The 'diagonal' approach to Global Fund financing: a cure for the broader malaise of health systems?

Perspective and investments in health system strengthening of Gavi, the Vaccine Alliance: a content analysis of health system strengthening-specific funding

BACKGROUND

This paper aimed to compare the health systems strengthening (HSS) framework of Gavi and WHO and to analyze resource allocation in HSS by Gavi.

METHODS

Among 76 countries which received HSS funding from Gavi from 2006 to 2013, summary reports of 44 countries and approved proposals of 10 countries were collected. After comparing the HSS framework of WHO and Gavi, each activity described in documents was categorized according to Gavi's framework and funding allocation was analyzed.

RESULTS

Compared with WHO's HSS framework, Gavi's has a distinctive function within the building block 'Drugs, Equipment, Supplies, Facilities' and a distinctive function of 'providing incentive and bonuses' under the building block 'Human Resource/Performance Management'. Gavi has steadily invested 10% of their total budget on HSS, but 47% were allocated in these categories, whereas 78% were for activities arguably not covered by WHO's HSS framework. In Africa, 70% of Gavi's budget fell under 'Drugs, Equipment, Supplies, Facilities' and 92.8% were for activities arguably not deemed as HSS by WHO.

CONCLUSIONS

Gavi's HSS support emphasized inputs with short-term measurable outcomes. Harmonization of the concept of HSS and collaboration between Gavi and multilateral international agencies, such as World Bank and WHO, are needed.

From emergency to sustainability: shifting objectives in the US Government's HIV response in Tanzania

The US President's Emergency Plan for AIDS Relief (PEPFAR) was originally designed as an emergency initiative, operating with considerable funds, immediate roll-out, fast scale-up, and top-down technocratic administration. In a more recent iteration, PEPFAR shifted its focus from an emergency response to more closely account for healthcare sustainability. This transition came on the heels of the 2008 financial crisis, which threatened to stall the 'marvellous momentum' of the 2000's boom in donor aid for global health overall. Now many programmes are having to do more with less as funding flattens or decreases. This paper examines how this transition took shape in Tanzania in 2011-2012, and the successes and challenges associated with it, using participant observation and interview data from 20 months of fieldwork in rural and urban healthcare settings. In particular, I discuss (1) efforts to increase sustainability and country ownership of HIV programmes in Tanzania, focusing on the shift from PEPFAR-funded American non-governmental organisations to Tanzanian partner organisations; (2) principal challenges stakeholders encountered during the transition, including fragmented systems of healthcare delivery and a weakened healthcare workforce; and (3) strategies informants identified to better integrate services in order to build a stronger, more equitable, and sustainable health system in Tanzania.

Assessment of risk of peripheral vascular disease and vascular care capacity in low- and middle-income countries

BACKGROUND

This study aimed to describe national peripheral vascular disease (PVD) risk and health burden, and vascular care capacity in Ghana. The gap between PVD burden and vascular care capacity in low- and middle-income countries was defined, and capacity improvement priorities were identified.

METHODS

Data to estimate PVD risk factor burden were obtained from the World Health Organization Study on Global Ageing and Adult Health (SAGE), Ghana, and the Institute of Health Metrics and Evaluation Global Burden of Disease (IHME GBD) database. In addition, a novel nationwide assessment of vascular care capacity was performed, with 20 vascular care items assessed at 40 hospitals in Ghana. Factors contributing to specific item deficiency were described.

RESULTS

From the SAGE database, there were 4305 respondents aged at least 50 years with data to estimate PVD risk. Of these, 57·4 per cent were at moderate to risk high of PVD with at least three risk factors; extrapolating nationally, the estimate was 1 654 557 people. Based on IHME GBD data, the estimated disability-adjusted life-years incurred from PVD increased fivefold from 1990 to 2010 (from 6·3 to 31·7 per 100 000 persons respectively). Vascular care capacity assessment demonstrated marked deficiencies in items for diagnosis, and in perioperative and vascular surgical care. Deficiencies were most often due to absence of equipment, lack of training and technology breakage.

CONCLUSION

Risk factor reduction and management as well as optimization of current resources are paramount to avoid the large burden of PVD falling on healthcare systems in low- and middle-income countries. These countries are not well equipped to handle vascular surgical care, and rapid development of such capacity would be difficult and expensive.

'Big push' to reduce maternal mortality in Uganda and Zambia enhanced health systems but lacked a sustainability plan

In the past decade, "big push" global health initiatives financed by international donors have aimed to rapidly reach ambitious health targets in low-income countries. The health system impacts of these efforts are infrequently assessed. Saving Mothers, Giving Life is a global public-private partnership that aims to reduce maternal mortality dramatically in one year in eight districts in Uganda and Zambia. We evaluated the first six to twelve months of the program's implementation, its ownership by national ministries of health, and its effects on health systems. The project's impact on maternal mortality is not reported here. We found that the Saving Mothers, Giving Life initiative delivered a large "dose" of intervention quickly by capitalizing on existing US international health assistance platforms, such as the President's Emergency Plan for AIDS Relief. Early benefits to the broader health system included greater policy attention to maternal and child health, new health care infrastructure, and new models for collaborating with the private sector and communities. However, the rapid pace, external design, and lack of a long-term financing plan hindered integration into the health system and local ownership. Sustaining and scaling up early gains of similar big push initiatives requires longer-term commitments and a clear plan for transition to national control.

In the shadowlands of global health: observations from health workers in Kenya

During the past decade, donor funding for health interventions in Kenya and other African countries has risen sharply. Focused on high-profile diseases such as HIV/AIDS, these funds create islands of intervention in a sea of under-resourced public health services. This paper draws on ethnographic research conducted in HIV clinics and in a public hospital to examine how health workers experience and reflect upon the juxtaposition of ‘global’ medicine with ‘local’ medicine. We show that health workers face an uneven playing field. High-prestige jobs are available in HIV research and treatment, funded by donors, while other diseases and health issues receive less attention. Outside HIV clinics, patient's access to medicines and laboratory tests is expensive, and diagnostic equipment is unreliable. Clinicians must tailor their decisions about treatment to the available medical technologies, medicines and resources. How do health workers reflect on working in these environments and how do their experiences influence professional ambitions and commitments?

