Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine ß The Author 2010; all rights reserved. Health Policy and Planning 2010;25:i53 i57 doi:10.1093/heapol/czq059 Critical interactions between Global Fund-supported programmes and health systems: a case study in Thailand Piya Hanvoravongchai, 1 * Busaba Warakamin 2 and Richard Coker 1 1 Communicable Diseases Policy Research Group, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, Bangkok, Thailand and 2 National AIDS Management Center, Department of Disease Control, Ministry of Public Health, Thailand *Corresponding author. Communicable Diseases Policy Research Group, London School of Hygiene and Tropical Medicine, 9th Floor, Anek Prasong Building, Mahidol University, 420/6 Rajvithi Road, Bangkok 10400, Thailand. E-mail: Piya.Hanvoravongchai@lshtm.ac.uk Accepted 23 September 2010 As part of a series of case studies on the interactions between programmes supported by the Global Fund to Fight AIDS, Tuberculosis and Malaria and health systems, we assessed the extent of integration of national HIV, tuberculosis (TB) and malaria programmes with the general health system, the integration of the Global Fund-portfolios within the national disease programmes, and system-wide effects on the health system in Thailand. The study relied on a literature review and 34 interviews with key stakeholders using the Systemic Rapid Assessment Toolkit and thematic analysis. In Thailand, the HIV, TB and malaria programmes structures and functions are well established in the general health care system, with the Department for Disease Control and the Ministry of Public Health s network of health providers at sub-national levels as the main responsible organizations for stewardship and governance, service delivery, monitoring and evaluation, planning, and to some extent, demand generation. Civil society groups are active in certain areas, particularly in demand generation for HIV/AIDS. Overall, the Global Fund-supported programmes were almost fully integrated and coordinated with the general health system. The extent of integration varied across disease portfolios because of different number of actors and the nature of programme activities. There were also specific requirements by Global Fund that limit integration for some health system functions namely financing and monitoring and evaluation. From the view of stakeholders in Thailand, the Global Fund has contributed significantly to the three diseases, particularly HIV/AIDS. Financial support from the early Global Fund rounds was particularly helpful to the disease programmes during the time of major structural change in the MoPH. It also promoted collaborative networks of stakeholders, especially civil societies. However, the impacts on the overall health system, which is relatively well developed, are seen as minimal. One major contribution is the establishment of a health service system for neglected population groups. No specific negative impacts on the health system were raised. Keywords Thailand, Global Fund, integration, health system, strengthening i53
i54 HEALTH POLICY AND PLANNING KEY MESSAGES Thailand has a relatively well developed health system with the HIV, tuberculosis and malaria programmes structures and functions well established in the general health care system. The Global Fund-supported programmes were almost fully integrated and coordinated with the general health system. The Global Fund has contributed to the three disease programmes but the impacts on the overall health system are seen as minimal with no specific negative impacts. Background Thailand is a lower-middle-income country in South East Asia with a population of over 60 million. The country has experienced significant improvement in population health, as shown in declining child and maternal mortality and increasing life expectancy over the past few decades similar to other middle-income developing countries in the region. Despite previous success in HIV/AIDS prevention in the late 1990s, the disease is still one of the top causes of disease burden and mortality. Apart from HIV/AIDS, mortality and morbidity rates from most other communicable diseases have been in decline over the past few decades (Wibulpolprasert 2008). Malaria incidence and mortality have declined from 6.8 and 2.7 in 1988 to 0.48 and 0.3 in 2006, respectively. The exceptions are tuberculosis (TB) and dengue fever, the mortality and incidence of which have not reduced much. The country s health system is relatively well developed with an extensive network of health care providers and wellestablished systems of financing and governance and stewardship. The Ministry of Public Health (MoPH) is the main actor in the health system, particularly in health system planning and management with administrative functions deconcentrated to its network of provincial and district health offices. At the local level, the MoPH s health facility network includes hospitals and health centres, which are under the Permanent Secretary s supervision. Total health spending accounted for about 3.5% of GDP, relatively low compared with other countries in the region (Wibulpolprasert 2008). Almost two-thirds of this (64%) came from the public sector where health spending shared 11.3% of total government expenditure. The majority of public funds were channelled through the MoPH and three major health insurance schemes. External funding for health is