Positive Synergies and the Health Workforce Andrew L Ellner M.D., M.Sc. Global Health Delivery Project Brigham and Women s Hospital Harvard Medical School
Policy Question How can global health initiatives and national health systems optimize their interactions to capitalize on positive synergies and minimize negative impacts, thereby achieving their common goal of improving health outcomes?
WHO Positive Synergies Initiative WHO-led initiative for G8 Summit, Italy 2009 3 consortia: Academic Civil society Implementers Fifteen academic partners from Africa, Asia, Europe, and the U.S. Academic Consortium Harvard University Agence Nationale de Recherche sur le Sida Center for Global Development Dakar University Teaching Hospital George Washington University Heartfile, Pakistan Imperial College, London Institute of Tropical Medicine, Antwerp Kenyatta University Public Health Foundation of India Royal College of Surgeons, Ireland The AIDS Support Organization (TASO) University of Pretoria University of the Western Cape University of Yaoundé
WHO Health Systems Building Blocks
Conceptual Framework Epidemiological Demographic Political Governance Social GHI investment Government expenditure Private expenditure Other external expenditure Financing Health workforce Monitoring and Evaluation Health Technologies Communities/Civil Society D E L I V E R Y Health Outcomes Fairness of Financing Responsiveness Legal Technological Economic Environmental Adapted from: WHO six building blocks and RA Atun et al, 2006
Pathways to Impact GHI investment Government expenditure Private expenditure Other external expenditure Governance Financing Health workforce M & E Technologies CSO/Communities D E L I V E R Y Health Outcomes Fairness of Financing Responsiveness
Levels of Analysis Cross-country Identify quantitative relationshipsanalysis Country-level Understand mixed relationships methods analysis Provider-unit Understand level the impact analysis
WHO Positive Synergies Research Questions How do GHI-funded programmes interact with health systems in varied country contexts?
WHO Positive Synergies Methods Qualitative and quantitative case studies Key informants: Institutions National AIDS Control Council WHO PEPFAR Global Fund for AIDS, Malaria, and Tuberculosis USAID CDC UNAIDS AAR Private Healthcare National Newspaper Ministry of Health Treasury Department Family Health International Aidspan GFATM watchdog Ministry of Public Health and Sanitation AIDS NGO Consortium
WHO Positive Synergies Research Questions How do different health system designs and specific implementation strategies influence the coverage of targeted and non-targeted interventions?
WHO Positive Synergies Methods Facility Assessment Tool
WHO Positive Synergies Timeline May 29-30: 1 st Consultation, Geneva July 15 16: Drs. Carissa Etienne & Badara Samb visit Harvard August 4: WHO Satellite Panel August 5: 2 nd Consultation, Mexico City August 15: Prof. Rifat Atun visits Harvard Summer 2008 October 2-3: 3 rd Consultation, Geneva November 3-4: Dr. Badara Samb visits Harvard Nov - Dec: Data collection begins August 5: 2 nd Consultation, Mexico City August 15: Prof. Rifat Atun visits Harvard Fall 2008 Jan - Feb: Data collection continues February 16-17: Lancet special issue mtg, Rome March 9: Consortium submits preliminary results March 20: Draft circulated to consortium March 26-27: 4 th Consultation, Geneva March 28: Working meeting of Academic Consortium, Gva. Winter 2008-2009 Mid-April: Monograph submitted April - May: Final analyses conducted Mid-May: Full-length report submitted August 4: WHO Satellite Panel August 5: 2 nd Consultation, Mexico City August 15: Prof. Rifat Atun visits Harvard Spring 2009 June: Publication of monograph & case study library July 8-10: Results presented at G8 Summit, Italy Mid-May: Full-length report submitted August 4: WHO Satellite Panel Summer 2009
Existing Evidence & Emerging Themes Potential impacts: Distortions in health labor market Uncompensated increases in workload Trainings compromising service delivery (See e.g. Banteyerga 2005, 2006; Gbangbadthore 2006; Mtonya 2005, 2006; Schott 2005)
Rationale for New Research Mostly Qualitative WHO Positive Synergies Project Mixed Methods Approach Cross-sectional????? Few countries ## countries Early in major GHI implementation GHIs Learning institutions PEPFAR: 6 years of evidence GFATM: 7 years of evidence????
New Evidence & Emerging Themes Potential Synergies: Strategic top-ups, QOL incentives, infrastructure improvements Building capacity through training and task-shifting Flexible GHI funding for health workforce (See e.g. Oomman 2007; Sepulveda 2007; Samb 2008; Atun 2009; Brenzel 2009)
WHO Positive Synergies Challenges 1. Time 2. Time 3. Time 4. Qualitative methods 5. Sampling strategy 6. Data Availability
WHO Positive Synergies Promise Global network/public-private-academic partnerships GHIs: learning institutions Improved health
References Atun R, Shakarishvili G, Kley N, Blakely M, Godfrey-Faussett P, Boillot F, Lansang MA 2009. Country demand for Health Systems Strengthening: Analysis of Proposals to the Global Fund to Fight Against AIDS, Tuberculosis and Malaria. Banteyerga H, Kidenu A, Bennet S & Stillman K. 2005. The System-Wide Effects of the Global Fund in Ethiopia: Baseline Study Report. The Partners for Health Reformplus, Abt Associates, Inc. Banteyerga H, Kidenu A, & Stillman K. 2006. The System-Wide Effects of the Global Fund in Ethiopia: Final Study Report. The Partners for Health Reformplus, Abt Associates, Inc. Brenzel L and Waddington C. Health System Strengthening (HSS) Support from the GAVI Alliance: Early Experience and Lessons. Gbangbadthore S, Hounsa A & Miller-Franco L. 2006. System-Wide Effects of the Global Fund in Benin: Final Report. Health Sytems 20/20 Project, Abt Associates, Inc. Mtonya B, Mwapasa V & Kadzandira J. 2005. The System-Wide Effects of the Global Fund in Malawi: Baseline Study Report. The Partners for Health Reformplus, Abt Associates, Inc. Mtonya B & Chizimbi, S. 2006. The System-Wide Effects of the Global Fund in Malawi: Final Report. The Partners for Health Reformplus, Abt Associates, Inc. Oomman N, Bernstein M & Rosenzweig S. 2007. Following the Funding for HIV/AIDS: a comparative analysis of funding practices of PEPFAR, the Global Fund and World Bank MAP in Mozambique, Uganda and Zambia. Center for Global Development. Schott W, Stillman K, & Bennett S. 2005. Effects of the Global Fund on reproductive health in Ethiopia and Malawi: baseline findings. The Partners for Health Reformplus, Abt Associates, Inc. Sepulveda J, Carpenter C, Curran J et al 2007. PEPFAR Implementation: Progress and Promise. Institute of Medicine.
It is not a case of either or: we do not have this option it is about making sure that all available resources produce the maximum possible benefits in improving the lives & well-beings of our people. -Dr. Carissa Etienne Assistant Director-General Health Systems & Services World Health Organization Thank you
WHO Positive Synergies Country Selection Develop sampling matrix in consultation with partners: Geographical representation GHI investment as a percentage of total health expenditure High burden of GHI-targeted disease Existing connections with partner institutions