Global Health Initiatives and Effects on Health Systems: Overview & Case Studies

1. Global Health Initiatives and Effects on Health Systems: Overview & Case Studies Carlos Bruen & Aisling Walsh PHS Academic Seminar 7th Dec 2010

2. Outline • Introduction • Global Health Initiatives • Global HIV/AIDS Network (GHIN) • Global Research • Stakeholder perspectives on the emergence and evolution of the Global Fund & GAVI • Country Research • Services Scale-up in Zambia • Zambia & Malawi - Health Workforce Responses

3. Global Health: From Projects to Partnerships • 1970s – 1990s • late 1990s • early 2000s • Project Support • Standalone projects & programmes • Donor-driven priorities • Sector-Wide Approaches (SWAp) • Shift to development of longer-term partnerships • Use of common funding pools in countries, disbursed to activities agreed by donors and government • Global Health Initiatives (GHIs) • “a blueprint for financing, resourcing, coordinating and / or implementing disease control across at least several countries in more than one region of the world” (Brugha)

4. New actors in addition to country governments (donor +/- recipient), notably: Philanthropy (e.g. Gates), Pharmaand Civil Society (e.g. NGOs) New global governance mechanisms outside of/transcending traditional multilateral bodies (WHO, World Bank, UN agencies) Different purposes Product (drug or vaccine) development Increase access to health products Global Coordinating mechanisms including funding vehicles Health service & system strengthening Public education & advocacy GHIs - What’s New?

5. GHIs –AIDS & Childhood Illness • World Bank Multicountry AIDS Program (MAP) • A traditional multilateral agency, disbursing funds in new ways: flexibility, learning by doing & reworking of projects, reliance on multiple implementation agenciesin a new way • Global Fund to Fight AIDS, TB and Malaria (GFATM) • A GHI with no country presence bringing a performance-based reward business model to disease control • US President’s Emergency Plan for AIDS Relief (PEPFAR ) • A bilateral donor introducing a new top-down program in parallel to its own bilateral vehicle – USAID • Global Alliance for Vaccines and Immunizations (GAVI Alliance) • A GHI with no country presence bringing a performance-based reward business model to disease control

6. Total Annual Resources for HIV/AIDS (1987-2007)

7. ANTIRETROVIRAL THERAPY COVERAGE IN SUB-SAHARAN AFRICA, 2003-2007

9. Development Assistance for Health

11. Part 1.2 GHIN • Network GHI Focus • 4 GHIs: GAVI; GFATM; PEPFAR; World Bank MAP • Network Aims: • Promote comparability through common research protocols and tools • Share expertise across country study teams and building research capacity • Generate multi-country comparisons and context specific lessons • Coordinate dissemination of findings/recommendations at global level

12. Multi-level research: GHI effects on country health systems 4. Global 2009-11 1. National 2003-05 (Tracking Study) 2006-08 (GHIN) 2. Sub-national / districts Health facilities (Africa) 2007-09 Community 3. - FSU (urban) 2007-10 5. - Zambia (rural ) 2010-11

13. Research Themes Global governance for health Scale-up of HIV/AIDS Services Human Resources for Health Coordination of HIV/AIDS policy/planning and service delivery Monitoring and Evaluation Civil Society Access and stigma

15. Stakeholder Perspectives on the Emergence & Evolution of GHIsThe Story of The Global Fund & GAVI Alliance Part 2 Global

16. Conceptual Framework Bruen, C & Brugha, R (2010) The Impact of GHIs on Country Health Systems: An Evidence Based Typology, 'GHIs in Africa' Project Research Report D16, Jan 2010

17. Aims & Methods • Methods: • Stakeholder mapping: Identification & classification of priority stakeholders and policy makers • In-Depth Interviewing: 35 semi-structured phone interviews conducted, purposively selected to include people with multi-constituency experience • Thematic Analysis: Transcription, anonymising and coding • Aims • Context: Emergence & evolution of GHIs, incl. GFATM and GAVI • Focus: Network dynamics, processes and mechanisms by which individuals from different constituencies interact, negotiate and shape GHIs

18. Theory & Key Concepts • Theory • Global Health Governance (GHG): “..totality of collective regulations to deal with international and transnational interdependence in the context of health issues” (Hein & Kohlmorgen, 2008: 84) • GHIs: New institutions within the field of GHG comprised of multiple constituencies for collective action • Network analysis: A framework for analysing strategic interactions between actors (individuals, groups and organisations) or categories of actors. • Global level application, including global-country interactions and individuals and organisations connecting with other global actors and country constituencies • Some key concepts • Networks & mechanisms in political and policy processes (e.g. Tilly, 2001): • Relational mechanisms include: • Cross-constituency coalition formation; Network brokering • Sociopsychological mechanisms include • Trust; Information and knowledge sharing; Emulation and adaptation

