MAXIMIZING POSITIVE SYNERGIES - World Health Organization

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Background The Republic of Kenya lies on the equator in East Africa and is home to 37.5 million people (see Table 1) [1]. In 2005, Kenya ranked 148 th out of 177 on the UN Human Development Index [2]. Seventy-nine percent of all Kenyans live in rural areas. Most of the rural population relies on smallscale subsistence agriculture. Fifty-eight percent of all Kenyans live below the poverty line, and unemployment is 40%. Official development Assistance (ODA) to Kenya was US$ 934.4 in 2006 [3], while total external debt was US$ 6.5 billion or 28.7% of GDP. The Kenyan Ministry of Public Health and Sanitation and the Ministry of Medical Services (which until April 2008 were united as the Ministry of Health) direct the public health activities in the country. In 2006, the Ministry of Health (MOH) managed approximately 52% of all health facilities, with the remainder managed by private and non-profit entities. Out-of-pocket expenditure compr 16 ised 80% of all private expenditure on health, while private prepaid plans comprised 6.9% in 2005. In 2006, external resources made up 14.8% of the total expenditure on health [3]. An estimated 40% of rural households had no access to health services in 2000. Approximately 12% of registered physicians living in Kenya worked in the public sector, and more than 80% of all physicians practiced in urban areas [4, 5]. Only 25% of Kenyan health facilities have year-round access to water, and 50% have a regular supply of energy or a back-up generator [6]. Table 1 Basic Socioeconomic, Demographic and Health Indicators (*) (*) Full data sources for all indicators are provided in Annex 1. Indicator Value Year Source Population (thousands) 37,531 2007 World Bank Geographic Size (sq. km) 569,140 2007 World Bank GDP per capita, PPP (constant 2005 international $) 1,456 2007 World Bank Gini index 42.5(†) 2007 UNDP Government expenditure on health (% of general government expenditure) 9.7 2007 WHO NHA Per capita government expenditure on health (current US$) 18 2007 WHO NHA Physician density (per 10,000) 1 2002 WHO SIS Nursing and midwifery density (per 10,000) 12 2002 WHO SIS Maternal mortality ratio (per 100,000 live births) 560 2005 WHO SIS DTP3 coverage (%) 81 2007 WHO SIS Estimated adult HIV (15-49) prevalence (%) 7.1-8.5 2007 UNAIDS Estimated antiretroviral therapy coverage (%) 42 2007 UNGASS Tuberculosis prevalence (per 100,000) 319 2007 WHO GTD Estimated malaria deaths 27,049 2006 WHO WMR 16 98
AIDS was first documented in Kenya in 1984, and by 2007, between 1.5 and 2.0 million people were living with HIV/AIDS [7]. Tuberculosis (TB) incidence in Kenya has increased steadily over the past two decades (see Table 2) [8]. Of all new cases, 52% occurred in HIV-positive individuals [9]. In 2009, Kenya ranked 13th among the 22 highest TB burden countries, as designated by the Stop TB Partnership, but had become the first country in sub-Saharan Africa to achieve global targets for both case detection and treatment success [10]. All tuberculosis treatment, monitoring, and drug procurement activities are coordinated by the Kenyan Ministry of Health’s Department of Leprosy, Tuberculosis, and Lung Disease (DLTLD) with support from international agencies such as the Global Fund. Since 2003, the Global Fund has approved US$ 326 million in funding for Kenya, although only US$ 160.1 million of those funds have been disbursed to date (see Table 3). In addition to the Global Fund, PEPFAR, the US government programme for international HIV control, is a major donor to HIV care providers in Kenya. Kenya was designated one of PEPFAR’s 15 focus countries at the programme’s inception in 2003, and has received US$ 1.3 billion for HIV treatment through the end of 2008 [11]. Methodology We collected data through semi-structured interviews, observation, and examination of documentary material. Key informant interviews followed a standardized semi-structured interview template designed to evaluate how GHIs—primarily PEPFAR and the Global Fund—have interacted with Kenya’s health system. Embedded units of analysis were limited to PEPFAR and the Global Fund to focus the scope of the initial nine-month research programme. Interviews addressed the following health system building blocks as defined by the WHO: governance, financing, health workforce, M&E, and health technologies. The key informant sampling strategy targeted a diverse range of implementers, policymakers and health leaders. The study used two sampling methods: purposive sampling and snowball sampling. Key informants had extensive experience with PEPFAR, the Global Fund, or both. The study had a sample size of 37 key informants: 12 Government of Kenya (GoK) officials working within key ministries at the national and provincial levels; 10 members of various Kenyan-based and international nongovernmental organizations (NGOs); three members of international multilateral organizations; eight US government employees; and four informants from the private sector. Interviews were recorded and transcribed to both ensure accurate data collection and facilitate qualitative analysis. Interviewers also took field notes based on their observations and postinterview debriefings. These notes were included in the qualitative data set. Transcribed interviews were entered into NVivo8, a qualitative data analysis tool (QSR International, Cambridge, MA). A thematic qualitative analysis approach with an iteratively developed set of codes was used to examine the data. To further support the authenticity of findings and auditability of analytic processes, we engaged in inter-rater reliability activities as we created and applied codes, developed memos about our analytic decision-making and conducted participant validation exercises. For the purposes of triangulating with the data collected in key informant interviews, we collected and reviewed publicly available documents (i.e. National Health Strategy, Demographic Health Surveys, and PEPFAR and Global Fund Country Reports). 99
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Table of Contents Key Acronyms Intr
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Policy analysis of the impact of Gl
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OIs Opportunistic infections OVC Or
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core section of the document then p
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Figure 1: Analytic framework for MP
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studies. MPS researchers have linke
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Burundi: Building a health system t
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at between US$ 14.5 and US$ 18.5 pe
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collaborations with European school
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epresent only US$ 1.75 per month pe
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Service Delivery The decentralizati
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Long term HSS will require governme
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Cameroon: Evaluation of the Nationa
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Table 1 Basic Socioeconomic, Demogr
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of treatment interruptions (>two da
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side effects) were associated with
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Prevention behaviours Nearly half (
