Positive Synergies and the Health Workforce

Andrew L Ellner M.D., M.Sc.Global Health Delivery Project

Brigham and Women’s HospitalHarvard Medical School

Policy Question

How can global health initiatives and national health systems optimize their interactions to capitalize on positive synergies and minimize negative impacts, thereby achieving their common goal of improving health outcomes?

WHO Positive Synergies Initiative

• WHO-led initiative for G8 Summit, Italy 2009

• 3 consortia: – Academic – Civil society– Implementers

• Fifteen academic partners from Africa, Asia, Europe, and the U.S.

Institute of Tropical Medicine, Antwerp

Kenyatta University

Public Health Foundation of India

Royal College of Surgeons, Ireland

The AIDS Support Organization (TASO)

University of Pretoria

University of the Western Cape

University of Yaoundé

Imperial College, London

Heartfile, Pakistan

George Washington University

Dakar University Teaching Hospital

Center for Global Development

Agence Nationale de Recherche sur le Sida

Harvard University

Academic Consortium

WHO Health Systems Building Blocks

Adapted from: WHO six building blocks and RA Atun et al, 2006

Health Outcomes

Fairness of Financing

Responsiveness

GHI investment

Health workforce

Governance

Monitoring and Evaluation

Health Technologies

D

E

L

I

V

E

R

Y

Privateexpenditure

Governmentexpenditure

Financing

Other externalexpenditure

Epidemiological

PoliticalDemographic

Environmental

Technological

Social

Economic

Legal

Communities/Civil Society

Conceptual Framework

Pathways to Impact

Health Outcomes

Fairness of Financing

Responsiveness

GHI investment

Health workforce

Governance

M & E

Technologies

D

E

L

I

V

E

R

Y

Privateexpenditure

Governmentexpenditure

Financing

Other externalexpenditure CSO/Communities

Country-level mixed methods analysis

Cross-country quantitative analysis

Provider-unit level analysis

Levels of Analysis

Identify relationships

Understand relationships

Understand the impact

WHO Positive SynergiesResearch Questions

How do GHI-funded programmes interact with health systems in varied country contexts?

WHO Positive SynergiesMethods

InstitutionsNational AIDS Control Council

WHOPEPFAR

Global Fund for AIDS, Malaria, and Tuberculosis

USAIDCDC

UNAIDSAAR Private Healthcare

National NewspaperMinistry of Health

Treasury DepartmentFamily Health InternationalAidspan GFATM watchdog

Ministry of Public Health and SanitationAIDS NGO Consortium

• Qualitative and quantitative case studies• Key informants:

WHO Positive Synergies Research Questions

How do different health system designs and specific implementation strategies influence the coverage of targeted and non-targeted interventions?

WHO Positive SynergiesMethodsFacility Assessment Tool

WHO Positive Synergies Timeline

Summer2008

Fall2008

Winter2008-2009

Spring2009

Summer2009

May 29-30:1st Consultation, Geneva

July 15 – 16:Drs. Carissa Etienne & Badara Samb visit Harvard

August 4:WHO Satellite Panel

August 5:2nd Consultation, Mexico City

August 15:Prof. Rifat Atun visits Harvard

• October 2 - 3:3rd Consultation, Geneva

• November 3 - 4:Dr. Badara Samb visits Harvard

• Nov - Dec:Data collection begins

• August 5:2nd Consultation, Mexico City

• August 15:Prof. Rifat Atun visits Harvard

• Jan - Feb:Data collection continues

• February 16 - 17:Lancet special issue mtg, Rome

• March 9:Consortium submits preliminary results

• March 20:Draft circulated to consortium

• March 26 - 27:4th Consultation, Geneva

• March 28:Working meeting of Academic Consortium, Gva.

