While we think of ways in the which the GFATM will really imopact Health Systems, with particular focus on renumeration of healthworkers, I will like to point out that there is need to be a serious paradigm shift in the fundamental principles of the GFATM from measuring the success of programs in terms of performance to measuring success in terms of impact. And there is no way we can expect any impact if countries have not been implementing HSS strategic actions as they indicated when they were filling the GF forms. After Seven Rounds of Funding, I believe it is time to really evaluate impact of the programs on the health systems of countries. I guess that will be good as another topic to be discussed seperately.

The emphasis on performance without doubt has been counterproductive in the sense that it puts pressure on GFATM implementers to just produce routine data and outcome data. Whether there is impact or not, they do not have to bother, all tey have to produce is just the data, the numbers. And this seems to have been the practice of a lot of programs that are vertically implemented.

 

This "Health Systems Strengthening" topic needs to be discussed deeply among the developpement sector stakeholders before we come to an appropriate and well-defined approach. We can already see that many developping countries are supportive to the Global Fund  to fight Aids, Tuberculosis and Malaria because of the significant level of  funds this new financial instrument is presently channeling to poor countries.

My opinion is that this is not the most impressive added value of the Global Fund to developping countries. The Global Fund thinking in relation to health system strengthening is what stakeholders in recipient countries need to look at very closely. Here we have a powerful principle which clearly states that national responses to these three deseases can only be successfull if they are comprehensive and hollistic..., if they go beyond the facts (drugs, treatements, awareness activities, etc.) and address actually the systems (ressources, structures, processes, etc.). This is really a new drive and a forward thinking. 

If the Global Fund succeeds in supporting developping countries to have performant health systems in place this will appear to be one of the most important achievement of the developpment sector in recent history. Of course developping countries need these round-based grants from the Global Fund at the moment to face urgent care and treatments needs of affected people but sustainablity and durable impact will only be achievable trough well structured and well managed national health systems. The international community (mainly the international financial institutions and developped countries) must bring  their efforts together with the Global Fund in this area.

In addition to funds already commited for the day-to-day fight againt Aids, Tuberculosis and Malaria in Asia, Latina America and Africa, the Global Fund will have to raise significant level of unrestricted funds. This is required to support affected countries in these continents to developp contextually adapted health systems with appropriate equipements and motivated human ressources. These are the big challenges faced by all stakeholders involved in this new Global Fund initiative regarding health systems strengthening.

May be the funds that will be made available through the GFATM will be the motivating factor that push countries to develop plans and strategies for the sustainabilty. Whatever the case may be, there is a seriuos need to work out modalities that ensure that efforts at fighting the three major will have not only maximum impact but as well will be susutainable.

The performance- and result-oriented strategy of the GFATM may as well be adopted to hold the countries accountable and may be the role countries have played in ensuring that migration of health care workers, both from the pirvate and public sector, is curtailed should as well be used as yardsticks before more funds are approved in the next rounds.

Dear Collegue,

I fully agree. Suriname's Round 7 proposal is rejected because and obvious for good reasons to much focuse goes to investments in building, training and HRD in stead of to PLWHA. This is exactly your point. Because there are no systems and structures in place first things has to be done first. One cannot help others without trained and skilled manpower abd if there is no office and no communication means.

We need to seriously discuss this point. My vision is that a certain part of the grant should first go the setup of infrastructure of indeed both public and private sector Health Institutions. After a solid base is established, we can build on that basement. Another possibility is that this should happen, but the local LFA and/or PR's are not on the right track.

Anyway a wide discussion can be useful.

Regards, Jan.

In it's simplest form, "a Health care system is an organization to deliver health care" Thus a health care system is a shared responsibility between the federal, provincial and territorial governments. It includes: Hospitals, Home based care agencies,Long term care facilities, People (physicians, nurses, social workers, health care providers).