Tracking Global Fund HIV/AIDS resources used for sexual and reproductive health service integration: case study from Ethiopia

OBJECTIVE/BACKGROUND

The Global Fund to Fight AIDS, Tuberculosis & Malaria (GF) strives for high value for money, encouraging countries to integrate synergistic services and systems strengthening to maximize investments. The GF needs to show how, and how much, its grants support more than just HIV/AIDS, TB and malaria. Sexual and Reproductive Health (SRH) has been part of HIV/AIDS grants since 2007. Previous studies showed the GF PBF system does not allow resource tracking for SRH integration within HIV/AIDS grants. We present findings from a resource tracking case study using primary data collected at country level.

METHODS

Ethiopia was the study site. We reviewed data from four HIV/AIDS grants from January 2009-June 2011 and categorized SDAs and activities as directly, indirectly, or not related to SRH integration. Data included: GF PBF data; financial, performance, in-depth interview and facility observation data from Ethiopia.

RESULTS

All HIV/AIDS grants in Ethiopia support SRH integration activities (12-100%). Using activities within SDAs, expenditures directly supporting SRH integration increased from 25% to 66% for the largest HIV/AIDS grant, and from 21% to 34% for the smaller PMTCT-focused grant. Using SDAs to categorize expenditures underestimated direct investments in SRH integration; activity-based categorization is more accurate. The important finding is that primary data collection could not resolve the limitations in using GF GPR data for resource tracking. The remedy is to require existing activity-based budgets and expenditure reports as part of PBF reporting requirements, and make them available in the grant portfolio database. The GF should do this quickly, as it is a serious shortfall in the GF guiding principle of transparency.

CONCLUSIONS

Showing high value for money is important for maximizing impact and replenishments. The Global Fund should routinely track HIV/AIDs grant expenditures to disease control, service integration, and overall health systems strengthening. The current PBF system will not allow this. Real-time expenditure analysis could be achieved by integrating existing activity-based financial data into the routine PBF system. The GF's New Funding Model and the 2012-2016 strategy present good opportunities for over-hauling the PBF system to improve transparency and allow the GF to monitor and maximize value for money.

Determinants of performance of health systems concerning maternal and child health: a global approach

AIMS

To assess the association of social determinants on the performance of health systems around the world.

METHODS

A transnational ecological study was conducted with an observation level focused on the country. In order to research on the strength of the association between the annual maternal and child mortality in 154 countries and social determinants: corruption, democratization, income inequality and cultural fragmentation, we used a mixed linear regression model for repeated measures with random intercepts and a conglomerate-based geographical analysis, between 2000 and 2010.

RESULTS

Health determinants with a significant association on child mortality(<1year): higher access to water (βa Quartile 4(Q4) vs Quartile 1(Q1) = -6,14; 95%CI: -11,63 to -0,73), sanitation systems, (Q4 vs Q1 = -25,58; 95%CI: -31,91 to -19,25), % measles vaccination coverage (Q4 vs Q1 = -7.35; 95%CI: -10,18 to -4,52), % of births attended by a healthcare professional (Q4 vs Q1 = -7,91; 95%CI: -11,36 to -4,52) and a % of the total health expenditure (Q3 vs Q1 = -2,85; 95%CI: -4,93 to -0,7). Ethnic fragmentation (Q4 vs Q1 = 9,93; 95%CI: -0.03 to 19.89) had a marginal effect. For child mortality<5 years, an association was found for these variables and democratization (not free vs free = 11,23; 95%CI: -0,82 to 23,29), out-of-pocket expenditure (Q1 vs Q4 = 17,71; 95%CI: 5,86 to 29,56). For MMR (Maternal mortality ratio), % of access to water for all the quartiles, % of access to sanitation systems, (Q3 vs Q1 = -171,15; 95%CI: -281,29 to -61), birth attention by a healthcare professional (Q4 vs Q1 = -231,23; 95%CI: -349,32 to -113,15), and having corrupt government (Q3 vs Q1 = 83,05; 95%CI: 33,10 to 133).

CONCLUSIONS

Improving access to water and sanitation systems, decreasing corruption in the health sector must become priorities in health systems. The ethno-linguistic cultural fragmentation and the detriment of democracy turn out to be two factors related to health results.

Implementation of a health management mentoring program: year-1 evaluation of its impact on health system strengthening in Zambézia Province, Mozambique

BACKGROUND

Avante Zambézia is an initiative of a Non-Governmental Organization (NGO), Friends in Global Health, LLC (FGH) and the Vanderbilt Institute for Global Health (VIGH) to provide technical assistance to the Mozambican Ministry of Health (MoH) in rural Zambézia Province. Avante Zambézia developed a district level Health Management Mentorship (HMM) program to strengthen health systems in ten of Zambézia's 17 districts. Our objective was to preliminarily analyze changes in four domains of health system capacity after the HMM's first year: accounting, Human Resources (HRs), Monitoring and Evaluation (M&E), and transportation management.

METHODS

Quantitative metrics were developed in each domain. During district visits for weeklong, on-site mentoring, the health management mentoring teams documented each indicator as a success ratio percentage. We analyzed data using linear regressions of each indicator's mean success ratio across all districts submitting a report over time.

RESULTS

Of the four domains, district performance in the accounting domain was the strongest and most sustained. Linear regressions of mean monthly compliance for HR objectives indicated improvement in three of six mean success ratios. The M&E capacity domain showed the least overall improvement. The one indicator analyzed for transportation management suggested progress.

CONCLUSION

Our outcome evaluation demonstrates improvement in health system performance during a HMM initiative. Evaluating which elements of our mentoring program are succeeding in strengthening district level health systems is vital in preparing to transition fiscal and managerial responsibility to local authorities.

