MAXIMIZING POSITIVE SYNERGIES - World Health Organization

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INDIA: Exploring how disease-specific programmes in TB and HIV/AIDS interact with health systems. Abstract Krishna Dipankar Rao 1 , Mathew Sunil George 1 , Aarushi Bhatnagar 1 , Babita Rajkumari 1 , Maulik Chokshi 1 , Preeti Kumar 1 and Indrajit Hazarika 1 1 Public Health Foundation of India, New Delhi. GHIs represent an important recent trend in international health. Several GHIs operate in India (Global Fund, PEPFAR and GAVI). Global Fund is the biggest contributor to India’s health sector. The aim of this study is to understand how programmes supported by the Global Fund in India, National Aids Control Programme (NACP-3) for HIV/AIDS and the Revised National TB Control Programme (RNTCP) for TB, interact with existing health systems. Key informant interviews and data from health facilities were collected in three states of India. Findings indicate that the RNTCP and especially the NACP have great potential for strengthening health systems in several ways: (1) by placing key staff at health facilities, especially at the periphery, who then function as a resource for the entire health facility; (2) by strengthening laboratory services, sharing supplies and resources with labs meant for general patients or providing services for non-programme specific patients; (3) by improving patient perceptions of public health facilities through the presence of relatively well-run programmes and creating demand for better quality services. The Global Fund has also helped to strengthen the presence, voice and capacity of civil society organizations (CSOs) to participate in national health programmes. Yet, these synergies did not take place at all health facilities and the RNTCP was more conducive to generating these synergies. Here, three factors appear to be important: (1) the explicit intention of the programme to strengthen health systems; (2) the locus of administrative control over programme-specific contractual health workers; and (3) the locus of administrative control over the programme as a whole. Background The largest country in South Asia, India is bordered by Pakistan to the west; China, Nepal, and Bhutan to the northeast; and Bangladesh and Myanmar to the east. India is home to 1.1 billion people with an average annual population growth rate of 1.4% [1]. Between 1997 and 2007, its GDP grew at 6.9% per year on average, making India one of the ten fastest growing economies in the world [1]. India ranked 132nd out of 179 countries on the UN Human Development Index in 2006 [2]. Premature death and illness due to major environmental health risks - such as a lack of safe water, vector borne diseases, and agro-industrial chemicals - account for nearly 20% of the total burden of disease [3]. India's public health spending is low at around 1% of GDP. The National Rural Health Mission (NRHM), launched in 2005 to strengthen the rural public health system, aims to increase public spending on health to 2-3% of GDP by 2012 [4]. In 2002, the Ministry of Health and Family Welfare in India estimated that less than 20% of the population which seek outpatient services, and less than 45% of that which seek inpatient treatment, make use of such services in public hospitals [5]. The private health sector in India is growing at a remarkable rate. In 2005, India ranked among the top 20 of the world's countries in its private spending. Employers paid for 9% of spending on private care, health insurance 5-10%, and 82% was from personal funds. More than 40% of all patients admitted to hospital had to borrow money or sell assets to cover expenses [6]. 88
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) 1,123,319 2007 World Bank Geographic Size (sq. km) 2,973,190 2007 World Bank GDP per capita, PPP (constant 2005 international $) 2,598.59 2007 World Bank Gini index 36.8 2005 World Bank Government expenditure on health (% of general government expenditure) 3.2 2007 WHO NHA Per capita government expenditure on health (current US$) 9 2007 WHO NHA Physician density (per 10,000) 6 2004 WHO SIS Nursing and midwifery density (per 10,000) 13 2004 WHO SIS Maternal mortality ratio (per 100,000 live births) 450 2005 WHO SIS DTP3 coverage (%) 62 2007 WHO SIS Estimated adult HIV (15-49) prevalence (%) 0.3 (0.2-0.5) 2007 UNAIDS Estimated adult antiretroviral therapy coverage (%) 20 2007 UNGASS Estimated pediatric antiretroviral therapy coverage (%) 35 2007 UNGASS Tuberculosis prevalence (per 100,000) 283 2007 WHO GTD Estimated malaria deaths 15,008 2006 WHO WMR Table 2 Global Health Initiative Investments Global Fund Round & Disease Priority Approved (in US$) Disbursed (in US$) Round 1, TB 8,655,033 8,655,033 Round 2, HIV/AIDS 248,367,328 92,702,000 Round 2, TB 99,755,540 23,258,723 Round 4, HIV/AIDS 140,878,118 78,663,024 Round 4, Malaria 63,544,954 47,705,431 Round 4, TB 25,823,483 19,113,943 Round 6, HIV/AIDS: 85,688,377 30,346,423 Round 6, TB 21,308,621 8,579,594 Round 7, HIV/AIDS 30,720,116 7,599,387 TOTAL: 739,561,352 329,457,252 89
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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
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of treatment interruptions (>two da
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side effects) were associated with
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Prevention behaviours Nearly half (
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References [1] The World Bank Group
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Out-of-pocket payments account for
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as well as the number of community
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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 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 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: References [1] The World Bank Group
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
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
Page 138 and 139: 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
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HIV/AIDS, mainly around the Compreh
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without substantial emphasis on pre
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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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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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