An assessment of interactions between global ... - ResearchGate

Health Policy
Hugo Rami/IRIN
determining factor in the assessment of the Global
Fund-supported scale up of antiretroviral drug treatment in
Cameroon (Boyer and colleagues, study 7, table 2). This
assessment showed that HIV services were delivered by
district facilities in rural areas with equal efficiency and
effectiveness as those provided by provincial or central
facilities, and that treatment in the district facilities was
reaching service users with low socioeconomic status and
in difficult-to-reach rural areas.
A further dimension of the effect on equity relates to an
emerging divide in which GHI-targeted services increase
in coverage more quickly than do non-GHI targeted
services. For example, whereas access to HIV services
increased from 5% to 31% over 4 years (2003–07), access to
maternal health services, as indicated by the number of
births attended by skilled health personnel, increased only
slightly from 61% to 65% during 16 years from 1990 to
2006, 2,73 which raises the question of whether the services
offered by GHIs correspond with country-specific
priorities. Although the global epidemiology of the specific
diseases targeted by GHIs is generally agreed, a precise
assessment of the need is not available for most low-income
countries because of few comprehensive epidemiological
and demographic data. Analysis of the disbursements of
GHIs, however, seems to correlate reasonably well with
the geographic distribution of need. Countries with a high
burden of HIV/AIDS, tuberculosis, malaria, vaccine
preventable diseases, and neglected tropical diseases (such
as trachoma or onchocerciasis) are well covered by GHIs.
However, some GHI disbursements in countries with low
disease burden indicate a tendency towards supply-induced
demand. For example, in Burkina Faso, diagnostic tests for
HIV were more frequently available in rural clinics than
was a basic test for blood haemoglobin. 74
Quality
Through their focus on a few interventions for specific
diseases, GHIs promote standardised guidelines for
prevention, treatment, and care. 69,75 These are intended to
improve the quality of care. Adoption of, and adherence to,
these guidelines is necessary for the assessment of criteria
for proposals for funding. GHIs, through reports,
monitoring, and assessment, encourage vigilance of issues
that have an important bearing on quality, such as patient
adherence to treatment or availability of health-service
providers. Because of the transnational nature of GHIs,
communities of practice have emerged that bring
individuals on the front lines of national service delivery to
share problems and good practices at the international
level—eg, at the PEPFAR implementers conferences.
Furthermore, scale efficiencies related to prequalification
of drugs, standardised packaging of commodities (eg,
blister packs for directly observed short-course treatment
of tuberculosis), and global procurement are important
factors in attaining universal standards of care.
However, in Nicaragua, the Global Fund’s performancebased
assessment risked the quality of services because
of pressure to meet numerical targets. 76 Anecdotal
evidence suggests that a rush to secure resources from
GHIs can lead to the submissions of proposals that do
not take into consideration whether the countries can
effectively implement the proposals. Receipt of funds
without credible implementation capacity, and tight
timelines for production and reporting of results lead to
services of substandard quality that are not adequately
indicated in the reports.
Although the weight of reason and activity suggests a
net positive effect of GHIs on quality of services, the
dearth of systematic evidence restricts this assessment.
2146 www.thelancet.com Vol 373 June 20, 2009