Higher quality of life and lower depression for people on ART in Uganda as compared to a community control group

Provision of antiretroviral treatment (ART) to people living with HIV (PLWH) has increased globally. Research measuring whether ART restores subjective well-being to "normal" levels is lacking, particularly in resource limited settings. The study objectives are to compare quality of life and depression symptoms for PLWH on ART to a general community population and to explore factors to explain these differences, including socio-economic status and the impact of urban or rural residence. PLWH on ART (n = 263) were recruited from ART delivery sites and participants not on ART (n = 160) were recruited from communities in Wakiso District, Uganda. Participants were interviewed using the translated World Health Organisation Quality of Life brief measure, the Hopkins Symptom Checklist depression section, and questions about socio-economic status, residence as urban or rural and, for PLWH on ART, self-reported adherence and use of HIV counselling. Compared to the community sample and controlling for location of residence, PLWH on ART had significantly higher quality of life (QOL) for physical, psychological and environment domains, but not the social domain. These differences were not due to socio-economic status alone. Depression scores were significantly lower for PLWH on ART. Both comparisons controlled for the effect of location of residence. People on ART self-reported high adherence and the majority had used HIV counselling services. Our findings show better QOL amongst PLWH on ART compared to a general community sample, which cannot be explained solely by differences in socio-economic status nor location of residence. The general community sample results point towards the challenges of life in this setting. Access to health services may underpin this difference and further research should explore this finding, in addition to identification of psychological mechanisms that relate to better QOL. ART provision infrastructure has clear benefits. Further work should consider sustainability and replication for other health conditions.

The GAVI Alliance and the 'Gates approach' to health system strengthening

Lauded for getting specific health issues onto national and international agendas and for their potential to improve value for money and outcomes, public-private global health initiatives (GHIs) have come to dominate global health governance. Yet, they have also been criticised for their negative impact on country health systems. In response, disease-specific GHIs have, somewhat paradoxically, appropriated the aim of health system strengthening (HSS). This article critically analyses this development through an ethnographic case study of the GAVI Alliance, which funds vaccines in poor countries. Despite GAVI's self-proclaimed ‘single-minded’ focus on vaccines, HSS support is fronted as a key principle of GAVI's mission. Yet, its meaning remains unclear and contested understandings of the health systems agenda abound, reflecting competing public health ideologies and professional pressures within the global health field. Contrary to broader conceptualisations of HSS that emphasise social and political dimensions, GAVI's HSS support has become emblematic of the so-called ‘Gates approach’ to global health, focused on targeted technical solutions with clear, measurable outcomes. In spite of adopting rhetoric supportive of ‘holistic’ health systems, GHIs like GAVI have come to capture the global debate about HSS in favour of their disease-specific approach and ethos.

From polarisation to practice: puzzles and insights on integrated approaches from public health professionals

Much of the debate in the global health literature about vertical and horizontal programmatic approaches, between narrowly targeted interventions and those providing broader system-wide support, has taken place at the global level. Based on a comparative case study of international donors in the health sector in Peru that varied in their vertical-horizontal orientation, this article examines the extent to which health care practitioners and national policy-makers perceive and attempt to reconcile the tension between these approaches. Informants readily identified advantages and disadvantages of both approaches, but did not perceive a marked vertical-horizontal division, suggesting that tensions appear to be less pronounced in practice than academic debates suggest. A clear consensus did not emerge, and although more people spoke of a mixed approached, they too puzzled over how best to balance trade-offs. In practice, there were examples of more integrated approaches, targeted aspects of horizontal programmes and system-strengthening elements of vertical programmes; however, they were not explicitly identified as such. Practitioner perspectives reinforced the diverse and dynamic nature of disease, both epidemics and country profiles, and suggest that focusing on periods of transition and points of integration may be a fruitful path forward.

Global perspective on acute coronary syndrome: a burden on the young and poor

Ischemic heart disease (IHD) is the greatest single cause of mortality and loss of disability-adjusted life years worldwide, and a substantial portion of this burden falls on low- and middle-income countries (LMICs). Deaths from IHD and acute coronary syndrome (ACS) occur, on average, at younger ages in LMICs than in high-income countries, often at economically productive ages, and likewise frequently affect the poor within LMICs. Although data about ACS in LMICs are limited, there is a growing literature in this area and the research gaps are being steadily filled. In high-income countries, decades of investigation into the risk factors for ACS and development of behavioral programs, medications, interventional procedures, and guidelines have provided us with the tools to prevent and treat events. Although similar tools can be, and in fact have been, implemented in many LMICs, challenges remain in the development and implementation of cardiovascular health promotion activities across the entire life course, as well as in access to treatment for ACS and IHD. Intersectoral policy initiatives and global coordination are critical elements of ACS and IHD control strategies. Addressing the hurdles and scaling successful health promotion, clinical and policy efforts in LMICs are necessary to adequately address the global burden of ACS and IHD.

Empowerment in the field of health promotion: recognizing challenges in working toward equity

Over the last 25 years, the language of empowerment has been woven into the guiding missions and descriptions of institutions, funding and projects globally. Although theoretical understandings of empowerment within the domain of health promotion remain contentious, we have little idea of how a shift toward an empowerment agenda has affected the daily work of those in the field of health promotion. A systematic examination of the implementation of the empowerment agenda is important as it can help us understand how redistributive agendas are received within the multiple institutional contexts in which health promotion work is carried out. The goal of this study, therefore, was to try to understand the empowerment agenda within the context of everyday health promotion. We conducted semi-structured interviews with health promoters from a variety of geographical regions, institutional backgrounds, and job capacities. Essentially we found that empowerment remains conceptually dear to health promoters' understanding of their work, yet at the same time, mainstreaming empowerment is at odds with central trends and initiatives that govern this work. We argue that many of the stumbling blocks that have hindered this specific agenda are actually central stumbling blocks for the wider field of health promotion. We examine some of the barriers to implementing transformational change. Overcoming the primary limitations uncovered in this exploration of empowerment is actually crucial to progressive work in health promotion in general, particularly work that would seek to lessen inequities.

How can health remain central post-2015 in a sustainable development paradigm?

In two years, the uncompleted tasks of the Millennium Development Goals will be merged with the agenda articulated in the 2012 United Nations Conference on Sustainable Development. This process will seek to integrate economic development (including the elimination of extreme poverty), social inclusion, environmental sustainability, and good governance into a combined sustainable development agenda. The first phase of consultation for the post-2015 Sustainable Development Goals reached completion in the May 2013 report to the Secretary-General of the High-Level Panel of Eminent Persons on the Post-2015 Development Agenda. Health did well out of the Millennium Development Goal (MDG) process, but the global context and framing of the new agenda is substantially different, and health advocates cannot automatically assume the same prominence. This paper argues that to remain central to continuing negotiations and the future implementation, four strategic shifts are urgently required. Advocates need to reframe health from the poverty reduction focus of the MDGs to embrace the social sustainability paradigm that underpins the new goals. Second, health advocates need to speak--and listen--to the whole sustainable development agenda, and assert health in every theme and every relevant policy, something that is not yet happening in current thematic debates. Third, we need to construct goals that will be truly "universal", that will engage every nation--a significant re-orientation from the focus on low-income countries of the MDGs. And finally, health advocates need to overtly explore what global governance structures will be needed to finance and implement these universal Sustainable Development Goals.