19. Trust ties expand within GFATM, though trust issues within and between some global and country constituencies emerge or remain entrenched • For NGOs/CSOs, external relational mechanisms facilitate coordination of activities and knowledge transfer, as well as expansion of ties between AIDS and non-AIDS organisations (important for CSO engagement with GAVI) • Changing role of NGOs/CSO towards PRs raises issues of representatives and accountability, though embedded positions increased legitimacy and willingness to trust NGO/CSO individuals with greater role in designing new funding streams Case 1: The Global Fund • Networks & Brokers in the Formation of the Global Fund • High-level cross-constituency ties: Develop pre-Global Fund, e.g. between key individuals in AIDS Non-governmental Organizations (NGOs)/Civil Society Organizations (CSOs), multilateral organizations and bilateral donors • Brokers emerge: Trusted individuals/brokers become representatives at high-level meetings, gaining direct access to Transitional Working Group negotiations and advocating emulation of UNAIDS governance model • Transnational networks as information channels: NGO/CSO networks used for input into negotiations on Global Fund design. • Embedded actors: NGO/CSO representatives gain institutional access to the Board and Secretariat. • Evolutionary Trends • Expansion of networks: • GFATM facilitated increased trust ties, but new trust issues emerged or remain entrenched  • External relational mechanisms play a vital role in global-level coordination & knowledge transfer   • CSO embeddedness builds legitimacy and Global Fund willingness to trust NGO/CSO individuals in shaping policies • New Actors, Broadening activities: • Influence of Board increases and changes to Secretariat staff created opportunities to broaden focus, incl Health Systems Strengthening (HSS)

20. Case 2: GAVI • Networks & brokers in the design of GAVI • A Closed network: Individuals in PATH Child Vaccine Program become key brokers connecting Gates Foundation & immunization programme ‘insiders’, establishing the Working Group to form GAVI • Prioritisation of technical knowledge over representation • Key driver to meet the aims of the Gates Foundation for new vaccine introduction • Network expansion: • Alliance model and financial resources to attract multilateral buy-in, but limit multilateral control • Embedding trusted brokers to advance donor and multilateral buy-in • Contested policies: Temporary truce in hostilities between immunization and health reform communities • Evolutionary Trends • Shifting influence: From the Working Group to the Board to the Secretariat • Partner or contractual arrangements? Changing relations between GAVI Secretariat and UNICEF, WHO & World Bank • Beyond the Hybrid’s Handmaidens? Civil Society engagement with GAVI is evolving

21. Case 3: Towards Health Systems Strengthening? • GFATM • A Fraught Proposal: the Health Systems Strengthening Platform • Non-Consensus: Perceived as driven by European donors, with support from small number of people in other constituencies, though lacking support from a wider range of influential individuals and constituencies • Unsuccessful brokerage: Brokers do not appear well-positioned between opposing networks and have not yet gained enough support • Retreating support? Speculation some of the donors that originally supported the HSS Platform are expressing serious reservations about current direction • GAVI - An old hostility re-emerges in the form of Health Systems Strengthening • A Shift in Relations of Influence: more finances committed by HSS-orientated European donors, the creation of the IFFIm and appointment of HSS-orientated staff to the Secretariat • Breaking the consensus: For various Board members, viewed as departing from original GAVI goals, with key stakeholders preferring no HSS strategic goal • A negotiated compromise?Indicators for GAVI Strategic Goal 2 (HSS) will likely focus on how HSS funding impacts on the bottlenecks to immunisation

22. Discussion & Conclusion • Benefits of an actor-orientated approach to HSR: • Builds on impact and outcome focused research by highlighting the role of actors in policy processes and agenda setting. • Generates knowledge of crucial mechanisms and interactions which exert strong effects on political and policy processes. • Highlights potential areas of tension in future negotiations and interactions • Limitations & Possible Future Work • Time-frame of GHI emergence and evolution makes a longitudinal network analysis difficult • Focusing on a more limited time period, it will be feasible to conduct a network analysis that maps in greater detail dyadic ties, information flow/barriers etc and the significance of network management strategies for governance networks like GHIs

23. Part 3Impact of GHIs in Countries Part 3 Country Case Studies • How HIV/AIDS scale-up has impacted on non-HIV priority services in Zambia • Health workforce responses to global health initiatives funding: a comparison of Malawi and Zambia

24. Part 3 Country • How HIV/AIDS scale-up has impacted on non-HIV priority services in Zambia Phillimon Ndubani, Joseph Simbaya – Institute of Economic and Social Research, Zambia Ruairi Brugha, Aisling Walsh, Pat Dicker – RCSI

