1
|
Bertone MP, Palmer N, Kruja K, Witter S. How do we design and evaluate health system strengthening? Collaborative development of a set of health system process goals. Int J Health Plann Manage 2023; 38:279-288. [PMID: 36576082 DOI: 10.1002/hpm.3607] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 11/24/2022] [Accepted: 12/06/2022] [Indexed: 12/29/2022] Open
Abstract
Strong health systems are widely recognized as a key requirement for improving health outcomes and also for ensuring that health systems are equitable, resilient and responsive to population needs. However, the related term Health Systems Strengthening (HSS) remains unclear and contested, and this creates challenges for how HSS can be monitored and evaluated. A previous review argued for the need to rethink evaluation methods for HSS to examine systemic effects of HSS investments. In line with that recommendation, this article describes the work of the HSS Evaluation Collaborative (HSSEC) in the development of a framework and tool to guide HSS monitoring, evaluation and learning by national and global actors. It was developed based on a rapid review of the literature and iterative expert consultation, with the aim of going beyond a focus on the building blocks of health systems and on health system outputs or health outcomes to think about the features that constitute a strong health system. As a result, we developed a list of 22 health system process goals which represent desirable attributes for health systems. The health system process goals (or rather, progress towards them) are influenced by positive and negative, intended and unintended effects of HSS interventions. Finally, we illustrate how the health system process goals can be operationalised for prospective and retrospective HSS monitoring, evaluation and learning, and how they also have the potential to be used for opening a space for participatory, inclusive policy dialogue about HSS.
Collapse
Affiliation(s)
- Maria Paola Bertone
- Institute for Global Health and Development, Queen Margaret University, Edinburgh, UK.,ReBUILD for Resilience Research Consortium, Edinburgh, UK
| | | | - Krista Kruja
- Independent Consultant on Behalf of Itad Ltd, Hove, UK
| | - Sophie Witter
- Institute for Global Health and Development, Queen Margaret University, Edinburgh, UK.,ReBUILD for Resilience Research Consortium, Edinburgh, UK
| | | |
Collapse
|
2
|
White SK, Kamya HA. Transactional sex, consumer society, and neoliberalism in Uganda: A political economic analysis of drivers and models of response. Glob Public Health 2021; 17:1343-1357. [PMID: 34061723 DOI: 10.1080/17441692.2021.1925943] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Transactional sex is a topic within HIV research that is relatively undertheorised and lacking consensus. In this study, it is understood as the implicit, non-marital, non-commercial exchange of sex for material goods or social status, and we examine the phenomenon among youth. Within the existing literature, the paradigms of sex-for-survival and sex-for-consumption emerge, representing differing senses of agency, particularly among young women. Based on interviews with human service providers in Kampala, Uganda, we consider the latter paradigm, examining how providers frame transactional sex against the political-economic backdrop of consumer culture, including the mainstreaming of communication technology in youths' lives. We also examine providers' depictions of available models of response, focused mainly on HIV prevention, in the context of international and national policies and politics. This study aims to situate analyses of transactional sex within political-economic context, considering how structural shifts toward neoliberalism have shaped both this phenomenon of behavioural health, and the existing models of response.
