Monitoring & Evaluating
Access to
and Effectiveness of
HIV and AIDS Treatment
in the
Private Sector
Lee Sarkin
6 November 2008
Agenda
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Aims
Why M&E?
Progress towards 2010 Universal Access
South African M&E implementation gap
Resource gap
Inaugural Private Sector M&E seminar
Closing remarks: Universal Access
Aims
• Communicate an M&E implementation gap
• Propose a solution to:
– Replace a duplicated & fragmented M&E
response with a unified response
– Promote evidence-based decision-making
– Review progress towards meeting targets
– Honour international & national commitments
Why M&E?
• Global commitments: global crisis –
global action
2000 UN Millennium Declaration
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UN Millennium Summit took place in September 2000. World
leaders agreed to reduce poverty and improve lives and issued
the eight Millennium Development Goals (MDGs).
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As a precursor to the Declaration of Commitment, MDG 6 calls
for combating AIDS, and beginning to reverse the spread of
HIV/AIDS by 2015.
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"We will have time to reach the Millennium Development Goals –
worldwide and in most, or even all, individual countries – but only
if we break with business as usual. We cannot win overnight.
Success will require sustained action across the entire decade
between now and the deadline. It takes time to train the
teachers, nurses and engineers; to build the roads, schools and
hospitals; to grow the small and large businesses able to create
the jobs and income needed. So we must start now. And we
must more than double global development assistance over the
next few years. Nothing less will help to achieve the Goals."
- Former United Nations Secretary-General, Kofi A. Annan
189 UN member states signed the
2001 Declaration of Commitment on HIV/AIDS
2001 Declaration of Commitment
on HIV/AIDS
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In June 2001, Heads of State and Representatives of Governments met at
the United Nations General Assembly Special Session dedicated to
HIV/AIDS.
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The meeting was a major milestone in the AIDS response. It was
recognized that the AIDS epidemic had caused untold suffering and death
worldwide. The UN Special Session also served to remind the world that
there was hope. With sufficient will and resources, communities and
countries could change the epidemic’s deadly course. The theme global
crisis requiring global action served to underline the need for urgent
attention.
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At the meeting, Heads of State and Representatives of Governments issued
the Declaration of Commitment on HIV/AIDS. The Declaration remains a
powerful tool that is helping to guide and secure action, commitment,
support and resources for the AIDS response.
Why M&E?
• Global commitments: global crisis – global action
– 2000: Millennium Declaration (8 MDG Goals & 2015 target)
– 2001: Declaration of Commitment on HIV/AIDS (25 UNGASS indicators)
The ‘Three Ones’
Key Principles – making the money work for people
• ONE
National Strategic Framework
• ONE
National AIDS Coordinating Authority
• ONE
National Monitoring and Evaluation System.
(NSP, 2007-2011)
(SANAC)
(NSP-M&E
framework)
The “Three Ones” –
Principles for the coordination of national AIDS responses
• 25 April 2004: UNAIDS, the United Kingdom and the United States cohosted a high-level meeting at which key donors reaffirmed their
commitment to strengthening national AIDS responses led by the
affected countries themselves.
• Endorsed the "Three Ones" principles, to achieve the most effective
and efficient use of resources, and to ensure rapid action and resultsbased management:
– One agreed HIV/AIDS Action Framework that provides the basis
for coordinating the work of all partners.
– One National AIDS Coordinating Authority, with a broad-based
multi-sectoral mandate.
– One agreed country-level Monitoring and Evaluation System.
Why M&E?
• Global commitments: global crisis – global action
– 2000: Millennium Declaration (8 MDG Goals & 2015 target)
– 2001: Declaration of Commitment on HIV/AIDS (25 UNGASS
indicators)
– 2004: “Three ones” guiding principles for coordination &
collaboration
2006 Political Declaration on HIV/AIDS
• A new and forward-looking Political Declaration on HIV/AIDS was
adopted unanimously by UN Member States on 2 June 2006 at the
close of the United Nations General Assembly 2006 High Level
Meeting on AIDS.
• Following intense negotiations on the text among Member States,
the final 2006 Declaration provides a strong mandate that will help
move the AIDS response forward, particularly with regards to scaling
up towards universal access to HIV prevention, treatment, care and
support.
• It reaffirms the 2001 Declaration of Commitment on HIV/AIDS and
the Millennium Development Goals, in particular the goal to halt and
begin to reverse the spread of AIDS by 2015.
Why M&E?
• Global commitments: global crisis – global action
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2000: Millennium Declaration (8 MDG Goals & 2015 target)
2001: Declaration of Commitment on HIV/AIDS (25 UNGASS indicators)
2004: “Three ones” guiding principles for coordination & collaboration
2006: Political Declaration on HIV/AIDS & 2010 Universal Access
• National commitments:
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1992: NACOSA plan
2000: National HIV/AIDS Strategic Plan (NSP) 2000-2005
2003: Operational Plan for CCMT
2007: NSP 2007-2011 & NSP-M&E framework
2008: UNGASS country reporting on implementing the 2001 Declaration
• Evidence-based decision-making
• Time-bound targets: need to assess progress towards meeting
targets of international & national commitments
Selected events in the response
What is Universal Access?
