Track E report by Patty WEBSTER
In a heavily attended session entitled, When Does HIV Funding Strengthen Health Systems? WESY02, panelists and participants discussed mechanisms to sustain funding for health system strengthening and HIV, including providing funders with evidence of how HSS strategies improve outcomes, creating universal national insurance plans, and a highly debatable idea to impose financial transaction taxes to raise more funds. Professor Ruairi Brugha from the Royal College of Surgeons in Ireland and Co-coordinator of the Global HIV/AIDS initiatives Network (GHIN) presented results from a cross-country comparison of how PEPFAR and Global funds in Malawi and Zambia have been spent and whether funding is achieving primary outcomes. Expansion or continuation of donor funds in Malawi may have been tied not only to outcomes but also evidence of increases in clinical staffing and health surveillance, demonstrating one component of health system strengthening. Even as outcomes demonstrated lives saved, funding has been cut from Zambia possibly due to no increases in spending on human resources or health surveillance efforts in the years studied. A possible conclusion was offered that funding is allocated to those governments that demonstrate both effective use of HSS and outcomes. Mary Ann Lansang, Director of Knowledge Management unit at Global Fund offered participants strategies for securing funding from donors including demonstrating understanding of the country’s National health sector strategy and overall burden of disease, creating plans for sustained and effective use of resources across systems, aligning with local health systems, addressing areas that are receiving global attention (ie. health workforce for systems strengthening), addressing MDGs 4/5/6, ensuring plans for ownership at country level, and planning for service delivery to reach wider population (integrated system plans). The Lesotho Minister of Health and Social Welfare, Mpu Ramatlapeng, outlined key achievements in Lesotho, including the introduction of universal health care, the provision of stipends for CHWs, and the strong political will to strengthen systems internally. She cautioned that parallel structures create problems when partners “close shop” and stressed the importance of integrating any partner support into local systems, aligning resources and standardizing guidelines. She noted that HIV had helped to uncovered a very weak national health system. She stressed to funders to fix “nightmare” reporting structures making a call for action now (all talk and no action). She scolded that often half the donor money is going home and not into the systems it is meant to strengthen. She asked for donors and partners to trust the local leaders and empower the people of the countries they work in. Jean-Paul Moatti, Professor of Health Care Economics at the University of Mediterranean, Director of INSERM/IRD and Advisor to Global Fund called for national plans to show how we can integrate services and spread. He urged for universal national insurance plans to defray direct out-of-pocket costs. He noted that while cost-effectiveness should not be used to deny care, it should be used to improve the care currently being provided (do better with what we have). He suggested that if doubling of resources is the only scenario to reach universal access then a financial transaction tax could generate 40 billion (USD) for use. He noted that economists have been arguing for this long before the global financial crisis in order to prevent this current crisis. He also recognized that “it would be miracle to impose this sort of tax”. Moderator Wafaa El-Sadr from ICAP posed several key questions that need to be asked, pertaining to outcomes. She made a call to all to focus around the question, what is it we are trying to achieve. Is it just increasing number of workers? She noted that this is a key process outcome but we also need to rally around an ultimate meaningful outcome. MDGs were noted as key global outcomes but a plea to focus around District-level outcomes and find evidence for what works at the District level was made by participants.
LAPC report by Rachel COHEN
This session focused on a hot topic: whether HIV funding harms or helps health systems strengthening (HSS). Although the evidence is mixed and data are insufficient, the majority of studies show HSS benefits from HIV funding.
Evidence from Malawi and Zambia was presented, with positive impact on human resources for health in Malawi, and negative impact in Zambia, and the Minister of Health of Lesotho, Mphu Ramatlapeng, shared the experience of Lesotho, which has seen numerous HSS benefits from HIV funding. “Once we had funding for AIDS, it opened our eyes to weaknesses in our health system,” she said. “But most donors insisted that funding could not go to human resources, for example.” She called upon donors and partners to avoid parallel structures, build local capacity, and adhere to national guidelines. She highlighted that a key reason why HIV care supported health systems was because in Lesotho HIV services are provided at primary care level using nurses.
Jean-Paul Moatti of ANRS said that although he agreed with Bill Gates and Bill Clinton that we can do better with the money we have, as an econometrician, he warned that cost-effectiveness analyses not be used to deny care, but to improve care. “Even if we do 50% efficiency gains, there is not enough money, and we will not reach universal access,” he said. “Calls for greater efficiency should not be seen as a pretext for retreating on funding.” He then made an impassioned plea for the financial transaction tax, which could generate a minimum of $40 billion per year.
Panelists emphasized that it is time to do away with the false dichotomy between HIV and HSS. “Health systems will be strengthened because HIV is in every part of the health system. It’s not one or the other, it’s both,” said Dr Ramatlapeng.