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Integration and Convergence in the context of National AIDS Program Planning in Resource-constrained Settings.

Author(s) Nabeel M K1
Affiliation(s) 1Education, Research, and Evidence-informed Advocacy, Public Health Organizations, New Delhi, India, 2, , , ,
Country - ies of focus Global,India
Relevant to the conference tracks Health Systems
Summary Using the principles of public health ethics, particularly resource allocation ethics, this paper conducts a conceptual analysis of Integration and Convergence in the light of National AIDS Program Planning in Resource-constrained Settings. Sustaining and maximizing current achievements equitably in a resource constrained environment is indeed a challenge. Resorting to a fair and legitimate priority setting framework is the bare minimum that countries ought to do, without which the AIDS programs stand a serious risk of implosion. By undertaking an exercise of meaningful deliberative democracy, there are potential substantive benefits beyond procedural ones.
Background HIV is now referred to as a chronic manageable condition – a class of conditions under which diabetes and hypertension are included. With the advent of ART and other advances in treatment, care, and support, and with the increasing number of persons newly infected with HIV, the number of people requiring prolonged care and treatment continues to grow. Thus there is a clear need to continue investments in order to consolidate and sustain the successes so far, as well as ensure that the successes of the global and national efforts are equitably distributed. Convergence and Integration have been advocated as means to achieve the above two goals. The Planning Commission of India working group on AIDS has also made remarks on similar lines that “one of the critical challenges is to move towards more effective and efficient approaches through convergence and integration of programme components such as basic HIV services, comprehensive care, support and treatment with National Rural Health Mission (NRHM) and general health systems to the extent possible” (Planning Commission Working Group on AIDS, 2011). Apart from reducing the costs of interventions, convergence and integration have the potential to strengthen overall health systems as well (Shakarishvili, G et al, 2011; 2010).
Objectives The objective of this paper is to analyse India's National AIDS Program planning through a lens of integration and a prism of resource allocation. The National AIDS Control Organization (NACO) – now a separate department under the central ministry of health and family welfare in India – conducted a series of consultations with stakeholder groups for planning the next phase of the National AIDS Control Program (NACP). Different reviews of the current phase of NACP indicate success against the set benchmarks on several fronts. The program is on track and will achieve the targets set for most of the indicators (NACO E-Consultation, 2011). The fourth phase of the program (NACP-IV) is projected as the logical next step in India’s efforts to halt and reverse the epidemic, which is also in line with the Millennium Development Goals (MDG). It is envisaged to build on the different achievements of its predecessor - NACP-III – in order to reverse the epidemic through enhanced prevention as well as reinforced care, support, and treatment. However, NACP officials themselves have stressed the need for concerted attention in future for “consolidating the gains and ensuring quality and coverage”. (NACO E-Consultation, 2011) In addition, there have been concerns regarding the availability of resources in order to continue the existing beneficial interventions and to accelerate the achievements in alignment with the national goals and the Millennium Development Goals (MDG) to halt and reverse the HIV epidemic. Quoting the Planning Commission of India’s steering committee on Health, media reports talked about a proposal to ‘merge’ NACP with the National Rural Health Mission (NRHM) (Times of India, 2012). According to some members of the steering committee, it is about training the front line health workers similar to the Auxiliary Nurse Midwives (ANMs) in the  AIDS program. However, officials from the Ministry of Health and NACO publicly expressed their unhappiness and emphasized that the NACP deals with a specialized issue and a clientele different from that of ANMs. (Times of India, 2012) It appears prima facie that this proposal for a “merger” originates with the objective to streamline the health programs. This most recent media debate does not mention the proverbial ‘elephant in the room’ which are the resource constraints faced by the AIDS program.
