1. Diseases: Global Burden & Response PHC & vertical programs GH 511/EPI 531 Stephen Gloyd October 2009

2. Essentially Synonyms Selective Primary Health Care (Walsh, Warren) Child Survival (USAID) GOBI-FFF (UNICEF) Growth monitoring Oral Rehydration Therapy Breast Feeding Immunizations Family Planning Female Literacy Food

3. Selective Primary Health Care Rationale PHC is great, but can’t afford it PHC requires political will that isn’t there PHC need immense organizational support Ideology of Cost-effectiveness Establish priorities (Can’t do everything at once) Quick fix (short term goals) Trust in power of technology to address social & economical problems

4. Selective Primary Health Care  Components of SPHC (Walsh, Warren Model) Flexibility (fixed or mobile units) Limited interventions of “proven efficacy”  Oral rehydration therapy  Immunizations  Breast feeding  Local disease control (malaria, schistosomiasis, tuberculosis)

5. GOBI – Child Survival mobilization  Bellagio (Italy) Conference – Nov 1979 (Rockefeller, Unicef, CDC, others)  Walsh, Warren Article in NEJM (plus lunch with Ken Warren)  Media efforts with famous people  Changing burden of childhood diseases (increased; more EPI/ORT)  WHO battles: disease specific WHO funding  USAID policy shifts

6. World Health Organization data 2001 (from Global Health Council http://www.globalhealth.org) Leading Causes of Death in Children (<5y/o) Role of malnutrition - 2001 Perinatal (22%) All other causes (29%) HIV / AIDS (4%) Diarrhea (12%) Measles (5%) Malaria (8%) Pneumonia (20%) Malnutrition underlying factor (60%)

7. Justification for ‘selective’ interventions - 1986

8. ‘Causes’ of deaths – UN Agencies Cause1986 deaths (millions) 2001 deaths (millions) WHO 2004 2003 deaths (millions) Cntr Glob Devt 2007 Diarrhea5.01.21.7 Malaria3.00.8 Measles2.10.50.4 Pneumonia1.32.01.9 Tetanus/pertussis1.4 Neonatal2.23.7 HIV/AIDS0.40.3 Other1.32.91.3 Total14.110.010.1

9. USAID policy shifts USAID Health Policy Paper (1986)  ‘Within AID’s health assistance program, priority will be given to support for child survival and improved maternal and child health, specifically immunizations, ORT, nutrition, and adequate birth spacing.  Priority will be placed on immunizations and diarrheal disease control/ORT, but the choice of which interventions to support will be made on the basis of country-specific conditions.  …other health activities, including primary health care, water and sanitation projects, and vector-borne disease treatment and control, will be supported where there is a need...  ….Where health programs beyond the four direct child survival interventions are proposed for USAID support, an additional burden of proof will be required to demonstrate their appropriateness. USAID, PN-AAV-462, December 1986

10. Child Survival Principles 1. Prioritize condition of most importance Focus on kids 2. Assess feasibility of interventions Consider intervention of “proven efficacy” ORT/Immunizations “Cost-effectiveness” 3. Postpone interventions that are either too expensive – Water/sanitation unproven efficacy-schisto/trypanomoiasis 4. Organizationally, consider mobile teams, campaigns, fixed units 5. Gradual, cost-effective way to achieve PHC

11. Questions regarding child survival programs - remember CS film- 1. Do Child Survival interventions reduce overall mortality in children under 5 years old? 2. Do they strengthen efforts to establish primary health care? 3. Do they address felt needs? 4. Do they encourage reallocation of resources?

12. Do Child Survival interventions reduce overall mortality in children under 5 years old?  Substitution mortality? If a malnourished child is immunized against measles, then malaria or pneumonia will be more likely to be a cause of death  Do the interventions have a multiplier or substitution effect? (e.g., water vs vaccines)

13. Do child survival programs strengthen efforts to establish primary health care?  Ignores political aspects of PHC (next slide)  Provides support for key components of PHC, but doesn’t address others  Creates parallel (and sometimes competitive) health systems

14. Declaration of Alma-Ata (1978) 1. Health is a fundamental human right & requires inter-sectoral action 2. Existing gross health inequality unacceptable 3. Improved health and peace require economic and social development based on a new international economic order (NIEO) 4. Governments have responsibility to provide adequate health and social measures for health 5. Primary health care is appropriate, accessible, acceptable, affordable and requires community participation (Specifies components of PHC) 6. Governments need the will to formulate and implement PHC policies 7. International cooperation is necessary 8. HFA 2000 requires redirecting resources from military to social expenditures (including health) Source: WHO, 1978

15. “Essential components” of Primary Health Care 1. Health education 2. Environmental sanitation, especially food and water 3. The employment of community health workers 4. Maternal and child health programs, including immunization and family planning 5. Prevention of local endemic diseases 6. Appropriate treatment of common diseases and injuries 7. Provision of essential drugs 8. Promotion of nutrition Source: Alma-Ata Conference documents.

