MAXIMIZING POSITIVE SYNERGIES - World Health Organization

Another survey of immunization coverage in the Kumba Health District showed that 10% of infants
had never received any vaccine while approximately 15% were incompletely immunised
according to the locally recommended immunisation schedule [7].
Discussion
We conducted this survey to appreciate the potential changes at the primary level of the health
system following the introduction of GHIs in Cameroon. Little reliable data were collected at each
facility to validly ascertain the recent changes in health outcomes in the facilities surveyed.
Nevertheless, the limited data available suggest modest increases in human resources and little
improvements in the financing of these health facilities, the infrastructure, and selected indicator
services such as the referral services, the tuberculosis care services and radiology services. Most
peripheral facilities could identify specific immunization activities that were indirectly supported
by GAVI. The impact of the Global Fund was mainly experienced in the regional (provincial) and
district hospitals in which there were improvements in the availability of human resources and
facilities involved in tuberculosis and/or HIV care.
While we describe some changes in the health system, these changes are not all attributable to
GHIs as multiple other initiatives could be implicated. For example with funding from the Highly
Indebted Poor Countries (HIPC) initiative, thousands of healthcare workers were recruited into the
national health workforce. Funding from bilateral sources such as the German co-operation (GTZ)
or the French assistance (through the “Contrat de Désendettement et de Développement”, C2D)
and international sources such as the African Development Bank and the World Bank also
improved the status of health facilities [8]. At best, the GHIs may have contributed to these
changes in the health system.
Deficiencies in data collection and storage at health facilities surveyed limited any exhaustive
assessment of the impact of GHIs. The improvement of health facilities in these districts will first
require a more rigorous monitoring and evaluation (M&E) of the processes and outcomes involved.
This may necessitate specific funding (either within the GHIs or through external mechanisms) to
set up M&E systems, including recruiting statisticians (or equipping health workers with basic
health statistics skills) and setting up electronic, rather than paper-based, data collection systems.
While the current health information system involved monthly reporting of data to intermediate
and central levels of the health system, there was no evidence of any meaningful use of these data
at peripheral facilities. Providing feedback to primary-level health care providers might go a long
way toward improving both the quality of the data collected and the use of this data to improve
health services at the primary level. The M&E need not be extensive: it could be based on a sentinel
system of representative and geographically diverse health districts and/or health facilities. The
accuracy of data collected could be guaranteed by setting up a prospective, rather than
retrospective, M&E system.
It will also be difficult to disentangle the specific effect on health systems of each GHI from that of
other funding sources, particularly at the primary level. Rather, it may be more realistic to assess
the overall impact of all funding sources. Future GHIs need to incorporate an assessment of
baseline indicators (including at primary level facilities) prior to their introduction, as an integral
part of the programme.
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