Global Health Initiative Strategy ARME NIA March 2012 Contents List of Acronyms ........................................................................................................................ 2 Executive Summary .................................................................................................................... 3 GHI Vision .................................................................................................................................. 4 GHI Partner Country Priorities and Context ............................................................................... 5 GHI Objectives, Program Structure, and Implementation .......................................................... 8 Health Resources Used More Efficiently ............................................................................................... 8 Armenians Exercise Their Health Rights and Responsibilities ............................................................. 10 Improved Quality of Health Care Services ........................................................................................... 11 Sustainability Plan .................................................................................................................... 13 Monitoring and Evaluations and Learning ............................................................................... 14 Communications and Management Plan .................................................................................. 15 Women, Girls, and Gender Equality Narrative ......................................................................... 16 Linking High-Level Goals to Programs .................................................................................... 17 Health resources used more efficiently ............................................................................................... 17 Armenians exercise their health rights and responsibilities ................................................................ 17 Improved quality of healthcare services ............................................................................................. 17 1 List of Acronyms ANC Antenatal Care BBP Basic Benefit Package CPG Clinical Practice Guidelines DHS Demographic Health Survey DoD Department of Defense DOTS Directly Observed Treatment, Short Course EUR/ACE Bureau of European and Eurasian Affairs FP Family Planning GDP Gross Domestic Product GFATM Global Fund for AIDS, TB, and Malaria GHI Global Health Initiative GIZ Gesellschaft für Internationale Zusammenarbeit GOAM Government of Armenia HIS Health Information System HIV/AIDS Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome HS-STAR Healthcare System Strengthening in Armenia Project ICT Information and Communication Technology IMR Infant Mortality Rate IR Intermediate Results M&E Monitoring and Evaluation MCH Maternal and Child Health MCPR Modern Contraceptive Prevalence Rate MDG Millennium Development Goals MDR-TB Multi-drug Resistant Tuberculosis MIDAS-3 Medical Institution Data Analysis System-3rd Version MMR Maternal Mortality Rate MOH Ministry of Health MSF Medecins Sans Frontieres NCD Non-Communicable Disease NTP National Tuberculosis Program ODC Office of Defense Cooperation PCV Peace Corps Volunteer PHC Primary Health Care PPP Public-Private Partnerships QA Quality Assurance QI Quality Improvement RH Reproductive Health SHA State Health Agency TB Tuberculosis UNFPA United Nations Population Fund UNICEF United Nations Children's Fund USAID United States Agency for International Development USG United States Government U5MR Under-5 Mortality Rate WB World Bank WHO World Health Organization WID/GAD Women in Development/Gender and Development XDR-TB Extremely Drug-Resistant Tuberculosis 2 Executive Summary The health system in the Soviet Union focused on specialization and in-patient hospital care with numerous vertical systems aimed at specific service areas. The Soviet system did not generally promote clinical practices based on evidence or guidelines. It also managed budgets centrally and distributed funding based on inputs (i.e., the number of hospital beds or doctors). The government served as both the purchaser and provider of health services, making the system inefficient, discouraging quality improvement, and inducing parallel systems of informal payments. Since independence, Armenia has made strides in reforming its health system and improving the overall health status of its citizens. Over 90% of the population is now enrolled with a provider of choice, and key health indicators have continuously improved over the past ten years. However, despite impressive strides in health care reform, much work remains. Armenians cannot access all free services contained in the government-guaranteed Basic Benefits Package, and there is a lack of alternative financing mechanisms. As a result, the poorest households are hardest hit, paying the largest share of expenses proportional to income. Furthermore, the primary care reimbursement system is outdated, the government allocates significantly less than the World Health Organization-recommended amount to health care, and these scarce resources are not used effectively. The United States Government, in coordination with the Government of Armenia and other international donors, will work to further reform the health system in order to achieve mutually desired health outcomes through sustainable approaches and increased host- country ownership. This five-year strategy is intended to be a roadmap for the United States Government to focus its health programming in Armenia in a manner that will effectively support the gains made so far as well as ensure the capacity of the Government of Armenia to follow through with current initiatives. Under GHI, the USG will take a broad, systems-level approach, while prioritizing maternal and child health including family planning health outcomes. The USG will focus programming in three areas: more