Collapse
Affiliation(s)
- Shelley K White
- Public Health and Sociology, Simmons University, Boston, MA, USA
| | - Hugo A Kamya
- Social Work, Simmons University, Boston, MA, USA
| |
Collapse
|
3
|
Zakumumpa H, Paina L, Wilhelm J, Ssengooba F, Ssegujja E, Mukuru M, Bennett S. The impact of loss of PEPFAR support on HIV services at health facilities in low-burden districts in Uganda. BMC Health Serv Res 2021; 21:302. [PMID: 33794880 PMCID: PMC8017884 DOI: 10.1186/s12913-021-06316-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 03/25/2021] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Although donor transitions from HIV programs are more frequent, little research exists seeking to understand the perceptions of patients and providers on this process. Between 2015 and 2017, PEPFAR implemented the ´geographic prioritization´ (GP) policy in Uganda whereby it shifted support from 734 'low-volume' facilities and 10 districts with low HIV burden and intensified support in select facilities in high-burden districts. Our analysis intends to explore patient and provider perspectives on the impact of loss of PEPFAR support on HIV services in transitioned health facilities in Uganda. METHODS We report qualitative findings from a larger mixed-methods evaluation. Six facilities were purposefully selected as case studies seeking to ensure diversity in facility ownership, size, and geographic location. Five out of the six selected facilities had experienced transition. A total of 62 in-depth interviews were conducted in June 2017 (round 1) and November 2017 (round 2) with facility in-charges (n = 13), ART clinic managers (n = 12), representatives of PEPFAR implementing organizations (n = 14), district health managers (n = 23) and 12 patient focus group discussions (n = 72) to elicit perceived effects of transition on HIV service delivery. Data were analyzed using thematic analysis. RESULTS While core HIV services, such as testing and treatment, offered by case-study facilities prior to transition were sustained, patients and providers reported changes in the range of HIV services offered and a decline in the quality of HIV services offered post-transition. Specifically, in some facilities we found that specialized pediatric HIV services ceased, free HIV testing services stopped, nutrition support to HIV clients ended and the 'mentor mother' ART adherence support mechanism was discontinued. Patients at three ART-providing facilities reported that HIV service provision had become less patient-centred compared to the pre-transition period. Patients at some facilities perceived waiting times at clinics to have become longer, stock-outs of anti-retroviral medicines to have been more frequent and out-of-pocket expenditure to have increased post-transition. CONCLUSIONS Participants perceived transition to have had the effect of narrowing the scope and quality of HIV services offered by case-study facilities due to a reduction in HIV funding as well as the loss of the additional personnel previously hired by the PEPFAR implementing organizations for HIV programming. Replacing the HIV programming gap left by PEPFAR in transition districts with Uganda government services is critical to the attainment of 90-90-90 targets in Uganda.
Collapse
Affiliation(s)
- Henry Zakumumpa
- School of Public Health, Makerere University, Kampala, Uganda.
| | - Ligia Paina
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, USA
| | - Jess Wilhelm
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, USA
| | | | - Eric Ssegujja
- School of Public Health, Makerere University, Kampala, Uganda
| | - Moses Mukuru
- School of Public Health, Makerere University, Kampala, Uganda
| | - Sara Bennett
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, USA
| |
Collapse
|
4
|
Nuzzo JB, Meyer D, Snyder M, Ravi SJ, Lapascu A, Souleles J, Andrada CI, Bishai D. What makes health systems resilient against infectious disease outbreaks and natural hazards? Results from a scoping review. BMC Public Health 2019; 19:1310. [PMID: 31623594 PMCID: PMC6798426 DOI: 10.1186/s12889-019-7707-z] [Citation(s) in RCA: 109] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Accepted: 09/30/2019] [Indexed: 11/24/2022] Open
Abstract
Background The 2014–2016 Ebola outbreak was a wake-up call regarding the critical importance of resilient health systems. Fragile health systems can become overwhelmed during public health crises, further exacerbating the human, economic, and political toll. Important work has been done to describe the general attributes of a health system resilient to these crises, and the next step will be to identify the specific capacities that health systems need to develop and maintain to achieve resiliency. Methods We conducted a scoping review of the literature to identify recurring themes and capacities needed for health system resiliency to infectious disease outbreaks and natural hazards and any existing implementation frameworks that highlight these capacities. We also sought to identify the overlap of the identified themes and capacities with those highlighted in the World Health Organization’s Joint External Evaluation. Sources of evidence included PubMed, Web of Science, OAIster, and the websites of relevant major public health organizations. Results We identified 16 themes of health system resilience, including: the need to develop plans for altered standards of care during emergencies, the need to develop plans for post-event recovery, and a commitment to quality improvement. Most of the literature described the general attributes of a resilient health system; no implementation frameworks were identified that could translate these elements into specific capacities that health system actors can employ to improve resilience to outbreaks and natural hazards in a variety of settings. Conclusions An implementation-oriented health system resilience framework could help translate the important components of a health system identified in this review into specific capacities that actors in the health system could work to develop to improve resilience to public health crises. However, there remains a need to further refine the concept of resilience so that health systems can simultaneously achieve sustainable transformations in healthcare practice and health service delivery as well as improve their preparedness for emergencies.
