efriedman - May 22, 2006

Hello,

The Global Fund has an important role to play in health system strengthening. A friend of mine who is HIV-positive recently observed that if even for him and his peers who are receiving AIDS treatment now, if they want to continue to receive it 3, 5, 10 years from now, health systems need to be strengthened. The Global Fund must continue to support health system strengthening. And partners must provide the continuing technical support required to ensure that countries can develop technically sound proposals, and then successfully implement them. This support is needed now for Round 6.

In January 2006, Physicians for Human Rights called for the Fund to retain its separate Health System Strengthening category. The documents are available at: http://www.phrusa.org/campaigns/aids/global_fund_hss.html.

The main points (slightly updated) about how the Global Fund is a good and necessary mechanism for support health system strengthening include:

* Malawi and Rwanda have used the Global Fund to support national health system strengthening plans (human resources for health and community-based insurance scheme, respectively).

* All opportunities for health system strengthening are needed because of the cost of HSS. WHO has estimated that over the next 10 years, the 57 countries with the most severe human resource crises will need to spend (by 2015) an additional $10 per capita to train and employ new health workers, and make significant additional investments to retain these health workers. Such funds cannot be met by a single institution or donor, all health funders, including the Global Fund, needs to contribute.

* All windows are needed because different development partners will have different strengths in different countries. For example, the World Bank might have a very effective presence in one country but only a weak presence in another country, where the Global Fund has a strong presence. In the latter country, the Global Fund would better positioned to support HSS than the Bank. Similarly, countries may have needs that one or another partner is better able to support. For example, a country might require grant funding which the Global Fund can provide, but might not be available from the Bank.

* HSS is needed for the success of HIV, TB, and malaria programs supported by the Global Fund. Just as a country needs medicines to fight AIDS, it also needs health workers. It is illogical to require a country to artificially limit the scope of the support it seeks from the Global Fund to only part of what it needs to effectively fight AIDS, TB, and malaria. Absent very smooth coordination with other partners -- which is always ideal but rarely the reality -- this could reduce the ability of Global Fund applicants to receive the HSS support they require for successful implementation of GF proposals.

* The possibility of using the GF to fund HSS promotes integration of HIV, tuberculosis, and malaria programs in the overall health system, thus reducing duplication and inefficiencies, while improving sustainability and enabling HIV, Tb, and malaria funding to have positive system-wide effects.

* The Global Fund has a proven, strong monitoring and evaluation system, which is particularly important for HSS, where it is easy to put money into a system while not expecting results because health system strengthening takes time. The Global Fund demands results, and demands the countries show the effective use of funding.

* The Global Fund can now support long-term activities, and with changes, could even better support long-term activities, such as a 10-year health system strengthening plan. ART requires long-term support too, after all. The Phase III process under discussion should enable this long-term support from the Fund. Changes to how the Fund operates could make such long-term support even easier to secure from the Fund.

* The Global Fund can utilize all available technical experts to support HSS. Given that such experts seem to be in short supply, nothing should be done that would could cut out some technical experts.

Physicians for Human Rights urges countries to take advantage of health system strengthening possibilities in Round 6. Please stay tuned to http://www.phrusa.org/campaigns/aids/index.html, as we will be posting a Guidance on Using the Global Fund to Fight AIDS, Tuberculosis and Malaria to Support Health System Strengthening soon (by May 30 or before). Thank you,

Peace,
Eric

Eric A. Friedman
Physicians for Human Rights
email: efriedman@phrusa.org

Apr 19, 2006

Online Discussion Summary and Lead Contributors: April 10-17.

Question: What is the most appropriate approach for the Global Fund to be involved in supporting health systems strengthening?

(a) To have a separate “health systems strengthening” funding component (as currently done for AIDS, TB & malaria components)?

(b) To encourage other donors to fund health systems strengthening, with the Global Fund focusing on specific programs for the three diseases?

(c) Other approaches (that still promote harmony and efficiency)?

Lead Contributors: Tarig Dafallah (Sudan), Tshabalala, R Vonrueden (USA), Beatrice Minja (Tanzania), Basmakh, Anjana Bhushan (Philippines), Pinaki Mukherjee (Kolkata, India), M Ngaara, ASM (Kazakhstan), Mark McPherson (UK), Umesh Vanahalli (Karnataka, India), Emma Adelakun Adeseyoju (Ondo, Nigeria), Wamari (Kenya), Tasleem Akhtar (Pakistan), Jambiani- Tuishi NGO, Jumoke Owoola (Nigeria), Bruno Moonen (Kenya), Lombardi, Aja Desiree Hardy (MO, USA), Becky A. Johnson (Switzerland), Oge Nkemakolam (Owerri, Nigeria), Yerro Sowe, Eugene Tshidimwena (DR Congo), Uwem Inyang (Abuja, Nigeria), Marion Quang.