efficient use of financial resources, improved quality of services, and enabling citizens to exercise their health rights and responsibilities. In these three areas, the following health outcomes will ensure a high level of sustainability and minimize potential back-sliding: • Reduction in out-of-pocket spending, with simultaneous increase in government spending on health care; • Licensing and certification mechanisms established to improve the quality of health services; • Improving the treatment and prevention of tuberculosis and multi-drug resistant tuberculosis; • Reduction of maternal, neonatal, and child mortality; and • Promotion of modern methods of family planning and access to quality reproductive health services. Despite improvements in the health status of Armenians over the past decade, work remains to ensure gains are sustainable and the Government of Armenia is positioned to continue implementing reforms. 3 GHI Vision The Global Health Initiative (GHI) Strategy for Armenia builds upon the priorities of the Government of Armenia (GOAM) and successes of the United States Government’s (USG) health assistance to date. The USG has long lived the principles of the GHI in Armenia through a country-led plan in the form of an Assistance Agreement with USAID, close collaboration with other international organizations and USG agencies, a focus on systems strengthening including instituting systems for monitoring reforms, and a focus on women and girls especially though programs to end domestic violence. This five-year strategy, designed in the context of reduced USG health funding and the need for a strategy with more targeted interventions, will work towards mutually desired health outcomes through a continued emphasis on sustainable approaches and increased host-country ownership. A strong, reliable, and quality health system in Armenia contributes to other USG strategic goals in the region such as improved economic productivity, institutionalized transparent governance, as well as domestic and regional stability. Because of this – and although only USAID receives designated health funding in Armenia – a collaborative approach to the implementation of the GHI strategy in Armenia in the years to come will further USG long-term interests in the region and promote economic and social development of the country. Over the past decade, the USG and the GOAM have worked closely together to lay the foundation for a more equitable and efficient Armenian health system. A Basic Benefits Package (BBP) was introduced, which provides free primary health care and maternity services to all Armenians. Every resident is also now able to choose his/her own health care provider in the Open Enrollment System. Additionally, improvements were made in family doctor and nursing skills, and independent family medicine practices were introduced. Despite these impressive strides in the health care sector, targeted work remains to ensure the broadest range of services is available to the Armenian population, especially women and girls, financial resources are used in the most efficient manner, the quality of services continues to improve, and citizens are able to exercise their health rights and responsibilities. Currently, the GOAM is finalizing an overarching national health plan with the assistance of the World Health Organization (WHO) and USAID. Meanwhile, the GOAM does have individual strategic plans focused on vertical priorities in tuberculosis (TB), primary health care (PHC), reproductive health (RH), child and adolescent health, and non-communicable disease (NCD). The GHI strategy will serve as a roadmap for all involved parties to target assistance and health reform priorities in an integrated manner to ensure sustainability of health reforms and outcomes. Under GHI, the USG will work in the following areas, in the prioritized order, and according to the funding streams. These areas are of equal priority for the GOAM: • Reducing maternal, neonatal, and child mortality; • Improving the treatment and prevention of TB and multi-drug resistant TB (MDR-TB); • Promoting healthier lifestyles and improving preventive service provision to mitigate the impact of NCDs; • Promoting modern methods of family planning (FP) and access to quality RH services; and 4 • Targeting an approach to HIV/AIDS prevention, care, and treatment that leverages Global Fund for AIDS, TB, and Malaria (GFATM) resources. In its efforts to achieve these health outcomes, the USG, in partnership with the GOAM, will embody key principles of the GHI to guide our assistance in the most effective manner. For instance, along with a strong focus on the promotion of gender equality, the USG will emphasize data-driven decision making through robust monitoring and evaluation (M&E) of projects and initiatives. The USG will also continue to build the capacity of the GOAM to use health statistics in future planning and service provision. By strategically coordinating our assistance with the similarly decreasing funding levels in the wider donor community (World Bank, UNICEF, UNFPA, GFATM, WHO) and working within GOAM country-led plans and priorities, the USG will not only ensure the delivery of evidence-based assistance, but also strengthen local capacity and sustainable Armenian institutions to promote good health outcomes in the long-term, independent of USG resources. GHI Partner Country Priorities and Context Despite impressive strides in PHC reform and health outcomes (See Table 1), much work remains to be done in order to use existing financial resources more efficiently, improve the quality of services, and enable citizens to exercise their health rights and responsibilities. Armenians cannot access all free services reputedly contained in the BBP. There is a lack of alternative health financing mechanisms—such as social health insurance, private health insurance, co-payments, fee for services, performance-based remuneration—to make up for the reality that not all services can be subsidized by the GOAM. Currently, the poorest households continue to finance the largest share of health system expenses proportional to household budgets, largely through out-of-pocket payments for services at point of delivery. The primary care reimbursement system is still outdated, relying on per-capita payment to facilities based on the estimated number of clients in the “catchment” area. According to the 2010 Armenia Corruption Survey of Households, the healthcare sector is perceived to be one of the most corrupt sectors in the country. It is generally considered that corruption is derived on the user level of the health system, in the form of under-the-table payments, rather than on an administrative level. 