1. The PHRplus Project is funded by U.S. Agency for International Development and implemented by: Abt Associates Inc. and partners, Development Associates, Inc.; Emory University Rollins School of Public Health; Philoxenia International Travel, Inc. Program for Appropriate Technology in Health; SAG Corp.; Social Sectors Development Strategies, Inc.; Training Resources Group; Tulane University School of Public Health and Tropical Medicine; University Research Co., LLC. URL: http://www.phrplus.orghttp://www.phrplus.org The System-Wide Effects of the Fund (SWEF) Research Network Health Systems and HIV/AIDS: The Experience of the Global Fund Sara Bennett PhD and Kate Stillman MPA With Hailom Banteyerga, Aklilu Kidanu, (Ethiopia), Owen Smith, Sourou Gbangbade, Assomption Hounsa, Lynne Franco (Benin), Brian Mtonya, Victor Mwapasa, and John Kadzandira (Malawi)

2. Research Objectives To document the effects of the processes involved in applying for and receiving a Global Fund grant, and implementing GF-supported activities on the health systems of recipient countries.

3. HIV/AIDS and Health Systems System Function Key Questions for HIV/AIDS Stewardship – policy process & governance How aligned with government policies? Extent of harmonization across donors? How inclusive & transparent policy processes for GF? Monitoring AIDS programs Resource Management Impact on quantity, distribution, skills, motivation & time allocation of health workers? Impact on drug management; availability; rational drug use? Financing - Promotes financial accessibility of services - Promotes financial sustainability Service Provision - Scaling up access to prevention & care (through the private sector) - Enhancing quality of clinical & personal services

4. Research Design & Methods  Country studies in Benin, Ethiopia and Malawi  Baseline and follow-up surveys (this is baseline)  Data collection: document review, in-depth interviews (national & sub-national), and facility survey  Benin: September – October 2004  Ethiopia: November 2004 – January 2005  Malawi: June-July 2005  Independent studies but extensive stakeholder engagement in-countries

5. Overview of HIV/AIDS Grants in Study Countries Overview of HIV/AIDS Grants in Study Countries (Rounds 1-4 only) BeninEthiopiaMalawi GF 2yr approved For HIV/AIDS (Round) $11.4m (Round 2) $97.3m (Round 2 & 4) $41.8m (Round 1) GF $ per person / per annum $1.69$1.38$3.45 Govt. health spending pp/pa $9.00$2.00$6.00 PRsUNDPHAPCONAC Other major AIDS initiatives MAP MAP, PEPFAR ClintonMAPClinton Sources: Global Fund, World Health Report 2005

6. The Global Fund and health systems  From initiation, stated commitment to addressing “HIV/AIDS in ways that contribute to strengthening of health systems”  But, no guidance on what sorts of health systems strengthening permitted, and few cross-cutting proposals approved  Round 5 (June 2005) first explicit call for health systems proposals

7. SWEF Findings - Policy Processes  Alignment  GF-supported programs perceived by respondents as a “gap filling opportunity” & fit within country plans  In practice, GF often distorts or creates additional structures & processes eg.separate funding channels, new management entities  Perceived to operate in a centralized and vertical manner

8. Impact of centralized decision making processes “GF is centralized and we have no say on it apart from implementing the activities set in the action plan….We have no ownership or say…This has affected the effectiveness and quick implementation of the GF programs.” Regional respondent, Ethiopia Regional respondent, Ethiopia “Unfortunately the CCM has no connection with us. In fact we need to have a regional coordination mechanism which should be represented in the CCM to reflect regional interests.” Regional respondent, Ethiopia Regional respondent, Ethiopia

9. SWEF Findings - Policy Processes  Harmonization  Country stakeholders perceived harmonization across donors…but heavy reporting load  Transparency & Accountability  Lack of transparency about allocation of resources between districts/regions  Limited knowledge of GF outside immediate stakeholders