Methodology The analysis in this paper is based on the Modified Accountability for Reasonableness Framework. Whereas ethics can guide policy makers and program planners on “what ought to be done”, economic analysis and research evidence can substantially help in setting the priorities in a resource constrained environment. Scientific and research evidence informs us of the effectiveness of particular interventions in order to guide resource allocation decisions and economics tries to find out the efficiency of interventions from a population-health point of view. (Gibson J et al, 2005). While there has been concerted efforts to incorporate evidence and economics into the priority setting process, decision makers often feel a gap in ensuring the ethics  of decision making are addressed. (Gibson J et al, 2005). It is in this context that a framework like the Accountability for Reasonableness (A4R) becomes handy for decision makers to ensure a fair and legitimate process in priority setting (Daniels N, 2000). The A4R framework has demonstrated the potential benefits of ethical considerations to deal with the “how” part in the decision making process of allocating scarce resources. The further addition of a fifth condition of empowerment to the original four conditions further strengthens the framework (Gibson J et al, 2005). This addition is an important step in respecting autonomy by virtue of citizens and groups who are empowered to participate in the process.
Results The results of the analysis is described under the following five conditions of the A4R+E framework: Condition 1: Relevance
As per the Relevance condition, the decisions need to be made on the basis of reasons that ‘fair-minded’ stakeholders can agree upon as criteria for decision making. The reasoning must comprise evidence, principles, and values.Condition 2: PublicityThis condition stipulates that the decisions along with the rationale for decisions should be transparent and publicly accessible. Condition 3: Revision and Appeals
As per this condition, NACP-IV planning process must have built-in opportunities to revisit and revise decisions in light of further evidence or arguments and there should be a mechanism for challenge and dispute resolution.Condition 4: Enforcement
As per this condition "enforcement" is necessary to ensure that the above three process-oriented conditions are met.Condition 5: Empowerment
According to this condition, there must be “efforts to optimize effective opportunities for participation in priority setting and to minimize power differences in the decision making context”.Further, the following also needs to be kept in mind based on the results of conceptual research on Convergence and Integration. Convergence and Integration have different meanings – former being more of a programmatic high level consideration and the latter as a grass-roots level service delivery consideration. Yet, these two terms have traditionally been used synonymously to broadly refer to the concepts discussed in the above two paragraphs. However, the term ‘Merger’ is relatively new in this context and connotes a more radical approach where one entity will lose its identity once the process of merger is completed. In the context of health care organizations, mergers have raised difficult ethical issues from the perspective of clients and patients, and service providers (Shaw D, 2003). Even though mostly in the context of hospitals, there have been instances where the mergers achieved neither cost-reduction nor quality-improvement (Weil T, 2010). Thus, mergers, especially those done in haste, have the potential to harm the program and its beneficiaries. Even in the case of integration of HIV related services with general health systems, there are cautions against blanket integration as opposed to carefully planned integration of select interventions.
Conclusion The analysis in this paper reveals that issues related to resource allocation have not been acknowledged and addressed adequately in the planning process of NACP-IV. As a result, the planning process, even though participatory in nature, did not have a resource allocation framework to adhere to. Neither was it able to consult the stakeholders with possible options and rationales for decision making in the context of shrinking resources. In addition, the concepts of integration and convergence have not been dealt with in detail leaving room for speculations and misinterpretations as mergers. It does not seem to be a problem exclusive to India that resource allocation within and between sectors related to health gets inadequate if not neglected attention. Critiquing the report of the Commission on Social Determinants of Health, Bayoumi in 2009 has stated that the Commission missed an opportunity by being “largely silent” on the issue of resource allocation. However, the Commission’s report did in fact show skepticism towards the current trends of health care reform which gives a very narrow focus on economic efficiency; as opposed to a broader attention to priority measures (Bayoumi A, 2009). It is still not too late for India to adopt a framework like the modified version of the Accountability for Reasonableness framework with empowerment as an additional condition (Gibson J et al, 2005). Certainly, this framework cannot stand in isolation but must form a broader frame on which evidence and economic analysis form superimposing rubrics for decision making (Gibson J et al, 2006). For this to happen, first there should be an explicit acknowledgement of the ‘elephant in the room’, rather than silence about resource constraints. Sustaining and maximizing the current achievements equitably in a resource constrained environment is indeed a challenge. Resorting to a fair and legitimate priority setting framework is the bare minimum that India ought to do, without which the AIDS program stands a serious risk of implosion. By undertaking an exercise of meaningful deliberative democracy, there are potential substantive benefits apart from procedural ones (Gutmann A, 1997).