HIV scale-up in Mozambique: exceptionalism, normalisation and global health

The large-scale introduction of HIV and AIDS services in Mozambique from 2000 onwards occurred in the context of deep political commitment to sovereign nation-building and an important transition in the nation's health system. Simultaneously, the international community encountered a willing state partner that recognised the need to take action against the HIV epidemic. This article examines two critical policy shifts: sustained international funding and public health system integration (the move from parallel to integrated HIV services). The Mozambican government struggles to support its national health system against privatisation, NGO competition and internal brain drain. This is a sovereignty issue. However, the dominant discourse on self-determination shows a contradictory twist: it is part of the political rhetoric to keep the sovereignty discourse alive, while the real challenge is coordination, not partnerships. Nevertheless, we need more anthropological studies to understand the political implications of global health funding and governance. Other studies need to examine the consequences of public health system integration for the quality of access to health care.

Fulfilling the PEPFAR mandate: a more equitable use of PEPFAR resources across global health

As PEPFAR moves beyond its "emergency stage," it should now help support a more sustainable development mode, including an equitable platform for meeting a broad range of priority health needs, while continuing to pursue the goal of an AIDS-free generation.

Redefining global health-care delivery

Initiatives to address the unmet needs of those facing both poverty and serious illness have expanded significantly over the past decade. But many of them are designed in an ad-hoc manner to address one health problem among many; they are too rarely assessed; best practices spread slowly. When assessments of delivery do occur, they are often narrow studies of the cost-effectiveness of a single intervention rather than the complex set of them required to deliver value to patients and their families. We propose a framework for global health-care delivery and evaluation by considering efforts to introduce HIV/AIDS care to resource-poor settings. The framework introduces the notion of care delivery value chains that apply a systems-level analysis to the complex processes and interventions that must occur, across a health-care system and over time, to deliver high-value care for patients with HIV/AIDS and cooccurring conditions, from tuberculosis to malnutrition. To deliver value, vertical or stand-alone projects must be integrated into shared delivery infrastructure so that personnel and facilities are used wisely and economies of scale reaped. Two other integrative processes are necessary for delivering and assessing value in global health: one is the alignment of delivery with local context by incorporating knowledge of both barriers to good outcomes (from poor nutrition to a lack of water and sanitation) and broader social and economic determinants of health and wellbeing (jobs, housing, physical infrastructure). The second is the use of effective investments in care delivery to promote equitable economic development, especially for those struggling against poverty and high burdens of disease. We close by reporting our own shared experience of seeking to move towards a science of delivery by harnessing research and training to understand and improve care delivery.

Second generation HIV surveillance in Pakistan: policy challenges and opportunities

From 2004 to 2011, the Canada-Pakistan HIV/AIDS Surveillance Project (HASP) worked with government and non-government partners in Pakistan to design and implement an HIV second generation surveillance (SGS) system. Insights into the development of scalable cost effective surveillance methodologies, implementation, use of data for HIV prevention and human rights were gained over the course of HASP. An ideal SGS system would be affordable, able to be implemented independently by local partners and produce data that could be readily applied in policy and programmes. Flexibility in design and implementation is important to ensure that any SGS system is responsive to information needs, political changes and changes in key population dynamics and HIV epidemics. HASP's mapping methodology is innovative and widely accepted as best practice, but sustainability of the SGS system it developed is a challenge.

Global health initiative investments and health systems strengthening: a content analysis of global fund investments

BACKGROUND

Millions of dollars are invested annually under the umbrella of national health systems strengthening. Global health initiatives provide funding for low- and middle-income countries through disease-oriented programmes while maintaining that the interventions simultaneously strengthen systems. However, it is as yet unclear which, and to what extent, system-level interventions are being funded by these initiatives, nor is it clear how much funding they allocate to disease-specific activities - through conventional 'vertical-programming' approach. Such funding can be channelled to one or more of the health system building blocks while targeting disease(s) or explicitly to system-wide activities.

METHODS

We operationalized the World Health Organization health system framework of the six building blocks to conduct a detailed assessment of Global Fund health system investments. Our application of this framework framework provides a comprehensive quantification of system-level interventions. We applied this systematically to a random subset of 52 of the 139 grants funded in Round 8 of the Global Fund to Fight AIDS, Tuberculosis and Malaria (totalling approximately US$1 billion).

RESULTS

According to the analysis, 37% (US$ 362 million) of the Global Fund Round 8 funding was allocated to health systems strengthening. Of that, 38% (US$ 139 million) was for generic system-level interventions, rather than disease-specific system support. Around 82% of health systems strengthening funding (US$ 296 million) was allocated to service delivery, human resources, and medicines & technology, and within each of these to two to three interventions. Governance, financing, and information building blocks received relatively low funding.

CONCLUSIONS

This study shows that a substantial portion of Global Fund's Round 8 funds was devoted to health systems strengthening. Dramatic skewing among the health system building blocks suggests opportunities for more balanced investments with regard to governance, financing, and information system related interventions. There is also a need for agreement, by researchers, recipients, and donors, on keystone interventions that have the greatest system-level impacts for the cost-effective use of funds. Effective health system strengthening depends on inter-agency collaboration and country commitment along with concerted partnership among all the stakeholders working in the health system.

Vertical funding, non-governmental organizations, and health system strengthening: perspectives of public sector health workers in Mozambique

BACKGROUND

In the rapid scale-up of human immunodeficiency virus (HIV) care and acquired immunodeficiency syndrome (AIDS) treatment, many donors have chosen to channel their funds to non-governmental organizations and other private partners rather than public sector systems. This approach has reinforced a private sector, vertical approach to addressing the HIV epidemic. As progress on stemming the epidemic has stalled in some areas, there is a growing recognition that overall health system strengthening, including health workforce development, will be essential to meet AIDS treatment goals. Mozambique has experienced an especially dramatic increase in disease-specific support over the last eight years. We explored the perspectives and experiences of key Mozambican public sector health managers who coordinate, implement, and manage the myriad donor-driven projects and agencies.

