Critical interactions between Global Fund-supported programmes and health systems: a case study in Indonesia

The Global Fund to Fight AIDS, Tuberculosis and Malaria has played an important role in financing the response to HIV/AIDS and tuberculosis (TB) in Indonesia. As part of a series of case studies, we assessed the nature and extent of integration of Global Fund portfolios into the national HIV and TB programmes, integration of the HIV and TB programmes within the general health system, and system-wide effects of Global Fund support on the health care system in Indonesia. The study relied on a literature review and interviews with 22 key informants using the Systemic Rapid Assessment Toolkit and thematic analysis. Global Fund programmes in Indonesia are highly vertical and centralized, in contrast with the decentralized nature of the Indonesian health system. Consequently, there is more integration of all functions at local levels than centrally. There is a high level of integration of planning of Global Fund HIV and TB portfolios into the National AIDS and TB programmes and some limited integration of these programmes with other disease programmes, through joint working groups. Other synergies include strengthening of stewardship and governance and increased staff recruitment encouraged by incentive payments and training. Monitoring and evaluation functions of the Global Fund programmes are not integrated with the disease programmes, with parallel indicators and reporting systems. System-wide effects include greater awareness of governance and stewardship in response to the temporary suspension of Global Fund funding in 2008, and increased awareness of the need to integrate programme planning, financing and service delivery. Global Fund investment has freed up resources for other programmes, particularly at local levels. However, this may hinder a robust exit strategy from Global Fund funding. Furthermore, Global Fund monetary incentives may result in staff shifting into HIV and TB programmes.     

Critical interactions between Global Fund-supported programmes and health systems: a case study in Papua New Guinea

In Papua New Guinea, investment by the Global Fund to Fight AIDS, Tuberculosis and Malaria (the Global Fund) has played an important role in scaling up the response to HIV and tuberculosis (TB). As part of a series of case studies on how Global Fund-supported programmes interact with national health systems, we assessed the nature and extent of integration of the Global Fund portfolios within the national HIV and TB programmes, the integration of the HIV and TB programmes within the general health system, and system-wide effects of Global Fund support in Papua New Guinea. The study relied on a literature review and 30 interviews with key stakeholders using the Systemic Rapid Assessment Toolkit and thematic analysis. Global Fund-supported activities were found to be largely integrated, or at least coordinated, with the national HIV and TB programmes. However, this has reinforced the vertical nature of these programmes with respect to the general health system, with parallel systems established to meet the demands of programme scale-up and the performance-based nature of Global Fund investment in the weak health system context of Papua New Guinea. The more parallel functions include monitoring and evaluation, and procurement and supply chain systems, while human resources and infrastructure for service delivery are increasingly integrated at more local levels. Positive synergies of Global Fund support include engagement of civil-society partners, and a reliable supply of high-quality drugs which may have increased patient confidence in the health system. However, the severely limited and overburdened pool of human resources has been skewed towards the three diseases, both at management and service delivery levels. There is also concern surrounding the sustainability of the disease programmes, given their dependence on donors. Increasing Global Fund attention towards health system strengthening was viewed positively, but should acknowledge that system changes are slow, difficult to measure and require long-term support.     

Critical interactions between Global Fund-supported programmes and health systems: a case study in Lao People's Democratic Republic

In Lao PDR, investment by the Global Fund to Fight AIDS, Tuberculosis and Malaria has played an important role in scaling up the response to HIV and tuberculosis (TB). As part of a series of case studies on how Global Fund-supported programmes interact with national health systems, we assessed the nature and extent of integration of the Global Fund portfolios within the national HIV and TB programmes, the integration of the HIV and TB programmes within the general health system, and system-wide effects of Global Fund support in Lao PDR. The study relied on a literature review and 35 interviews with key stakeholders using the Systemic Rapid Assessment Toolkit and thematic analysis. In Lao PDR, the HIV and TB programmes remain vertical and mostly weakly integrated with the general health system. However, Global Fund investments have extended the network of facilities delivering care at local level, resulting in greater integration with primary care and improved access for patients, particularly for TB. For HIV, as the prevalence remains low, services primarily target high-risk groups in urban areas. Less integrated functions include procurement and drug supply, and monitoring and evaluation. HIV and TB programmes are only starting to coordinate with each other. Global Fund-supported activities are generally integrated within the national disease programmes, except for monitoring and evaluation. Synergies of Global Fund support with the health system include improved access to services, institutional strengthening and capacity building, improved family planning (with wider condom distribution through HIV/AIDS social marketing programmes), and the delivery of add-on interventions, such as vaccinations and health education, alongside Global Fund-supported interventions at community level. Unintended consequences concern the lack of alignment between national stated priorities (maternal and child health) and the strong focus of external partners, such as the Global Fund, on financing communicable disease programmes.     

