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Is HIV funding strengthening the health system? A quasi-experimental study in Rwanda
Presented by Donald S Shepard (United States).
D.S. Shepard1, P. Amico1, W. Zeng1, A.K. Rwiyereka1, C. Avila-Figueroa2
1Brandeis University, Heller School, Waltham, United States, 2UNAIDS, Geneva, Switzerland
Background: HIV/AIDS has brought new resources and new questions to international public health over the past twenty years. Policy makers are concerned whether the considerable influx of HIV/AIDS funding has undermined the health care system in the recipient country. By examining the inputs and outputs of heath services, this study assesses the impact of HIV/AIDS funding on the primary health care system in Rwanda.
Methods: Using a quasi-experimental design, we randomly selected 26 rural health centers that initiated antiretroviral treatment (ART) services from 2003 through 2006 (intervention group) and matched 1:1 on four factors (e.g., location, district income, ownership, and phase of performance-based financing) with health centers that did not provide ART services (control group). Data on sampled health centers were retrospectively collected from site visits and central records by year from 2003 through 2007. Inputs focused on personnel by types of service (HIV/AIDS or non-HIV/AIDS), while outputs included non-HIV/AIDS services such as vaccinations, curative care, hospitalizations, in-center deliveries, and child growth monitoring. We conducted a difference-in-difference analysis controlling relevant variables with a random-effects model.
Results: Compared with the control group, the intervention group had 2.7 (p< 0.05) fewer staff working on non-HIV/AIDS services after ART services started, but had 3.3 (p< 0.05) more on HIV/AIDS services. Nevertheless, most non-HIV services (7 out of 9) improved more in the intervention group than the control group; one of these improvements reached or approached statistical significance. That service, tuberculosis (BCG) vaccination, grew by 10.5% after AIDS funding was introduced (p< 0.10). No non-HIV service experienced a significant reduction after HIV/AIDS programs started.
Conclusions: Although fewer medical personnel worked on non-HIV/AIDS services in health centers with ART services compared to those without these services, HIV/AIDS services did not undermine the delivery of non-HIV/AIDS services. Instead, we found favorable trends towards enhanced outputs for several non-HIV/AIDS services.
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