MAXIMIZING POSITIVE SYNERGIES - World Health Organization

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Haiti: Maximizing Positive Synergies between Global Health Initiatives and the Health System Abstract Background LC Ivers 11 12 13, JG Jerome 10, E Sullivan 14 15, JR Talbot 11 14, N Dhavan 11 14, M StLouis, W Lambert 10, J Rhatigan 11 12 14, JS Mukherjee 10 11 12. Increasing attention is being paid to the impact that GHIs such as the Global Fund and PEPFAR have on health systems as a whole. We aimed to evaluate the impact of these two GHIs on the health system in Haiti. Methods We used mixed qualitative and quantitative methods: semi-structured interviews, observation, examination of documentary material, and collection of quantitative data. Twelve key informants from nongovernmental organizations (NGOs), international organizations and the Ministry of Health (MOH) participated in semi-structured interviews. Results The Global Fund /PEPFAR were largely associated with strengthening the health system in Haiti, particularly in geographic areas and programmes where NGO leaders and/or MOH specifically designed and coordinated their interventions to have such an impact. The Global Fund/PEPFAR were associated with overall improvement in human resources capacity and retention but did cause some tensions due to salary inequities. The Global Fund/PEPFAR funds were not received directly by the government of Haiti, and this empowered NGOs to work independently of the MOH. Discussion GHIs such as the Global Fund and PEPFAR can successfully strengthen health systems if this objective is included in planning and design and if leadership and coordination are ensured. 11 Partners In Health, Boston, USA 12 Brigham and Women’s Hospital, Boston, USA 13 Harvard Medical School, Boston, USA 14 Harvard School of Public Health, FXB Center for Health and Human Rights 15 Global Health Delivery Project, Boston, USA 74
Background The Republic of Haiti occupies the western third of the island of Hispaniola, sharing its 360 kilometre eastern border with the Dominican Republic. Haiti is home to more than 9.6 million people (see Table 1), up from just over three million in 1955 [1]. As of 2007, approximately 1% of the population controlled nearly half of Haiti’s wealth [2]. In 2005, Haiti ranked 146 th out of 177 countries on the UN Human Development Index [3]. Official Development Assistance (ODA) to Haiti in 2006 was US$ 581.4 million [1], but the country remains highly indebted due largely to loans incurred from 1964 to 1986 [4]. At the end of 2007, Haiti’s total external debt was US$ 1.463 billion or 24% of gross domestic product (GDP) in 2006 [5]. Widespread deforestation, soil destruction, and poor agricultural output contribute to food insecurity; the island’s vulnerability to natural disasters, including floods and hurricanes, exacerbate the situation. A 2004 hurricane killed approximately 3000 people and caused damage estimated at 3.5% of GDP [6], while a 2008 series of hurricanes killed over 800 people, displaced 1 000 000, and wiped out 60% of the year’s harvest [7]. Haiti has some of the worst health statistics in the Americas (see Table 1), including the highest infant mortality and maternal mortality rates in the Western hemisphere (60.0 per 1000 in 2006 and 670 per 100 000 live births in 2005 respectively). WHO estimated that incidence of smearpositive pulmonary TB in Haiti was 133 per 100,000 in 2006; prevalence was 402 per 100 000. First identified in Haiti in 1981, HIV/AIDS became the leading cause of death in 1999. In 2007, 120 000 people in Haiti were living with HIV [8]. In 2003, health services reached only 60% of the population. In addition to the public sector, which comprises about 35.7% of the health infrastructure, the health system includes for-profit service providers catering to urban professionals; private non-profit organizations; and mixed non-profit facilities, including Ministry of Health (MOH) personnel working in private institutions or religious organizations [9]. About 40% of the population—mostly in rural areas—relies on traditional medicine, lacking access to other services [9]. Physicians are concentrated in the capital city of Port-au-Prince and in other large towns. In some provinces, there is one physician for every 67 000 people [10]. Nearly 30% of health professionals left the country between 2005-2008 for the U.S. or Canada [11]. The government has regularly increased the health budget, but the recent funds are lower in real terms than in the 1980s due to inflation [12]. Currently, 18.9% of the country’s total health budget comes from external sources [11,13]. Haiti was among the first set of grant recipients from the Global Fund in 2003, and since then, the country has received two additional grants for HIV/AIDS and one for TB, with a total approved funding amount of approximately US$ 248 million, though only US$ 130.1 million has been disbursed (see Table 2). The U.S. government began funding HIV/AIDS prevention, treatment, and care interventions in Haiti through PEPFAR in 2004, working largely with existing USAID contracts and partners, half of which were faith-based organizations (FBOs) [14]. 75
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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
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Cameroon: Evaluation of the Nationa
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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 76 and 77: Health Workforce Ghana is challenge
Page 78 and 79: Discussion GHIs are critical for ra
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
Page 128 and 129: 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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