2. HIV/AIDS Monitor Objectives Create new knowledge on HIV/AIDS aid design, delivery and management Inspire and influence change in donor programs for HIV/AIDS Stimulate informed conversation about global HIV/AIDS donors among a wide group of stakeholders—recipient countries, implementers, advocacy groups and the media

3. Key Research Question How do the HIV/AIDS donor programs interact with key operational parts of health systems? Study Objective investigates and compares the donors’ interactions with three components of health systems: –the health information system, –the supply chain system for essential medicines, –And human resources for health. in Mozambique, Uganda, Zambia

4. HIV/AIDS Donors’ Interactions with the Health System

5. Study Design Before field work began, CGD and country teams decided on a common set of research questions and outcomes of interest Formative Research yielded three Country Case Studies –conducted from October 2007-March 2008 by individual research teams: UNZA, University of Makerere, Austral-Cowi Consulting Results synthesized from individual country case studies for final report –Conducted from April-August 2008 by CGD team with country teams

6. Methodology Countries selection--Mozambique, Uganda, and Zambia because of variation in: –Size –HIV prevalence –development indicators –maturity of the epidemic –nature and strength of government and donor response –All three AIDS donor programs in country: The Global Fund, PEPFAR and the World Bank MAP Research teams in three countries conducted desk review of: –donor and national documents –grey literature—reports –other secondary data

7. Methodology Using purposive and snowball sampling, conducted key informant interviews with: –donor officials –government officials –funding recipients and implementers in country Triangulation of data from different methods for analysis Peer reviewed by AIDS and health systems experts, including researchers, policymakers, and program implementers, and senior staff at each donor organization

8. Limitations Very limited ability to uncover effects – primarily describes interactions and possible implications so more hypothesis generating than hypothesis testing Way in which donor programs are implemented in the three countries might not be representative of donor practice elsewhere Sometimes difficult to triangulate data when researchers receive conflicting reports about donor activities from key informants—validity issues

9. Findings Health information systems: AIDS information flows are a priority for donors and national governments, but are fragmented—and donor- funded programs are at once inside and outside existing systems Supply chain systems: Antiretroviral systems are separate for procurement, but most closely interact with systems for essential medicines in storage, distribution, and logistics management Human resources for health: AIDS donors focus on training existing health workers rather than hiring or training new ones

10. Seizing the opportunity to strengthen health systems while expanding AIDS programs AIDS-specific processes that donors have helped set up for human resources, health information, and supply chains use many of the same resources as the broader health system As donors continue to increase AIDS funding and expand their programs, they will require greater shares of the resources in each country’s health system, but by doing so without strengthening already weak systems, they are likely to strain them

11. Health information systems Giacomo Pirozzi / Panos Pictures

12. Fragmentation…

13. Duplication…

14. Supply chain systems Sven Torfinn / Panos Pictures

15. In all three countries studied, once procurement is completed, essential medicines and antiretroviral drugs follow paths with clear similarities. Despite these similarities, the three global AIDS donors have decided for several reasons—including weaknesses in existing health drug distribution systems and the critical importance of avoiding stockouts of ARVs—to largely support procedures for ARVs that are separate from those for essential medicines.

16. Human resources for health Anders Gunnartz / Panos Pictures

17. Donors fund very little pre-service training, choosing to focus on in-service training for HIV/AIDS services instead The hiring of new public sector staff has been sporadic, with PEPFAR doing the most PEPFAR and the Global Fund have provided salary top-ups for public sector workers, at times diverting staff time from general health to HIV/AIDS service provision All have funded the hiring of nongovernmental staff to varying degrees

18. Some movement toward integration has already occurred… Partial integration in Mozambique Distribution on same trucks in Zambia Development of LMIS for all health goods in Uganda

19. From interactions to effects

20. Findings raise questions for further research including… Is fragmentation good or bad? Does it lead to more focused systems, with clear lines of accountability and opportunities for cross-learning? Or does it create inefficiencies by duplicating efforts and making coordination difficult? Do top-ups have a positive or negative effect on health worker shortages in the short, medium, and long term? Are AIDS-specific monitoring and evaluation programs improving data management for the health sector at large?