MAXIMIZING POSITIVE SYNERGIES - World Health Organization

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Health Workforce Ghana is challenged by inadequate skill mix, insufficient numbers and improper distribution of its health workforce. To improve workforce retention, distribution and motivation the government has initiated several measures. These include additional duty allowance, consolidation of salary structures, improved training opportunities and other fellowship programmes, as well as loans towards the purchase of cars or for housing schemes. These measures have led to an increase in payroll costs, which account for nearly 90% of the GoG health budget, and 47% of total health budget. Except for dedicated data managers at regional levels for the HIV/AIDS programme, and technical officers at the national level, no additional human resources have been recruited under the projects (accounting for less than 5% of the project costs). Global Fund support has contributed to programme-related training of the workforce, fellowship trainings and participation in international workshops/seminars, which improve provider confidence and quality of care. However, combined with the training burden of national programmes, such activity by GHIs has tended to overload the system: the NACP annual report observes that scale up of antiretroviral therapy (ART) services was delayed by the non-availability of staff engaged in ongoing training programmes. Medical Products, Vaccines, and Technologies All informants agreed that Global Fund projects have ensured availability of high quality drugs at competitive prices through mechanisms like the Global Drug Facility (GDF) and the Green Light Committee (GLC). The HIV/AIDS programme has developed a logistic management information system and trained over 265 pharmacists and dispensing technologists on logistic management of antiretrovirals (ARVs). ARVs are distributed to the ART sites based on their rates of consumption. Both programmes use the national medical stores and logistic supply chain for the distribution of drugs, and they are available through pharmacies within the health institutions. The (national) Public Health Laboratory coordinates the supply of laboratory supplies and consumables. Although there is clearly a need for additional funds to further strengthen warehouses and transport, these activities have not been budgeted under the grants, indicating greater ownership by the national health system. Information The demand for health information to monitor performance-based funding (input-process-outputoutcome and impact) is known to exert great strain on project staff and fragile health systems in most low-income countries, and Global Fund-supported projects are no exception. Although the Global Fund project has supported M&E staff at key levels, the burden of reporting and the emphasis on completeness and timeliness has created vertical programme reporting. Ghana has invested appreciably in the national Health Management Information System (HMIS), which is electronic at district level and upwards, but the programmes are reluctant to integrate them, more out of lack of trust rather than technical obstacles. Integration is made difficult by the demand for information on innumerable indicators, and also the frequent changes in reporting formats. One key informant on the staff of a development partner suggested ironically that it would be interesting to explore whether the Global Fund or the UN agencies, including WHO, place more 70
urden on public health personnel with their frequent demands for information to fill in reports and analytic publications. Service Delivery The TB and HIV/AIDS programmes have consciously used existing service delivery systems for rolling out interventions; and, have therefore, avoided creating parallel structures. To coordinate and monitor programme interventions, existing staff have been designated as nodal officers, but continue to contribute to other public health interventions like leprosy control, guinea worm control and promotion of family planning. The expansion of voluntary counseling and testing (VCT) services to sub-district level, and ART facilities to district level and some polyclinics, has definitely led to improved collaboration between the two programmes as well as improved client convenience. Global Fund projects have contributed significantly to strengthening service delivery through refurbishment of health facilities; provision of equipment (microscopy/auto-analyzers); ensuring uninterrupted supply of high quality TB drugs and improved access to ART; and vehicles for monitoring and evaluation, which are used by the system at large. Though these contributions are important, critics often complain that they only support programmes and do not often lead to overall improvements in other areas of service delivery – such as institutional density, health workforce and availability of essential drugs – that constitute major challenges for many health systems. In spite of GHI support, private out-of-pocket expenditures continue to be high and are rising as a percentage of overall health sector expenditures. Comparative coverage indicators for non-GHI-supported initiatives like maternal and child health – these include antenatal care (ANC) coverage, family planning acceptance, and deliveries by skilled attendants - have failed to show comparable improvements during the same time frame. Community/Civil Society Civil society, including FBOs, have been partners with the public health system for delivery of health care to such an extent that a portion of the Christian Health Association of Ghana’s (CHAG) staff salaries are borne by the government. The Global Fund projects have facilitated the extension of these formal arrangements with individual private providers and private associations. However, a perception also exists that, with large sums of money being made available there has been an unprecedented surge in the number of NGOs, and identifying credible ones has become a challenge. Inputs have been sub-optimal for strengthening local NGOs and community-based organizations (CBOs), and the bulk of resources are channelled through international or large NGOs. 71
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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
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at between US$ 14.5 and US$ 18.5 pe
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collaborations with European school
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epresent only US$ 1.75 per month pe
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Service Delivery The decentralizati
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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 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 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
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
Page 124 and 125: Commission (NAC) in 2001 as a multi
Page 126 and 127:
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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