Transcript The Global Fund and Health Systems: Beefing up or Breaking

The System-Wide Effects of the Fund (SWEF) Research Network
Health Systems and HIV/AIDS: The Experience of
the Global Fund
Sara Bennett PhD and Kate Stillman MPA
With Hailom Banteyerga, Aklilu Kidanu, (Ethiopia), Owen Smith, Sourou Gbangbade,
Assomption Hounsa, Lynne Franco (Benin), Brian Mtonya, Victor Mwapasa, and John
Kadzandira (Malawi)
The PHRplus Project is funded by U.S. Agency for International Development and implemented by:
Abt Associates Inc. and partners, Development Associates, Inc.; Emory University Rollins School of
Public Health; Philoxenia International Travel, Inc. Program for Appropriate Technology in Health;
SAG Corp.; Social Sectors Development Strategies, Inc.; Training Resources Group; Tulane
University School of Public Health and Tropical Medicine; University Research Co., LLC.
URL: http://www.phrplus.org
Research Objectives
To document the effects of the processes
involved in applying for and receiving a
Global Fund grant, and implementing
GF-supported activities on the health
systems of recipient countries.
HIV/AIDS and Health Systems
System
Function
Key Questions for HIV/AIDS
Stewardship –
policy process &
governance
How aligned with government policies?
Extent of harmonization across donors?
How inclusive & transparent policy processes for GF?
Monitoring AIDS programs
Resource
Management
Impact on quantity, distribution, skills, motivation & time
allocation of health workers?
Impact on drug management; availability; rational drug
use?
Financing
-
Service
Provision
- Scaling up access to prevention & care (through the
private sector)
- Enhancing quality of clinical & personal services
Promotes financial accessibility of services
- Promotes financial sustainability
Research Design & Methods
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Country studies in Benin, Ethiopia and Malawi
Baseline and follow-up surveys (this is baseline)
Data collection: document review, in-depth
interviews (national & sub-national), and facility
survey
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Benin: September – October 2004
Ethiopia: November 2004 – January 2005
Malawi: June-July 2005
Independent studies but extensive stakeholder
engagement in-countries
Overview of HIV/AIDS Grants in Study
Countries (Rounds 1-4 only)
Benin
Ethiopia
Malawi
GF 2yr approved
$11.4m
$97.3m
$41.8m
For HIV/AIDS (Round)
(Round 2)
(Round 2 & 4)
(Round 1)
GF $ per person
/ per annum
$1.69
$1.38
$3.45
Govt. health
spending pp/pa
$9.00
$2.00
$6.00
UNDP
HAPCO
NAC
MAP
MAP,
PEPFAR
Clinton
MAP
Clinton
PRs
Other major
AIDS initiatives
Sources: Global Fund, World Health Report 2005
The Global Fund and health systems
 From
initiation, stated commitment to
addressing “HIV/AIDS in ways that
contribute to strengthening of health
systems”
 But, no guidance on what sorts of health
systems strengthening permitted, and few
cross-cutting proposals approved
 Round 5 (June 2005) first explicit call for
health systems proposals
SWEF Findings - Policy Processes
 Alignment
GF-supported programs perceived by
respondents as a “gap filling opportunity” &
fit within country plans
 In practice, GF often distorts or creates
additional structures & processes
eg.separate funding channels, new
management entities
 Perceived to operate in a centralized and
vertical manner

Impact of centralized decision making
processes
“GF is centralized and we have no say on it apart from
implementing the activities set in the action plan….We have no
ownership or say…This has affected the effectiveness and
quick implementation of the GF programs.”
Regional respondent, Ethiopia
“Unfortunately the CCM has no connection with us. In fact we
need to have a regional coordination mechanism which should
be represented in the CCM to reflect regional interests.”
Regional respondent, Ethiopia
SWEF Findings - Policy Processes
 Harmonization

