MAXIMIZING POSITIVE SYNERGIES - World Health Organization

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NGOs and Civil Society The overall perception was that GHIs, the Global Fund in particular, substantially improved the participation of NGOs in the health system in CAR. Local and international NGOs were represented in the CCM. Some local NGOs also served as secondary beneficiaries of funds, while others have been involved in HIV information and education campaigns, mosquito net distributions, homebased HIV-care and even TB care. GAVI also supported NGOs involved in vaccination campaigns. While NGOs are hampered by the lack of financial and human resources, there was a perception that partnership with governmental institutions allowed for training in areas where their capacity is presently inadequate. Informants believed that NGOs played an important role in the system and that their participation was a plus for the system. There was however a concern that some NGOs would not be likely to be sustainable in the absence of GHI funds. Service Delivery Overall there were perceived improvements in all aspects of health care delivery and these were not limited to HIV/AIDS, TB and malaria or vaccine-preventable diseases. There was also improved public awareness about the target diseases. Testing and counselling for HIV was fuelled by the sense that an HIV diagnosis was not fatal, owing to increased access to antiretroviral treatment (ART). With the availability of GHI funding the price of drugs and laboratory assays has been markedly reduced. Malaria treatment and insecticide-treated bed nets are free for children and pregnant women. TB treatment is also free and there have been fewer interruptions in drug supply. Drugs are also more widely distributed nationwide. GHIs have thus made a significant impact in the numbers of patients receiving services. Under GAVI more vaccines have been made available and supplemental vaccination campaigns have been organized with the aim of “catching-up” vaccinations in children who may have missed some regularly scheduled vaccines because of armed conflict. Key informants did not have hard data on the impact of the GHIs on health outcomes per se. Nevertheless there was an impression that there was reduced mortality and prolonged survival in patients with HIV. It was not known however whether HIV prevalence was decreasing, as the surveys that have been conducted used different methodologies. It was not clear what impact may have been made on the frequency of high-risk behaviour. Although data specific to malaria were also lacking, at least one informant felt that an observed reduction in infant mortality could be due, in part, to better malaria care. GAVI was perceived to have improved vaccine coverage and also to have increased the number of diseases targeted in the expanded immunization program. Vaccines against Haemophilus influenza b and Hepatitis B Virus were expected to be added with support from GAVI. Cross-Cutting Themes Some themes discussed by the informants did not fit into any of the aforementioned categories or included multiple categories. One such area was the coordination and integration of GHIs within the health system. Informants thought that while some aspects of GHIs were well integrated in the system, others were not. GHIs are well coordinated at the central level of the MOH. Drug supply, training and M&E also appear to be well integrated. Funds from GAVI in particular have been involved in strengthening the health system and there was a belief that GAVI was well integrated 46
as funds were pooled centrally, and some programme equipment (such as motorcycles and other vehicles) has been used for other purposes. Nevertheless, there was an impression that integration was not complete: the Global Fund was felt to recruit personnel and make funds available only for target diseases. Some aspects of GHIs were parallel to existing systems, essentially running as vertical programs. The monitoring, evaluation and reporting system of the Global Fund and surveillance for polio were considered as examples of systems running parallel to CAR’s National <strong>Health</strong> Information System. With respect to equity and regional variation, there was an overwhelming sense that GHI funding had made it possible for services (including preventive, screening/diagnosis and treatment) and infrastructure to be decentralized from urban centres into remote rural areas, thus improving access to care. The extent of decentralization was however perceived to be insufficient; rural populations still needed more help. Many informants had concerns about the long-term sustainability of services provided by GHIs. What would happen to patients, infrastructure, personnel, and NGOs when funding was no longer available? Spillover Effects Informants described a number of unplanned or unexpected effects of GHIs. On the positive side, GAVI and the Global Fund strengthened overall health system infrastructure and improved services for non -targeted diseases. On the other hand, negative effects included migration of health care workers from non-GHI-funded units (or activities) to GHI-funded units (or activities). In a few cases there was also a perception that free access to drugs could have negative consequences, including a reduction in patient choice of treatment, undercutting of local pharmaceutical companies (one informant mentioned a local infusion fluid manufacturer being undercut by the provision of free infusion fluids from foreign sources), and undermining the costrecovery system of financing in health facilities. For example, malaria is the most prevalent disease in health facilities in the CAR. Prior to drugs and some laboratory assays being made free, a small proportion of patient payments went to maintaining and running some health facilities. With drugs being made free, the amount of money recovered could be substantially reduced, thus impacting the financing of the health facilities. Recommendations Informants made numerous suggestions on how to improve the impact of GHIs on the health system. Some informants thought that GHIs should focus on reinforcing the health system as a whole, not just targeted diseases. In the grant allocation procedures, consideration should be given to country needs and not simply the quality of proposals. Informants felt that technical support should be made available to countries to assist in writing high-quality proposals. More funding was also felt to be needed for training, recruitment of human resources and infrastructure. Informants recommended efforts to improve reporting, archiving and computerization of the health system. There was also a perceived need for better incentives and salaries for health care workers. Finally, concern was expressed about the potential interruption of GHI funding; in the event that discontinuation was being considered, informants stressed the importance of ensuring that states can provide resources for the system to continue functioning at the same level. 47
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 50 and 51: Financing There was a general appre
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
Page 110 and 111:
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
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
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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
Page 152 and 153:
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
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
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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
Page 206 and 207:
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
Page 212 and 213:
Nonetheless, efforts to recruit and
Page 214 and 215:
Page 216 and 217:
average annual population growth of
Page 218 and 219:
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
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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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