Collapse
Affiliation(s)
- Jennifer B Nuzzo
- Johns Hopkins Center for Health Security, 621 East Pratt Street, Suite 210, Baltimore, MD, 21202, USA
| | - Diane Meyer
- Johns Hopkins Center for Health Security, 621 East Pratt Street, Suite 210, Baltimore, MD, 21202, USA.
| | - Michael Snyder
- Johns Hopkins Center for Health Security, 621 East Pratt Street, Suite 210, Baltimore, MD, 21202, USA
| | - Sanjana J Ravi
- Johns Hopkins Center for Health Security, 621 East Pratt Street, Suite 210, Baltimore, MD, 21202, USA
| | - Ana Lapascu
- Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA
| | - Jon Souleles
- Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA
| | - Carolina I Andrada
- Johns Hopkins Center for Health Security, 621 East Pratt Street, Suite 210, Baltimore, MD, 21202, USA
| | - David Bishai
- Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA
| |
Collapse
|
5
|
The impact of PEPFAR transition on HIV service delivery at health facilities in Uganda. PLoS One 2019; 14:e0223426. [PMID: 31596884 PMCID: PMC6785126 DOI: 10.1371/journal.pone.0223426] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Accepted: 09/20/2019] [Indexed: 12/03/2022] Open
Abstract
Background Since 2004, the President’s Emergency Plan for AIDS Relief (PEPFAR) has played a large role in Uganda’s HIV/AIDS response. To better target resources to high burden regions and facilities, PEPFAR planned to withdraw from 29% of previously-supported health facilities in Uganda between 2015 and 2017. Methods We conducted a cross-sectional survey of 226 PEPFAR-supported health facilities in Uganda in mid-2017. The survey gathered information on availability, perceived quality, and access to HIV services before and after transition. We compare responses for facilities transitioned to those maintained on PEPFAR, accounting for survey design. We also extracted data from DHIS2 for the period October 2013–December 2017 on the number of HIV tests and counseling (HTC), number of patients on antiretroviral therapy (Current on ART), and retention on first-line ART (Retention) at 12 months. Using mixed effect models, we compare trends in service volume around the transition period. Results There were 206 facilities that reported transition and 20 that reported maintenance on PEPFAR. Some facilities reporting transition may have been in a gap between implementing partners. The median transition date was September 2016, nine months prior to the survey. Transition facilities were more likely to discontinue HIV outreach following transition (51.6% vs. 1.4%, p<0.001) and to report declines in HIV care access (43.5% vs. 3.1%, p<0.001) and quality (35.6% vs. 0%, p<0.001). However, transition facilities did not differ in their trends in HIV service volume relative to maintenance facilities. Conclusions Transition from PEPFAR resulted in facilities reporting worsening patient access and service quality for HIV care, but there is insufficient evidence to suggest negative impacts on volume of HIV services. Facility respondents’ perceptions about access and quality may be overly pessimistic, or they may signal forthcoming impacts. Unrelated to transition, declining retention on ART in Uganda is a cause for concern.