From the above, it is clearly evident that in every functional system, all the basic components MUST function. When these systems are functional, then the actual output (control of diseases) becomes very simple. The Global Fund as an organization has committed several billions of tax-payers funds into battling the major diseases in many countries including mine. However, the dismal performance in these countries may not be unconnected to the absence of a functional health system. These abysmal performance when carefully analyzed can be traced to issues of non-sustaining human resources for health.

It is known that the most critical issue in organizational success is the determination of it's human resources. Funds committed can only be useful if the human resources are evenly distributed, committed and and determined. Most committed "men" are also motivated either in cash or in kind.

In most developing countries, the discounted salaries and wages often times lag behind the inflationary trend over the same period. It is known that the local currencies may depreciate against the USD and these can lead to poor outcomes both in procurement of commodities as well as other implementation activities.

Recent findings by Michael A. Clemens et al showed that about 20% of African-born Physicians and 10% of Nurses work outside their country. Also that the fraction of health workers outside their countries varies between 1% and 70%. The primary reason for migration is remuneration!

In 2007, an online poll of Foreign doctors working in the NHS showed that India and Nigeria were at 1st and 2nd position respectively. These countries are regional giants and the flight of their supposedly "well paid" workers should reflect the major constraint to success in disease control in their countries.

Nigeria is presently undergoing a National Health System Reform but all efforts will come to nullity if the high attrition rate of it's health workers aren't addressed through a policy. It is known that some young doctors feel alienated in the Ministry of Health because of certain policies bordering on remuneration.

A major strategy aimed at addressing Maternal, Newborn and Child health mortalities in Nigeria has identified that a critical mass of health workers need be in position to attend to the cases in even the local hospitals. The issue of posting recent medical graduates to the rural areas has been raised. But what will keep a doctor and Nurse in these communities is not too far from appropriate commensurate remuneration.

From the foregoing, the Global Fund can not succeed except the host country puts it's acts together and address the issue of remuneration for it's health manpower. It is not correct to depend on the resources of the GfATM in the short term to address the Health System component without a National Investment Plan for sustainability.

Dear all

i fully agree with Dr.Tony views. The problem is same in all developing countries.In India, the public healthcare system is in bad shape. only 20% of population utilise the massive public healthcare system. People have lost trust and faith in system.We have nearly 500,000 pharmacies across india and about 10 million people visit them every day.The pharmacist whether qualified or not is trusted by community, easily acessbile and operates without charging any fee.

So far our government could not utilise this basic healthcare resource and goes on putting money in to public healthcare system which people does not visit or trust. For last four years i have been trying to build capacity in the most ignored but trusted human resource. Although iam in a position to reach through my news letter 200,000 pharmacies across india every fortnight the resource crunch disables me.

our news letter is free for all members on Request.

Bhava Narayana Editor Pharmed Trade News , India pharmedbhava@gmail.com

The GF has really done a lot in the fight against the three dealiest diseases in human history and have achieved quite a lot. However, in my work implementing some GF sponsored projects, I have noticed that problem runs deeper than trying to specifically tackle these three diseases individually.

The very reason why developing countries are not able to manage the impact of these diseases is beacuse over the years, they have not been able to develop strong health care sysytems. And the truth is that whatever successes achiveved through the funds made available by the GF, will not be susutained if the GF does not make contributions towards the strengthening of the healthcare systems and structures in these countries.

And the particular challenge that these coountries have is the migration of the much needed healthcare personnel from these coountries. As bad as that is, the truth is that it is the best of the best get employment in countries where they will be better paid.

Lets open discussions to tackle these problem, to tackle HSS issues both in private and public sectors, just as distinctly as we are tackling the three diseases that GF has been dedicated to tackling.

The GF has done something that has never been done before in human history and has initiated an innovative way of bringing together the public and private sectors on the same platform. The GF can further extend its powerful financial tentacles to this very important area of the fight to ensure that healthcare is within the reach of all.