poverty

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Role of Economic and Epidemiological Modeling for
Global Health Delivery
Objective Build a broader global coalition to
combat poverty and disease based on scientific
understanding of their interactions and their
response to healthcare interventions.

• Monitoring and evaluating impacts of programs
• Miscellaneous programmatic questions e.g., user
  fees cost-effectiveness analysis of proposed
  investments, cost-effectiveness analysis of
  Community Health Worker Model, etc.
• Development of epidemiological and economic model
  frameworks to contribute to basic knowledge of
  disease patterns in areas of extreme poverty

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Cost of Accampagnateur Program

• Accompagnateurs account for only 9.3 of labor
  costs and 4.2 of overall operating costs.

Monitoring and Evaluation
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Role of Economic and Epidemiological Modeling for
Global Health Delivery
Objective Build a broader global coalition to
combat poverty and disease based on scientific
understanding of their interactions and their
response to healthcare interventions.

• Monitoring and evaluating impacts of programs
• Miscellaneous programmatic questions e.g., user
  fees cost-effectiveness analysis of proposed
  investments, cost-effectiveness analysis of
  Community Health Worker Model, etc.
• Development of epidemiological and economic model
  frameworks to contribute to basic knowledge of
  disease patterns in areas of extreme poverty

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Role of Economic and Epidemiological Modeling for
Global Health Delivery
Important Monitoring and Evaluation Questions

• What is the long-term Impact of programs on
  population health?
• Under-five mortality
• HIV
• Malaria
• What are the costs of the interventions are
  their examples wherethe interventions are
  cost-saving
• Household costs of disease
• Health system costs of disease

We need models!
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Role of Economic and Epidemiological Modeling for
Global Health Delivery
Objective Build a broader global coalition to
combat poverty and disease based on scientific
understanding of their interactions and their
response to healthcare interventions.

• Monitoring and evaluating impacts of programs
• Miscellaneous programmatic questions e.g., user
  fees cost-effectiveness analysis of proposed
  investments, cost-effectiveness analysis of
  Community Health Worker Model, etc.
• Development of epidemiological and economic model
  frameworks to contribute to basic knowledge of
  disease patterns in areas of extreme poverty

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Programmatic Questions
Objective Build a broader global coalition to
combat poverty and disease based on scientific
understanding of their interactions and their
response to healthcare interventions.

• Monitoring and evaluating impacts of programs
• Miscellaneous programmatic questions e.g., user
  fees cost-effectiveness analysis of proposed
  investments, cost-effectiveness analysis of
  Community Health Worker Model, etc.
• Development of epidemiological and economic model
  frameworks to contribute to basic knowledge of
  disease patterns in areas of extreme poverty

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Programmatic Questions
User Fees at Health Clinics in Rwanda
How many secondary infections are prevented by
removing user fees at the clinics?
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Programmatic Questions
How should we subsidize health insurance?
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Role of Economic and Epidemiological Modeling for
Global Health Delivery
Objective Build a broader global coalition to
combat poverty and disease based on scientific
understanding of their interactions and their
response to healthcare interventions.

• Monitoring and evaluating impacts of programs
• Miscellaneous programmatic questions e.g., user
  fees cost-effectiveness analysis of proposed
  investments, cost-effectiveness analysis of
  Community Health Worker Model, etc.
• Development of epidemiological and economic model
  frameworks to contribute to basic knowledge of
  disease patterns in areas of extreme poverty

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Developing Model Frameworks
Economic Growth
PovertyTrap
Public Health as Economic Development
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Summary

• Providing healthcare in areas of extreme poverty
  requires resources
• Availability of resources is determined in part
  by knowledge of the impact of the use of those
  resources
• The first line of defense to diseases in the
  health system is at the community level
• Community Health Workers (CHWs) are the most
  basic level of human resources available for
  healthcare
• A fully operative rural health system in Rwanda
  costs about 32 per capita per year
• CHWs cost about 1.80 per capita per year 4.2
  of total operating budget.
• Models are necessary for understanding the full
  costs and impacts of healthcare systems and can
  be used to inform policy while contributing to
  basic knowledge of patterns of disease.

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Acknowledgments

• Rwanda Ministry of Health
• Partners In Health (PIH)
• Clinton Foundation
• Global Fund
• UNICEF
• CNLS
• WFP
• Gates Foundation
• Local HIV Associations