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Daniel Degbotse, MoH Ghana

Extent and Nature of Integration of HIV/AIDS programme and national health systems: Case Study in Ghana. Daniel Degbotse, MoH Ghana “Bridging the Divide: Inter-disciplinary Partnerships for HIV and Health Systems” 16th to 17th July 2010.

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Daniel Degbotse, MoH Ghana

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  1. Extent and Nature of Integration of HIV/AIDS programme and national health systems:Case Study in Ghana Daniel Degbotse, MoH Ghana “Bridging the Divide: Inter-disciplinary Partnerships for HIV and Health Systems” 16th to 17th July 2010

  2. “You cannot have centers of excellence (the programs) in the midst of degradation (health system).” - National Government Stakeholder

  3. Objectives & Methodology Objectives: To document the Extent and Nature of Integration of HIV/AIDS programme into national health system Interactions between Global Fund supported programmes and national health systems System-wide effects of HIV/AIDS on National Health Systems Methodology Field work undertaken Nov 2008 to Jan 2009 Semi-structured interviews with Key informants 36 informants interviewed 2 regions visited

  4. Ghana: Contextual Background Demographic/Socio-economic Population: 24.2 million (2009 projections) 46% Urban; concentrated in 3 regions Literacy: 57.9% (2000 Census) Political: Multiparty democracy restored in 1992 Economy: National economy / GDP growing at 5 -6% GNI per Capita Int $ 1,480 (PPP) HDI – 0.526; Ghana ranks 152 out of list of 182 countries in 2009 Health Profile: Ranking and Percentage contribution (Source: WHOSIS)Mortality Morbidity (DALYs) HIV/AIDS 1 (13.7%) 1 (12.5%) Malaria 3 (6.9%) 3 (7.7%) Tuberculosis 7 (5.1%) 6 (4.0%) Perinatal conditions 2 (8.3%) 2 (9.5%)

  5. HIV/AIDS in Ghana Estimated National HIV Prevalence – 1.9% (1.7% - 2.2%) Urban 2.3%; Rural 1.7% Amongst MARPS (Sex Workers) 25.1% (reduced from 34% in 2006) Predominantly hetero-sexual transmission Low risk (30.2%); Casual (15.5%); sex with partners of clients of sex workers (23%); Awareness of HIV (2009) - Universal (98%) Comprehensive knowledge – males 34%; females 28% (33% and 25% in 2006)

  6. Health Sector Reforms Initiative Sectoral reforms initiated in 1990s Adoption of SWAp - 1997 Medium Term Health Strategy developed with 5 year Programme of Work 1st 5 yr POW 1997-2001 – Building systems for improving health 2nd 5 Yr POW 2002-2006 – Maximize the gains and develop new strategies 3rd 5 Yr POW 2007-2001 – Creating Wealth Through Health 1997 – Act 525 was passed MOH – Policy formulation and regulatory function Ghana Health Services and other agencies – Service delivery and implementation of programmes Introduction of NHIS - 2003 Innovation - VAT is charged at 15% (10% for general government revenue, 2.5% as an earmarked tax for education and 2.5% as an earmarked tax for health insurance).

  7. Health Financing: Trends in contribution by source GOG SBP NHIF User Fees Earmarked Item 1(Personal Emoluments) 93% 3% 4% Item 3: (Service Expenses) 3% 11% 64% 23% Item 4: (Investment Expenses 10% 7% 33% 35%

  8. Key System related challenges High disease burden – Communicable diseases - including HIV & Malaria, burden of Neglected tropical Diseases, high Maternal and child mortality; rising trend of NCDs Health financing Large proportion of government funds allocated to salaries Item 3 of budget – for service delivery – donor fund dependent (34%) 99% of CD control budget comes either from SBS (7%) / Earmarked funds (93%) NHIS – roll out and management of NHIS Human resource availability and distribution High attrition rate, mal-distribution in numbers and by skill mix Governance and Performance Management

  9. Integration and Synergies of HIV/AIDS Program and national health systems

  10. Financing of HIV/AIDS Response Increasing investments in HIV/AIDS US$ 28 million in 2005 US$ 52 million in 2007 US$ 38 million in 2008 Global Fund HIV grants (Rd 1, 5 and 8) Total approved funding US$ 160 M Total disbursed US$ 112 M 67% of expenditure is towards procurement of health products/ commodities/ equipments Global Fund accounted for 82% of external funding in 2007

  11. Extent of Integration Highly Integrated Moderate Integration Limited Integration Not Integrated

  12. Extent of Integration Highly Integrated Moderate Integration Limited Integration Not Integrated

  13. Factors influencing Integration Positive influences Strong Political Commitment Epidemiological situation - Generalized epidemic Underlying SWAp programme A relatively strong Government Public Health system and leadership Challenges Disproportionate availability of funds to few priority interventions influencing underlying governance structures Role of CCM viewed as an additional layer and duplication of national structures for sector coordination and oversight; sub-optimal oversight function performed by CCM Ever increasing global demand for information and reporting for the priority interventions Project/ Round based nature of donor commitments leading to piece-meal approach to addressing disease strategy/ planning

  14. Perceptions of Stakeholders ‘The 3 disease control programmes due to the abundance of resources have grown bigger and pushed the disease control unit into oblivion. Now their offices are separate and much bigger than the ministry’ “Programmes are too strong. They are a State within a State” “Every disease is under the management of public health officer be it national, regional or district level. If this system is distorted, it would affect the whole structure. … … The delegation of responsibility of implementing and monitoring the programme to programme officers does not absolve the senior officers from being accountable. Lapses are individualistic and not a system related issue. ”

  15. What has been achieved? Cumulative totals of clients on HIV clinical care and those receiving ART

  16. System-Wide Effects Positive effects On System inputs – health products, commodities/ equipment Improved collaboration with other sectors and programs On M&E – growing recognition of need for strong HMIS Limited evidence Human resource availability or distribution (salary top-ups limited to national program staff) Institutional capacity (other than Disease program units) Challenges Re-enforcement of parallel disease reporting systems Continued use of ear-marked (non-pooled) funding Effects on Governance structures/ arrangements

  17. “As you painfully improve the performance, the system would push itself to maintain the current levels of performance. Even if additional funding ceases, and if basic supplies (drugs/ vaccines) are ensured the system would be able to deliver”

  18. THANK YOU

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