MAXIMIZING POSITIVE SYNERGIES - World Health Organization

Service Delivery
All the health facilities surveyed reported an increase in both the range of health care services and
the volume of service delivery associated with interaction between GHI implementation and
health systems at the facilities. This relationship was also noted between non-targeted services
and the targeted services.
For the majority of the population, there was significantly increased access to a wide range of high
quality HIV, tuberculosis (TB) and malaria services.. In addition, the GHIs brought about a
tremendous reduction in the cost of health care for the targeted conditions and, to a lesser extent,
the non-target conditions. GHIs had limited impact on infrastructural development and the focus
was narrow.
Although the range and volume of service delivery were increased, there remained several critical
gaps. The UPHOLD Final Evaluation found that Artemisinin-based combination therapy (ACT) was
prescribed in only 41% of cases of malaria, despite the fact that more than 90% of health workers
had been oriented and given policy guidelines on management of uncomplicated malaria. More
than 80% of the health workers in the UPHOLD supported districts had adequate skills in malaria
case management. However, more than 70% of these health workers were not communicating
effectively with patients regarding malaria and its treatment. Other problems included stock outs
of ACT in 27% of the supervised facilities [10].
Researchers found improvements in the areas of TB diagnosis and treatment with significant
increase in implementation of the Directly Observed Treatment, Short-course (DOTS) programme.
Access to Multidrug-Resistant Tuberculosis (MDR-TB) treatment more than doubled. Key
informants also reported significant improvements in supply chain management for TB drugs and
laboratory reagents. Laboratory technicians were trained and there was funded supervision of
health workers providing TB services. The national programme was also able to significantly scaleup
the provision of community-based DOTS services (CB-DOTS). There was a near double increase
in case detection rates for TB in some districts. However respondents felt that less money was
allocated to TB compared with HIV and malaria.
The health facilities surveyed indicated some positive synergies between supported services and
radiology services. However, some variables indicated a reduction in access to radiology services
despite implementing GHI at surveyed facilities. There was approximately 10% increased
availability of plain X-rays on site but no change in access within two hours. There was however a
reduction in fees charged. There was a 15% increase in availability of ultrasound services on site,
there was reduced access to ultrasound services within 2 hours and an increase in the fee charged
for ultrasound services.
Table 6: Referral Practices at Surveyed Health Facilities shows the referral mechanisms at the
surveyed health facilities before the GHIs and the current situation.
% Facilities Before GHI % Facilities Currently
Higher Level Facility within 2 Hrs 62.9 77.1
Phone, etc Link to Higher Level Facility 34.3 48.6
Ambulance Available 60.0 88.6
Fee Charged to Facilitate Referral 11.4 40.0
Referral Form used (Facility to Facility) 80.0 91.4
Referral Accompanied to Facility 48.6 68.6
Referral Form used by Community Workers 31.4 62.9
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