Collapse
|
6
|
Abstract
Austerity across Africa has been operationalized through World Bank
and IMF structural adjustment programs since the 1980s, later rebranded euphemistically
as poverty reduction strategies in the late 1990s. Austerity’s constraints
on public spending led donors to a “civil society” focus in which NGOs would fill
gaps in basic social services created by public sector contraction. One consequence
was large-scale redirection of growing foreign aid flows away from public services
to international NGOs. Austerity in Africa coincides with the emergence of what
some anthropologists call “audit cultures” among donors. Extraordinary data collection
infrastructures are demanded from recipient organizations in the name of
transparency. However, the Mozambique experience described here reveals that
these intensive audit cultures serve to obscure the destructive effects of NGO proliferation
on public health systems.
Collapse
|
7
|
Zakumumpa H, Dube N, Damian RS, Rutebemberwa E. Understanding the dynamic interactions driving the sustainability of ART scale-up implementation in Uganda. Glob Health Res Policy 2018; 3:23. [PMID: 30123838 PMCID: PMC6091155 DOI: 10.1186/s41256-018-0079-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Accepted: 07/16/2018] [Indexed: 01/01/2023] Open
Abstract
Background Despite increasing recognition that health-systems constraints are the fundamental barrier to attaining anti-retroviral therapy (ART) scale-up targets in Sub-Saharan Africa, current discourses are dominated by a focus on financial sustainability. Utilizing the health system dynamics framework, this study aimed to explore the interactions in health system components and their influence on the sustainability of ART scale-up implementation in Uganda. Methods This study entailed qualitative organizational case-studies within a two-phased mixed-methods sequential explanatory research design. In Phase One, a survey of 195 health facilities across Uganda which commenced ART services between 2004 and 2009 was conducted. In Phase Two, six health facilities were purposively selected for in-depth examination involving i) In-depth interviews (n = 44) ii) and semi-structured interviews (n = 35). Qualitative data was analyzed by coding and thematic analysis. Descriptive statistics were managed in STATA (v 13). Results Five dynamic interactions in ART program sustainability drivers were identified; i) Failure to update basic ART program records contributed to chronic ART medicines stock-outs ii) Health workforce shortages and escalating patient volumes prompted adaptations in ART service delivery models iii) Broader governance issues manifested in poor road networks undermined ART medicines supply chains iv) Sustained financing for ART programs was influenced by external donors v) The values associated with the ownership-type of a health facility affected ART service delivery and coverage. Conclusion The sustainability of ART programs at the facility-level in Uganda is a function of a complex interaction in elements of the health system and must be understood beyond sustaining international funding for ART scale-up.
Collapse
Affiliation(s)
- Henry Zakumumpa
- 1School of Public Health, Makerere University, Kampala, Uganda
| | - Nkosiyazi Dube
- 2School of Health and Community Development, University of the Witwatersrand, Johannesburg, South Africa
| | | | | |
Collapse
|
8
|
Longenecker CT, Kalra A, Okello E, Lwabi P, Omagino JO, Kityo C, Kamya MR, Webel AR, Simon DI, Salata RA, Costa MA. A Human-Centered Approach to CV Care: Infrastructure Development in Uganda. Glob Heart 2018; 13:347-354. [PMID: 29685638 PMCID: PMC6258347 DOI: 10.1016/j.gheart.2018.02.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Revised: 01/19/2018] [Accepted: 02/20/2018] [Indexed: 12/28/2022] Open
Abstract
In this case study, we describe an ongoing approach to develop sustainable acute and chronic cardiovascular care infrastructure in Uganda that involves patient and provider participation. Leveraging strong infrastructure for HIV/AIDS care delivery, University Hospitals Harrington Heart and Vascular Institute and Case Western Reserve University have partnered with U.S. and Ugandan collaborators to improve cardiovascular capabilities. The collaboration has solicited innovative solutions from patients and providers focusing on education and advanced training, penicillin supply, diagnostic strategy (e.g., hand-held ultrasound), maternal health, and community awareness. Key outcomes of this approach have been the completion of formal training of the first interventional cardiologists and heart failure specialists in the country, establishment of 4 integrated regional centers of excellence in rheumatic heart disease care with a national rheumatic heart disease registry, a penicillin distribution and adherence support program focused on retention in care, access to imaging technology, and in-country capabilities to treat advanced rheumatic heart valve disease.
