Skip to main content

Currently Skimming:

5 Managing Scale-Up of Antiretroviral Therapy
Pages 134-175

The Chapter Skim interface presents what we've algorithmically identified as the most significant single chunk of text within every page in the chapter.
Select key terms on the right to highlight them within pages of the chapter.


From page 134...
... An integrated management structure that includes these principal components will be necessary for the long-term success of ART programs. BUILDING HUMAN RESOURCE CAPACITY Although scientific data on health care personnel in resource-constrained settings, particularly sub-Saharan Africa, are extremely difficult 134
From page 135...
... The problem is compounded not only by the shortage of trained workers with specific HIV/AIDS experience or expertise, but also by severe shortages in many resource-constrained settings of the well-trained professionals needed to handle other critical functions, such as commodity logistics, pharmaceutical regulation, laboratory support, information management, and operations research. The seriousness of the situation is illustrated by an October 2003 report analyzing the cost and resource requirements associated with providing ART through the Zambian public health sector (Kombe and Smith, 2003)
From page 136...
... Given the desperate and growing demand for health workers and the losses of trained workers to better jobs in more well-to-do countries, many African nations have reportedly been encouraged to adopt human resource policies that lead to the deliberate overproduction of health workers to fill the growing gaps in human resource capacity. Filling these gaps is not a simple task, however, as the African health sector's human resource crisis is multidimensional and involves a complex set of underlying upstream and more-proximal causal factors (Puku, 2002; Narasimhan et al., 2004; Schwab, 2001)
From page 137...
... The human resource crisis in the health sectors of resource-constrained settings reflects the underlying crisis in tertiary education throughout the developing world, particularly in sub-Saharan Africa. The quality of such education tends to be low; access is limited; and as most health professional training is conducted under the auspices of national governments (through their ministries of health)
From page 138...
... 1 per 5,000 Botswana, Cape Verde, D.R. Congo, Equitorial Guinea, Gabon, Guinea, Guinea-Bissau, Kenya, Mauritania, Mauritius, Namibia, Nigeria, Sao Tome and Principe, Seychelles, South Africa, Swaziland, and Zimbabwe (16)
From page 139...
... need, while Box 5-2 reviews how the factors discussed above affect the potential role of nurse-based care. To aid in the effort to bolster human resource capacity in resourceconstrained settings, multinational participation is encouraged.
From page 140...
... Although adherence and treatment success are possible based on clinical criteria alone, this is true only if health care providers are knowledgeable and capable with regard to monitoring and evaluating patient response to treat ment in the absence of laboratory monitoring. There is an urgent need for an ob jective evaluation of the extent to which nurse-based care can fill the gaps in hu man resource capacity.
From page 141...
... government and similar initiatives by other countries should be utilized to support the develop ment of effective training programs in HIV care in order to prepare local physicians, nurses, community health workers, laboratory profes sionals, pharmacists, and logisticians in heavily HIV-afflicted countries facing severe human resource shortages. DEVELOPING A SUSTAINABLE WORKFORCE The Brain Drain The brain drain (i.e., the departure of trained and educated individuals from one place to another)
From page 142...
... According to one anecdotal report, many nonpharmacy graduates are teaching courses in South African pharmacy schools, and almost all of the academic staff of the University of Zimbabwe department of pharmacy have emigrated. As most African governments already allocate 50 to 70 percent of their overall public health expenditures to salaries and wages, there is little money left over to address the problematic salary differences between local civil service and private, NGO, or foreign employment opportunities for physicians and other highly trained workers (Over, 2004; USAID, 2003)
From page 143...
... A July 2003 article in Lancet (de Castella, 2003) reports that this country's brain drain is particularly prevalent among doctors and anesthetists, who flee the country for the United Kingdom, New Zealand, and South Africa.
From page 144...
... According to data from Malawi, Zambia, and Zimbabwe, in the late 1990s there were 2 to 10 times more professional health workers in central and provincial hospitals than in rural health centers (USAID, 2003)
From page 145...
... Laboratory Technicians In addition to physicians, pharmacists, nurses, and other health care workers directly involved in care and treatment for HIV/AIDS patients, laboratory technicians are essential to the actual administration and monitoring of ARVs. For example, as noted above, Zambia has estimated that its initial ART scale-up program (for 10,000 patients)
From page 146...
... .) General Health-Sector Training Clearly, given the decreasing number of well-qualified and highly trained health workers in resource-constrained settings, there is a need for cost-effective training programs that better prepare graduates for working in the field and on the front line.
From page 147...
... . Box 5-4 describes the efforts of one country -- Botswana -- to build health-sector human resource capacity to address the HIV/AIDS epidemic.
From page 148...
... National Behavior Change Interventions Training Program -- developed by ACHAP and the National AIDS Coordinating Agency (NACA) to provide behavior modification intervention skills to government workers, civil servants, and district level employees.
From page 149...
... The people collecting and analyzing the data should not be those who are administering treatment and managing programs. Thus there is a need to mobilize data analysts and others to support monitoring and evaluation and to address associated operations research issues.
From page 150...
... Countries should establish information systems at the regional and national levels so they can regularly assess and coordinate their evolving human resource needs. Both countries with relatively adequate human resources and those that are more resource constrained must pursue appropriate policies and programs to stem the "brain drain" of local expertise that is critically needed for the scale-up of ART programs.
From page 151...
... The AMDS was created to expand the access of developing countries to quality drugs and diagnostic services. To this end, it offers the following support: · Provides manufacturers with information about the global market demand for drugs and diagnostics, and provides technical support to countries for procur ing and supplying these goods.
From page 152...
... The tendering process results in not just one but three suppliers winning bids so as to encourage competition, with the Clinton Foundation price serving as the ceiling price under which prequalified suppliers must bid. · Participating countries back up their payment with a letter of credit or other secure instrument (since the potential for nonpayment is of concern to some sup pliers)