French Forum: Robert Toubon (France), Peter Kimbondo (DR Congo), Valentin Traore, Sidi Abdillahi (Mauritania), Techi Alio (Niger), Celestin Ele (Cameroon), DAFFE (Senegal), Lisungi NGO (DR Congo) and Peter Kimbondo( DR Congo)

Spanish & Russian Forums: Ivan Palacios (Ecuador), Amira Kimirina, Gabriel Carrasquilla (Colombia), and Ulyanov (Russia).

Summary:

There are basically three emerging positions from the discussions so far. These include:

1. The first group of contributors, proposing a separate health system strengthening (HSS) component. Among their reasons:
a) Health systems strengthening has been accorded little strategic attention or priority since focus is on ‘frontline’ interventions involving the prevention and treatment of AIDS, Tuberculosis and Malaria. Institutional and human resource capacity building is one of the opportunities / entry points for the Global Fund.
b.)The low quality of health systems and the degree of duplication of effort created by single-disease interventions affect the effectiveness and ultimate value of the Global Fund’s initiatives. A condition for this approach would be close collaboration between all partners.
c.) A third argument for this approach is that a separate funding component is needed especially to combat Malaria. The current health system is weak and not structured to empower community and household levels, which are the levels at which fighting Malaria is most effective. Malaria also demands a significant share of hospital beds and family spending, and could be further eased by promoting technology transfer towards community ownership programmes, and subsidizing hospital costs.
d.)Health systems strengthening is ‘Everyone’s business’, and funding through a unique component emphasizes this. It is further argued that the poor performance of this approach in round 5 was due to inadequate detail in guidelines, indicators, good practices and recommended activities which were provided for the AIDS, Tuberculosis and Malaria components. Also, proposal submitters did not want to jeopardize their overall proposal by linking a HSS component to it, on which they were not confident of securing approval. The Global Fund should provide more guidance to proposal submitters about how to strengthen the quality of the HSS aspects of their proposals.
e.) While it is almost impossible to separate endemic disease control results from the performance of the health system as a whole, this approach should be adopted, including health systems research to fine-tune implementation towards local organizational issues and different epidemiological levels. It provides better possibilities to develop and implement combined or integrated approaches among the three diseases or even with other prevalent ones, according to the local epidemiological or operational situation.
(f) Countries in transition: The most appropriate strategy for the post-soviet countries would be an introduction of a “health systems strengthening” approach as a separate financed component, including best practice sharing among specialists, training aimed at raising the level of professional skills, financing research work, etc. The priority goals in the sphere of “health systems strengthening” must be defined in co-operation with the national institutes.

2. Those arguing against a separate health system funding component say that it might be unsustainable, against the holistic approach principle, and against the integrated health services concept.
3. The second group proposing that other donors are encouraged to fund health systems strengthening state that:
(a) The Global Fund should avoid duplicating other donors’ efforts. This group argues that if HSS, alongside other technical assistance and grants are directed to the general structure of the health system, with emphasis on the three diseases it increases the outcome of grants.
(b) This group further argues that the Global Fund’s current approach to fighting the three diseases represents a first wave, or rapid response through information and treatment in order to obtain immediate results. To ensure sustainability, there is need for a special fund external to the Global Fund, which would be financed by other donors, and improve synergy in fighting the three diseases. It would also ensure that the Global Fund does not scatter resources, but concentrates its efforts on the three diseases.
4. Those arguing against this approach say that it works against the principle of a coordinated multisectoral approach and makes HSS the premise of a few; i.e. Less inclusive; among other reasons.

A further contention is that many donors and cooperation agencies have invested millions of dollars in Strengthening Health Systems (public), with dubious results. Few systems have managed to improve the quality and access to health services. In one named public health ministry, a lot of money has been invested in training human resources. Although this was a positive and necessary action, problems regarding fairness, quality and efficiency persist.

It is on the "demand" side, for the population receiving health services in general, where little or virtually nothing has been invested in some countries. ''Pressure needs to be put upon suppliers from the demand side. ''

5. Group preferring neither approach, and proposing other approaches: e.g. (a) GFATM makes HSS its additional proposal selection criteria so that proposals relate HSS to the three diseases and avoid diverting focus from the diseases (b) Either donors, the Global Fund, or the two jointly finance HSS through a separate financing mechanism, focusing on crosscutting challenges to national health sectors and strategic plans e.g. human resource capacity, salaries, procurement and supplies, etc. (c) Mainstream Health systems strengthening into funding for the three diseases because of their close association. The Global Fund should also help to fund fair salaries for health care personnel to ensure that adequate human resources are available to provide much needed care, treatment and prevention services.

In conclusion, all agree that strategies for health system strengthening should be clearly defined. Some of the objectives should be improving access, fairness and quality in health services.

To proceed to the next discussion forum, please click on the following link:

http://forum.theglobalfund.org/en/viewtopic.php?t=108

Looking forward to reading your message. Thank You!