small but the country also received support from the Global Fund to Fight AIDS, Tuberculosis and Malaria (the Global Fund) for all the three disease programmes under several rounds of funding at an approved maximum of more than US$266 million or US$4.4 as a cumulative per capita investment (Table 1). The findings from how Thailand integrates its Global Fund-supported activities into its relatively well developed health system could be an interesting experience for other low and lower-middle income countries. Methods The study design was based on that described for a Vietnam case study in Conseil et al. (2010), with the analytical framework and toolkit extended to assess not only the integration of the national HIV, TB and malaria programmes with the general health system, but also the integration of Global Fund HIV, TB and malaria portfolios within their respective disease programmes, and any system-wide effects of Global Fund support. As in Conseil et al. (2010), data were collected through a literature review and the use of the Systemic Rapid Assessment Toolkit (SYSRA) for gathering information about structures and modes of operation of complex health systems (Atun et al. 2004; Atun et al. 2010). Primary data were collected through qualitative interviews using a semi-structured interview topic guide designed as part of the SYSRA, conducted from August to October 2009. Overall, 34 interviews were conducted with government health officials, partners and civil society actors at national, regional and district levels, both within the disease programmes and in the general health care system. All of the interviewees at regional or lower levels were from a province in the northern region of the country. Full details of data analysis can be found in Conseil et al. (2010). Briefly, the six health system functions proposed by the SYSRA framework (stewardship and governance, financing, planning, service delivery, monitoring and evaluation, and demand generation) were subdivided into 25 elements (as defined in Table 2), for which we classified the level of integration as not integrated, partly integrated or fully integrated, through iterative analysis and triangulation of the collected data. Classification of the level of integration was agreed upon by two staff of the London School of Hygiene & Tropical Medicine, one of whom was also an assessor across three other case studies presented in this supplement, to ensure consistency. Results and discussion Integration Overall, the Global Fund-supported programmes are partially integrated in the general health system. The extent of integration varies by the diseases because of different number of actors and the nature of programme activities. There are also specific requirements by the Global Fund that limit the level of integration for some health system functions, namely financing and monitoring and evaluation (M&E). A schematic presentation of the integration of Global Fund portfolios into the disease programmes is provided in Table 2, with more details by disease below. The Global Fund-supported TB programmes are mostly integrated in the TB national programme, given that the former is addressing the gaps in the national plan not already covered by the latter. The Bureau of TB Control, the national agency for TB control, was also the main contributor to
GLOBAL FUND PROGRAMMES IN THAILAND i55 Table 1 Summary of approved Global Fund proposals in US$, Thailand Intervention Global Fund Round and time period Funding requested Total approved funding Amount disbursed till Nov 2009 HIV/AIDS Rd 1: 1 Oct 03 to 30 Sep 14 104 864 001 109 353 700 RCC 98 309 153 37 413 128 Total 203 173 154 146 766 828 109 944 308 Rd 2: 1 Oct 03 to 31 May 09 30 156 771 30 156 771 28 079 213 Rd 3: 1 Oct 04 to 30 Sep 07 1 236 108 1 236 108 1 236 108 Rd 8: 2009 to 2015 100 127 462 32 258 521 11 457 466 Total 334 693 495 210 418 228 150 717 095 Malaria Rd 2: 1 Mar 04 to 28 Feb 09 5 282 000 5 282 000 5 282 000 Rd 7: 1 Jul 08 to 30 Jun 10 24 689 670 11 939 346 10 889 633 Total 29 971 670 17 221 346 16 171 633 Tuberculosis Rd 1: 1 Oct 03 to 30 Sep 08 12 058 359 12 058 359 10 834 003 Rd 6: 1 Oct 07 to 31 Dec 09 16 995 947 16 995 947 7 993 314 Rd 8: 1 Aug 09 to 30 Jun 11 28 366 881 10 240 102 3 655 220 Total 57 421 187 39 294 408 22 482 537 Grand total 422 086 352 266 933 982 189 371 265 previous Global Fund TB proposals so the activities supported by the Global Fund are fully integrated in the general health system. There is, however, an expansion of TB services to the non-health sector such as the provision of demand-generation activities in the workplace (e.g. factories and offices) which is carried out by NGOs with support from the Ministry of Labour and MoPH. Additionally, due to specific requirements from the Global Fund on financing and M&E procedures, these two functions are considered as partially integrated with the national disease programme. Similar to TB, the Global Fund supported malaria programme is mostly integrated in the national malaria programme. The financing and M&E functions are not fully integrated because specific procedures and processes are required by the Global Fund. However, because there are no active actors/ providers such as NGOs working on malaria, the demand generation function for malaria is also fully integrated in the general health system. The M&E and the financing function are coordinated with the national malaria