John P. McGovern Award and Lecture

Global health equity
Community-based care, human resources for health,
and implementation challenges
Paul Farmer, MD, PhD
Partners In Health
Harvard Medical School
Brigham and Women’s Hospital
American Association of Colleges of Nursing • 28 October 2007
HIV prevalence
(www.worldmapper.org Poster 227)
Nurses working
(www.worldmapper.org Poster 216)
$1
0,
22
0
$1
0,
62
$12,000
2
Annual per-patient ART cost, 2002
d4T, 3TC, NVP
AZT, 3TC, NVP
$10,000
$6,000
$4,000
$4
12
$3
00
$5
77
$2,000
$7
01
Price (US$)
$8,000
$0
Avg. wholesale price
PIH price
Drug source
IDA price
March 2003
September 2003,
six months later
Scaling up in rural Haiti
Strengthening and rebuilding health systems
HIV/AIDS program as chwal batay:
Launching “virtuous social cycles”
Job creation at Zanmi Lasante:
2746 employees as of December 31, 2006
Haitian Ministry of
Health employees
(mostly
medical/admin)
137 (5%)
CHWs
1179 (43%)
PIH/ZL medical
personnel
247 (9%)
Non-medical
personnel
1183 (43%)
Distribution of HIV-related clinical care tasks
Zanmi Lasante, Haiti
40
36
Percentage of care tasks
35
30
25
25
18
20
15
12
10
5
2
4
2
1
0
MD
RN
Non-clinical
staff
MD/RN
MD or RN/
MD/RN/
MD and/or
MD/RN/
Non-clinical Non-clinical RN/CHW CHW/Nonclincal
Ivers et al. Tasks performed by community health workers in Thomonde, Haiti: a case study of task-shifting.
Abstract 751. HIV Implementers Meeting June 2007, Kigali, Rwanda.
First contact with health system for people
living with HIV in Boucan Carré, Haiti
Other
6%
Social Worker
16%
MD
24%
Even people who do not have
an accompagnateur often go to
one as their first point of contact
with the health system.
Auxillary
2%
RN
15%
N = 200
CHW
37%
Ivers et al. Tasks performed by community health workers in Thomonde, Haiti: a case study of task-shifting.
Abstract 751. HIV Implementers Meeting June 2007, Kigali, Rwanda.
Distribution of HIV-related clinical care tasks
Rwinkwavu, Rwanda
50
46
Percentage of care tasks
45
40
35
28
30
25
20
15
10
7
5
9
7
0
0
RN
Non-clinical
staff
2
0
MD
MD/RN
MD or RN/
Non-clinical
MD/RN/
Non-clinical
MD/RN/
CHW
MD/RN/CHW/
Non-clinical
Ivers et al. Tasks performed by community health workers in Thomonde, Haiti: a case study of task-shifting.
Abstract 751. HIV Implementers Meeting June 2007, Kigali, Rwanda.
Inshuti Mu Buzima cost breakdown
Accompagnateurs account for only 9.3% of labor costs
and 4.2% of overall operating costs.
referrals
transport
infrastructure
administration
social
nonmedical staff
staff support
Labor
45%
supplies
PIH Boston staff
medical staff
CHWs
MOH staff
food
New partnerships
Inshuti Mu Buzima
Rwanda
March 2005
Bo-Mphato Litšebeletsong tsa Bophelo
Lesotho
March 2006
Abwenzi Pa Za Umoyo
Malawi
January 2007
What about in the urban U.S.?
New investments in global health
ORGANIZATION
FOCUS
DONORS
Bill and Melinda Gates
Foundation
Global health
Bill and Melinda Gates
$6.2 B*
The Global Fund to Fight
AIDS, TB, and Malaria
Financing treatment and prevention
Governments, foundations,
corporations
$8.6 B
President’s Emergency Plan
for AIDS Relief
Financing and delivery of HIV/AIDS
prevention and treatment
U.S. government
$15 B
International Finance Facility
for Immunization
Financing vaccine delivery/GAVI
U.K., France, Italy, Spain,
Sweden
$4 B
Multi-Country HIV/AIDS
Program
Financing scale-up of existing
prevention and treatment efforts
World Bank
Global Alliance for Vaccines
and Immunizations
Financing and delivery of childhood
vaccines
Gates Foundation,
governments
Public-private partnerships
Drugs, vaccines, microbicides,
diagnostics, etc.
Philanthropists, governments,
industry
$1.2 B
Anti-Malaria Initiative in
Africa (proposed)
Cut malaria incidence in half by 2010
in 15 countries
U.S. government
$1.2 B
United Nations Fund
Children’s and women’s health
Ted Turner
$360 M
*Total $40.7 billion… not including Warren Buffett!
Funds pledged, committed, or spent. Overlap exists between organizations (e.g., PEPFAR money supports the Global Fund).
Adapted from Jon Cohen, The new world of global health. Science 2006;311(5758):162-167.
FUNDS
$1.1 B
$3 B
New resources, old challenges
New technologies,
monies,
and strategies must still
pass through old
bottlenecks
Thank you