Collapse
Affiliation(s)
- Christopher T Longenecker
- Division of Cardiovascular Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, USA; Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, OH, USA.
| | - Ankur Kalra
- Division of Cardiovascular Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, USA; Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | | | | | | | - Cissy Kityo
- Joint Clinical Research Centre, Kampala, Uganda
| | - Moses R Kamya
- Department of Medicine, Makerere University School of Medicine, Mulago Hill, Kampala, Uganda
| | - Allison R Webel
- Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, OH, USA
| | - Daniel I Simon
- Division of Cardiovascular Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, USA; Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Robert A Salata
- Division of Cardiovascular Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, USA; Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Marco A Costa
- Division of Cardiovascular Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, USA; Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| |
Collapse
|
9
|
Stover B, Lubega F, Namubiru A, Bakengesa E, Luboga SA, Makumbi F, Kiwanuka N, Ndizihiwe A, Mukooyo E, Hurley E, Lim T, Borse NN, Bernhardt J, Wood A, Sheppard L, Barnhart S, Hagopian A. Conducting a Large Public Health Data Collection Project in Uganda: Methods, Tools, and Lessons Learned. JOURNAL OF RESEARCH PRACTICE 2018; 14:M1. [PMID: 30057632 PMCID: PMC6058317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
We report on the implementation experience of carrying out data collection and other activities for a public health evaluation study on whether U.S. President's Emergency Plan for AIDS Relief (PEPFAR) investment improved utilization of health services and health system strengthening in Uganda. The retrospective study period focused on the PEPFAR scale-up, from mid-2005 through mid-2011, a period of expansion of PEPFAR programing and health services. We visited 315 health care facilities in Uganda in 2011 and 2012 to collect routine health management information system data forms, as well as to conduct interviews with health system leaders. An earlier phase of this research project collected data from all 112 health district headquarters, reported elsewhere. This article describes the lessons learned from collecting data from health care facilities, project management, useful technologies, and mistakes. We used several new technologies to facilitate data collection, including portable document scanners, smartphones, and web-based data collection, along with older but reliable technologies such as car batteries for power, folding tables to create space, and letters of introduction from appropriate authorities to create entrée. Research in limited-resource settings requires an approach that values the skills and talents of local people, institutions and government agencies, and a tolerance for the unexpected. The development of personal relationships was key to the success of the project. We observed that capacity building activities were repaid many fold, especially in data management and technology.
Collapse
Affiliation(s)
- Bert Stover
- School of Public Health, University of Washington, Seattle, UNITED STATES
| | - Flavia Lubega
- College of Health Science, Makerere University, Kampala, UGANDA
| | - Aidah Namubiru
- College of Health Science, Makerere University, Kampala, UGANDA
| | | | | | | | - Noah Kiwanuka
- College of Health Science, Makerere University, Kampala, UGANDA
| | | | | | - Erin Hurley
- Centers for Disease Control and Prevention, UNITED STATES
| | - Travis Lim
- Centers for Disease Control and Prevention, UNITED STATES
| | - Nagesh N Borse
- Centers for Disease Control and Prevention, UNITED STATES
| | - James Bernhardt
