MAXIMIZING POSITIVE SYNERGIES - World Health Organization

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1994, private spending and emergency assistance from international donors became a major source of health sector financing. Despite structural and systematic changes such as moving from a costly primary care model to a more affordable family medicine model; and introducing an insurance scheme, Georgia’s financing for health care services is highly dependent on out-of-pocket payments. As a result of the high out-of-pocket expenses as well as a scarcity of qualified providers in rural areas, Georgia has relatively low service utilization rates. A 2002 survey conducted in the Georgian countryside found that only 59.5% of those who face a health problem seek care, while 15.1% self-treat [4]. To address these problems, the Georgian government launched a Primary Health Care (PHC) reform initiative in 2002 aimed at improving care in both rural and urban areas [5]. However, the PHC reform has not received adequate financing. By 2007, most hospitals, dental clinics, and pharmacies in Georgia had been privatized [6]. In 2007, public funds accounted for only 18% of total health expenditure, compared to nearly 72% from out-of-pocket sources [7]. External resources made up 6.7% of total health expenditure in 2006 [8]. Official Development Assistance (ODA) to Georgia was US$ 360.6 million in 2006 [9]. Its total external debt was US$ 1.96 billion or 25.4% of GDP [9, 10]. Table 1 Basic Socioeconomic, Demographic and Health Indicators (*) (*) Full data sources for all indicators are provided in Annex 1. Indicator Value Year Source Population (thousands) 4,400 2007 World Bank Geographic Size (sq. km) 69,700 2007 World Bank GDP per capita, PPP (constant 2005 international $) 3,365 2007 World Bank Gini index 40.4 2007 World Bank Government expenditure on health (% of general government expenditure) 4.2 2007 WHO NHA Per capita government expenditure on health at average exchange rate (current US$) 35 2007 WHO NHA Physician density (per 10,000) 45 2007 WHO SIS Nursing and midwifery density (per 10,000) 39 2007 WHO SIS Maternal mortality ratio (per 100,000 live births) 66 2005 WHO SIS DTP3 coverage (%) 98 2007 WHO SIS Estimated adult HIV (15-49) prevalence (%) 0.1 [
Objectives and Methodology The effects of Global Fund funding on Georgia’s health system were assessed in a two-phase study conducted during 2004-2008. The study was part of the System Wide Effects of the Fund (SWEF) Network, which participates in the Global HIV/AIDS Initiatives Network (GHIN), where researchers are studying the effects of GHIs on countries’ HIV/AIDS programmes and health systems. The studies were designed to assess the effects of the Global Fund on the policy environment, on public-private interactions, on human resources, and on access to HIV/AIDS services. The findings presented draw from a base-line survey implemented in 2004; the survey was carried out in 35 health facilities, in 26 districts, with a follow up study a year later [11, 12]. Data collected was both quantitative and qualitative, based on structured questionnaires with service providers and semistructured interviews with 36 key stakeholders. Study protocols were approved by the Bioethics Committee of Georgia. For each of the themes identified, the following tools were utilized by the research team, following SWEF and GHIN protocols [13]: Policy environment Stakeholder interviews were conducted. In total, 24 interviews were completed between January 2006 and February 2007, with representatives of the Country Coordinating Mechanism (CCM), the Ministry of Health (MoLHSA), members of the Parliamentary Committee on Health and Social Issues, representatives of International and local NGOs, members of the donor community, and managers at the National AIDS Center, the National Institute of Drug addiction, and with the Principal Recipient. Public-private mix Structured interviews were conducted with managers at 10 NGOs, who are implementing the Global Fund-financed HIV/AIDS programme in Georgia. These interviews were complemented by on-site visits to projects and a review of documents. Human resources Thirty-five health facilities were selected in three different geographical locations, and 201 primary health care providers interviewed. Sampling was based on incidence rates of the three target diseases. Access to HIV/AIDS and TB services Exit interviews were conducted with a small sample of TB (n=19) and AIDS (n=20) patients. Additionally, in-depth interviews were conducted among high risk group representatives (60 injecting drug users [IDUs] and 60 commercial sex workers [CSWs]). Results Leadership and Governance Global Fund resources contributed to the establishment of CCMs, which over time have improved their overall governance and functionality since the initiation of the Global Fund grant. Interviews with key individuals revealed that multi-sectoral coordination has benefited from the process, which respondents attributed to the leadership qualities of the CCM chair. The follow-up survey revealed that CCM members became much more active and had developed a better 61
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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
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 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 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 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 114 and 115: A comprehensive, long-term reform o
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The effects of GHIs on the capacity
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their budget was comprised of Globa
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Quality of services The majority of
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References [1] Kyrgyzstan at a glan
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Commission (NAC) in 2001 as a multi
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Objectives and methodology The main
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Discussion The findings of the Mala
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Pakistan: The impact of the Global
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international standards. The Under
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the US Centers for Disease Control
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Some negative effects are also attr
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to country health systems by way of
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Peru: Effects of the Implementation
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Table 2 Global Health Initiative In
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HIV/AIDS, mainly around the Compreh
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without substantial emphasis on pre
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References [1] The World Bank Group
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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
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Some informants felt that local NGO
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Senegal: The effects of Global Heal
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Table 1: Basic Health System and Ep
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case study. Data analysis was condu
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of respondents aware of treated net
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South Africa: The effects of Global
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Table 2 Global Health Initiative In
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of South Africa (GHI2, ND6). 26 Don
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NDOH to disburse external funds in
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The lack of effective monitoring an
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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
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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
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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
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Objectives and Methodology This stu
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Nonetheless, efforts to recruit and
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References [1] The World Bank Group
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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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