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Universal access signifies both a concrete commitment and a renewed resolve among the world
over to reverse the course of the epidemic. It is a process that builds on past initiatives and
infuses existing efforts with greater momentum.
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Universal access does not imply that there will be, or should be, 100% coverage of HIV
prevention, treatment, care, and support services.
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Even in high-income countries where health care is universally available, some patients who are
medically eligible for ART are not receiving them for various reasons (e.g. a deliberate decision
not to undergo testing or a decision to initiate therapy at a later time).
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Rather, by moving towards nationally set targets for universal access, the world has committed
to make concrete, sustained advances towards a high level of coverage.
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The basic principles for scaling up towards universal access emphasize that services must be
equitable, accessible, affordable, comprehensive, and sustainable over the long-term.
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By setting national targets, countries are holding themselves accountable to reach
universal access within a time frame that is both urgent— galvanizing support and
momentum around this goal—and feasible, and that will set them on the way to reach the
2015 Millennium Development Goals.
Progress towards 2010 Universal Access
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Reaching the MDG on HIV/AIDS – to halt and reverse the spread of the epidemic by 2015 – requires far greater access
to HIV prevention services and AIDS treatment, care and support than is currently available.
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As per the commitments made in the 2006 Political Declaration on HIV and AIDS, countries around the world are
currently in the process of revising their national AIDS plans and targets so as to significantly scale up their
response towards universal access to HIV prevention, treatment, care and support by 2010.
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Participation and country focus is what makes this effort special. The other critical elements of the process are:
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It occurs within and builds upon existing processes at all levels.
Countries drive the process, supported by international and bilateral institutions and donors, in line with the “Three
Ones” principles.
It covers the scale up of a comprehensive and integrated response, including prevention, treatment, care and
support.
It focuses on finding practical solutions to the main obstacles to scaling up, building on decisions already made.
The participation of a wide range of stakeholders—especially civil society and people living with HIV—is critical to
its elaboration and success.
It encourages countries to set their own roadmaps – including midpoint targets and milestones - for themselves in
order to advance toward universal access and to achieve the Millennium Development Goal on HIV/AIDS.
Access to ART
Access to ART
3 by 5
• Launched in December 2003, the “3 by 5” initiative proposed a
massive scale-up of ART, sufficient to ensure that 3 million people
would be on ART by the end of 2005.
• Although the goal of 3 million people on treatment was not reached
until two years after the 2005 deadline, “3 by 5” was critical in
catalysing unprecedented action to expand treatment access in
resource-limited settings.
NSP, 2007-2011
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The NSP flows from the NSP of 2000-2005, the Operational Plan for CCMT as well as other HIV
and AIDS strategic frameworks developed for government and sectors of civil society in the past
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In 2006, the Department of Health was mandated by SANAC, under the leadership of South
Africa’s Deputy President, to lead a process of developing a new 5-year plan for the years 20072011
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Represents South Africa’s multi-sectoral response to the HIV/AIDS epidemic
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The primary aims of the NSP are to:
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Reduce the rate of new HIV infections by 50% by 2011.
Reduce the impact of HIV and AIDS on individuals, families, communities and society by
expanding access to appropriate treatment, care and support to 80% of all HIV positive
people and their families by 2011.
The interventions needed to reach the NSP’s goals are structured under four key priority areas:
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Prevention;
Treatment, care and support;
Research, monitoring, and surveillance; and
Human rights and access to justice
What is M&E?
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M&E provides a way of assessing the ongoing progress of a plan/programme in
achieving its goals and objectives and informing key stakeholders about the results.
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An effective M&E system is essential for a co-ordinated national response.
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The M&E system must provide timely and reliable data that can be used by
stakeholders to inform decisions on whether any changes to the response are
needed.
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This in turn requires the development of annual M&E work plans in order to guide the
design of M&E, highlight what information or data need to be collected, describe how
best to collect it, and specify how to disseminate and use the results.
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Monitoring:
– Monitoring is the routine assessment of ongoing activities and progress.
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Evaluation:
– In contrast, evaluation is the episodic assessment of overall achievements.
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Thus monitoring looks at what is being done, whereas evaluation examines what has
been achieved or what impact has been made.
South African M&E implementation gap
•Extract from the NSP M&E
framework:
It is expected that each of the
sectors would develop their own
operational plans on
implementing the NSP. The
activities and interventions from
the sector operational plans
would follow that of the NSP. It
is important for each sector to
develop processes on how to
collect information to submit to
the SANAC sector M&E
coordinating unit.
