MAXIMIZING POSITIVE SYNERGIES - World Health Organization

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medical staff to higher-paying administrative positions at the Global Fund, exacerbating the human resource shortage. As one informant reported: Doctors and nurses have quit the patient’s bedside in a scramble for ‘AIDS’ money, as cynics like to call it. These medical people leave the mainstream clinical work to take up administrative jobs in Global Fund coordination offices. This has escalated the scarcity of medical professionals even further. In addition to the movement of clinical staff to administrative Global Fund positions, PEPFAR was also seen as pulling human resources out of the public sector and into NGOs, as the latter were often able to offer higher salaries. While many informants viewed this as a negative consequence of PEPFAR’s funding system, others commented that overall it increased human resources within Rwanda, as it prevented practitioners from seeking jobs abroad. GHI funding impact on workforce capacity GHIs have built significant capacity through their investments in training. In particular, respondents saw great potential in the willingness of GHIs to recognize community health workers as an important cadre of human resources for health. One informant stated, “If they reinforce community health workers, everything will be achieved.” Since community health workers are rarely limited to addressing HIV at the community level, capacity building within this population was seen as a form of health system strengthening, as it could increase access to services for the general population. Data showed PEPFAR increased employment opportunities and built capacity in the Rwandan workforce, but not in the public sector given that it funded NGOs. In contrast, the Global Fund contributed to capacity building of all personnel. Global Fund funding could be used for measures that would sustainably enhance the workforce, such as investing in nursing schools. Quantitative analysis demonstrated increases in the number of doctors (non-specialized), nursing staff, non-degree laboratory technicians, non-degree pharmacists, and community health workers. Altogether, facilities in Rwanda had no doctors before GHI funding, and 1.45 after, all of whom were non-specialist practitioners. GHI impact on human resource strategies GHIs have helped with the human resource shortages by contributing to salaries for doctors and nurses. Global Fund monies were used to increase salaries in rural areas, leading physicians to accept jobs and remain in areas where positions had previously not been able to be filled. Retention also increased in the public sector overall and the number of health practitioners seeking opportunities abroad fell. In addition, the GHI’s decision to support the GoR’s performance-based financing system has enabled payment structures that are more effective and that provide incentives to health care professionals. However, despite these changes, informants often stated that the government could not compete with the salaries that NGOs offered. Some described NGO salaries as “destabilizing” to a market where there were so few doctors and nurses. 152
Medical Vaccines, Products and Technologies GHI funding impact on health system infrastructure Most informants felt that more GHI investment in infrastructure was needed despite significant contributions. The Global Fund contributes to the renovation and construction of health facilities to deliver Prevention of Mother to Child Transmission (PMTCT), Multidrug-Resistant Tuberculosis (MDR-TB) treatment, and VCT, in addition to the general laboratories in health centres and the creation of a national MDR-TB referral centre. In most cases, these projects improved the care of all patients, not just patients with HIV or TB. One respondent described infrastructure improvements as follows: I mentioned that they built these 100 plus health centres – buildings – to allow capacity for, really HIV treatment centres. Again, they aren’t dedicated only to HIV treatment centres. They’ve done a number of other things for these facilities that are HIV treatment centres. They’ve provided generators. They’ve helped build up the national laboratory. They’ve helped fund the [TRAC] Centre…. PEPFAR monies were used only for the renovation, not construction, of health centres and the percentages of funding that had to be spent on different programme components (i.e. prevention, treatment, support) were considered limiting. One PEPFAR-funded NGO was thought to have renovated more than 30 facilities. In addition, PEPFAR supported the installation of solar power at many facilities. The quantitative analysis demonstrated significant increase in physical space: on average, physical infrastructure increased by 1138 square feet per facility in Rwanda, a growth of 83%. GHI impact on access to innovative technologies The GHIs contribute to procuring equipment for hospitals and laboratories. Global Fund funding has been used to purchase microscopes, x-ray machines, ambulances and other equipment. Global Fund monies also improved the referral system between health facilities and community health workers, leading to improved coordination of care. PEPFAR’s investments in equipment and materials are accompanied by technical support, which is beneficial. GHI materials and equipment benefited those with non-target illnesses as well as those with the target diseases. In particular, great gains were seen in primary care and family planning. One respondent explained, “We equip antenatal clinics, we equip delivery rooms. All those infrastructures and equipments serve not only for malaria or for TB or for HIV itself, but for the overall population, and among them people suffering from TB, malaria, and HIV.” Supply Chain Both GHIs have invested significantly in Rwanda’s supply chain and logistics system. All drugs, supplies and consumables purchased with Global Fund monies and most purchased with PEPFAR monies are handled by CAMERWA. In addition, all antiretrovirals (ARVs) distributed nationally are warehoused by CAMERWA. Antiretroviral therapy (ART) sites submit their forecasted needs through the National Quantification Committee, in which both the Global Fund and PEPFAR participate. The Quantification Committee approves the total quantities of medications needed and divides the costs among the donors. CAMERWA then receives all the medications at the national level and distributes them to the sites through the coordinated procurement distribution 153
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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
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Discussion Interviews with key info
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China: The Impact of the Global Fun
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Table 2 Global Health Initiative In
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In Yunnan and Henan, the epidemic i
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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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Background The Republic of Kenya li
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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 112 and 113: References [1] The World Bank Group
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 148 and 149: References [1] The World Bank Group
Page 150 and 151: Rwanda: The Impact of Global Health
Page 152 and 153: Rwanda was US$ 584.9 million in 200
Page 154 and 155: International Health Partnership, t
Page 156 and 157: PEPFAR’s funding practices were l
Page 160 and 161: system (CPDS), in which many stakeh
Page 162 and 163: needing medical transport. Both GHI
Page 164 and 165: Some informants felt that local NGO
Page 166 and 167: Senegal: The effects of Global Heal
Page 168 and 169: Table 1: Basic Health System and Ep
Page 170 and 171: case study. Data analysis was condu
Page 172 and 173: of respondents aware of treated net
Page 174 and 175: South Africa: The effects of Global
Page 176 and 177: Table 2 Global Health Initiative In
Page 178 and 179: of South Africa (GHI2, ND6). 26 Don
Page 180 and 181: NDOH to disburse external funds in
Page 182 and 183: The lack of effective monitoring an
Page 184 and 185: Despite these problems, GHI funding
Page 186 and 187: [19] The Global Fund for Aids Tuber
Page 188 and 189: Official Development Assistance (OD
Page 190 and 191: The study employed both purposive s
Page 192 and 193: Figure 1: Number of Clinicians at S
Page 194 and 195: There were very significant increas
Page 196 and 197: GHIs created an opportunity to cond
Page 198 and 199: Ukraine: Effects of the Global Fund
Page 200 and 201: GAVI (in US$) Disease Priority Amou
Page 202 and 203: government and nongovernmental prov
Page 204 and 205: • The introduction of new service
Page 206 and 207: 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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