HIV and Health system strengthening Strengthening the Evidence Base to Maximise Synergies

1. HIV and Health system strengtheningStrengthening the Evidence Base to Maximise Synergies Royal Tropical Institute (KIT) Amsterdam Lucie Blok, et al. Vienna, 19th July 2010

2. Royal Tropical Institute Amsterdam KIT Royal Tropical Institute Development Policy & Practice Collaborating partners: Ghana Center for Health and Social Services Malawi College of Medicine Burkina Faso Institute de Recherche en Sciences de la Santé Madagascar Institute Nationale de Santé Publique et Communautaire Congo DRC Ecole de Santé Publique Swaziland/UK University of Bradford

3. Aim of research project • To clarify the relationship between AIDS programs and health systems strengthening (HSS) • To understand the health priorities and health system strengthening needs in different countries • To explore the contribution of AIDS programs to HSS • To analyse and provide recommendations for greater synergies between HIV programs and HSS

4. Burkina Faso HIV prev 1.6% HEx 40$ per capita Aids budget: 53 million $ DRC HIV prev 3.3% HEx ??$ per capita Aids budget: 96 million $ Malawi HIV prev 12% HEx 30$ per capita Aids budget: 107 million $ Ghana HIV prev 1.9% HEx 58$ per capita Aids budget: 39 million $ Madagascar HIV prev 0.1% HEx 27$ per capita Aids budget: 9 million $ Swaziland HIV prev 26% HEx 180$ per capita) Aids budget: 49 million $ Amsterdam www.kit.nl

5. Methods & Sampling • National • - Desk review • KI-interviews • - Stakeholder meetings Purposive sampling District B KI interviews District A KI Interviews Community District capital • In each community • KI interviews • FGD community members (women/men/youth) Remote, easy access to HF Difficult access to HF Amsterdam www.kit.nl

6. Findings (1)HIV as a health priority? HIV/AIDS accepted as important problem at national level Level of importance disputed Community often has other priorities “ I think the government should stop the AIDS program and use the money for more important things [such as] pipe born water, hospital…” (Ghana, Community level) Important influence of DP’s

7. Findings (2) Has HIV influenced Infrastructure & Supply chain management? Improved infrastructure & supplies “New services have been put in place such as treatment centres for STI, maternities including PMTCT” (DRC, National level government) Medical procurement and supply chain management capacity improved “One of the good things about Global fund, it has instituted post market survey and quality assurance” (Ghana, National level government)

8. Findings (3) HRH capacity & performance • Capacity & skills building health staff (all countries) “The trainings include aspects of maternal and child health, they include TB care and so HIV has been the entry point for capacity building but a capacity building that was not limited to HIV alone”(Malawi,NGO repres.) • Increased HW availability through ERPH (Malawi) • On the 52% salary “… that made the health workers to go home with a [good] package as compared to some others […] this has been a way to improve the situation. People are no longer moving in large numbers to [other work and abroad] as it was in the previous years”(Malawi, District level respondent)

9. Findings (4)HRH But, Absence of staff due to training “In the given situation there is a major incentive for not working. Training is the major source of income”(Malawi, Development Partner) Brain drain « We see a transfusion of staff from one system to the other, not only those, like me, that left the services to work in program management, but also those that joined CSO’s and NGO’s or even left the country called for international duties in the fight against AIDS»  (Burkina Faso, National level)

10. Findings (5) Access and quality of care • Health worker - client interaction improved as result of AIDS programs • Infection control & universal precautions protects patient and provider • Improved trust in formal services  increased utilization • Improved community care and services • Improved access to general health services for MARP (Madagascar capital)

11. Amsterdam www.kit.nl

12. Findings (7) Financing & accountability Improved accountability • “One could expect that [HIV funding] would lead to poor governance. But what we see is that actually in the field of HIV there is better management, perhaps because that is where there is more control, more oversight, more political implications at the highest level” (Burkina Faso, National level) • Parallelism & Divide “In general, I think the amount of money coming in for HIV/AIDS is disastrous, it’s too big so it is dwarfing out all kinds of other things. In general there is too much money and it is too verticalized”(Ghana, Development partner)

13. Findings (8) Monitoring and evaluation improved? Capacity for M&E and Research improved • recruitment and training m&e staff • Digitalization • Regular review meetings • Use of info Parallel structures “Most programs are now having their own M&E officer, instead of strengthening this unit,[…] we are having fragmented sort of M&E systems at the moment” (Malawi, National level) Heavy burden “The Evaluation system has evolved and improved, but to a cost. We used to fill health reports of not more that 4 pages, if I am not mistaken we have now arrived at 28” (Madagascar, Hospital manager)

14. “The civil society mobilization has been tremendous coming in for HIV. […] there could have been more than 800 CBOs being funded […]. They have been critical partners and they have had influence. They have been able to address and reach vulnerable groups, the most at risk population” (Ghana, National level respondent) “There also has been an effect on empowerment and engagement of civil society regarding health. It has been strengthened as compared to how it was before. Like the district AIDS committee, its composition has to take on board the civil society”(Malawi, Senior District Officer) Findings (9) Community engagement increased

15. Conclusions (1) • Positive globally • Infrastructure (especially Lab) • M&E capacity (limited to HIV program?) • Procurement & Supply chain management • Capacity development HR • Community engagement • Negative trends • Undermining planning & management • HR availability (exception Malawi) and moral • Parallelism • Variant • Access & quality of care • Accountability & transparency

16. Conclusions (2) • Most effects were ‘spin-off’ effects rather than results of a planned action to strengthen wider Health system by AIDS programs • Parallelism and divide as an overarching theme • More research piloting strategies to bridge the gap

17. “The HIV money is going to go away one day. How soon, we all don't know. Most of the systems now are being built around HIV. And I'm always hoping that when the HIV money goes away that the systems that have been built, have been built on rocks and not on sand.” (Malawi, District level respondent)

18. Acknowledgements: • Acknowledgement • We wish to acknowledge • Partners • Co-investigators • Country research teams • A great thanks to all respondents Funding from DGIS(Dutch Development Cooperation) Stop Aids Now! Cordaid ICCO AIDS Fonds HIVOS Oxfam Novib Global Fund to Fight AIDS, Tuberculosis and Malaria