16. Primary Health Care Systems Planning Budgeting Procurement Secondary (Provincial) Hospital Provincial Health Office District Health Office District Hospital Health Post MOH Central Tertiary (National) Hospital Supervision Drugs, Lab M&E Service support Integration of services CHW TBA All services Private NGO clinics

17. MCH Integrated Programs Do child survival (vertical) programs strengthen primary health care? Health Center Health Post CHW TBA CHW Support Managers and providers Referral systems Facility maintenance Lab, pharmacy systems

18. Integrated MCH programs in MOH CS (vertical program) CHW Immunizations ORT Health Education Support Vaccination Campaigns Mobile Units Cold Chain Child Survival (vertical) Projects

19. MOH Integrated Programs National, provincial, district Primary Health Care Health Center Health post Health post Health post Health post Mid-level practitioners Cold chain Referral center Rx common diseases Health education CHW TBA CHW TBA “Child Survival” Projects MOH CS CHW Support Vaccination campaigns Mobil units Cold chain Immunizations ORT Health Education ‘Community’

20. PHC System - for ARV treatment Starting curative care at referral site Provincial Health Center District Health Center Center District Health District Health Center ARV Care Sites - Health Post MOH support Drugs, Lab, M&E

21. PHC System: Expansion to District Centers Provincial Health Center District Health Center Center District Health District Health Center ARV Care Sites - Health Post MOH support Drugs, Lab, M&E

22. PHC System Expansion to some Health Posts Provincial Health Center District Health Center Center District Health District Health Center MOH support Drugs, Lab, M&E Care Sites - Health Post District Health Center

23. PHC System Expansion to most Health Posts Provincial Health Center District Health Center Center District Health District Health Center MOH support Drugs, Lab, M&E Care Sites - Health Post District Health Center

24. Typical NGO Approach Coverage and system support Provincial Health Center District Health Center Center District Health District Health Center Care Sites - NGO 1 supportNGO 2 support MOH support Drugs, Lab, M&E Health Post

25. Guro Tambara Chemba Maringue Macossa Sussundenga Machaze Machanga Muanza Cheringoma Chibabava HIV Treatment Expansion Plan 2003 2004 2005 2006 2007 Facilities providing HAART 47 HIV+ Registered63,000 Pts in HAART13,000 (22%) MOH in Central Mozambique by end 2007

26. MOH-Chimoio NGO Machava MOH_Beira NGO - Chingass Coverage – NGO vs PHC

27. Questions regarding child survival programs 3. Do they address felt needs? (curative vs preventive) 4. Do they encourage reallocation of resources?

28.  Family Planning (pre-Child Survival)  ORT-Immunizations (Child Survival,Gobi) - 1979  Vitamin A -1983  Maternal mortality, TBAs - 1986  ALRI (Acute lower respiratory diseases) - 1986  HIV-AIDS prevention and care - 1988  Polio eradication ~1990  Roll Back Malaria ~ 1999  Integrated management of childhood illnesses (IMCI) - 2000  Tuberculosis ~1995, MDR ~ 2000 Evolution of disease-specific (vertical) approaches – donor driven

29. Stated reasons for child survival vs PHC 1. Rapid results 2. Efficiency 3. Application of new, appropriate technologies

30. Stated reasons for child survival (1) 1. Rapid Results Donor agencies tired of big programs with little chance of measurable impact Need for short-term results (3-5 years) Funding cycle, tenure of administrations is also short Single outcome, measurable results (EPI vs water)

31. Underlying reasons for child survival (2) 2. Efficiency Change organizational structure to achieve goals ( e.g. immunization programs often work better outside of the usual MOH structure; cold chain, distribution) Thus, there is a tendency for: Independent organizational structure (usually within MOH) Singular focus Mobile teams/campaigns CHWs (esp for ORT, mobilization for Immuniz) LESS NEED FOR complex organization of PHC (e.g., training of mid-level health providers, distribution system, referral network, link with hospitals)

32. Stated reasons for child survival (3) 3. Application of new, appropriate technologies  faith in capacity of vaccines, ORT  less faith in organizational structure to cope with diseases  magic bullet ideology

33. Ideological shifts with vertical programs Individual responsibility Government bureaucracy Resource scarcity Cost-effectiveness Priority disease control Interventions with low recurrent costs Community focus Public responsibility Government health services Resource reallocation Spending appropriateness ( education vs. military) Comprehensive & integrated interventions Broad ranging interventions Health systems focus

34. Child Survival Strategies Summary of Theoretical Problems 1. Validity of effectiveness assumptions - Shifting mortality 2. Cost-effectiveness approach - Undervalues externalities 3. PHC organizational structure ignored 4. Resource draw from PHC systems (money, people) 5. Inadequate response to “felt needs” 6. Depoliticized - low resistance, no reallocation 7. Feeds myth of resource scarcity

35. Vertical programs in Mozambique - 2007  Provide bulk of funding  PEPFAR has expanded vertical programming  ‘Neocolonization’ by province  NGOs and donors budgets exceed MOH  Confusing multiplicity of vertical projects, diseases, inputs  Not likely to change soon

36. Total funding by agency ($ 157 mln.)

37. Relative weight of vertical funds

38. Input at central level ($ 29m)

39. Donor presence by province Mozambique Health Financing

40. Mozambique: Type of implementing agencies and comparative funding - 2006 $million/ yr

41. Multiplicity of vertical projects: Thematic area (as %)

42. Thematic areas (Number of projects) ATMMCHPHCCom. H.OthersTotal Maputo C. 321129 Maputo P. 4475121 Gaza 9677130 Inhambane 4441215 Sofala 6540217 Manica 5420112 Tete 7710116 Zambezia 5641117 Nampula 11682128 Cabo Delgado 7576328 Niassa 6243116 Total 6751492616209

43. Multiplicity of inputs Inputs as %

44. Varying inputs by province Infrastructur eMed. Equipm.DrugsIncentivesTATransportTrainingAll Maputo C. 3214224 18 Maputo P. 76754310 42 Gaza 66035312 35 Inhambane 8401226 23 Sofala 4506559 34 Manica 2101117 13 Tete 0334409 23 Zambezia 2513537 26 Nampula 7638109 53 Cabo Delgado 7523419 31 Niassa 2301217 16 All 48461739443090 314

45. Conclusions in Mozambique  Vertical funding is an important funding mechanism of the health sector and will increase  It is mainly focussed on control of the three big diseases  Variations in allocations between provinces are difficult to understand