programme. The creation of new village malaria posts under the Global Fund Round 1 grant can be considered as an extension of the existing system to provide demand-generation services in endemic communities, and hence fully integrated. These posts were planned and are financed, supervised and supported through the apparatuses of the MoPH. For HIV/AIDS, the activities funded by the Global Fund are partially integrated with the HIV/AIDS disease programme for most of the health systems functions. There is also one round of the AIDS programme funded by the Global Fund that has no involvement of the MoPH as principal recipient so the integration of this round s activities is limited. The stewardship and governance function of Global Fund AIDS portfolios are partially integrated with the national programme because the MoPH and its Department for Disease Control play prominent roles in both the National AIDS Committee as well as the Global Fund Country Coordinating Mechanism (CCM). Similar to TB, the financing function is not integrated due to specific Global Fund requirements prohibiting integration. It uses the same structure but a separate accounting system is in place. The payment system is also different in most cases, with specific protocol to follow. In terms of demand generation, this is not fully integrated but coordinated with the national HIV programme. Some specific information, education and communication activities are carried out by NGOs through separate structures, especially for the most at risk target population groups (drug users, commercial sex workers, men who have sex with men, and illegal migrants). Planning is fully integrated because the Global Fund-supported activities are mainly to address the gaps in the national AIDS plan not being met by existing health system actions. Service delivery also relies mainly on the existing human resources and service provision system. The M&E activities are not integrated but are under a process to harmonize the Global Fund portfolio s M&E requirements into the national M&E system for HIV/AIDS, as supported by the Global Fund Round 8 proposal. In addition to the integration of Global Fund portfolios into disease programmes, this study also assessed the integration of the disease programmes into the overall health system (Table 2). It shows that existing HIV, TB and malaria programmes structures and their functions are predominantly well established in the general health care system. The MoPH, particularly the Department for Disease Control, and its network of health providers in the sub-national levels are the main responsible organizations for stewardship and governance, service delivery, M&E, planning, and to a certain extent, demand generation. Financing for the three diseases is integrated in the routine government budgetary system or supported by the national health insurance systems. Only the demand generation function of the HIV programme is not fully integrated. Separate structures were established, mainly by the civil society groups, to provide information, education and communication to specific populations such as most-at-risk
i56 HEALTH POLICY AND PLANNING Table 2 Extent of integration of Global Fund portfolios into the disease programmes, and the disease programmes into the general health system, for each health system element and function in Thailand Global Fund portfolio into the disease programme Disease programme into the health system Health system functions Elements of integration HIV TB Malaria HIV TB Malaria Stewardship and governance 1: Regulatory mechanisms Service delivery 2: Accountability framework Demand generation Monitoring and evaluation Planning Financing 3: Human resources for counselling and testing 4: Human resources for laboratory testing 5: Human resources for care and treatment 6: Human resources for delivery of HIV-positive mothers 7: Physical infrastructure for counselling and testing 8: Physical infrastructure for laboratory testing 9: Physical infrastructure for care and treatment 10: Physical infrastructure for pregnant HIV-positive females 11: Procurement and supply of laboratory equipment 12: Procurement and supply of medicines 13: Care pathways for opportunistic infections 14: Care pathways for preventing mother-to-child transmission (PMTCT) 15: Financial incentives 16: Information, education and communication 17: Data collection and recording 18: Data analysis? 19: Reporting systems 20: Performance management system 21: Planning 22: Fund pooling 23: Provider payment methods 24: Funding source n.a. n.a. n.a. 25: Cross-programme use of funds Key: This element is fully or predominantly integrated into the general health system, i.e. this element is (quasi) exclusively under the management and control of the general health care system. This element is partially integrated into the health system or; this element is integrated in some but not all cases, i.e. this element is managed and controlled both by the general health care system and a specific programme-related structure. This element is not, or only to a very limited extent, integrated into the health system as a whole, i.e. this element is (quasi) exclusively under the management and control of a specific programme-related structure which is distinct from the general healthcare system. n.a. Does not apply.? = unknown; insufficient data collected to inform the researchers on a level of integration.