HIV Treatment vs Prevention Debate must Reconcile the Post-MDG Development Agenda Focus on Social Determinants and Human Rights

Author(s) Nabeel M K1
Affiliation(s) 1Education, Research, and Evidence-informed Advocacy, Public Health Organizations, New Delhi, India.
Country - ies of focus Global, India
Relevant to the conference tracks Advocacy and Communication
Summary With recent scientific advances in HIV, an old debate based on the treatment-prevention dichotomy is re-emerging. One side appeals that resources must now be diverted from conventional prevention strategies towards early treatment as it can prevent new infections. The other side argues, among other reasons, that treatment can realistically reach only a small subsection of those in need of it. Therefore investments in prevention need to be furthered in order to effectively contain HIV. This paper analyses the HIV prevention vs. treatment debate in the context of a post-2015 development agenda, particularly in light of Social Determinants and Human Rights.
Background With the global flat-lining of resources for HIV, there are appeals to prioritize based on reasonable resource allocation decisions and a search for high impact interventions that maximize ‘benefit’. In this context, and with recent scientific advances in HIV on the preventive benefits of Anti-retroviral Therapy (ART), an old debate based on the treatment-prevention dichotomy is re-emerging. One argument is that resources must now divert from conventional prevention strategies towards early treatment as it can prevent new infections. The other side argues that treatment can only realistically reach a small subsection of those in need so prevention investments need to be furthered in order to effectively contain HIV. Amidst the treatment vs. prevention debate, with the backdrop of the global financial crunch, concerns emerge as to how the goals of zero new infections and zero AIDS related death can be achieved as agreed upon by member states at the United Nations High Level Meeting in June 2011. Incidentally, the Millennium Development Goals of which halting and reversing the HIV epidemic is a key target, will soon give way to a new development agenda in the post-2015 period.
Objectives Public health professionals and national governments face this ethical challenge – whether to take the side of treatment or prevention. This paper aims to address the resource allocation dilemma arising from the choice whether to prefer HIV prevention or treatment in programs run by governments, by comparing the merits and demerits of the two positions from a public health point of view. It explores different theories and approaches which could be used for the analysis. Apart from this primary objective, the paper aims to feed into the post-2015 development agenda by proposing an integrated approach to several interconnected challenges encompassing not only HIV, but Social Determinants of Health, Human Rights, and Equitable health.
Methodology The main aspect of the methodology used in this analysis is to compare and contrast the two divergent positions:Position 1: With the evidence on “Treatment as Prevention” to divert scarce resources from prevention towards treatment: Position 2: Re-allocating funds from prevention budget to treatment is faulty as strengthening prevention is the way forward.The approach for analysis is to examine the following dimensions:i. Merits and Demerits of the two positions

ii. Problems in subscribing to either of the two

iii. Possibility of an alternative position

iv. Lessons from the past in related areas

Within this broad framework, the analytic methodology adopts a systems approach with an understanding that interconnected challenges need integrated solutions. Political and contextual factors, especially those related to power differences get too little attention in many of our discourses especially the ‘high theories’ (Arras J, 2010). In the process, individuals and groups with different types of vulnerabilities based on factors like gender, poverty and race tend to be disproportionately skewed in their respective risk-benefit equations. By ignoring the political and contextual factors related to power imbalances, people with different vulnerabilities tend to receive more harm than others. (Bertomeu M, 2009). Feminist approaches try to address this gap by adopting a bottom-up approach as opposed to some of the traditional theories that are top-down, abstract, and deductive in nature (Arras J, 2010; and Beauchamp TL, 2009). Accordingly, people who are otherwise oppressed or devalued in society are considered in discourses about policy options (Sherwin S, 1999). Moreover, critiques have pointed out the inappropriateness of using theories and approaches which were originally designed in the context of clinical ethics or research ethics for the purpose of public health ethics. (Baylis F, 2008, and Kenny N, 2010). Hence, we need an systems approach to research methodology not only considering health systems, but also integrating Social Determinants of Health, Human Rights, and Equity.