5 Table 1: Key Health and Population Indicators in Armenia Indicator Source Population 2,967,975 CIA World Factbook (2011 est.) Life expectancy 70 years 2009 WHO Fertility rate 1.7 2010 DHS Contraceptive prevalence rate 54.9% any method 2010 DHS 24.2% modern method Maternal mortality rate 29/100,000 live births 2008 WHO Proportion of women accessing 99.1% 2010 DHS antenatal care from a skilled provider Proportion of deliveries 99.5% 2010 DHS assisted by skilled birth attendant Neonatal mortality rate 8/1,000 live births 2010 DHS Infant mortality rate 13/1,000 live births 2010 DHS Under-five mortality rate 16/1,000 live births 2010 DHS Fully immunized children <1 91.5% 2010 DHS year TB incidence (all forms) 73/100,000 population 2009 WHO MDR-TB 9.4% new TB cases 2008 WHO 43% retreated TB cases HIV prevalence 0.1% 2009 WHO Most prevalent causes of Cardiovascular diseases: 50% 2009 WHO, MOH, WB mortality1 Malignant neoplasms: 20% Respiratory system diseases: 6% Traumas and poisoning: 5% Diabetes mellitus: 5% Digestive system diseases: 5% Smoking prevalence 61% men 2006 WHO 2.7% women According to the 2009 Health Systems Performance Assessment in Armenia, the GOAM allocated only 1.5% of GDP on government health expenditures, among the lowest allocations in the world, and well below WHO-recommended levels of 3-4%. Scarce health resources are not effectively distributed among health care providers and institutions. While a foundation has been established by USAID to track the number of patients registered by facility, as well as understand where improvements are occurring in healthcare outcomes, continued targeted technical support is needed to familiarize the GOAM with these tools which can assist them in more effectively allocating resources. 1 These figures present the most prevalent causes of mortality in Armenia as a percentage of the total disease burden. Armenia Health System Performance Assessment, 2009 6 Additionally, problems with structure impede positive change. U nder the Soviet system, Armenia had several parallel, vertical systems that were disease-specific which functioned as a person’s first point of contact with the health system. Now, more Armenians are using the primary care system when they need care. However, payment methods, incentives, and enforcement mechanisms supporting quality primary care are not in place. While USAID has introduced systems to improve the quality of care, there is limited motivation for health care providers to establish and maintain continuous quality assurance mechanisms at health facilities. Poor licensing regulations and continuous medical education requirements, coupled with the lack of an accreditation system, impede progress in health reform. Private sector capacity is also weak in primary care service delivery. Competitiveness in the health sector is restricted, and motivation for facilities to provide customer-oriented services is low, leading to low quality health services. The GOAM has addressed quality assurance (specifically in terms of guidelines for NCDs), financing and incentives in their Primary Health Care Strategy. It also prioritizes improvements to the quality of healthcare and motivates providers through performance-based financing and incentive payments. This will complement the enrollment based financing for BBP services at the PHC level. High rates of TB and MDR-TB ensure that Armenia ranks among the countries with the highest burden of the disease (See Table 1). According to WHO, in 2009 the prevalence of TB was 107 per 100,000 population, incidence was 73 per 100,000, and case detection rate was 73 per 100,000. Armenia reports 100% DOTS coverage for treatment, but gaps remain in the quality of implementation of the program and its case detection and treatment success rates. Challenges also exist in the laboratory system in Armenia, with only 35% of new TB cases being confirmed as smear positive. According to the 2009 Health System Performance Assessment in Armenia, there has been limited progress in reducing maternal mortality, cardiovascular diseases and malignant neoplasms (See Table 1). The 2009 State of the World’s Children report noted that women in Armenia are nine times more likely to die from pregnancy or childbirth than women in developed countries. Despite progress towards the Millennium Development Goals (MDG) of reducing maternal mortality rate (MMR) and under five mortality rate (U5MR), data shows that Armenia is not quite on track to easily meet the goals by 2015. Through several strategy documents, the GOAM has outlined its priorities for PHC, TB and MDR-TB, and maternal and child health (MCH). Table 2 summarizes GOAM priorities in these areas. Table 2: Priority Areas for the GOAM Priority Area Specific Priorities Implement quality assurance in PHC services Prevent NCD Strengthen human capacity, performance-based financing and incentives PHC Continue Open Enrollment Improve the provider mix Raise public awareness 7 Reduce morbidity, mortality and drug resistance TB and MDR-TB Diagnose 80% of MDR-TB cases Treat 60% of MDR-TB cases Reduce levels of maternal mortality Define standards and responsibilities of PHC providers MCH Increase utilization of modern contraceptive means by all those