Global Fund-supported programmes contribution to international targets and the Millennium Development Goals: an initial analysis

Objective

The Global Fund to Fight AIDS, Tuberculosis and Malaria is one of the largest funders to fight these diseases. This paper discusses the programmatic contribution of Global Fund-supported programmes towards achieving international targets and Millennium Development Goals, using data from Global Fund grants.

Methodology

Results until June 2006 of 333 grants supported by the Global Fund in 127 countries were aggregated and compared against international targets for HIV/AIDS, tuberculosis and malaria. Progress reports to the Global Fund secretariat were used as a basis to calculate results. Service delivery indicators for antiretrovirals (ARV) for HIV/AIDS, case detection under the DOTS strategy for tuberculosis (DOTS) and insecticide-treated nets (ITNs) for malaria prevention were selected to estimate programmatic contributions to international targets for the three diseases. Targets of Global Fund-supported programmes were projected based on proposals for Rounds 1 to 4 and compared to international targets for 2009.

Findings

Results for Global Fund-supported programmes total 544 000 people on ARV, 1.4 million on DOTS and 11.3 million for ITNs by June 2006. Global Fund-supported programmes contributed 18% of international ARV targets, 29% of DOTS targets and 9% of ITNs in sub-Saharan Africa by mid-2006. Existing Global Fund-supported programmes have agreed targets that are projected to account for 19% of the international target for ARV delivery expected for 2009, 28% of the international target for DOTS and 84% of ITN targets in sub-Saharan Africa.

Conclusion

Global Fund-supported programmes have already contributed substantially to international targets by mid-2006, but there is a still significant gap. Considerably greater financial support is needed, particularly for HIV, in order to achieve international targets for 2009.     

Critical issues in the development of health information systems in supporting environmental health: a case study of ciguatera

Background

Emerging environmental pressures resulting from climate change and globalization challenge the capacity of health information systems (HIS) in the Pacific to inform future policy and public health interventions. Ciguatera, a globally common marine food-borne illness, is used here to illustrate specific HIS challenges in the Pacific and how these might be overcome proactively to meet the changing surveillance needs resulting from environmental change.

Objectives

We review and highlight inefficiencies in the reactive nature of existing HIS in the Pacific to collect, collate, and communicate ciguatera fish poisoning data currently used to inform public health intervention. Further, we review the capacity of existing HIS to respond to new data needs associated with shifts in ciguatera disease burden likely to result from coral reef habitat disruption.

Discussion

Improved knowledge on the ecological drivers of ciguatera prevalence at local and regional levels is needed, combined with enhanced surveillance techniques and data management systems, to capture environmental drivers as well as health outcomes data.

Conclusions

The capacity of public HIS to detect and prevent future outbreaks is largely dependent on the future development of governance strategies that promote proactive surveillance and health action. Accordingly, we present an innovative framework from which to stimulate scientific debate on how this might be achieved by using existing larger scale data sets and multidisciplinary collaborations.     

