Global Health Delivery
Matthew H. Bonds
The François-Xavier Bagnoud Center for Health and Human Rights
Harvard School of Public Health
Partners in Health
Outline of Presentation
1. Introduction to Partners in Health in Rwanda
2. Principles of Global Health Delivery
- Community Health Workers System
- Outcomes
3. Further Economic Epidemiology Research
Relevant to Global Health Delivery
www.pih.org
(Insert PIH Website)
http://www.pih.org/inforesources/news/60_Minutes_May_2008.html
Introduction to Partners in Health
Rwanda
Introduction to Partners in Health
Introduction to Partners in Health
Regional Health Indicators
Rwanda
Kibungo
Rural
Rwanda
Rural
Under-5 mortality rate (per 1000)*
189
116
Infant mortality rate (per 1000)*
130
84
Percentage of deliveries taken place
at a health facility
14%
24%
Percentage of women reporting
lack of money for treatment
68%
74%
Percentage of moderate/severely
underweight children
21%
24%
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$250
Health Indicator
Per Capita Income
Leading Diseases: Malaria, Respiratory Infections, Diarrhea,
HIV/AIDS, TB, Hookworm, Malnutrition
Introduction to Partners in Health
Rwanda
Introduction to Partners in Health
Introduction to Partners in Health
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
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
Strengthening the Delivery of an Integrated Primary
Healthcare and Health System
Health Center
District Hospital
Strengthen district hospitals and health centers to
provide comprehensive primary care coordinated
with community-based work
Community
District-wide cohort of CHWs
trained in health promotion,
referrals and treatment
Develop strong district network of primary care including
prevention, case finding, care, treatment and outreach
Introduction to Partners in Health
Strengthening the Delivery of an Integrated Primary
Healthcare and Health System
Health Center
District Hospital
3 district hospitals
Community
4 (8) Health Centers
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
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.
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.
Accompagnateur Program Collateral Benefits
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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
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.
1. Monitoring and evaluating impacts of programs
2. Miscellaneous programmatic questions: e.g., user fees;
cost-effectiveness analysis of proposed investments,
cost-effectiveness analysis of Community Health Worker
Model, etc.
3. Development of epidemiological and economic model
frameworks to contribute to basic knowledge of disease
patterns in areas of extreme poverty
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.
1. Monitoring and evaluating impacts of programs
2. Miscellaneous programmatic questions: e.g., user fees;
cost-effectiveness analysis of proposed investments,
cost-effectiveness analysis of Community Health Worker
Model, etc.
3. Development of epidemiological and economic model
frameworks to contribute to basic knowledge of disease
patterns in areas of extreme poverty
Cost of Accampagnateur Program
Accompagnateurs account for only 9.3% of labor costs and 4.2% of
overall operating costs
.
Monitoring and Evaluation
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.
1. Monitoring and evaluating impacts of programs
2. Miscellaneous programmatic questions: e.g., user fees;
cost-effectiveness analysis of proposed investments,
cost-effectiveness analysis of Community Health Worker
Model, etc.
3. Development of epidemiological and economic model
frameworks to contribute to basic knowledge of disease
patterns in areas of extreme poverty
Role of Economic and Epidemiological Modeling for
Global Health Delivery
Important Monitoring and Evaluation Questions:
1. What is the long-term Impact of programs on population health?
- Under-five mortality
- HIV
- Malaria
2. What are the costs of the interventions – are their examples where
the interventions are cost-saving
- Household costs of disease
- Health system costs of disease
We need models!
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.
1. Monitoring and evaluating impacts of programs
2. Miscellaneous programmatic questions: e.g., user fees;
cost-effectiveness analysis of proposed investments,
cost-effectiveness analysis of Community Health Worker
Model, etc.
3. Development of epidemiological and economic model
frameworks to contribute to basic knowledge of disease
patterns in areas of extreme poverty
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.
1. Monitoring and evaluating impacts of programs
2. Miscellaneous programmatic questions: e.g., user fees;
cost-effectiveness analysis of proposed investments,
cost-effectiveness analysis of Community Health Worker
Model, etc.
3. Development of epidemiological and economic model
frameworks to contribute to basic knowledge of disease
patterns in areas of extreme poverty
Programmatic Questions
User Fees at Health Clinics in Rwanda
How many secondary infections are prevented by removing user fees at
the clinics?
Programmatic Questions
0
.2
.4
.6
.8
1
Household Mutuelle Coverage and Wealth
0
.2
.4
.6
PCA Wealth Score
.8
Sample Excludes Households who Recieve Mutuelle from Projects or Government (n = 36)
How should we subsidize health insurance?
1
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.
1. Monitoring and evaluating impacts of programs
2. Miscellaneous programmatic questions: e.g., user fees;
cost-effectiveness analysis of proposed investments,
cost-effectiveness analysis of Community Health Worker
Model, etc.
3. Development of epidemiological and economic model
frameworks to contribute to basic knowledge of disease
patterns in areas of extreme poverty
Developing Model Frameworks
Economic
Growth
Poverty
Trap
Public Health as Economic Development
Summary
1. Providing healthcare in areas of extreme poverty requires
resources
2. Availability of resources is determined in part by
knowledge of the impact of the use of those resources
3. The first line of defense to diseases in the health system
is at the community level
4. Community Health Workers (CHWs) are the most basic
level of human resources available for healthcare
5. A fully operative rural health system in Rwanda costs
about $32 per capita per year
6. CHWs cost about $1.80 per capita per year = 4.2% of
total operating budget.
7. 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.
Acknowledgments
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Rwanda Ministry of Health
Partners In Health (PIH)
Clinton Foundation
Global Fund
UNICEF
CNLS
WFP
Gates Foundation
Local HIV Associations