International Treatment
Preparedness Coalition (ITPC)
Treatment Monitoring &
Advocacy Project
Why monitoring through
Missing the Target (MTT)?
• Started with need to track “3 by 5”
initiative from a civil society perspective
• Recognition: scale up dependent on
politics, money and implementation issues
• Need to make governments and global
agencies accountable for progress
• Focus on outcomes, identify specific
barriers & be solution-oriented
• Inform advocacy with objective research
Research Approach
and Methods
• Civil society teams based in countries
• Standardized research template
• Research based on confidential interviews
with diverse informants: civil society, local
and national government, health workers,
policy makers
• Centralized editing, coordination, global
and domestic media
• Focus on recommendations to change
national policies and response of global
agencies
MTT 1, 2 & 3: Findings
• November 2005, May 2006, November
2006
– Reports cover: Dominican Republic, India,
Kenya, Nigeria, Russia, South Africa
– Lack of urgent, global strategic plan driving
HIV treatment scale up
– Inadequate national leadership in response to
ARV treatment access gap
– Specific barriers (and solutions)
– Technical support needs of government and
civil society unmet
– Pervasive HIV-related stigma
– Very limited or no connections between HIV
and TB responses
Findings: MTT 4 & 5
• July 2007, November 2007
– New countries join: Morocco, Pakistan,
Uganda, China, Belize, Cameroon, Kenya,
Cambodia, Argentina, Zambia, Zimbabwe,
Malawi, Philippines
– Need for increased attention to marginalized
populations, supportive services including
nutrition, human resources, free access to
medications and testing, integration of
prevention and treatment services
– MTT 5 documents that treatment regimens in
many countries do not meet new WHO
standards for 1st and 2nd line care
MTT Outcomes
• “The report ignited a debate with policy makers.”
• “The reporting process strengthened the network of
PLWHA and focused the efforts of treatment
advocates.”
• “The scrapping of user fees for ARVs followed
recommendations we made in the report.”
• “The report has opened up dialogue with the AIDS
and TB program in the Ministry of Health.”
• Informs domestic and international media
coverage and dialogue on AIDS
– Recommendations endorsed by The Lancet; covered in
The New York Times, FT, IHT as well as national media
in the countries studied
MTT 6: AIDS and
Health Systems
• Six civil society country research teams in
Zambia, Zimbabwe, Uganda, Dominican Republic,
Argentina, Brazil
• Country teams selected through competitive
process based on demonstrated capacity,
expertise
• Project coordinators also strive for geographic
representation
MTT 6: Methodology
• Interviews and focus groups using standardized
questionnaires
• Questionnaire template developed in
collaborative process with all country teams
participating
• Respondents: People with HIV, grassroots level
key informants, hospital administrators,
government officials (disease specific and health
in general), caregivers, health workers, national
heads of multilateral agencies, national civil
society, etc.
• Literature review, including of key national health
documents (eg Uganda’s HSSP II)
MTT 6: Main findings
• AIDS response has far-reaching positive impacts on
health care service access: building infrastructure,
raising quality, and extending the reach of health care
to socially marginalized groups (eg sexual minorities,
drug users, migrants, poorest)
• AIDS response has revealed existing fragilities in
health systems in some cases has increased burdens
on systems because AIDS response has not yet been
used to create additional capacity (eg GHIs rarely
used to fund additional health workers)
MTT 6: Main findings
• Engaging advocates and health consumers has
increased accountability and urgency of response
• Expansion of resources requires simultaneous work to
increase on human resources, transparency, and
strengthen infrastructure
• Untapped opportunities to improve broader delivery of
comprehensive primary health care services using GHI
funding
• Scaling up coverage in rural/peri urban/remote areas
extremely challenging: must use GHIs to strengthen
health systems in order to extend impact of AIDS
programs
MTT 6: Main findings
• Civil society plays a vital role in helping service users
demand their health rights and in providing HIV and
health care services
• External funding for HIV can result in a country
viewing HIV treatment programs as separate from
health system, undermining integration--no
requirement by GHIs to do so
Positive Synergies
• Civil society involvement in monitoring,
governance and implementation at the country
level
• Civil society identifies existing opportunities that
are not being used to leverage positive synergies,
using funding to fight AIDS while improving
health outcomes for the larger communities
• In particular, health worker shortages: critical
barrier in countries studied, while GHI funding
not used to address problem
MTT 7 to be released Oct. 6
Where to next?
• Budget monitoring training for all teams in Cape
Town and Bangkok in 2008
• One minute audio comments by all CCM
Advocacy report researchers on itpcglobal.org
• MTT 7 on PMTCT+ (6 countries) – March 09
Goals for the future:
• Closer tie to advocacy – all teams to implement
advocacy plans
• Fully integrated research and monitoring,
advocacy, and ongoing capacity building,
mentoring and training for country teams
• Integration of budget monitoring and other skills
• Advocate on access to health services while
keeping AIDS focus
www.itpcglobal.org
www.aidstreatmentaccess.org
MTT 6: Uganda
• AIDS claims the biggest share of health
financing of any single disease in the country
• Massive inflow of funds from foreign donors for
AIDS programs has resulted in broader
improvements to public health but significant
additional funding is needed to meet health
care needs
• AIDS programs have improved community
mobilization, including TB and village health
teams
• Limited successful examples of integrating
AIDS care into primary health care services
MTT 6: Uganda
• AIDS has placed increased workload and strain
on medical personnel—whose numbers have
not increased proportionally to the demand—
and on existing weak infrastructure
• Personnel working in often AIDS are better
paid, and their facilities better equipped leading
to further attrition
• An increase in AIDS funding has not led to the
efficient delivery of services and commodities
(eg stock-outs persist)
MTT 6: Uganda
• Urgent need to train and equip health workers
and devolve ARV treatment to lower-tier health
facilities, engaging communities in health
service delivery and planning
MTT 6: Zambia
• Ongoing ART roll out has reduced HIV
related hospital admissions, reducing
workloads
• Basic health services and supplies still not
available in public system, forcing poor
patients to go without
• Serious health worker shortage
exacerbated by IMF-imposed
conditionalities
MTT 6: Zambia
• High reliance on donor support, often
conditional, but donor funds not being used to
increase capacity of local health workers and
implementers, or increase overall number of
health workers
• Donors should train additional health workers to
compensate for those hired from the public
system to work in their projects
• Low levels of community mobilization to demand
better access to comprehensive health care
services