MAXIMIZING POSITIVE SYNERGIES - World Health Organization

Discussion
Global Fund- supported programmes have been critical for making TB and HIV/AIDS services
available to the population and are the health system’s primary means of controlling these
diseases. In particular, Global Fund funds contributed importantly to the expansion of ART services
in India. Global Fund proposals have consciously required applicants to detail how their disease
specific strategies can strengthen health systems. Further, the latest round of Global Fund funding
to India includes the Nursing Council of India as a primary recipient. This should provide much
needed support to strengthen the position of nurses in India and the health system.
Both the RNTCP and especially the NACP have a great potential for strengthening health systems
in several ways. First, they place health workers at health facilities, especially at the periphery, who
function as a resource for the entire health facility and not just for their specific programme. Key
functions of health facilities like lab services can also be strengthened by sharing supplies and
resources with labs meant for general patients or providing services for non-programme specific
patients. Furthermore, the presence of these well run programmes at health facilities improves
patient perceptions of public health facilities and also creates demand for better quality services.
The Global Fund has also contributed in important ways to strengthen the presence, voice and
capacity of civil society organizations to participate in national health programmes.
While there is tremendous potential for Global Fund-supported disease control programmes to
strengthen health systems, these synergies did not take place at all health facilities. Programmes
like the RNTCP seem more conducive to generating these synergies. It is important to understand
why disease control programmes have not been able to contribute more to strengthening health
systems. Three factors appear to be important: (1) the explicit intention of the programme to
strengthen health systems; (2) the locus of administrative control over programme-specific
contractual health workers; and (3) the locus of administrative control over the programme.
The RNTCP was designed to work through the existing health system infrastructure and with
human resources available in the public health system. Where these are lacking, the programme
has an explicit policy of supplementing it, thereby strengthening the capacity of health facilities.
The NACP also works through the public health system and there were several instances where
resources for the NACP contributed to health services beyond services specific to HIV/AIDS care.
Yet, there did not seem to be an emphasis within the programme and by its managers on building
connections and contributing to non-HIV/AIDS specific services.
While both NACP and RNTCP staff receive salaries directly from the relevant programme, RNTCP
employees are supervised by the health facility and district managers since they are typically filling
an existing vacancy. NACP staff report to the AIDS control society of their state. This chain of
command gives health facility and health system managers little control over NACP staff;
consequently, they found it difficult to engage them in work beyond HIV/AIDS.
In each state, the Directorate of Health Services is responsible for organizing and managing the
delivery of curative and preventive health services through the public health system. The
management unit of the RNTCP is housed within the Health Directorate, while the NACP is
administered by the State AIDS Control Society (SACS) which is housed outside the state Health
Directorate (though in some instances officers from the directorate are also SACS officers). The
programme management unit’s location influences the degree to which programme activities and
resources contribute to strengthening the health system. Since the Directorate is responsible for
the entire health system in a state, close coordination with it enables better alignment of disease
control programme activities and resources with those of the health system.
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