Results Even after three decades of responding to HIV, prevention programming continues to be ‘largely deficient’ (Bertozzi SM, 2008). Hence some proponents of the test and treat strategy, citing recent evidence, argue for the diversion of resources towards scaling up Antiretroviral Therapy (ART) as a strategy for HIV prevention. Yet, conventional prevention modalities continue to be the most inexpensive options. One of the arguments against conventional programs among sex workers is that condom use is not universal. It is often pointed out that sex workers tend to agree to transactional sex without condoms if there is a premium in the payment over and above what they get for sex with condom. However studies have identified the factors that make women vulnerable to such compromises (de la Torre A, 2010). Hence, prevention programs must broaden to influence structural determinants that make women vulnerable rather than totally denouncing behavioral and non-biomedical modes of HIV prevention. Studies also report that people who are treatment optimistic or who believe that ART can reduce the viral load and hence HIV transmissibility, tend to indulge more in risky sexual behaviour (Brennan DJ, 2010). This is especially profound when we consider education levels and other factors like power relations in the provider-patient relationship. The results of the detailed (not included here due to space constraints) analysis did not favor one over the other in the treatment vs. prevention debate. However, the analysis led to an alternative position where it is demonstrated that the treatment-prevention dichotomy is in fact irrelevant in the context of recent scientific advances that profess the very concept of “Treatment as Prevention”. By opting for an integrated continuum model, HIV programs can still have treatment as one of the options in a combination prevention strategy. By doing so, HIV programs demolish the water-tight compartments of treatment and prevention, thereby leading to a more realistic path towards the goals of zero new infections, zero AIDS related deaths, and zero discrimination. This approach is crucial to uphold the rights and interests of those who are marginalized in society due to different socio-political, economic and cultural factors. In the absence of a holistic approach relevant to the local contextual factors, issues of the marginalized will skip the frameworks created for monitoring and evaluation of programs; and hence remain unaddressed.
Conclusion Analysis of the two conflicting positions has demonstrated both advantages as well as disadvantages of these positions. Any bias towards treatment or prevention in a public health scenario tends to overlook some issue or the other and is faced predominantly by the oppressed or otherwise less-valued groups of people in the society. It is in this context that this paper argues to strengthen the prevention-treatment-care continuum. This has been proposed earlier, before the recent advances that led to calls for ‘test and treat’ strategy based on the premise of ‘treatment is prevention’ (de Loenzien M 2009; and Simon V, 2006). Further within this broader continuum model, a continuum of prevention is also identified: one which takes into consideration not only the uninfected, but also infected persons at different clinical stages ranging from asymptomatic individuals to those who clinically require ART and other advanced forms of care (Simon V, 2006). HIV policies and programs in some developing countries have taken this model to higher holistic levels by including palliative care in the continuum model. At the same time, they have acknowledged the need to address other larger issues like poverty, gender-based power differences, and other health issues - especially reproductive health issues, which are also determinants of success in HIV control programs (de Loenzien M 2009). Thus we can see that by over-emphasizing a medicalized model through a test and treat strategy, national HIV programs will be missing crucial opportunities in addressing larger human development issues. Even within the domain of health, an HIV prevention strategy predominated by early ART alone ignores the interconnected challenges including other sexually transmitted diseases and the social factors that determine many diseases which are disproportionately prevalent among poor and socially marginalized sections of society (Reading JL, 2009). Success in HIV prevention programs has been shown to be associated with measures to address gender disparities, counter stigma and discrimination and mobilize affected communities (Merson MH, 2008). A continuum approach or an integrated one has also been shown to provide a human rights framework for examining state responsibility with respect to obligations towards a wide range of people whose lives are infected and affected by HIV (Walker E, 2007). In the move from MDGs to post-2015 agenda, such integrated approaches must guide us.