Measuring operational efficiency in a health care system: a case study from Thailand

This paper investigates the economic relationship among medical resources and efficiency of the health care system in a developing Asian country. The rapid growth in the use of limited resources and the escalating national health expenditure, raise the critical economic question of whether the use of health care resources are efficient. We estimated a four-factor production system, based on 1982-1997 annual operational data comprising five cross-sectional regions per year. The translog production function and three derived demand for factor input equations were jointly estimated using systems regression method. Results show that different types of medical care workers (doctors, nurses, pharmacists) influenced efficiency differently. The marginal products (MPs) of nurses and capital are the highest and they varied across the regions. Third, the estimates of factor substitution possibilities indicate difficult factor adjustments; these estimates differ in magnitudes and significance across regions but they similarly classify all but one (different) input pair as economic substitutes. Fourth, the regional variations in returns to scale estimates in live births tend to converge to that of the Bangkok metropolis. Finally, technical change is physician and pharmacist labor using, but capital and nursing labor saving. Policy implications of these findings touch on Article 78 of the Thailand Constitution.     

National health services and family planning: Thailand, a case study.

The family planning program of Thailand was organized, planned, and implemented by means of the rural health and hospital services of the Ministry of Public Health. Without this integration, the program would not have been allowed by the government. The Thai health system was reasonably well-established, the use of its personnel lessened cost and duplication of efforts, and the resulting integration was successful. The program operated very quietly between 1968 and 1970. No public information was allowed. There were no full-time family planning workers, and no goals and incentives were offered. Only in 1970 when the government announced a national population policy were the restrictions on public information removed. In the development of the program, more than 7600 employees of the Ministry of Public Health received the 1-week training program. After training, family planning clinics were opened in the provincial hospitals and in those rural health centers staffed with a physician. Initially, the auxiliary midwives were expected only to motivate and provide information to those in their areas, referring interested couples to the centers and hospitals for the IUDs, oral contraceptives, and sterilization programs that were available. However, after the successful completion of a pilot study in 1970, the midwives were permitted to prescribe the oral contraceptive. A postpartum program which attempted to motivate women in the use of family planning 2-4 days following delivery revealed that with proper motivation efforts a majority of women will accept family planning services postpartum. A special evaluation section was developed within the Ministry to assess the progress of the program. Many problems continue to require attention, such as the need for high level government support shown by a budget increase and the development of effective supervision for staff within the health system.     

Integration of health systems and priority health interventions: a case study of the integration of HIV and TB control programmes into the general health system in Vietnam

This case study on Vietnam aims to generate empirical evidence on the relative merits of integration of two priority health interventions, HIV/AIDS and tuberculosis (TB), into six functions of the wider health system: stewardship and governance, service delivery, demand generation, monitoring and evaluation, planning, and financing. Selective documentary reviews and 25 qualitative, semi-structured interviews were conducted in early 2009 in Hanoi, Hai Duong province, Chih Linh district and Hoang Tien commune with informants from international, national and sub-national agencies steering or managing the HIV/AIDS and TB programmes and from health facilities providing HIV/AIDS and TB services. Data collected were collated and evaluated against 25 elements of integration. Each element of integration was ultimately classified as being 'fully/predominantly integrated', 'partially integrated', 'not or predominantly not integrated'. The results showed that none of the six programme functions was fully integrated into the general health care system as a whole. They were established either in parallel, notably at higher administrative levels, or were partially integrated. The study findings also revealed that little integration across all functional levels has occurred between the two programmes. Generally international agencies and sub-national domestic stakeholders supported more integration between vertical programmes (HIV and TB) and the general health systems, while national bodies responsible for HIV and TB favoured reinforcing a more vertical and thus less integrated approach. In the absence of shared assumptions and goals, this polarization of views may result in sub-optimal effectiveness and efficiency of each of the disease programmes as well as of HIV/TB interventions.     

District health programmes and health-sector reform: case study in the Lao People's Democratic Republic

