title: Positive spill-over effects of ART scale up on wider health systems development: evidence from Ethiopia and Malawi.
abstract: BACKGROUND
  Global health initiatives have enabled the scale up of antiretroviral treatment (ART) over recent years. The impact of HIV-specific funds and programmes on non-HIV-related health services and health systems in genera has been debated extensively. Drawing on evidence from Malawi and Ethiopia, this article analyses the effects of ART scale-up interventions on human resources policies, service delivery and general health outcomes, and explores how synergies can be maximized.
  
  
  METHODS
  Data from Malawi and Ethiopia were compiled between 2004 and 2009 and between 2005 and 2009, respectively. We developed a conceptual health systems framework for the analysis. We used the major changes in human resources policies as an entry point to explore the wider health systems changes.
  
  
  RESULTS
  In both countries, the need for an HIV response triggered an overhaul of human resources policies. As a result, the health workforce at health facility and community level was reinforced. The impact of this human resources trend was felt beyond the scale up of ART services; it also contributed to an overall increase in functional health facilities providing curative, mother and child health, and ART services. In addition to a significant increase in ART coverage, we observed a remarkable rise in user rates of non-HIV health services and an improvement in overall health outcomes.
  
  
  CONCLUSIONS
  Interventions aimed at the expansion of ART services and improvement of long-term retention of patients in ART care can have positive spill-over effects on the health system. The responses of Malawi and Ethiopia to their human resources crises was exceptional in many respects, and some of the lessons learnt can be useful in other contexts. The case studies show the feasibility of obtaining improved health outcomes beyond HIV through scaled-up ART interventions when these are part of a long-term, system-wide health plan supported by all decision makers and funders.
authors.affiliation: Institute of Tropical Medicine, Department of Public Health, Belgium, Antwerp, Belgium. frasschaert@itg.be
authors.forename: Freya
authors.initials: F
authors.lastname: Rasschaert
authors.forename: Marjan
authors.initials: M
authors.lastname: Pirard
authors.forename: Mit P
authors.initials: MP
authors.lastname: Philips
authors.forename: Rifat
authors.initials: R
authors.lastname: Atun
authors.forename: Edwin
authors.initials: E
authors.lastname: Wouters
authors.forename: Yibeltal
authors.initials: Y
authors.lastname: Assefa
authors.forename: Bart
authors.initials: B
authors.lastname: Criel
authors.forename: Erik J
authors.initials: EJ
authors.lastname: Schouten
authors.forename: Wim
authors.initials: W
authors.lastname: Van Damme
mesh_terms: D000293:Adolescent; D000328:Adult; D019380:Anti-HIV Agents / Q000627:therapeutic use*; D002648:Child; D005002:Ethiopia; D005260:Female; D006078:Government Programs / Q000191:economics; D015658:HIV Infections / Q000188:drug therapy* / Q000191:economics; D006296:Health Services / Q000191:economics; D006280:Health Workforce; D006801:Humans; D008295:Malawi; D008297:Male; D015397:Program Evaluation; D055815:Young Adult
chemical_list: D019380:Anti-HIV Agents