- School of Public Health, University of Washington, Seattle, UNITED STATES
| | - Angela Wood
- School of Public Health, University of Washington, Seattle, UNITED STATES
| | - Lianne Sheppard
- School of Public Health, University of Washington, Seattle, UNITED STATES
| | - Scott Barnhart
- School of Public Health, University of Washington, Seattle, UNITED STATES
| | - Amy Hagopian
- School of Public Health, University of Washington, Seattle, UNITED STATES
| |
Collapse
|
10
|
Luboga SA, Stover B, Lim TW, Makumbi F, Kiwanuka N, Lubega F, Ndizihiwe A, Mukooyo E, Hurley EK, Borse N, Wood A, Bernhardt J, Lohman N, Sheppard L, Barnhart S, Hagopian A. Did PEPFAR investments result in health system strengthening? A retrospective longitudinal study measuring non-HIV health service utilization at the district level. Health Policy Plan 2016; 31:897-909. [PMID: 27017824 PMCID: PMC4977428 DOI: 10.1093/heapol/czw009] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/01/2016] [Indexed: 01/17/2023] Open
Abstract
OBJECTIVES : PEPFAR's initial rapid scale-up approach was largely a vertical effort focused fairly exclusively on AIDS. The purpose of our research was to identify spill-over health system effects, if any, of investments intended to stem the HIV epidemic over a 6-year period with evidence from Uganda. The test of whether there were health system expansions (aside from direct HIV programming) was evidence of increases in utilization of non-HIV services-such as outpatient visits, in-facility births or immunizations-that could be associated with varying levels of PEPFAR investments at the district level. METHODS : Uganda's Health Management Information System article-based records were available from mid-2005 onwards. We visited all 112 District Health offices to collect routine monthly reports (which contain data aggregated from monthly facility reports) and annual reports (which contain data aggregated from annual facility reports). Counts of individuals on anti-retroviral therapy (ART) at year-end served as our primary predictor variable. We grouped district-months into tertiles of high, medium or low PEPFAR investment based on their total reported number of patients on ART at the end of the year. We generated incidence-rate ratios, interpreted as the relative rate of the outcome measure in relation to the lowest investment PEPFAR tertile, holding constant control variables in the model. RESULTS : We found PEPFAR investment overall was associated with small declines in service volumes in several key areas of non-HIV care (outpatient care for young children, TB tests and in-facility deliveries), after adjusting for sanitation, elementary education and HIV prevalence. For example, districts with medium and high ART investment had 11% fewer outpatient visits for children aged 4 and younger compared with low investment districts, incidence rate ratio (IRR) of 0.89 for high investment compared with low (95% CI, 0.85-0.94) and IRR of 0.93 for medium compared with low (0.90-0.96). Similarly, 22% fewer TB sputum tests were performed in high investment districts compared with low investment, [IRR 0.78 (0.72-0.85)] and 13% fewer in medium compared with low, [IRR 0.88 (0.83-0.94)]. Districts with medium and high ART investment had 5% fewer in-facility deliveries compared with low investment districts [IRR 0.95 for high compared with low, (91-1.00) and 0.96 for medium compared with low (0.93-0.99)]. Although not statistically significant, the rate of maternal deaths in high investment district-months was 13% lower than observed in low investment districts. CONCLUSIONS : This study sought to understand whether PEPFAR, as a vertical programme, may have had a spill-over effect on the health system generally, as measured by utilization. Our conclusion is that it did not, at least not in Uganda.
