MAXIMIZING POSITIVE SYNERGIES - World Health Organization

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Burundi: Building a health system together with Global Health Initiatives, in the aftermath of war Abstract Johann Cailhol, 3, 4 Thuba Mathole, 3 Annie Parsons, 3 David Sanders, 3 Denise Kandondo, 2 Innocent Ndayiragije 2 and Théodore Niyongabo 2,5 Burundi’s health system was destroyed by civil war and has subsequently faced severe economic constraints, creating an unreliable public health system. GHI activities in Burundi started in 2002, initially relying on nongovernmental organizations (NGOs) and civil society organizations (CSOs). This study used qualitative and quantitative methods to gather data on GHI activities in Burundi, focusing on the health workforce. The study found that GHIs and the Ministry of Health (MOH) have created parallel supervision, monitoring and evaluation (M&E), and supply systems. This has led to distinct groups of patients, health care providers and programmes managers, and a loss of efficiency. GHI funding is not regularly channelled through the MOH: both the MOH and the Ministry of AIDS provide HIVrelated care. This prevents the integration of HIV/AIDS into primary health services. There is a high turnover of health care workers, lack of clear human resources policies and insufficient salaries in public facilities. Both government and donors have attempted to address such concerns, but joint efforts remain essential. In essence, improving the efficiency of GHI funding requires health system strengthening. The pooling of donor funds for such initiatives is an essential first step. Special attention should be given to health providers, as the core of the health system. Background Burundi is a small land-locked country in central Africa, bordered to the north by Rwanda, to the east and the south by the United Republic of Tanzania and to the west by the Democratic Republic of Congo and Lake Tanganyika. It is home to 8.5 million people, 90% of them living in rural areas [1]. The country averaged a 3.9% population growth rate from 2001 to 2007 [1] of which 46% is less than 15 years of age [2]. Burundi’s inflation rate is high (23.5% in 2008) [1] and economic growth is low (3.6% real GDP growth in 2007) [1]. It ranked 172 nd out of 179 countries on the UN Human Development Index in 2006 [3]. After independence in 1962, the country experienced cyclical crises attributed to ethnic tensions. The last civil war lasted 13 years and ended in 2005, though a 3 National Center for HIV Reference, Bujumbura, Burundi 4 University of Western Cape 5 University of Burundi, Bujumbura, Burundi 8
ebel organization operated until 2008 despite a cease-fire signed in 2006. Burundi is a fragile state in a post-crisis situation, where ethnic issues remain problematic. The constitution was voted in by the population in 2005 and includes a balance of ethnic groups in public employment. 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) 8,496 2007 World Bank Geographic Size (sq. km) 25,680 2007 World Bank GDP per capita, PPP (constant 2005 international $) 321.75 2007 World Bank Gini index 33.27 2006 World Bank Government expenditure on health (% of general government expenditure) Per capita government expenditure on health at average exchange rate (current US$) 5.3 2007 WHO NHA 2 2007 WHO NHA Physician density (per 10,000)
Page 2 and 3: Table of Contents Key Acronyms Intr
Page 4 and 5: Policy analysis of the impact of Gl
Page 6 and 7: OIs Opportunistic infections OVC Or
Page 8 and 9: core section of the document then p
Page 10 and 11: Figure 1: Analytic framework for MP
Page 12 and 13: studies. MPS researchers have linke
Page 16 and 17: at between US$ 14.5 and US$ 18.5 pe
Page 18 and 19: collaborations with European school
Page 20 and 21: epresent only US$ 1.75 per month pe
Page 22 and 23: Service Delivery The decentralizati
Page 24 and 25: Long term HSS will require governme
Page 26 and 27: Cameroon: Evaluation of the Nationa
Page 28 and 29: Table 1 Basic Socioeconomic, Demogr
Page 30 and 31: of treatment interruptions (>two da
Page 32 and 33: side effects) were associated with
Page 34 and 35: Prevention behaviours Nearly half (
Page 36 and 37: References [1] The World Bank Group
Page 38 and 39: Out-of-pocket payments account for
Page 40 and 41: as well as the number of community
Page 42 and 43: Table 1: Characteristics of facilit
Page 44 and 45: Table 4: Estimated changes in human
Page 46 and 47: Central African Republic: Impact of
Page 48 and 49: Objectives and Methodology In this
Page 50 and 51: Financing There was a general appre
Page 52 and 53: 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
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References [1] China at a glance. W
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1994, private spending and emergenc
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understanding of their roles and re
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References [1] Human Development Re
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In 2003, the government launched th
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Objectives and Methodology The data
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Health Workforce Ghana is challenge
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Discussion GHIs are critical for ra
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Haiti: Maximizing Positive Synergie
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Table 1 Basic Socioeconomic, Demogr
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with need. With GHI funding, distri
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I know that within [the organizatio
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Much of the initial enthusiasm abou
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services, or for measures of qualit
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funds and more funding focused on i
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INDIA: Exploring how disease-specif
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PEPFAR* Year Amount Disbursed (in U
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Primary data collection - facility
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The Global Fund has strengthened th
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References [1] The World Bank Group
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Background The Republic of Kenya li
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Results Leadership and Governance D
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Informants noted that a general lac
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time periods. Informants believed t
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A comprehensive, long-term reform o
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The effects of GHIs on the capacity
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their budget was comprised of Globa
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Quality of services The majority of
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References [1] Kyrgyzstan at a glan
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Commission (NAC) in 2001 as a multi
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Objectives and methodology The main
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Discussion The findings of the Mala
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Pakistan: The impact of the Global
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international standards. The Under
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the US Centers for Disease Control
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Some negative effects are also attr
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to country health systems by way of
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Peru: Effects of the Implementation
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Table 2 Global Health Initiative In
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HIV/AIDS, mainly around the Compreh
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without substantial emphasis on pre
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Rwanda: The Impact of Global Health
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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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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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