MAXIMIZING POSITIVE SYNERGIES - World Health Organization

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Financing There was a general appreciation of the funds being made available through various GHIs. The process of channelling the funds was, however, considered to be excessively centralized. According to informants, GAVI funding was pooled by the MOH with other funds targeting immunization, in contrast to the Global Fund, which directed resources to a primary recipient and sub-beneficiaries based on proposals. Both positive and negative features were attributed to the GHI-funding processes. Performancebased financing was perceived as important, allowing for accountability and less waste. It also served as an incentive to improved performance, transparency and management. On the other hand, delays between approval of funds and their disbursement apparently forced some activities to be launched in the absence of funds or some activities to be delayed with a potential impact on patient care. Restrictions placed on the use of funds–for example, cases in which funds could only be used for the targeted diseases and not other, often more pressing, health problems–concerned some informants. Furthermore, there was concern that human resources limitations were delaying reporting, and might thus slow much-needed funding. Most health-care expenditure in the CAR is in the form of out-of-pocket payments by patients. While very far from ideal, this financial contribution by patients has meant that they had a say in the operation of the system. A potential unintended consequence of the availability of free drugs is that patient input in the choice of care could be markedly reduced or eliminated altogether. Monitoring and Evaluation The health information system is believed to have improved (with a greater and faster availability of data) but much still needs to be done to computerize the system and train providers in the use of information technologies. GAVI has improved surveillance systems, particularly for vaccinepreventable diseases. There has also been some parallel reporting, as the indicators and frequencies requested by the Global Fund differ from those used by the national health system. Driven by reporting requirements of both GAVI and the Global Fund, providers and other health personnel have been trained in data collection and are more aware of its importance. Nevertheless, some informants felt that personnel responsible for data collection at the primary level did not prioritize this task – they do not use the information locally, but simply send it to the national level where the data are aggregated and sent on to funding organizations. Clinical staff were also perceived to be focused on patient care and less inclined to spend time on data collection. There is therefore a need for personnel dedicated to data collection and reporting. Problems such as poorly understood formulae, language barriers or inaccurate translation have also been encountered in the Global Fund reporting forms, underscoring the need for specific training of personnel who collect primary data. In general the Global Fund reporting requirements were considered more complex in comparison to the forms proposed by GAVI. Health Workforce GHIs had a noticeable positive impact on the size of the healthcare workforce in CAR. The capacity (skills) and competencies of these personnel have also been reinforced through numerous trainings and refresher courses offered to personnel in various parts of the health system, from central level cadres to doctors, nurses, counsellors, laboratory technicians and community leaders. 44
Some of these personnel were supported with resources from the Global Fund, thus strengthening the health system more broadly. Despite these improvements in the workforce, there was a perception that salaries were still too low, and that more financial incentives were needed to compensate for the increased patient load in health facilities. While some informants believed that the general decentralization of services may have reduced “brain drain” of skilled personnel from rural to urban areas, others thought that some health workers had abandoned their ministry positions to work for GHIs, where compensation was better. The freeze on public-sector recruitment imposed by IMF-backed structural adjustment programs was perceived to be a problem: personnel recruited and trained to reinforce Global Fund activities could not be absorbed into the public sector, despite obvious need. Some trained personnel were reported to have left their posts because they could not secure a fixed contract with either the MOH or the Global Fund. Strategies to support some of these temporary workers were being considered, though precisely how that could be accomplished was a matter of debate. Overall there was a perceived improvement in the health workforce following the advent of GHI funding. Nevertheless, long patient wait times and over-burdened health services underscored continuing challenges in this area. Medical Products, Vaccines and Technologies There was overwhelming agreement on the positive role played by GHIs in improving the availability of drugs, health commodities, and equipment for laboratory diagnosis. GHI funding was felt to have improved access to antiretroviral drugs (ARVs), antimalarials, bed nets, TB treatment, treatment for opportunistic infections vaccines, sterile needles, syringes and infusion supplies. Many laboratories, particularly in rural areas, now have the capacity to perform CD4 assays, as well as being equipped with microscopes for TB diagnosis, and reagents for other biochemistry assays. Health facilities were also provided with equipment such as refrigerators and motorcycles or transport vehicles for immunization campaigns. Some central-level units were also believed to have received computers for monitoring & evaluation (M&E). GHIs were felt to have improved the supply chain. In particular, Global Fund resources strengthened the existing drug procurement infrastructure, while GAVI improved the cold-chain supply for vaccines. Technical support from international organizations, such as WHO, and from external consultants, were also considered important in the development, validation and dissemination of local management guidelines for the care of HIV/AIDS, TB and malaria. Health Infrastructure Several new facilities were constructed and existing ones renovated with GHI support. In some cases voluntary counselling and testing (VCT) centres were erected next to existing hospitals. This was particularly important in CAR, where much infrastructure has been destroyed by armed conflict. The current level of infrastructure was still considered to be insufficient, with bed shortages in many hospitals. 45
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 14 and 15: Burundi: Building a health system t
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 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
Page 64 and 65: References [1] China at a glance. W
Page 66 and 67: 1994, private spending and emergenc
Page 68 and 69: understanding of their roles and re
Page 70 and 71: References [1] Human Development Re
Page 72 and 73: In 2003, the government launched th
Page 74 and 75: Objectives and Methodology The data
Page 76 and 77: Health Workforce Ghana is challenge
Page 78 and 79: Discussion GHIs are critical for ra
Page 80 and 81: Haiti: Maximizing Positive Synergie
Page 82 and 83: Table 1 Basic Socioeconomic, Demogr
Page 84 and 85: with need. With GHI funding, distri
Page 86 and 87: I know that within [the organizatio
Page 88 and 89: Much of the initial enthusiasm abou
Page 90 and 91: services, or for measures of qualit
Page 92 and 93: funds and more funding focused on i
Page 94 and 95: INDIA: Exploring how disease-specif
Page 96 and 97: PEPFAR* Year Amount Disbursed (in U
Page 98 and 99: Primary data collection - facility
Page 100 and 101:
The Global Fund has strengthened th
Page 102 and 103:
References [1] The World Bank Group
Page 104 and 105:
Background The Republic of Kenya li
Page 106 and 107:
Results Leadership and Governance D
Page 108 and 109:
Informants noted that a general lac
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time periods. Informants believed t
Page 112 and 113:
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
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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
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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
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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:
Page 150 and 151:
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
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
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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
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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
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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
Page 194 and 195:
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
Page 200 and 201:
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
Page 210 and 211:
Objectives and Methodology This stu
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Nonetheless, efforts to recruit and
Page 214 and 215:
Page 216 and 217:
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
Page 224 and 225:
Policy analysis of the impact of Gl
Page 226 and 227:
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
Page 232 and 233:
Global Fund In two country applicat
Page 234 and 235:
TABLE 3: Selected Countries: MPS Ca
Page 236 and 237:
HRH Intervention Categories GAVI: C
Page 238 and 239:
HRH Intervention Categories GLOBAL
Page 240 and 241:
HRH Intervention Categories PEPFAR
Page 242 and 243:
Conclusion: Directions for future r
Page 244 and 245:
GHIs and health systems. Civil soci
Page 246 and 247:
Annex 01: Data sources for tables i
Page 248 and 249:
Annex 02: Contributing Institutions
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MAXIMIZING POSITIVE SYNERGIES - World Health Organization

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