25. Zambia – core HIV indicators-2007 • Population – 12.2million • Adult HIV prevalence - 13.1% • ART coverage – 51% (adults and children) • Prevention of Mother to Child Transmission coverage – 39% • Largest funders – PEPFAR (62%) and Global Fund (16%); bilateral donors

26. Background Debate about positive and negative effects of scale-up of HIV services on health systems -- Crowding-out non-HIV services + Strengthening health systems, eg lab systems, pharmacy management. Assess how HIV/AIDS scale-up has impacted on non-HIV services delivery in Zambia

27. Methods 3 districts – Lusaka (capital); Kabwe (urban); Mumbwa (rural) Mapping of HIV services 2007/2008 Sampling: all fixed facilities providing ART (29); other HIV services (10) Facility record data gathered for 2004-2007 and district health office facility record return data

28. Results (1) Scale-up in HIV services and infant vaccinations

29. Results(2)ART Coverage 2004 to 2007

30. Results (3) PMTCT and reproductive health

31. Intrafacility correlations between HIV and non-HIV services, 2005-07 (rank correlations > 0.3 highlighted).

32. Correlations of changes in services, 2005 and 2007

33. Drugs and commodities normally stocked and stock-outs, 2007

34. Discussion & Conclusion • Facilities showing scale-up of HIV services also show increases in reproductive health services • Reciprocal connections • PMTCT and Antenatal care • ART and Family Planning • Importance of routine health information systems and facility institutionalisation • Top-down (Health Metrics Network/Institute of Health Metrics) • Bottom-up (Household surveys) • Middle (routine facility data)

35. Further Research • Need for explanatory studies that move beyond correlation studies to analyse in-facility processes • Sequential mixed methods: • Staff interviews to explain trends • Client interviews

36. Health Workforce Responses to GHI Funding: A Comparison of Malawi & Zambia Victor Mwapasa, John Kadzandira – Uni of Malawi Phillimon Ndubani, Joseph Simbaya – Uni of Zambia Ruairi Brugha, Aisling Walsh, Pat Dicker, RCSI

37. Core HIV indicators - Malawi and Zambia (2007)

38. Malawi & Zambia: 2004-08 (1)Global Fund & PEPFAR Funding to HIV

39. Research Methods

40. Numbers of clients receiving ART, PMTCT, VCT + outpatient visits: Malawi and Zambia (2004-07)

41. Staff trends Malawi: 2006-08(52 facilities)

42. Staff trends Zambia: 2004-07(29 facilities)

43. Malawi: average clinical staff- outpatient workload 45facilities (6 urban, 6 district hospital, 13 rural health centre) 2006-08

44. Zambia: average clinicalstaff- outpatient workload22 facilities (9 urban 13 rural) 2004-07

45. Malawi – qualitative • Staff numbers have increased, but not at the same rate as workload • Provision of new services, ie nutritional support • Burden worst on the nurses “ Although the nurses have the skills necessary to counsel a client, they are still following short cuts when executing their duties because of too much work...because counselling takes too much time to complete and with many clients waiting for you outside, you just do what you can afford.” • By 2008 HSAs providing VCT • Opening of more sub-district facilities.

46. Zambia – qualitative • Voluntary lay counsellors relieving some pressure for HIV counselling • Failure of the rural retention scheme • HWs being poached by NGOs paying higher salaries “The biggest problem is like where they have been also providing support to the NGOs and NGOs tend to offer good salaries and health workers when trained, go to the private sector. The support… has contributed to brain drain, work overload for the remaining staff.”

47. Conclusion • Global Fund (+ UK DfID) agreed to re-allocation of MALAWI Round 1 grant, which enabled Malawi to start to implement its Emergency Human Resource Programme • Doubling in training of new health workers • Hiring 10,000 new staff (mainly HSAs) • Salary supplements • ZAMBIA’sNational Human Resources Strategic Plan lacked concerted donor support for hiring new health workers • Recipient governments (and their partners) need to prioritise the development of HSS strategies • Donors can then be encouraged to fund them

48. Recent publications Brugha R, Simbaya J, Walsh A, Dicker P, Ndubani P: How HIV scale-up has impacted on non-HIV priority services in Zambia. BMC Public Health 2010, 10:540 Walsh A, Ndubani P, Simbaya J, Dicker P, Brugha R: Task sharing in Zambia: HIV service scale-up compounds the human resource crisis. BMC Health Services Research 2010, 10:372 Brugha R, Kadzandira J, Simbaya J, Dicker P, Mwapasa V, Walsh A: Health workforce responses to global health initiatives funding: a comparison of Malawi and Zambia. Human Resources for Health 2010, 8:19 Biesma RG, Brugha R, Harmer A, Walsh A, Spicer N, Walt G: The effects of global health initiatives on country health systems: a review of the evidence from HIV/AIDS control. Health Policy Plan 2009, 24(4):239-252