• Mid-April:Monograph submitted

• April - May:Final analyses conducted

• Mid-May:Full-length report submitted

• August 4:WHO Satellite Panel

• August 5:2nd Consultation, Mexico City

• August 15:Prof. Rifat Atun visits Harvard

• June:Publication of monograph & case study library

• July 8 - 10:Results presented at G8 Summit, Italy

• Mid-May:Full-length report submitted

• August 4:WHO Satellite Panel

Existing Evidence & Emerging Themes

Potential impacts:• Distortions in health labor market• Uncompensated increases in workload• Trainings compromising service delivery

(See e.g. Banteyerga 2005, 2006; Gbangbadthore 2006; Mtonya 2005, 2006; Schott 2005)

WHO Positive Synergies Project

GHIsLearning institutions

Early in major GHI implementation

Few countries

Cross-sectional

Mostly Qualitative

????

PEPFAR: 6 years of evidenceGFATM: 7 years of evidence

## countries

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Mixed Methods Approach

Rationale for New Research

New Evidence &Emerging Themes

Potential Synergies:• Strategic top-ups, QOL incentives,

infrastructure improvements• Building capacity through training and

task-shifting• Flexible GHI funding for health workforce

(See e.g. Oomman 2007; Sepulveda 2007; Samb 2008; Atun 2009; Brenzel 2009)

1. Time2. Time3. Time4. Qualitative methods5. Sampling strategy6. Data Availability

WHO Positive SynergiesChallenges

• Global network/Public-private-academic partnerships

• GHIs: learning institutions• Improved health

WHO Positive SynergiesPromise

References• Atun R, Shakarishvili G, Kley N, Blakely M, Godfrey-Faussett P, Boillot F, Lansang MA 2009. Country demand for Health Systems

Strengthening: Analysis of Proposals to the Global Fund to Fight Against AIDS, Tuberculosis and Malaria.

• Banteyerga H, Kidenu A, Bennet S & Stillman K. 2005. The System-Wide Effects of the Global Fund in Ethiopia: Baseline Study Report. The Partners for Health Reformplus, Abt Associates, Inc.

• Banteyerga H, Kidenu A, & Stillman K. 2006. The System-Wide Effects of the Global Fund in Ethiopia: Final Study Report. The Partners for Health Reformplus, Abt Associates, Inc.

• Brenzel L and Waddington C. Health System Strengthening (HSS) Support from the GAVI Alliance: Early Experience and Lessons.

• Gbangbadthore S, Hounsa A & Miller-Franco L. 2006. System-Wide Effects of the Global Fund in Benin: Final Report. Health Sytems20/20 Project, Abt Associates, Inc.

• Mtonya B, Mwapasa V & Kadzandira J. 2005. The System-Wide Effects of the Global Fund in Malawi: Baseline Study Report. The Partners for Health Reformplus, Abt Associates, Inc.

• Mtonya B & Chizimbi, S. 2006. The System-Wide Effects of the Global Fund in Malawi: Final Report. The Partners for Health Reformplus, Abt Associates, Inc.

• Oomman N, Bernstein M & Rosenzweig S. 2007. Following the Funding for HIV/AIDS: a comparative analysis of funding practices of PEPFAR, the Global Fund and World Bank MAP in Mozambique, Uganda and Zambia. Center for Global Development.

• Schott W, Stillman K, & Bennett S. 2005. Effects of the Global Fund on reproductive health in Ethiopia and Malawi: baseline findings. The Partners for Health Reformplus, Abt Associates, Inc.

• Sepulveda J, Carpenter C, Curran J et al 2007. PEPFAR Implementation: Progress and Promise. Institute of Medicine.

Thank you

It is not a case of either or: we do not have this option… it is about making sure that all available resources produce the maximum possible benefits in improving the lives & well-beings of our people.

-Dr. Carissa EtienneAssistant Director-GeneralHealth Systems & ServicesWorld Health Organization

• Develop sampling matrix in consultation with partners:– Geographical representation– GHI investment as a percentage of total

health expenditure– High burden of GHI-targeted disease– Existing connections with partner institutions

WHO Positive SynergiesCountry Selection