MAXIMIZING POSITIVE SYNERGIES - World Health Organization

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needing medical transport. Both GHIs provided funding for Mutuelles de Santé. To achieve integration between the GHI-funded programmes and the health system, the CCM funded organizations that would invest in health system strengthening. System strengthening was seen as a necessary part of developing targeted responses, and the Global Fund approved funding being used in this way. Overall, the Global Fund and PEPFAR investments supported the national response to HIV, TB, and malaria. Both GHIs supported the national decentralization of HIV services and the MOH’s national HIV treatment guidelines so that all patients accessing HIV treatment would receive the same medications, regardless of the site’s funding source. One respondent talked about a similar means of integration for the TB programme: The [Global Fund] project has allowed us to integrate the money in the national plan for response to the disease; it has been a success. Also what is good is that all the funds for tuberculosis have been aligned to the same plan and the same programme. So, in one word, we have applied what we call the three one’s. That means one action plan, one monitoring and evaluation [M&E] plan, and one unique authority to lead people around that plan and that monitoring and evaluation [M&E] plan. That’s how we managed. It has help also to, to provide the same level of services with geographic equity. Treatment programmes for HIV and TB have also been integrated with one another at the facility level. The MOH dictates where its partners (NGOs providing HIV services) - who are also required to provide a minimum package of primary care services - implement programmes and therefore where GHI-funded programmes work. Several coordination bodies exist between GHI and the government. These include the GHIspecific groups, such as the CCM and the PEPFAR steering committee, but also entities like the coordinated procurement and distribution system, which organizes the ARV supply chain for the country (see the supply chain section below for more information). Respondents perceived PEPFAR’s funding model as resulting in less integrated programmes than the Global Fund’s model. The number of NGOs in the health sector can result in lack of coordination or duplication of activities. As one informant noted: Again this [impact on non-target diseases and access] depended entirely on the NGOs involved. It depended on the goodwill of the country representative or the ladies and gentlemen who were managing them. We could get some good impact only when they accepted to integrate their actions with ours. Otherwise our systems run parallel. The Government’s interest was to integrate them into the system but theirs was to stay isolated. Impact of delivery models on access and coverage GHI investment in Rwanda had a significant impact on geographic equity of health delivery, increasing the availability of ART and other services, particularly in rural areas. The Global Fund enabled the government to implement community-based delivery models, including malaria management and DOTS, which increased the accessibility of care and treatment for many. In addition, investments in Mutuelles de Santé - covering the fees for those who met the criteria for poverty (regardless of HIV status) - helped reduce financial barriers to care for those without target diseases as well. 156
The quantitative portion demonstrated a more robust referral system temporally associated with the arrival of GHI monies. All of the facilities in Rwanda experienced a referral score i increase after the introduction of GHI funding, which was statistically significant overall (p=.04). The average change in referral score for the facilities in Rwanda was 3.5 points. Out of a possible score of 7, the average referral score for Rwanda was 3.25 before GHI funding and 6.75 afterwards. Community/Civil Society GHI impact on health seeking behaviour GHI support has increased health-seeking behaviour. Funding for Mutuelles de Santé contributed to making health care accessible to poor and vulnerable populations, alleviating the financial barrier. Patients who previously would have had to travel long distances to receive care are able to find care closer to their homes given the increased presence of physicians in health centres. Both GHIs have made significant efforts to sensitize the population about HIV and educate them on prevention and treatment. With the availability of free HIV medications, some informants felt the stigma surrounding HIV had decreased as communities saw individuals living with HIV retain or regain their health. Demand for services, including primary care and timely presentation for TB treatment, increased, along with the opportunity to screen for HIV and other diseases. In particular, the increases of services in the health centres has impacted the demand for prenatal and delivery services. As one informant explained: <strong>Health</strong>care services are taken close to the population and the patients seek treatment in time. Pregnant women deliver at health centres, family planning methods are taught at health centres, and we also become able to easily teach family planning methods in the community and men and women attend teaching sessions at health centres for education and communication sessions, it is also an advantage. GHI impact on the focus and role of NGOs Monies from both GHIs flow to NGOs. The CCM in Rwanda favours local and more established NGOs and ensures that NGOs adhere to national priorities and coordinate their activities with other providers. Some informants saw NGOs as a means of keeping the government accountable as well; for example, one informant reported: The NGO is also there to, I think, help make sure the government fulfils its promise to the people, the rights of the people – the right to healthcare and other rights. …The NGO is there to make sure the free market doesn’t screw up, and the NGO is there to make sure, or help the government, let’s say, assist the government, to provide these rights to people. And I think that PEPFAR and [the] Global Fund have significantly allowed these NGOs to play a bigger role because of these resources. But I think there’s probably also some negative effects, and that you have to be careful. We don’t want to create parallel systems where an NGO provides, in my opinion, a separate clinic and weakens the public health sector. PEPFAR, while it has the MOH verify that its overall plan is aligned with national priorities, makes its own decisions about who to fund, and many informants felt that recipients of PEPFAR funding were not all of high quality. 157
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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
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Informants noted that a general lac
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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 158 and 159: medical staff to higher-paying admi
Page 160 and 161: system (CPDS), in which many stakeh
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
Page 208 and 209: The health system struggles with a
Page 210 and 211: 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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