Health Systems: malaria and HIV

Major new funding for HIV and Malaria has been coming in over the past eight years. The question is how that funding has not only impacted on the two diseases, but what has it done to the health systems that are expected to deliver disease control services?

From the beginning of RBM, partners and planners has stressed that malaria cannot be rolled back outside the context of health sector reforms and improvements.  Except for the possibility of ITN distribution campaigns, malaria control activities such as case management with ACTs and delivery of IPTp via directly observed treatment, require a strong, accessible and affordable primary health care system.  The issue of home management is tackled in the context of the health system training, supplying and supervising community volunteers. Even campaigns are run from a base in the district health department and linked with child immunization activities.

To some extent we have seen negative effects on the health system with new malaria funding when there is donor pressure to achieve and report quickly on performance – parallel procurement and distribution systems have been set up as well as parallel monitoring and evaluation processes, but ultimately the delivery of malaria control services requires that primary health services – facilities and staff – function on the ground.

seizing-the-opportunity-p1-sm.jpgIn contrast critics have pointed to HIV/AIDS programming as creating its own structures resulting in internal brain drain within countries – pulling staff and resources away from the basic health system in order to reach treatment and coverage targets. A recent publication, Seizing the Opportunity of AIDS and Health Systems, explores this issue through three country examples. The report focuses on health information, supply chain and human resources in Mozambique, Uganda and Zambia. Concerning information system the report summarizes the situation thus:

In each of the three countries donors draw information from parts of the health information system and from national monitoring and evaluation systems. Meanwhile, all three donors have their own donor-specific reporting requirements in all three countries. The proliferation of information systems results partly from donors’ own priorities and accountability requirements. But it also reflects weak government coordinating structures for health information system management. And it reflects the ill-equipped, underfinanced state of national AIDS councils.

There is evidence of functional antiretroviral supply chains, but not a strengthening of the overall supply chain within countries. “In all three countries, the Global Fund, PEPFAR, and the MAP have worked with governments to develop supply chains for antiretroviral drugs. The supply chains are still fairly small, however, often serving 300 facilities or fewer. They rely largely on public structures. Yet they generally function more smoothly than the much larger government-managed supply chains for other essential medicines.”

In addressing human resources the report says that donors have focused more on in-service training of existing workers than on helping enlarge the pool of health staff. Because of better salaries and benefits in donor-supported programs, health staff have been pulled away from the public sector, thus weakening the health system. The report concludes by saying …

As PEPFAR, the Global Fund, and the MAP work to extend the reach and effectiveness of their HIV/AIDS programs, they will continue to find that country health system weaknesses create barriers to program expansion. To surmount those barriers they should finance programs in ways that increase the abilities of country health systems to provide broad quality health services, while doing the least possible harm to those systems. But to create greater incentives for donors to seize this opportunity, actions by country governments are also urgently needed. Earmarked funding for HIV/AIDS is evidently here to stay. The approach recommended here will ensure that donor funds bring the greatest possible benefits to country health systems while also achieving desired AIDS-specific outcomes.

We might add that benefits to the country health systems will ultimately also benefit efforts to control malaria.

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