HIV This Week

The effects of global health initiatives on country health systems: a review of the evidence from HIV/AIDS control.

Biesma RG, Brugha R, Harmer A, Walsh A, Spicer N, Walt G. Health Policy Plan. 2009; 24:239-52.

This paper reviews country-level evidence about the impact of global health initiatives, which have had profound effects on recipient country health systems in middle- and low- income countries. Biesma and colleagues have selected three initiatives that account for an estimated two-thirds of external funding earmarked for HIV control in resource-poor countries: the Global Fund to Fight AIDS, TB and Malaria, the World Bank Multi-country AIDS Program (MAP) and the US President’s Emergency Plan for AIDS Relief (PEPFAR). This paper draws on 31 original country-specific and cross-country articles and reports, based on country-level fieldwork conducted between 2002 and 2007. Positive effects have included a rapid scale-up in HIV service delivery, greater stakeholder participation, and channelling of funds to non-governmental stakeholders, mainly NGOs and faith-based bodies. Negative effects include distortion of recipient countries’ national policies, notably through distracting governments from coordinated efforts to strengthen health systems and re-verticalization of planning, management and monitoringand evaluation systems. Sub-national and district studies are needed to assess the degree to which global health initiatives are learning to align with and build the capacities of countries to respond to HIV; whether marginalized populations access and benefit from global health initiatives-funded programmes; and about the cost-effectiveness and long-term sustainability of the HIV programmes funded by the global health initiatives. Three multi-country sets of evaluations, which will be reporting in 2009, will answer some of these questions.

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Editor’s note: Global health initiatives are defined as ‘ a blueprint for financing, resourcing, coordinating and/or implementing disease control across at least several countries in more than one region of the world’. They may be bilateral (e.g. US PEPFAR), multilateral (e.g. World Bank MAP), or public-private partnerships (Global Fund) aid mechanisms. This first systematic review of published and unpublished reports from 2002 to 2007 examines the effects of these three initiatives on national policy; coordination and planning; stakeholder involvement; disbursement, absorptive capacity, and management; monitoring and evaluation; and human resources. It suggests that these initiatives, each with different effects, initially often had negative effects, revealing country system weaknesses. As lessons were learned, the effects on health systems were more positive. The principal recommendations of this review are first, that global health initiatives, recipient donor countries, civil society organisations, and technical agencies alike should engage more fully with the Paris Principles for AIDS Effectiveness. Secondly, country and global policy makers and donors should demand and fund the acquisition of better evidence, including more analytical health policy and health systems evaluation. This article should be very high on your reading list!

Sanjana P, Torpey K, Schwarzwalder A, Simumba C, Kasonde P, Nyirenda L, Kapanda P, Kakungu-Simpungwe M, Kabaso M, Thompson C. Hum Resour Health. 2009 ;7:44.

The human resource shortage in Zambia is placing a heavy burden on the few health care workers available at health facilities. The Zambia Prevention, Care and Treatment Partnership began training and placing community volunteers as lay counsellors in order to complement the efforts of the health care workers in providing HIV counselling and testing services. These volunteers are trained using the standard national counselling and testing curriculum. This study was conducted to review the effectiveness of lay counsellors in addressing staff shortages and the provision of HIV counselling and testing services. Quantitative and qualitative data were collected by means of semistructured interviews from all active lay counsellors in each of the facilities and a facility manager or counselling supervisor overseeing counselling and testing services and clients. At each of the 10 selected facilities, all counselling and testing record books for the month of May 2007 were examined and any recordkeeping errors were tallied by cadre. Qualitative data were collected through focus group discussions with health care workers at each facility. Lay counsellors provide counselling and testing services of quality and relieve the workload of overstretched health care workers. Facility managers recognize and appreciate the services provided by lay counsellors. Lay counsellors provide up to 70% of counselling and testing services at health facilities. The data review revealed lower error rates for lay counsellors, compared to health care workers, in completing the counselling and testing registers. Community volunteers, with approved training and ongoing supervision, can play a major role at health facilities to provide counselling and testing services of quality, and relieve the burden on already overstretched health care workers.

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Editors’ note: Zambia is more than an order-of-magnitude (10 times) below the recommended staff-to-population ratios for nurses (1:700 versus 1:8064) and pharmacists (1:8000 versus 1:473,000), spurring it on to find solutions to this health care bottleneck. A two-week classroom component followed by a four-week supervised practicum and training in finger-prick HIV testing has created a cadre of lay counsellors providing quality services to satisfied clients. Some lay counsellors view reducing stigma and representing community role models as additional responsibilities. The fact that this is a voluntary programme (lay counsellors receive 25USD per month to defray travel costs but no other compensation) may jeopardise its sustainability. Continued supervision of the work of these lay counsellors, along with formalisation of their relationship with health facilities, could enhance both performance and retention.