From page 153...
... At the program level, the consistent and secure delivery of high-quality drugs depends on five key components, a breakdown in any one of which could cause the entire system to collapse (Chandani, 2004; World Bank, 2004) : · The capacity to forecast programmatic needs · The capacity to finance product requirements and to effectively coordinate funding for the purchase of required commodities · The capacity to procure the products in a timely and efficient manner · The capacity to deliver the products to those who need them on a reliable basis · The availability of good logistics data and an information system (e.g., to enable accurate forecasting)
From page 154...
... The importance of logistics systems to a smoothly operating drug supply chain raises questions about what can be done to improve already existing systems in some countries. In developing or assessing logistics systems, short- and long-term demands must be appropriately balanced.
From page 155...
... The following example illustrates how improving just one aspect of a coun try's logistics system can improve program outcomes. In 1995, Kenya received a US$600,000 donation of more than 2,500 sexually transmitted infection (STI)
From page 156...
... There was an awareness that, in a country the size of Brazil, the logistical demands of ART scale-up would require the ready availability and usability of valuable, accurate information pertaining to all aspects of drug delivery -- from procurement to patient adherence. Thus the demand was recognized for the creation and implementation of two computerized systems: SICLOM (Sistema de Controle Logistico de Medicamentos, or System of Logistical Control of ARV)
From page 157...
... At the end of each day, the prescription information from each drug dispensing unit is sent via modem, online connection, email, or CD-ROM to the office of the National AIDS Programme in Brasilia. At this main center, the data are synchronized, allowing analysis of problems or errors in drug prescriptions; a report indicating any prob lems or errors detected is generated.
From page 158...
... Quality Assurance of Antiretroviral Drugs The benefits of high levels of adherence to ARV regimens would be illusory if those drugs were not themselves efficacious, safe, and of consistent quality. The extension of these treatments to millions of persons in need over the next several years will involve a growing number of established and new manufacturers.
From page 159...
... found that "it took a long time for many of the suppliers to submit product data to the specifications requested. Data on product quality and on bioequivalence were often inadequate and some manufacturing sites requested postponement of scheduled site inspections." As the project has
From page 160...
... Box 5-9 describes one example of a strategy that can be employed by countries without established, reliable regulatory systems in place: the use of foreign procurement agencies. FDCs raise some challenging quality assurance issues.
From page 161...
... . Despite the success of the Clinton Foundation's procurement work thus far, as well as the initial value of WHO's prequalification guidelines and other similar resources and options, the capacity of national regulatory agencies to conduct ongoing quality monitoring both at the point of entry and throughout the supply chain must be enhanced as ART programs expand -- particularly if national gov ernments are expected to eventually procure ARVs on their own.
From page 162...
... The bottom line is that the approval process for ARVs must be swift while not compromising the quality and efficacy of the drugs. MONITORING AND EVALUATION Given the unprecedented magnitude of global ART scale-up and the paucity of data on how to provide ART safely and effectively in resourceconstrained settings, scale-up programs must be based on a learn-by-doing
From page 163...
... M&E also helps identify efficient, effective programmatic activities that warrant expansion and underperforming programs that should be either discontinued or improved. Another important role for M&E is to ensure that funded ART programs are sensitive to ongoing country activities and are not negatively impacting HIV/AIDS prevention or other public health initiatives or programs.
From page 164...
... Given that ART scale-up is only just beginning, it is difficult to find examples of how M&E could be used by treatment programs in resourceconstrained settings to identify practices that are working versus those that need to be improved. Countries' efforts to evaluate their national AIDS programs have varied.
From page 165...
... · Maintain individual patient records using unique patient identifiers. · Involve people living with HIV/AIDS.
From page 166...
... 166 SCALING UP TREATMENT BOX 5-10 The Institute for Healthcare Improvement Model for Improvement IHI's Model for Improvement requires collaborative teams to ask three funda mental questions: (1) What are we trying to accomplish?
From page 167...
... Real-time interactive operations research is designed to capture local knowledge and experience by making health care teams active partners in the refinement and improvement of care process. (See the figure be low.)
From page 168...
... The same is true for tracking and monitoring staffing patterns (whether human resource capacity is really increasing, or ART scale-up is diverting staff from malaria control, childhood immunization, and other programs)
From page 169...
... Central/National Level · Presence of a strategic information system · Presence of standardized data collection forms · Number of data collection forms disseminated to providers · Percent of patients assessed and prescribed ART who receive medications within 1 month · Percent of central, district, and dispensing site drug storage locations whose stock cards for ARVs are up to date and accurate · Percent of central, district, and dispensing site drug storage locations that experience ARV stock-out SOURCE: Delay, 2004. vival patterns, infection incidence, and economic productivity (i.e., whether the economic impact of HIV/AIDS is really changing over time)
From page 170...
... And a mechanism for regular international communication of M&E results, inspired by the regular international rounds conducted during the SARS crisis, needs to be established. Box 5-13 summarizes some important features of M&E for ART scale-up.
From page 171...
... · Maintain individual patient records with unique patient identifiers. · Involve people living with HIV/AIDS in M&E activities.
From page 172...
... 2003. Health workers struggle to provide care in Zimbabwe.
From page 173...
... . The Brain Drain and Retention of Health Professionals in Africa.
From page 174...
... Presentation at the 13th International AIDS Conference in Durban, South Africa. WHO (World Health Organization)
From page 175...
... 2004c. 3 by 5 Technical Brief: AIDS Medicines and Diagnostic Service (AMDS)


This material may be derived from roughly machine-read images, and so is provided only to facilitate research.
More information on Chapter Skim is available.