GLOBAL FUND PROGRAMMES IN THAILAND i57 population groups. Nevertheless, their activities are still coordinated with those of the health systems. System-wide effects From the view of stakeholders, the Global Fund has contributed significantly to responding to the three diseases. The Global Fund support is seen by some as a catalyst for adoption of innovative interventions for the three diseases. One key informant believed that Global Fund projects indirectly drive policy direction through model development of new initiatives on prevention and control for the three diseases in various areas. The financial support from the Global Fund in its early rounds was particularly helpful to the disease programmes during the time of major structural change in the MoPH. It also promoted active collaborative work and long-term networking of related stakeholders, especially civil societies, in the country. At the same time, there were concerns over the extensive data requirements by the Global Fund M&E system, which constitutes an additional burden for staff due to additional workloads. Recent requirements to provide proof of identity of service recipients could also jeopardize the success of some activities for the most-at-risk populations due to privacy concerns. The positive impacts on the overall health system are seen as minimal given the limited share of Global Fund investment in overall health financing. One impact would be its contribution to the establishment of a health service system for neglected population groups such as illegal immigrants and intravenous drug users. There has also been investment in infrastructure, particularly laboratory equipment, which could be helpful to non-global Fund service delivery. M&E is another area that a number of stakeholders mentioned as an improvement for the disease programmes from their experience from Global Fund M&E requirements. The management information systems for the diseases were strengthened given the existing M&E function, particularly for HIV/AIDS, is rather weak. There were also other alleged negative impacts where no clear evidence is available. It was felt by some informants that additional financial incentives provided by the Global Fund programmes may contribute to organizational conflicts or motivation problems among some health workers who are not involved in Global Fund activities. However, there was no proof or study to evaluate the existence or the intensity of such a problem. A few informants also raised their concerns over a potential dependency problem, where NGOs or some government programmes may be reliant on Global Fund monies and will not be able to function sustainably after the end of Global Fund projects when the activities are fully absorbed into routine health-system budgets. Policy implications for the Global Fund Global Fund investment is a small portion of health financing in Thailand. Hence, its impact on the Thai health system is very limited. However, it has major roles in the three diseases although the share of financial contributions may not be large. This is because Global Fund money came at the time when the government s decentralization and health financing reform took place and less money was available to the three programmes at the central level. Thailand s experience with the Global Fund shows that in a relatively well-established system these activities can be integrated effectively. The main limitations to the integration are primarily due to the specific requirements from the Global Fund itself that go beyond existing capacity such as in M&E or accounting procedures. It is therefore in the tradeoff between accountability and operational feasibility that the Global Fund should be concerned. The Global Fund s projects have been seen as very useful in filling the gaps in national policy/strategies in HIV, TB and malaria. The challenge is for stakeholders to take up those activities and necessary funding. Because the Global Fund activities are totally dependent on the proposal submitted and approved by the Global Fund board, it is crucial for the proposal development process to be broadly participatory to ensure that priority issues for the country are addressed first. The tendency to focus on activities that are likely to be approved by the Global Fund technical review panel and the Global Fund Board should be avoided. Acknowledgements We are very grateful to all interviewees who took part in the study, and to the Thailand CCM Secretariat for logistical support. Funding This work was funded by the Global Fund to Fight AIDS, Tuberculosis and Malaria. 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