METHODS

Over a four-month period, we conducted 41 individual qualitative interviews with key Ministry workers at three levels in the Mozambique national health system, using open-ended semi-structured interview guides. We also reviewed planning documents.

RESULTS

All respondents emphasized the value and importance of international aid and vertical funding to the health sector and each highlighted program successes that were made possible by recent increased aid flows. However, three serious concerns emerged: 1) difficulties coordinating external resources and challenges to local control over the use of resources channeled to international private organizations; 2) inequalities created within the health system produced by vertical funds channeled to specific services while other sectors remain under-resourced; and 3) the exodus of health workers from the public sector health system provoked by large disparities in salaries and work.

CONCLUSIONS

The Ministry of Health attempted to coordinate aid by implementing a "sector-wide approach" to bring the partners together in setting priorities, harmonizing planning, and coordinating support. Only 14% of overall health sector funding was channeled through this coordinating process by 2008, however. The vertical approach starved the Ministry of support for its administrative functions. The exodus of health workers from the public sector to international and private organizations emerged as the issue of greatest concern to the managers and health workers interviewed. Few studies have addressed the growing phenomenon of "internal brain drain" in Africa which proved to be of greater concern to Mozambique's health managers.

Evidence for integrating eye health into primary health care in Africa: a health systems strengthening approach

Background

The impact of unmet eye care needs in sub-Saharan Africa is compounded by barriers to accessing eye care, limited engagement with communities, a shortage of appropriately skilled health personnel, and inadequate support from health systems. The renewed focus on primary health care has led to support for greater integration of eye health into national health systems. The aim of this paper is to demonstrate available evidence of integration of eye health into primary health care in sub-Saharan Africa from a health systems strengthening perspective.

Methods

A scoping review method was used to gather and assess information from published literature, reviews, WHO policy documents and examples of eye and health care interventions in sub-Saharan Africa. Findings were compiled using a health systems strengthening framework.

Results

Limited information is available about eye health from a health systems strengthening approach. Particular components of the health systems framework lacking evidence are service delivery, equipment and supplies, financing, leadership and governance. There is some information to support interventions to strengthen human resources at all levels, partnerships and community participation; but little evidence showing their successful application to improve quality of care and access to comprehensive eye health services at the primary health level, and referral to other levels for specialist eye care.

Conclusion

Evidence of integration of eye health into primary health care is currently weak, particularly when applying a health systems framework. A realignment of eye health in the primary health care agenda will require context specific planning and a holistic approach, with careful attention to each of the health system components and to the public health system as a whole. Documentation and evaluation of existing projects are required, as are pilot projects of systematic approaches to interventions and application of best practices. Multi-national research may provide guidance about how to scale up eye health interventions that are integrated into primary health systems.

The health systems funding platform and World Bank legacy: the gap between rhetoric and reality

Global health partnerships created to encourage funding efficiencies need to be approached with some caution, with claims for innovation and responsiveness to development needs based on untested assumptions around the potential of some partners to adapt their application, funding and evaluation procedures within these new structures. We examine this in the case of the Health Systems Funding Platform, which despite being set up some three years earlier, has stalled at the point of implementation of its key elements of collaboration. While much of the attention has been centred on the suspension of the Global Fund's Round 11, and what this might mean for health systems strengthening and the Platform more broadly, we argue that inadequate scrutiny has been made of the World Bank's contribution to this partnership, which might have been reasonably anticipated based on an historical analysis of development perspectives. Given the tensions being created by the apparent vulnerability of the health systems strengthening agenda, and the increasing rhetoric around the need for greater harmonization in development assistance, an examination of the positioning of the World Bank in this context is vital.

Administrative integration of vertical HIV monitoring and evaluation into health systems: a case study from South Africa

BACKGROUND

In light of an increasing global focus on health system strengthening and integration of vertical programmes within health systems, methods and tools are required to examine whether general health service managers exercise administrative authority over vertical programmes.

OBJECTIVE

To measure the extent to which general health service (horizontal) managers, exercise authority over the HIV programme's monitoring and evaluation (M&E) function, and to explore factors that may influence this exercise of authority.

METHODS

This cross-sectional survey involved interviews with 51 managers. We drew ideas from the concept of 'exercised decision-space' - traditionally used to measure local level managers' exercise of authority over health system functions following decentralisation. Our main outcome measure was the degree of exercised authority - classified as 'low', 'medium' or 'high' - over four M&E domains (HIV data collection, collation, analysis, and use). We applied ordinal logistic regression to assess whether actor type (horizontal or vertical) was predictive of a higher degree of exercised authority, independent of management capacity (training and experience), and M&E knowledge.

RESULTS

Relative to vertical managers, horizontal managers had lower HIV M&E knowledge, were more likely to exercise a higher degree of authority over HIV data collation (OR 7.26; CI: 1.9, 27.4), and less likely to do so over HIV data use (OR 0.19; CI: 0.05, 0.84). A higher HIV M&E knowledge score was predictive of a higher exercised authority over HIV data use (OR 1.22; CI: 0.99, 1.49). There was no association between management capacity and degree of authority.

CONCLUSIONS

This study demonstrates a HIV M&E model that is neither fully vertical nor integrated. The HIV M&E is characterised by horizontal managers producing HIV information while vertical managers use it. This may undermine policies to strengthen integrated health system planning and management under the leadership of horizontal managers.

Integrating HIV care into primary care services: quantifying progress of an intervention in South Africa

BACKGROUND

Integration of human immunodeficiency virus (HIV) care into primary care services is one strategy proposed to achieve universal access to antiretroviral treatment (ART) for HIV-positive patients in high burden countries. There is a need for controlled studies of programmes to integrate HIV care with details of the services being integrated.

METHODS

A semi-quantitative questionnaire was developed in consultation with clinic staff, tested for internal consistency using Cronbach's alpha coefficients and checked for inter-observer reliability. It was used to conduct four assessments of the integration of HIV care into referring primary care clinics (mainstreaming HIV) and into the work of all nurses within ART clinics (internal integration) and the integration of pre-ART and ART care during the Streamlining Tasks and Roles to Expand Treatment and Care for HIV (STRETCH) trial in South Africa. Mean total integration and four component integration scores at intervention and control clinics were compared using one way analysis of variance (ANOVA). Repeated measures ANOVA was used to analyse changes in scores during the trial.