Selected Indicators of
Treatment Access & Effectiveness
MDG Goal 6:
UNGASS Indicators:
NSP Indicators
Target 6B: Achieve,
4. % of adults and children
Priority area 2, goal 6:
by 2010, universal
access to treatment for
HIV/AIDS for all those
who need it
with advanced HIV infection
receiving ART.
Enable people living with
HIV and AIDS to lead
healthy and productive lives.
24.
• % of women, men and
children with advanced HIV
infection who are receiving
ART relative to projected
new stage IV (2011 target
80%)
Indicator 6.5
% of
population with advanced
HIV infection with access
to ART
2000 UN Millennium
Declaration
% of adults and children
with HIV known to be on
treatment 12 months after
initiation of ART
6.
% of estimated HIV-positive
incident Tuberculosis cases
that received treatment for
Tuberculosis and HIV
•2001 UN Declaration of
Commitment on HIV/AIDS
2001
2006
•Percentage of adults and
children on ART who are still
alive and in care 12 months
after initiation of ART (2011
target 85%)
•Viral load suppression 12
months (target 80%)
•2006 UN Political
Declaration on HIV/AIDS
2000
•% of patients at start of ART
with CD4< 50
2007
2008 2009 2010 2011 2015
Retention once initiated on ART
• Extract from the SA UNGASS 2008 report:
Resource gap?
Total annual resources available for AIDS, 1986–2007
Resource gap: US$ 8 Billion in 2007
Statement at the UN General Assembly
High Level Meeting on AIDS New York, 10
June 2008.
Global annual resources available 2000–2007 and funding
gap between projected financial resources if current scaleup continues and a phased scale-up scenario to reach
universal access between 2010 and 2015.
Dr Peter Piot, UNAIDS Executive Director:
“And it is time to increase funding.
Sometimes I hear that there is “too much
money for AIDS”. Nothing could be further
from the truth. Since the creation of the
Global Fund to Fight AIDS,Tuberculosis and
Malaria and the US President’s Emergency
Programme for AIDS Relief, there’s been a
tremendous increase in resources for AIDS.
But the sobering reality is that the AIDS
response remains under funded: last year
there was an $8 billion shortfall. If we’re
going to sustain the gains we’ve made
already – if we’re to get anywhere near
Universal Access to HIV prevention,
treatment, care and support, the world will
need to significantly increase investment in
AIDS.”
Source: 2008 Report on the Global AIDS Epidemic, UNAIDS
Closing an M&E implementation gap
• Currently no routine monitoring on a sector-level of
numbers accessing ART via private sector nor retention
once initiated
• International & national commitments necessitate
implementation of M&E frameworks
• Progress to date: 2008 - Joint workshop by Actuarial and
HIV Clinician’s Societies resulting in a patient level data
specification currently under peer-review
• Next step: early 2009 - Inaugural seminar for South
African Private Sector providers of HIV disease
management, treatment and care
Inaugural Private Sector M&E Seminar:
“the Storm to end the ART Data Drought”
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Objectives:
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Convey the findings of a data specification jointly developed by the Actuarial and Southern
African HIV Clinicians Societies to participating stakeholders, in particular the providers.
Discuss the role of providers as a vital source of data in relation to the NSP, particularly in
regard to monitoring and evaluating access to and effectiveness of treatment through the
Private Sector (including certain non-state programmes) of South Africa.
Lay a foundation for sustained collaboration amongst the participating stakeholders.
To obtain the support of providers to provide the requested data on an ongoing basis and
thereby support Pillar 3 of the NSP, 2007 – 2011 and UNGASS reporting requirements
Potential delegates:
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HIV disease management providers
Corporate HIV workplace programmes
Pharmaceutical manufacturers and distributors
Health care professionals (e.g. clinician’s and case managers)
Research institutions (e.g. Medical Research Council (MRC), the Human Sciences Research
Council (HSRC), University researchers)
Other (SANAC, the Council for Medical Schemes (CMS), the Board of Healthcare Funders
(BHF) and database design and software/technology development companies).
A message from the UNGA President
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H.E. Srgjan Kerim, President of the UN General Assembly in his closing
statement of the 2008 High Level meeting on AIDS, New York:
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“History will judge how effectively we rose to the challenge of AIDS;
Our global response must continue to be a collective effort;
No state or individual organisation can succeed alone;
Our renewed determination must be matched with accelerated
implementation of commitments to achieve universal access to HIV/AIDS
prevention, treatment, care and support by 2010;
– We must not lose momentum of our global response;
– For every 2 people that begin treatment there are 5 new HIV infections; and
– The implications of HIV prevention failures are clear: unless we act now,
treatment queues will get longer and longer and it will become more and more
difficult to get anywhere near universal access to ART.”
Lee Sarkin
[email protected]
Mobile: +27 (0) 83 242 4381
Brad Mears
Dr Francois Venter
Fatima Hassan / Mark Heywood