The Lao People's Democratic Republic (Lao PDR) is classified by the World Bank as a low-income country under stress. Development partners have sought to utilize effective aid instruments to help countries classified in this way achieve the Millennium Development Goals; these aid instruments include sector-wide approaches (SWAps) that support decentralized district health systems and seek to avoid fragmentation and duplication. In Asia and the Pacific, only Bangladesh, Papua New Guinea and the Solomon Islands have adopted SWAps. Since 1991, a comprehensive primary health care programme in the remote Sayaboury Province of Lao PDR has focused on strengthening district health management, improving access to health facilities and responding to the most common causes of mortality and morbidity among women and children. Between 1996 and 2003, health-facility utilization tripled, and the proportion of households that have access to a facility increased to 92% compared with only 61% nationally. By 2003, infant and child mortality rates were less than one-third of the national rates. The maternal mortality ratio decreased by 50% despite comprehensive emergency obstetric care not being available in most district hospitals. These trends were achieved with an investment of approximately 4 million US dollars over 12 years (equivalent to US 1.00 US dollars per person per year). However, this project did not overcome weaknesses in some national disease-control programmes, especially the expanded programme on immunization, that require strong central management. In Lao PDR, which is not yet committed to using SWAps, tools developed in Sayaboury could help other district health offices assume greater planning responsibilities in the recently decentralized system. Development partners should balance their support for centrally managed disease-specific programmes with assistance to horizontally integrated primary health care at the district level.     

Biomass power plants and health problems among nearby residents: A case study in Thailand

Objectives

Electricity generation from biomass has become a boom business. However, currently, concerns over their environmental and health impact have emerged. This study aimed to explore these health problems by studying two small biomass power plants in Thailand.

Materials and Methods

Data concerning chronic diseases and health symptoms was collected from 392 people by trained interviewers by the use of a questionnaire.

Results

Residents living within 1 km from the power plants had a higher prevalence of allergies (Odds ratio = 2.4, 95% CI: 1.5–4.0), asthma (OR = 2.1, 95% CI: 1.0–4.4) and chronic obstructive pulmonary disease (COPD) (OR = 2.7, 95% CI: 1.0–8.4). The risks of other symptoms, itching/rash, eye irritation, cough, stuffy nose, allergic symptoms, sore throat, and difficulty breathing among those living within 0.5 km from the power plants (OR = 2.5–8.5) were even more marked.

Conclusions

It has been concluded that without a proper control, pollution from the biomass power plants can cause significant health problems to the nearby residents.     

International service trade and its implications for human resources for health: a case study of Thailand

This study aims at analysing the impact of international service trade on the health care system, particularly in terms of human resources for health (HRH), using Thailand as a case study. Information was gathered through a literature review and interviews of relevant experts, as well as a brainstorming session.     

Building primary health care systems: a case study from Sweden.

Health policy planners have discussed for some years how to transform existing hospital-based health delivery systems into primary-care-driven systems. Although this policy goal has been adopted in a number of western European nations, the actual process of implementing such a major change has proven stubborn and complex. In particular, efforts to transfer existing resources out of the hospital sector for use in building primary care activities have proven difficult. This paper examines the effort to design and implement a primary health care strategy in Sweden. It is divided into two segments. The first section sketches the broad health system context within which the Swedish primary care effort is being conducted. The second section focuses directly on Sweden's primary care strategy, detailing both its conceptual foundation and the organizational obstacles that have impeded the policy's implementation. This discussion is punctuated with findings from a 1981 survey of county council administrators' attitudes toward this primary care strategy. The paper concludes with a short discussion of several alternative organizational approaches that might speed the development of a primary-care-driven health system.     

Responding to health changes: a case study of dental health conditions and systems in Japan and Australia

This paper presents an analysis of the mail policy and organisational issues confronting dental health systems in Japan and Australia. Using the changes in the epidemiology of dental disease (the oral disease which still affects much of public dental health planning) as evidence of fundamental differences in the dental health systems of the two countries, the analysis seeks to illuminate, first, the structures and processes in both nations to review and implement changes to educational practices and workforce planning and, second, the constraints on each nation's capability to respond quickly and appropriately to the changing dental health needs. It is argued that Japan's ability to rapidly change its oral health outcomes, its dental educational system and its traditional workforce structure and service-mix, is more constrained than appears to be the case in the Australian dental system. The major barriers to Japan's ability to change appear to lie in both its traditional cultural decision-making processes and in a series of specific health and educational structures which place high reliance on a private educational system for health providers, a national insurance system which rewards treatment under a fee-for-service reimbursement scheme and the lack of a formal, transparent, infra-structure for planning health priorities. Barriers to Australia achieving culturally appropriate oral health outcomes for the next century appear more related to whether national unity in goal setting and implementation strategies can be achieved. The constraints in Australia are related to its federal system and to the low priority given to financing public dental services.     