RESULTS

Cronbach's alpha coefficients for total integration, pre-ART and ART integration and mainstreaming HIV and internal integration scores showed good internal consistency. Mean total integration, mainstreaming HIV and ART integration scores increased significantly at intervention clinics by the third assessment. Mean pre-ART integration scores were almost maximal at the first assessment and showed no further change. There was no change in mean internal integration score.

CONCLUSION

The questionnaire developed in this study is a valid tool with potential for monitoring integration of HIV care in other settings. The STRETCH trial interventions resulted in increased integration of HIV care, particularly ART care, by providing HIV care at referring primary care clinics, but had no effect on integrating HIV care into the work of all nurses with the ART clinic.

Schistosomiasis control and the health system in P.R. China

Over the last sixty years advances have been made in the control of schistosomiasis in P.R. China. There are, however, difficult challenges still to be met. This paper looks at the extent to which the health system offers a positive environment for the control of the disease. It starts by tracing three phases in schistosomiasis control: disease elimination strategy through snail control (1950s-early 1980s); morbidity control strategy based on chemotherapy (mid 1980s to 2003); integrated control strategy (2004+). Each one of these phases took place in distinct policy-making environments. The paper partly draws on these phases to set out five issues of disease control and discusses them in the context of the health system and its recent trends. These cover the policy-making process, intersectoral action for health, equity and access to health services, funding for public goods and externalities, and strengthening resource management and planning. These issues form the basis of an agenda for integrating research and capacity strengthening in the Chinese health system with a view to creating a more positive enabling environment for schistosomiasis control. In so doing it is important to emphasize the role and integrity of the public sector against its commercialization, the underlying value of equity, a systems wide perspective, and the role of advocacy.

Understanding health systems, health economies and globalization: the need for social science perspectives

The complex relationship between globalization and health calls for research from many disciplinary and methodological perspectives. This editorial gives an overview of the content trajectory of the interdisciplinary journal 'Globalization and Health' over the first six years of production, 2005 to 2010. The findings show that bio-medical and population health perspectives have been dominant but that social science perspectives have become more evident in recent years. The types of paper published have also changed, with a growing proportion of empirical studies. A special issue on 'Health systems, health economies and globalization: social science perspectives' is introduced, a collection of contributions written from the vantage points of economics, political science, psychology, sociology, business studies, social policy and research policy. The papers concern a range of issues pertaining to the globalization of healthcare markets and governance and regulation issues. They highlight the important contribution that can be made by the social sciences to this field, and also the practical and methodological challenges implicit in the study of globalization and health.

In the shadow of HIV/AIDS: forgotten diseases in sub-Saharan Africa: global health issues and funding agency responsibilities

The HIV/AIDS pandemic has generated international solidarity, particularly with sub-Saharan Africa. The mainly vertical approach to this challenge has, however, mobilized so much attention and so many resources that other crucial public health problems, such as chronic viral hepatitis and non-communicable diseases (NCDs), have been left in the shadows. One year after the first official World Hepatitis Day launched by WHO and the first UN meeting on NCDs, the world needs a vigorous debate on a more comprehensive approach to public health challenges in developing countries.

Impact of community-based support services on antiretroviral treatment programme delivery and outcomes in resource-limited countries: a synthetic review

Background

Task-shifting to lay community health providers is increasingly suggested as a potential strategy to overcome the barriers to sustainable antiretroviral treatment (ART) scale-up in high-HIV-prevalence, resource-limited settings. The dearth of systematic scientific evidence on the contributory role and function of these forms of community mobilisation has rendered a formal evaluation of the published results of existing community support programmes a research priority.

Methods

We reviewed the relevant published work for the period from November 2003 to December 2011 in accordance with the guidelines for a synthetic review. ISI Web of Knowledge, Science Direct, BioMed Central, OVID Medline, PubMed, Social Services Abstracts, and Sociological Abstracts and a number of relevant websites were searched.

Results

The reviewed literature reported an unambiguous positive impact of community support on a wide range of aspects, including access, coverage, adherence, virological and immunological outcomes, patient retention and survival. Looking at the mechanisms through which community support can impact ART programmes, the review indicates that community support initiatives are a promising strategy to address five often cited challenges to ART scale-up, namely (1) the lack of integration of ART services into the general health system; (2) the growing need for comprehensive care, (3) patient empowerment, (4) and defaulter tracing; and (5) the crippling shortage in human resources for health. The literature indicates that by linking HIV/AIDS-care to other primary health care programmes, by providing psychosocial care in addition to the technical-medical care from nurses and doctors, by empowering patients towards self-management and by tracing defaulters, well-organised community support initiatives are a vital part of any sustainable public-sector ART programme.

Conclusions

The review demonstrates that community support initiatives are a potentially effective strategy to address the growing shortage of health workers, and to broaden care to accommodate the needs associated with chronic HIV/AIDS. The existing evidence suggests that community support programmes, although not necessarily cheap or easy, remain a good investment to improve coverage of communities with much needed health services, such as ART. For this reason, health policy makers, managers, and providers must acknowledge and strengthen the role of community support in the fight against HIV/AIDS.

Push, pull, and reverse: self-interest, responsibility, and the global health care worker shortage

The world is suffering from a dearth of health care workers, and sub-Saharan Africa, an area of great need, is experiencing the worst shortage. Developed countries are making the problem worse by luring health care workers away from the countries that need them most, while developing countries do not have the resources to stem the flow or even replace those lost. Postmodern philosopher Emmanuel Levinas offers a unique ethical framework that is helpful in assessing both the irresponsibility inherent in the current global health care situation and the responsibility and obligation held by the stakeholders involved in this global crisis. Drawing on Levinas' exploration of individual freedom and self-pursuit, infinite responsibility for the Other, and the potential emergence of a just community, we demonstrate its effectiveness in explaining the health care worker crisis, and we argue in favor of a variety of policy and development assistance measures that are grounded in an orientation of non-indifference toward Others.