who want to use them Integrate RH services in to PHC In recent years, due largely to donor involvement and coordination, Armenia has made great improvements in the health status of its citizens. It is within this context that the USG will work through GHI to begin to target interventions while building on past successes in integrated systems reform in the health sector. The elements and activities of this strategy are all necessary to reach a point of progress that will be sustainable by GOAM resources and are contingent on the availability of future funding and the nature of earmarks. Sustained USG investment at current levels over the next five years is needed to realize critical health reforms in Armenia, and make those reforms known to and understood by Armenians. GHI Objectives, Program Structure, and Implementation The GHI strategy will outline how the USG will address the weaknesses and gaps in the primary health care system and leading causes of maternal and neonatal morbidity and mortality by strengthening the Armenian health care system to: • Use health resources more efficiently; • Empower Armenians to exercise their health rights and responsibilities; and • Improve the quality of health care services. These three areas of focus were chosen as they are GOAM priorities outlined in several strategy documents, as well as crucial areas that must be improved if the health care system will be sustainable and of high quality. Additionally, USAID signed an Assistance Agreement with the MOH in 2010 which defines these areas as mutual priorities. USAID regularly coordinates with other international donors in the health sector to minimize duplication and amplify results. The USG’s development hypothesis states that by focusing USG efforts in these three areas to address the bottlenecks in the health system, Armenia will have a sustainable health system with improved quality in five years, setting the country on path to meet its strategic goals. Health Resources Used More Efficiently Financial resources, both from the government and from individuals, are essential to maintaining and sustaining health reforms. Health funds are generated by increasing government expenditures and/or by using existing resources more efficiently. The USG will focus on the latter while maintaining a dialogue with the GOAM to increase its allocation of public expenditures as a percent of GDP for health programs. GOAM performance in using public financial resources more efficiently will be measured by the proxy indicator of reducing 8 individuals’ out-of-pocket payments as a percent of total health expenditures from 51% in 2011 to 37% in 2015, based on National Health Account data. Building on the Open Enrollment system implemented by USAID, the GOAM will utilize USG assistance to expand the system to include a provider payment mechanism based on the actual enrolled population at each facility. Incentive payments to PHC facilities will be implemented through an innovative pay-for-performance system that will reward high performance against a set of agreed upon PHC indicators including pre-conception RH care seeking, early prenatal care, and preventive child care visits. The USG will support the GOAM’s work to simultaneously address health purchasing and risk pooling mechanisms. Specifically, USAID will support the State Health Agency (SHA) in the design, development, and implementation of a new hospital payment system to close the funding gap by increasing health system efficiency and linking payment for inpatient care to BBP services; and in strengthening legal, regulatory, technical, and operational frameworks for the national funds for the BBP. The USG will coordinate with other donors, including the WHO and the GFATM, to work with the SHA and National Tuberculosis Program (NTP) on refining the provider payment system for TB services. The BBP is integral to ensure that all Armenians have access to health services, as well as to achieve GHI goals in MCH, TB, and RH. USAID will work with the GOAM to redefine the health care services and populations covered under the BBP, and ensure that it continues to include and prioritize MCH/RH/FP/TB/NCD and prevention services. Coordination with the World Bank (WB) will contribute to restructuring the co-payment system for inpatient care. USAID will continue to participate with other donors and the GOAM in a national working group created to identify the most effective organizational structure for PHC in urban areas, encouraging an optimal provider mix. USAID will also support the formation of independent PHC practices, help create an enabling environment for independent providers, provide management support to help newly established private practices, and provide commodity support for those new practices. USAID will closely monitor the progress and ease of establishing these practices to ensure efficiency and effectiveness. A key component to developing and maintaining a strong health sector is developing and retaining skilled human resources. The current workforce in Armenia continues to favor specialization over general practice, and its distribution remains unbalanced across regions and urban and rural areas. USAID will work with the MOH to build internal capacity, especially targeting women as they comprise the majority of the health workforce, for workforce planning which includes a rapid assessment of the workforce using existing data; automating paper-based exercises that are currently in use to analyze supply; mining health information systems to tease out workforce information; and creating a simple computerized human resource information system linked to other operating health information systems. In particular, technical assistance provided by USAID will introduce and refine health financing mechanisms, such as provider payment systems and decentralized decision making, and will improve transparency and accountability in resource allocation. By changing how services are 9