Influenza in Thailand: a case study for middle income countries

Recent studies in Hong Kong and Singapore suggest that the annual impact of influenza in these wealthy tropical cities may be substantial, but little is known about the burden in middle-income tropical countries. We reviewed the status of influenza surveillance, vaccination, research, and policy in Thailand as of January 2004. From 1993 to 2002, 64-91 cases of clinically diagnosed influenza were reported per 100,000 persons per year. Influenza viruses were isolated in 34% of 4305 specimens submitted to the national influenza laboratory. Vaccine distribution figures suggest that less than 1% of the population is immunized against influenza each year. In January 2004, Thailand reported its first documented outbreak of influenza A H5N1 infection in poultry and the country's first human cases of avian influenza. Thailand's growing economy, well-developed public health infrastructure, and effective national immunization program could enable the country to take more active steps towards influenza control.     

Influenza in Thailand: a case study for middle income countries

Recent studies in Hong Kong and Singapore suggest that the annual impact of influenza in these wealthy tropical cities may be substantial, but little is known about the burden in middle-income tropical countries. We reviewed the status of influenza surveillance, vaccination, research, and policy in Thailand as of January 2004. From 1993 to 2002, 64–91 cases of clinically diagnosed influenza were reported per 100,000 persons per year. Influenza viruses were isolated in 34% of 4305 specimens submitted to the national influenza laboratory. Vaccine distribution figures suggest that less than 1% of the population is immunized against influenza each year. In January 2004, Thailand reported its first documented outbreak of influenza A H5N1 infection in poultry and the country’s first human cases of avian influenza. Thailand’s growing economy, well-developed public health infrastructure, and effective national immunization program could enable the country to take more active steps towards influenza control.     

Integrated dementia care in The Netherlands: a multiple case study of case management programmes

The number of dementia patients is growing, and they require a variety of services, making integrated care essential for the ability to continue living in the community. Many healthcare systems in developed countries are exploring new approaches for delivering health and social care. The purpose of this study was to describe and analyse a new approach in extensive case management programmes concerned with long‐term dementia care in The Netherlands. The focus is on the characteristics, and success and failure factors of these programmes. A multiple case study was conducted in eight regional dementia care provider networks in The Netherlands. Based on a literature study, a questionnaire was developed for the responsible managers and case managers of the eight case management programmes. During 16 semistructured face‐to‐face interviews with both respondent groups, a deeper insight into the dementia care programmes was provided. Project documentation for all the cases was studied. The eight programmes were developed independently to improve the quality and continuity of long‐term dementia care. The programmes show overlap in terms of their vision, tasks of case managers, case management process and the participating partners in the local dementia care networks. Differences concern the targeted dementia patient groups as well as the background of the case managers and their position in the local dementia care provider network. Factors for success concern the expert knowledge of case managers, investment in a strong provider network and coherent conditions for effective inter‐organizational cooperation to deliver integrated care. When explored, caregiver and patient satisfaction was high. Further research into the effects on client outcomes, service use and costs is recommended in order to further analyse the impact of this approach in long‐term care. To facilitate implementation, with a focus on joint responsibilities of the involved care providers, policy recommendations are to develop incentives for collaborative financial contracts between insurers and providers.     

Regional health systems management: a case study in Rio Grande do Sul, Brazil

This article analyzes the management system in a health district in the State of Rio Grande do Sul, Brazil, through qualitative analysis, using a case study as the methodology and macro-organization theory as the analytical framework. For the current management system in the 6th Health Region, a clear mission statement and wide acceptance by health workers are facilitating factors for the current organizational practices within the health system. Nevertheless, the way health coordinators are currently prioritizing their time has diverted necessary resources from critical problems towards more remedial issues. The 6th Health Region has encouraged social control (or public oversight) in order to improve accountability. However, there is room for improvement in quality assurance management, since there were no well-defined goals, objectives, or accountability. Decentralized consultancy provided to the municipalities and the funding model itself have both promoted decentralization and autonomy, although the strategy requires better regional integration and greater commitment in managerial practices.