10. SWEF Findings – Human Resources for Health  Capacity constraints - currently most conspicuous at the central level – but concerns at lower levels  HRH strategies  Benin & Ethiopia - no comprehensive strategy – uncoordinated approach, distorted incentives  Malawi comprehensive national strategy – GF money re- directed to this (and successful in Round 5)  GF-supported training focuses on  clinical (not managerial) skills  in-service (rather than basic) training  Potential positive impact on motivation via improvements in work environment

11. Respondent perspectives on HRH constraints “ There is a need for more senior staff members in the MOH to supervise and coordinate the implementation of HIV/AIDS activities in the public sector. Currently TAs outnumber full- time senior MOH staff, a situation which might lead to loss of local ownership” Malawi, MOH official “The ART clinic is overwhelmed with patients…Gradually we have increased the number of clinicians working in the ART clinic from 1 to 3, much to the detriment of other hospital clinical services” Malawi, Health worker

12. SWEF Findings – Public/Private Mix  Infertile ground for public/private partnerships  lack of clear policy or common understanding about roles for the private sector  New collaborative arrangements emerging umbrella organizations, sub-contracts, subsidies, etc. – potential to change culture  Growth in non-profit sector – but concerns about capacity and diversion from non-ATM activities  Lack of capacity to coordinate within private sector an obstacle – but also emerging initiatives  No or limited evidence of migration between sectors

13. Perspectives on Public/Private Relations “There is a tension between government and NGOs. It is all attitudinal…..I think NGOs are not getting GF grants because Government does not have a positive attitude towards NGOs and doesn’t trust NGOs.” Ethiopia, NGO/private sector respondent “The option of referring patients to other private facilities or CHAM hospitals to receive ARVs is a non-starter, government would not allow it. Government does not want to show that is not capable of delivering HIV services with the current resources in the hospitals.” MOH Official, Malawi

14. SWEF Findings: Pharmaceuticals and Commodities ProcurementDistribution Benin ITNsPSI Benin ARVsUNICEFMOH (HIV/AIDS program) Ethiopia all drugsPASS Malawi ARVsUNICEF Malawi other drugsUNICEFCentral Medical Stores

15. SWEF Findings: Pharmaceuticals and Commodities  LFA assessments led to extensive by-passing to “speed up” procurement particularly for ARVs.  Inefficiencies: system duplication, additional workload  Difficulties tracking drugs  Missed opportunities for system strengthening  No clear plans for strengthening routine systems  Ethiopia – PASS procurement slow to start, but promising signs of internal improvements  Danger of differential pricing for the same commodities – and parallel cost recovery approaches (ITNs)

16. Conclusions – Do No Harm!  If by-passing routine systems, then make plans to build them up  Try to encourage planning processes which take account of decentralization or integration policies  Don’t allow development of alternative user fee or revenue collection structures

17. Conclusions – What is needed to build health systems for HIV/AIDS - Big Picture?  More countries need clearer visions, policies and plans about what is needed to strengthen health systems in general and specific elements of health systems.  HRH strategies  Policies on collaboration with private sector  Pharmaceutical management  Responsibility of broader health and development community - not just GF  At the global level, we need greater consensus on what works.

18. Conclusions – What is needed to build health systems for HIV/AIDS – Little Picture?  Transparent processes for allocating HIV/AIDS money between different areas (and activities?)  Governments/CCMs which see information provision as part of their core mandate  Increased support for continuous education in management and M&E skills  Greater investment in basic training (to increase numbers of health workers)  Support to the development of private for-profit umbrella organizations  Use of subsidies to enhance equitable access to HIV/AIDS services.

19. Conclusions - continued  Sustainability - without the promise of secure future financing broader changes in culture will not occur – health systems strengthening is a longer term objective;  M&E - Substantial variation across countries in GF implementation with respect to health systems creates opportunities for M&E  Follow-up work in Benin, Ethiopia and Malawi, to be supported in 2005/06 by USAID  New support from The Alliance for Health Policy and Systems Research, SIDA and Open Society Institute, also being planned.

20. On behalf of the SWEF network, thank you to:  The CCMs which supported the study  The respondents who generously gave of their time  The GF Secretariat for its support  USAID for financial assistance.