Priorities for developing countries in the global response to non-communicable diseases

The growing global burden of non communicable diseases (NCDs) is now killing 36 million people each year and needs urgent and comprehensive action. This article provides an overview of key critical issues that need to be resolved to ensure that recent political commitments are translated into practical action. These include: (i) categorizing and prioritizing NCDs in order to inform donor funding commitments and priorities for intervention; (ii) finding the right balance between the relative importance of treatment and prevention to ensure that responses cover those at risk, and those who are already sick; (iii) defining the appropriate health systems response to address the needs of patients with diseases characterized by long duration and often slow progression; (iv) research needs, in particular translational research in the delivery of care; and (v) sustained funding to support the global NCD response.

Disease control and health systems in low- and middle-income countries: enhancing positive interrelation

There is a growing interest in improving the relationship between disease control programmes and the rest of the health system in low- and middle-income countries. This short study seeks to contribute to this movement by providing a multi-dimensional approach for policy-makers and researchers. It recognizes the different and often conflicting perspectives in health systems held by stakeholders. Two such perspectives are those of disease control programmes and health systems. Both are based on perceived health needs and put forward requirements on each other through resource demands and organizational needs. Failure to reconcile these perspectives can lead to health system fragmentation. This study proposes a framework to address the importance of mutual support across stakeholder perspectives, striving to understand and analyse the consequences of their reciprocal views. In doing this, the study stresses the importance of common understanding around health system values, the political interplay between stakeholders, the contextual setting and the need to integrate research and capacity development in this area.

Development cooperation for health: reviewing a dynamic concept in a complex global aid environment

The 4^th High Level Forum on Aid Effectiveness, held in Busan, South Korea in November 2011 again promised an opportunity for a "new consensus on development cooperation" to emerge. This paper reviews the recent evolution of the concept of coordination for development assistance in health as the basis from which to understand current discourses. The paper reviews peer-reviewed scientific literature and relevant 'grey' literature, revisiting landmark publications and influential authors, examining the transitions in the conceptualisation of coordination, and the related changes in development assistance. Four distinct transitions in the understanding, orientation and application of coordination have been identified: coordination within the sector, involving geographical zoning, sub-sector specialisation, donor consortia, project co-financing, sector aid, harmonisation of procedures, ear-marked budgetary support, donor agency reform and inter-agency intelligence gathering; sector-wide coordination, expressed particularly through the Sector-Wide Approach; coordination across sectors at national level, expressed in the evolution of Poverty Strategy Reduction Papers and the national monitoring of the Millennium Development Goals; and, most recently, global-level coordination, embodied in the Paris Principles, and the emergence of agencies such as the International Health Partnerships Plus. The transitions are largely but not strictly chronological, and each draws on earlier elements, in ways that are redefined in the new context. With the increasing complexity of both the territory of global health and its governance, and increasing stakeholders and networks, current imaginings of coordination are again being challenged. The High Level Forum in Busan may have been successful in recognising a much more complex landscape for development than previously conceived, but the challenges to coordination remain.

The emergence of global attention to health systems strengthening

After a period of proliferation of disease-specific initiatives, over the past decade and especially since 2005 many organizations involved in global health have come to direct attention and resources to the issue of health systems strengthening. We explore how and why such attention emerged. A qualitative methodology, process-tracing, was used to construct a case history and analyse the factors shaping and inhibiting global political attention for health systems strengthening. We find that the critical factors behind the recent burst of attention include fears among global health actors that health systems problems threaten the achievement of the health-related Millennium Development Goals, concern about the adverse effects of global health initiatives on national health systems, and the realization among global health initiatives that weak health systems present bottlenecks to the achievement of their organizational objectives. While a variety of actors now embrace health systems strengthening, they do not constitute a cohesive policy community. Moreover, the concept of health systems strengthening remains vague and there is a weak evidence base for informing policies and programmes for strengthening health systems. There are several reasons to question the sustainability of the agenda. Among these are the global financial crisis, the history of pendulum swings in global health and the instrumental embrace of the issue by some actors.

Human rights in health systems frameworks: what is there, what is missing and why does it matter?

Global initiatives and recent G8 commitments to health systems strengthening have brought increased attention to factors affecting health system performance. While equity concerns and human rights language appear often in the global health discourse, their inclusion in health systems efforts beyond rhetorical pronouncements is limited. Building on recent work assessing the extent to which features compatible with the right to health are incorporated into national health systems, we examine how health systems frameworks have thus far integrated human rights concepts and human rights-based approaches to health in their conceptualisation. Findings point to the potential value of the inclusion of human rights in these articulations to increase the participation or involvement of clients in health systems, to broaden the concept of equity, to bring attention to laws and policies beyond regulation and to strengthen accountability mechanisms.

Scale-up of community-based malaria control can be achieved without degrading community health workers' service quality: the Village Malaria Worker project in Cambodia

BACKGROUND

Malaria control has been scaled up in many developing countries in their efforts to achieve the Millennium Development Goals. Cambodia recently scaled up their Village Malaria Worker (VMW) project by substantially increasing the number of VMWs and expanding the project's health services to include treatment of fever, diarrhoea, and Acute Respiratory Infections (ARI) in children under five. This study examined if the scale-up interfered with VMWs' service quality, actions, and knowledge of malaria control, and analysed VMWs' overall achievements and perceptions of the newly added health services.

METHODS

Structured interviews were conducted pre scale-up in February-March 2008 with 251 VMWs and post scale-up in July-August 2010 with 252 VMWs. Comparing the pre and post scale-up survey results (n = 195), changes were examined in terms of VMWs' 1) service quality, 2) malaria prevention and vector control actions, and 3) knowledge of malaria epidemiology and vector ecology. In addition, VMWs' newly added health services were descriptively analysed based on the post scale-up survey (n = 252).

RESULTS

VMWs' service quality and actions significantly improved overall during the scale-up of the VMW project (mean index score: +0.805, p < 0.001; +2.923, p < 0.001; respectively). Although most of knowledge areas also showed significant improvement (between +0.256 and +0.499, p < 0.001), less than half (10.3%-47.7%) of the VMWs correctly answered a set of questions on malaria epidemiology and vector ecology, even in the post scale-up survey. About 70% of the respondents reported that their health services to control malaria remained the same or that they were more active after the scale-up. Two-thirds (66.3%) had become more enthusiastic about serving as a VMW since the scale-up, and all but one respondent reported being willing to continue the new services.