Collapse
Affiliation(s)
- Samuel Abimerech Luboga
- Faculty of Health Sciences, Makerere University, PO Box 7062, Kampala University Road, Kampala, Uganda
| | - Bert Stover
- Department of Health Services, University of Washington, PO Box 357660, Seattle, WA 98195, USA
| | - Travis W Lim
- Division of Global HIV and Tuberculosis, 1600 Clifton Road, Atlanta, GA 30333, USA
| | - Frederick Makumbi
- Faculty of Health Sciences, Makerere University, PO Box 7062, Kampala University Road, Kampala, Uganda
| | - Noah Kiwanuka
- Faculty of Health Sciences, Makerere University, PO Box 7062, Kampala University Road, Kampala, Uganda
| | - Flavia Lubega
- Faculty of Health Sciences, Makerere University, PO Box 7062, Kampala University Road, Kampala, Uganda
| | - Assay Ndizihiwe
- Division of Global HIV and Tuberculosis, 1600 Clifton Road, Atlanta, GA 30333, USA
| | - Eddie Mukooyo
- Resource Center for the Uganda Ministry of Health, Uganda Ministry of Health, PO Box 7272 Kampala Uganda Plot 6 Lourdel Road, Nakasero
| | - Erin K Hurley
- Division of Global HIV and Tuberculosis, 1600 Clifton Road, Atlanta, GA 30333, USA
| | - Nagesh Borse
- Division of Global HIV and Tuberculosis, 1600 Clifton Road, Atlanta, GA 30333, USA
| | - Angela Wood
- Department of Global Health, University of Washington, PO Box 357965, Seattle, WA 98195, USA and
| | - James Bernhardt
- Department of Global Health, University of Washington, PO Box 357965, Seattle, WA 98195, USA and
| | - Nathaniel Lohman
- Department of Global Health, University of Washington, PO Box 357965, Seattle, WA 98195, USA and
| | - Lianne Sheppard
- Department of Biostatistics, University of Washington, PO Box 357232, Seattle, WA 98195, USA
| | - Scott Barnhart
- Department of Global Health, University of Washington, PO Box 357965, Seattle, WA 98195, USA and
| | - Amy Hagopian
- Department of Health Services, University of Washington, PO Box 357660, Seattle, WA 98195, USA Department of Global Health, University of Washington, PO Box 357965, Seattle, WA 98195, USA and
| |
Collapse
|
11
|
Mwisongo A, Nabyonga-Orem J. Global health initiatives in Africa - governance, priorities, harmonisation and alignment. BMC Health Serv Res 2016; 16 Suppl 4:212. [PMID: 27454542 PMCID: PMC4959383 DOI: 10.1186/s12913-016-1448-9] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The advent of global health initiatives (GHIs) has changed the landscape and architecture of health financing in low and middle income countries, particularly in Africa. Over the last decade, the African Region has realised improvements in health outcomes as a result of interventions implemented by both governments and development partners. However, alignment and harmonisation of partnerships and GHIs are still difficult in the African countries with inadequate capacity for their effective coordination. METHOD Both published and grey literature was reviewed to understand the governance, priorities, harmonisation and alignment of GHIs in the African Region; to synthesise the knowledge and highlight the persistent challenges; and to identify gaps for future research. RESULTS GHI governance structures are often separate from those of the countries in which they operate. Their divergent funding channels and modalities may have contributed to the failure of governments to track their resources. There is also evidence that basically, earmarking and donor conditions drive funding allocations regardless of countries' priorities. Although studies cite the lack of harmonisation of GHI priorities with national strategies, evidence shows improvements in that area over time. GHIs have used several strategies and mechanisms to involve the private sector. These have widened the pool of health service policy-makers and providers to include groups such as civil society organisations (CSOs), with both positive and negative implications. GHI strategies such as co-financing by countries as a condition for support have been positive in achieving sustainability of interventions. CONCLUSIONS GHI approaches have not changed substantially over the years but there has been evolution in terms of donor funding and conditions. GHIs still largely operate in a vertical manner, bypassing country systems; they compete for the limited human resources; they influence country policies; and they are not always harmonised with other donors. To maximise returns on GHI support, there is need to ensure that their approaches are more comprehensive as opposed to being selective; to improve GHI country level governance and alignment with countries' changing epidemiologic profiles; and to strengthen their involvement of CSOs.
Collapse
Affiliation(s)
- Aziza Mwisongo
- Health Systems and Services Cluster, World Health Organization Regional Office for Africa, B.P. 06, Brazzaville, Congo
| | - Juliet Nabyonga-Orem
- Health Systems and Services Cluster, World Health Organization Regional Office for Africa, B.P. 06, Brazzaville, Congo
| |
Collapse
|