Framework Dimension: Resources
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The adequate investment of resources (implementation event)
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• From the 1990’s to 2007, the country received ARV donations from Brazil; • In 2002 the country starts receiving resources from the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM); • Between 2002 and 2003, 48 treatments are supplied through litigation; • In 2003 US$ 20,000 were allocated for ARV purchase by government; • In 2006, the GFATM grant is renewed. |
• A first strategic plan for HIV which dealt with resource investment was established in 1999; • In 2002, the Clinton Foundation (Clinton Health Access Initiative - CHAI) begins supporting the implementation of World Bank and GFATM projects; • Hospitals in Maputo started offering treatment in 2003-04 • In 2003-04 NGOs trained staff and channeled resources for diagnosis in Maputo, Beira, Nampula; • From 2004 to 2009: continuous effort to train health professionals and medical technicians to meet staffing needs for planned care. |
• 1995-2000 there was no budget for ARV provision. (out-of-pocket payments for services and medicines); • 2000: a specific budget allocation for ARVs; • 2003: First ARV purchase with GFATM resources, expanding coverage to 3800 PWH; • 2006: MoH becomes responsible for ARV provision (60% of costs). • 2007: Percentage was upped to 70% of costs; • 2008: 100% of costs. Coverage expanded to 14,300 PWH. |
Resource stabilization (routinization event)
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• GFATM contract since 2002; • GFATM renewed in 2006; • 1990’s -2007 irregular flow of donations from Brazil. (In 2007, donations are discontinued); • 2007: HIV / AIDS law (Law 3729/07); no additional legislation has been passed to make the law operational; there is no guarantee of budget allocation for ARVs; • 2007-2009 many changes in program coordination. |
• 2004-08 strategic plan reflects gradual increase-in-coverage choice; • Highly variable flow of resources for AIDS; funding from the GFATM and renewal of WB not guaranteed; • Existence of a common health fund, including human resources and medicine provision for the purchase and distribution of all medicines, including ARVs; • 2006: Brazil (represented by the Oswaldo Cruz Foundation), offers continuous training to health boards, doctors and other professionals. |
• 2006-2008, the MoH becomes fully responsible for ARV financing; • 2008: the government changed the type of employment contracts stipulating fixed-term renewable contracts. |
Framework Dimension: Activities
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Compatibility of program activities with those of the organization (implementation event)
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• Lack of technical capabilities for procurement of ARVs by MoH. External agents (CIESS, UNDP, Ibis-Hivos) involved in procurement. |
• Since 1999, first MEDIMOC then the Center of Medicines and Medical Items (CMAM) have collaborated with MINSAU routinely with medicines purchases. |
• 2003: DIGEMID already exercised provision-related activities such as selection and forecasting for other medicines and became responsible for ARVs; • Procurement, storage and distribution, were taken over by OGA, which already carried out these same activities for other medicines. |
Adaptation of activities (joint implementation and routinization event)
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• 2004-2006 CIESS involved in ARV provision; • In 2006, after an evaluation by the GFATM, CIESS is removed from activities; • In 2006 UNDP temporarily substitutes CIESS; • In 2006, Ibis / Hivos and PROSALUD are chosen for ARV procurement and distribution activities, after tender carried out in the country. • Since the Ibis / Hivos Foundation began operations, continuity of provision of ARVs can be observed. • With Ibis / Hivos Foundation there was a change in procurement strategies resulting in the introduction of new suppliers and the obtaining of lower prices for ARVs. |
• From 2007: responsibility of ARV procurement was transferred from MEDIMOC to CMAM (change of status of MEDIMOC from public to privately-held); • After 2008: the rapid expansion and decentralization of treatment coverage required an upgrade in provincial management and structural capabilities exposing management failures (shortages, surplus stocks and expired medicines). |
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Framework Dimension: Reinforcement strategies
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Incentives (joint implementation and routinization event)
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• There was specific hiring of professionals for purchase ARVs in CMAM; • Until 2008 there were day hospitals, and selective recruitment of physicians for HIV / AIDS care. There were financial resources for extra work, training trips, courses and conferences which led to physicians to desire working exclusively for the program. |
• 2008: employees receive career benefits that they did not enjoy previously. |
Transparent communication (joint implementation and routinization event)
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• Regular meetings are scheduled between ESN, DIGEMID, OGA and DISA for discussion and planning of ARV selection and forecasting. |
Risk Taking (routinization event)
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• Innovative procedures in entrance clearance for ARVs have streamlined the release of lots by customs, making it possible to make imported medicines available in 24 hours. |
• 2008: the health system has integrated HIV / AIDS care into general health care which requires greater quantity and quality of human resources. |
• Since 2003, Peru has participated in ARV price negotiation rounds in order to achieve lower prices and greater coverage. • 2009: Peru has the best buyer profile among Latin America countries. |
Integration of rules (joint implementation and routinization event)
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• 2004: official regulations on the use of ARVs were released and all health professionals have to adhere to them. • 2004-2008 :The strategic plan of 2004-08 reinforced the legitimacy of the protocols. |
• Since 1997 a succession of laws, edicts and other legislation have regulated HIV/Aids care within the health system. |
Framework Dimension: Context and organizational culture
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Adjustment of goals/ Objectives fit (joint implementation and routinization event)
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• March 2008: closing of the Day Hospital, replaced by Health Counseling and Testing Service (ATS), for diseases in general, not just AIDS. • 2008: the decision to expand treatment with the definition of the Health Facility network and of treatment goals. |
• In 2008, the MoH becomes fully responsible for ARV provision. New duties assigned to existing MoH agencies are synchronic with their institutional missions. |
Sharing Cultural Issues (joint implementation and routinization event)
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• 2008: with the closing of the Day Hospitals, many patients felt discriminated against by the newer Health Facilities and left to seek care outside the system. |
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