CONCLUSIONS

The Cambodian experience clearly demonstrated that a nationwide scale-up of community-based malaria control can be achieved without degrading community health workers' service quality. The government's strategy to expand VMWs' health services, while providing sufficient training to maintain the quality of their original malaria control services, could have contributed to the improvement of VMW's service quality, actions, and knowledge in spite of the rapid scale-up of the project.

Volunteerism or Labor Exploitation? Harnessing the Volunteer Spirit to Sustain AIDS Treatment Programs in Urban Ethiopia

Based on ethnographic research in Addis Ababa, Ethiopia, this paper describes NGO efforts to encourage AIDS care volunteers to eschew material returns for their labor and instead reflect on the goodness of sacrificing to promote the survival of people living with HIV/AIDS. Consensus analysis of motivational survey data collected from a sample of AIDS care volunteers (n=110) suggests that they strongly share a sacrificial and prosocial motivational model. These results may be explained by several factors, including the efforts of the organizations to shape volunteers' motivations, the self-selection of volunteers, positive reinforcement in seeing one's patients become healthy, and social desirability bias. In-depth interviews examining the motivations and behaviors of volunteers reveal a more complicated picture: even ostensibly devoted and altruistic volunteers strongly question their service commitments. The complexity and ambivalence of volunteers' motivations reflect the profound uncertainty that they face in achieving improved socioeconomic status for themselves and their families amid widespread unemployment and sharply rising food prices. Their desires for economic opportunities explain why local NGOs exert so much effort to shape and sustain-and yet fail to completely control-their motivations. This recasts economically-insecure volunteers' consent to donate their labor as a process of negotiation with their organizers. Future research should explore how models of health care volunteerism and volunteer motivations are shaped by individual and collective experiences in political-economic context.

Health system determinants of infant, child and maternal mortality: A cross-sectional study of UN member countries

OBJECTIVE

Few studies have examined the link between health system strength and important public health outcomes across nations. We examined the association between health system indicators and mortality rates.

METHODS

We used mixed effects linear regression models to investigate the strength of association between outcome and explanatory variables, while accounting for geographic clustering of countries. We modelled infant mortality rate (IMR), child mortality rate (CMR), and maternal mortality rate (MMR) using 13 explanatory variables as outlined by the World Health Organization.

RESULTS

Significant protective health system determinants related to IMR included higher physician density (adjusted rate ratio [aRR] 0.81; 95% Confidence Interval [CI] 0.71-0.91), higher sustainable access to water and sanitation (aRR 0.85; 95% CI 0.78-0.93), and having a less corrupt government (aRR 0.57; 95% CI 0.40-0.80). Out-of-pocket expenditures on health (aRR 1.29; 95% CI 1.03-1.62) were a risk factor. The same four variables were significantly related to CMR after controlling for other variables. Protective determinants of MMR included access to water and sanitation (aRR 0.88; 95% CI 0.82-0.94), having a less corrupt government (aRR 0.49; 95%; CI 0.36-0.66), and higher total expenditures on health per capita (aRR 0.84; 95% CI 0.77-0.92). Higher fertility rates (aRR 2.85; 95% CI: 2.02-4.00) were found to be a significant risk factor for MMR.

CONCLUSION

Several key measures of a health system predict mortality in infants, children, and maternal mortality rates at the national level. Improving access to water and sanitation and reducing corruption within the health sector should become priorities.

Neglected tropical disease (NTD) control in health systems: the interface between programmes and general health services

Disease control programmes are an intrinsic part of health systems. Neglected tropical disease (NTD) control is a clear case in point. While there is a growing consensus that NTD control and health services are linked, with important mutual impacts, little is known of what actually happens at the interface between the two entities. Here, we review the rationale, viewpoints and experiences of NTD control programmes regarding general health services, and vice versa, and compare their respective arguments. We discuss the interactions and interface between disease control and health systems, and present possible scenarios for health system strengthening by NTD- and other disease-specific programmes. Focusing on countries in sub-Saharan Africa, we suggest a number of principles that could pave the way for fruitful discussions and development of synergies.

HIV/AIDS, chronic diseases and globalisation

HIV/AIDS has always been one of the most thoroughly global of diseases. In the era of widely available anti-retroviral therapy (ART), it is also commonly recognised as a chronic disease that can be successfully managed on a long-term basis. This article examines the chronic character of the HIV/AIDS pandemic and highlights some of the changes we might expect to see at the global level as HIV is increasingly normalised as "just another chronic disease". The article also addresses the use of this language of chronicity to interpret the HIV/AIDS pandemic and calls into question some of the consequences of an uncritical acceptance of concepts of chronicity.

Task shifting and integration of HIV care into primary care in South Africa: the development and content of the streamlining tasks and roles to expand treatment and care for HIV (STRETCH) intervention

BACKGROUND

Task shifting and the integration of human immunodeficiency virus (HIV) care into primary care services have been identified as possible strategies for improving access to antiretroviral treatment (ART). This paper describes the development and content of an intervention involving these two strategies, as part of the Streamlining Tasks and Roles to Expand Treatment and Care for HIV (STRETCH) pragmatic randomised controlled trial.

METHODS

DEVELOPING THE INTERVENTION: The intervention was developed following discussions with senior management, clinicians, and clinic staff. These discussions revealed that the establishment of separate antiretroviral treatment services for HIV had resulted in problems in accessing care due to the large number of patients at ART clinics. The intervention developed therefore combined the shifting from doctors to nurses of prescriptions of antiretrovirals (ARVs) for uncomplicated patients and the stepwise integration of HIV care into primary care services.

RESULTS

COMPONENTS OF THE INTERVENTION: The intervention consisted of regulatory changes, training, and guidelines to support nurse ART prescription, local management teams, an implementation toolkit, and a flexible, phased introduction. Nurse supervisors were equipped to train intervention clinic nurses in ART prescription using outreach education and an integrated primary care guideline. Management teams were set up and a STRETCH coordinator was appointed to oversee the implementation process.

DISCUSSION

Three important processes were used in developing and implementing this intervention: active participation of clinic staff and local and provincial management, educational outreach to train nurses in intervention sites, and an external facilitator to support all stages of the intervention rollout.The STRETCH trial is registered with Current Control Trials ISRCTN46836853.