Country stakeholders perceived
harmonization across donors…but heavy
reporting load
 Transparency
& Accountability
Lack of transparency about allocation of
resources between districts/regions
 Limited knowledge of GF outside immediate
stakeholders
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SWEF Findings – Human Resources
for Health
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Capacity constraints - currently most
conspicuous at the central level – but concerns at
lower levels
HRH strategies
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GF-supported training focuses on
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Benin & Ethiopia - no comprehensive strategy –
uncoordinated approach, distorted incentives
Malawi comprehensive national strategy – GF money redirected to this (and successful in Round 5)
clinical (not managerial) skills
in-service (rather than basic) training
Potential positive impact on motivation via
improvements in work environment
Respondent perspectives on HRH
constraints
“There is a need for more senior staff members in the MOH to
supervise and coordinate the implementation of HIV/AIDS
activities in the public sector. Currently TAs outnumber fulltime senior MOH staff, a situation which might lead to loss of
local ownership”
Malawi, MOH official
“The ART clinic is overwhelmed with patients…Gradually we
have increased the number of clinicians working in the ART
clinic from 1 to 3, much to the detriment of other hospital
clinical services”
Malawi, Health worker
SWEF Findings – Public/Private Mix

Infertile ground for public/private partnerships
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lack of clear policy or common understanding about
roles for the private sector
New collaborative arrangements emerging
umbrella organizations, sub-contracts, subsidies,
etc. – potential to change culture
Growth in non-profit sector – but concerns about
capacity and diversion from non-ATM activities
Lack of capacity to coordinate within private
sector an obstacle – but also emerging initiatives
No or limited evidence of migration between
sectors
Perspectives on Public/Private
Relations
“There is a tension between government and NGOs. It is all
attitudinal…..I think NGOs are not getting GF grants because
Government does not have a positive attitude towards NGOs
and doesn’t trust NGOs.”
Ethiopia, NGO/private sector respondent
“The option of referring patients to other private facilities or
CHAM hospitals to receive ARVs is a non-starter, government
would not allow it. Government does not want to show that is
not capable of delivering HIV services with the current
resources in the hospitals.”
MOH Official, Malawi
SWEF Findings: Pharmaceuticals and
Commodities
Procurement
Distribution
Benin ITNs
PSI
PSI
Benin ARVs
UNICEF
MOH (HIV/AIDS program)
Ethiopia all drugs
PASS
PASS
Malawi ARVs
UNICEF
UNICEF
Malawi other drugs
UNICEF
Central Medical Stores
SWEF Findings: Pharmaceuticals and
Commodities
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LFA assessments led to extensive by-passing to
“speed up” procurement particularly for ARVs.
 Inefficiencies: system duplication, additional
workload
 Difficulties tracking drugs
 Missed opportunities for system strengthening
No clear plans for strengthening routine systems
Ethiopia – PASS procurement slow to start, but
promising signs of internal improvements
Danger of differential pricing for the same
commodities – and parallel cost recovery
approaches (ITNs)
Conclusions – Do No Harm!
 If
by-passing routine systems, then make
plans to build them up
 Try to encourage planning processes
which take account of decentralization or
integration policies
 Don’t allow development of alternative
user fee or revenue collection structures
Conclusions – What is needed to
build health systems for HIV/AIDS Big Picture?

More countries need clearer visions, policies and
plans about what is needed to strengthen health
systems in general and specific elements of
health systems.
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HRH strategies
Policies on collaboration with private sector
Pharmaceutical management
Responsibility of broader health and development
community - not just GF
At the global level, we need greater consensus on
what works.
Conclusions – What is needed to
build health systems for HIV/AIDS –
Little Picture?

Transparent processes for allocating HIV/AIDS
money between different areas (and activities?)
 Governments/CCMs which see information
provision as part of their core mandate
 Increased support for continuous education in
management and M&E skills
 Greater investment in basic training (to increase
numbers of health workers)
 Support to the development of private for-profit
umbrella organizations
 Use of subsidies to enhance equitable access to
HIV/AIDS services.
Conclusions - continued

Sustainability - without the promise of secure
future financing broader changes in culture will
not occur – health systems strengthening is a
longer term objective;
 M&E - Substantial variation across countries in
GF implementation with respect to health
systems creates opportunities for M&E
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Follow-up work in Benin, Ethiopia and Malawi, to be
supported in 2005/06 by USAID
New support from The Alliance for Health Policy and
Systems Research, SIDA and Open Society Institute,
also being planned.
On behalf of the SWEF network,
thank you to:
 The
CCMs which supported the study
 The respondents who generously gave of
their time
 The GF Secretariat for its support
 USAID for financial assistance.