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References [1] The World Bank Group
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Out-of-pocket payments account for
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as well as the number of community
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Table 1: Characteristics of facilit
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Table 4: Estimated changes in human
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Central African Republic: Impact of
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Objectives and Methodology In this
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Financing There was a general appre
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NGOs and Civil Society The overall
Page 54 and 55: Discussion Interviews with key info
Page 56 and 57: China: The Impact of the Global Fun
Page 58 and 59: Table 2 Global Health Initiative In
Page 60 and 61: In Yunnan and Henan, the epidemic i
Page 62 and 63: funded only from the MOH Pilot Prog
Page 64 and 65: References [1] China at a glance. W
Page 66 and 67: 1994, private spending and emergenc
Page 68 and 69: understanding of their roles and re
Page 70 and 71: References [1] Human Development Re
Page 72 and 73: In 2003, the government launched th
Page 74 and 75: Objectives and Methodology The data
Page 76 and 77: Health Workforce Ghana is challenge
Page 78 and 79: Discussion GHIs are critical for ra
Page 80 and 81: Haiti: Maximizing Positive Synergie
Page 82 and 83: Table 1 Basic Socioeconomic, Demogr
Page 84 and 85: with need. With GHI funding, distri
Page 86 and 87: I know that within [the organizatio
Page 88 and 89: Much of the initial enthusiasm abou
Page 90 and 91: services, or for measures of qualit
Page 92 and 93: funds and more funding focused on i
Page 94 and 95: INDIA: Exploring how disease-specif
Page 96 and 97: PEPFAR* Year Amount Disbursed (in U
Page 98 and 99: Primary data collection - facility
Page 100 and 101: The Global Fund has strengthened th
Page 102 and 103: References [1] The World Bank Group
Page 106 and 107: Results Leadership and Governance D
Page 108 and 109: Informants noted that a general lac
Page 110 and 111: time periods. Informants believed t
Page 114 and 115: A comprehensive, long-term reform o
Page 116 and 117: The effects of GHIs on the capacity
Page 118 and 119: their budget was comprised of Globa
Page 120 and 121: Quality of services The majority of
Page 122 and 123: References [1] Kyrgyzstan at a glan
Page 124 and 125: Commission (NAC) in 2001 as a multi
Page 126 and 127: Objectives and methodology The main
Page 128 and 129: Discussion The findings of the Mala
Page 130 and 131: Pakistan: The impact of the Global
Page 132 and 133: international standards. The Under
Page 134 and 135: the US Centers for Disease Control
Page 136 and 137: Some negative effects are also attr
Page 138 and 139: to country health systems by way of
Page 140 and 141: Peru: Effects of the Implementation
Page 142 and 143: Table 2 Global Health Initiative In
Page 144 and 145: HIV/AIDS, mainly around the Compreh
Page 146 and 147: without substantial emphasis on pre
Page 150 and 151: Rwanda: The Impact of Global Health
Page 152 and 153: Rwanda was US$ 584.9 million in 200
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International Health Partnership, t
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PEPFAR’s funding practices were l
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medical staff to higher-paying admi
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system (CPDS), in which many stakeh
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needing medical transport. Both GHI
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Some informants felt that local NGO
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Senegal: The effects of Global Heal
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Table 1: Basic Health System and Ep
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case study. Data analysis was condu
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of respondents aware of treated net
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South Africa: The effects of Global
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Table 2 Global Health Initiative In
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of South Africa (GHI2, ND6). 26 Don
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NDOH to disburse external funds in
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The lack of effective monitoring an
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Despite these problems, GHI funding
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[19] The Global Fund for Aids Tuber
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Official Development Assistance (OD
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The study employed both purposive s
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Figure 1: Number of Clinicians at S
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There were very significant increas
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GHIs created an opportunity to cond
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Ukraine: Effects of the Global Fund
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GAVI (in US$) Disease Priority Amou
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government and nongovernmental prov
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• The introduction of new service
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References [1] Data are from the Mi
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The health system struggles with a
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Objectives and Methodology This stu
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Nonetheless, efforts to recruit and
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References [1] The World Bank Group
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average annual population growth of
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2006 149,022,153 2007 216,012,780 2
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isks duplication of services but al
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centres have only one qualified hea
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Policy analysis of the impact of Gl
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countries” [6]. The TRP apply sev
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PEPFAR I & II The newest PEPFAR leg
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Types of fundable HRH interventions
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Global Fund In two country applicat
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TABLE 3: Selected Countries: MPS Ca
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HRH Intervention Categories GAVI: C
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HRH Intervention Categories GLOBAL
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HRH Intervention Categories PEPFAR
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Conclusion: Directions for future r
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GHIs and health systems. Civil soci
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Annex 01: Data sources for tables i
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Annex 02: Contributing Institutions
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