Maximizing positive synergies at the
front lines of global health
Overview and findings of the
civil society consortium
High level dialogue on maximizing positive synergies
between health systems and global health initiatives
Venice • June 22-23
Maximizing Positive Synergies
civil society consortium
UCOBAC (Uganda)
Alice Kayongo
Layolah Muhwemza
GROOTS Kenya
Esther Jael Amati
Esther Mwaura-Miuru
Ruth Kihiu
Reach Trust Malawi
Lot Nyirenda
Tchaka Ndhlovu
TALC Zambia
Felix Mwanza
Health GAP
Asia Russell
Jen Cohn, MD
Paul Davis
Brook Baker
Global AIDS Alliance
Alia Khan
Paul Zeitz
Maximizing positive synergies
• Financial crisis threatens millions more with
disease, death
• Disease specific investments are still critical
– An expectation that HIV funding improves access to
comprehensive primary health care
– No reason leveraging positive synergies means
‘slowing down’ disease specific responses
• Funding gap growing: for AIDS alone $40 billion
needed annually by 2010; funding comprehensive
primary health care
Research questions
• What are the views of civil society regarding the interaction
between the health system and GHIs?
• What are the roles of civil society in optimizing the interactions
between global health initiatives and national health systems, in
order to capitalize on positive synergies and minimize negative
impacts?
– How has civil society participation influenced the interaction between
GHIs and country health systems?
– In what ways have civil society modified GHIs to increase their
responsiveness to country/consumer needs?
– What reforms and actions should GHIs take to be more responsive to
grassroots civil society priorities and health needs?
– How can CSOs work with governments and/or GHIs to navigate
implementation roadblocks? What are CSOs doing already?
– What priority health issues identified by front-line CSOs are not being
addressed by GHIs, or are being impacted GHIs (positively or
negatively)?
Assumption
Civil society and community groups are the front
line actors and primary customers of health
systems:
1) Providers of health care and implementers of
health programmes
2) Advocates for improved health systems
3) End-users of health care
Research objectives
• Move beyond toxic, false debate
• Generate practical recommendations to civil
society implementers, advocates
• Apply findings in real time
– Immediate expressions of country demand to GHIs
that maximize positive synergies
Civil society in health systems
Needs-based
advocacy
Communityled
implementati
on: health
promotion,
care and
support
Hands-on
experience of
what works
Community
mobilization for
comprehensive
health services
ID practical
challenges &
gaps in
health
service
delivery
Services for
excluded and
vulnerable
populations
Independent
oversight,
monitoring
Building community systems
Access to
predictable and
sufficient funding
Training and
capacity for
management,
advocacy, oversight,
service delivery
Enabling cultural,
legal and sociopolitical
environment
Community
systems
strengthening
Advancing comprehensive primary health care
community
systems
strengthening
advocacy
optimizing
GHIs
community
led demand
creation
Civil society: what is the added value?
• Needs-based advocacy: define needs
comprehensively in national and global target
setting
– Resource Mobilization: from national and global
sources to meet needs
– Evidence-based policies: prevention, access to
medicines, discrimination, criminalization
• Authentic inclusive governance: in local,
national, and global institutions
Civil society: what is the added value?
• Significant role in GHIs
– Global Fund: 20% in Round 7 and PEPFAR: Over
40% to NGOs and FBOs
• Strong performance in many contexts
– Global Fund civil society Principal Recipients
outperform government
– Partner where state sector is weak/unwilling (eg
due to stigma and discrimination)
– Engaging empowered communities and
consumers
Civil society consortium
Coordinators
– Health GAP
– Global AIDS Alliance
Lead country partners
– Treatment Advocacy and Literacy Campaign, Zambia
– GROOTS, Kenya
– Uganda Community Based Association for Child Welfare
(UCOBAC), Uganda
– Reach Trust, Malawi
Global advisory network
– Civil society experts from range of health constituencies
Maximizing Positive Synergies
civil society consortium global advisory network
Organization
Representative
International Association of Physicians in AIDS Care
Dr Jose Zuniga
International Council of Nurses
David Benton
Positive Action for Treatment Access (PATA), Nigeria
Rolake Nwagwu
World YWCA
Nyzardazai Gumbozvanda
Bangladesh Rural Advancement Commission (BRAC)/GAVI
Dr Faruque Ahmed
Family Care International
Ann Starrs
Health Systems 20/20 and Health Systems Action Network
Gilbert Kombe
Project UPHOLD, Uganda
Samson Kironde
ACOSHED, Nigeria
Dr Lola Dare
AMREF
Grace Mukasa
Stop TB Partnership
Ezio Santos Filho
The Malaria Consortium/RBM Partnership
Enid Wamani
UNITAID Communities Board Representative
Carol Maimbolwa
International Planned Parenthood Federation
Matthew Lindley
Health Alliance International
Wendy Johnson
Civil society consortium
Methodology
• Qualitative approaches
– Semi structured interviews, focus group discussions
– Standardized questionnaire
•
•
•
•
positive/negative effects of GHI funded programs
HSS priorities and priorities apart from AIDS, tuberculosis and malaria
strengths/weaknesses of civil society
what could be done differently to leverage civil society’s roles
– Research teams comprising grassroots experts, social scientists,
caregivers
– Targeting NGO implementers, community health workers,
health workers (district and peripheral levels), advocates,
policymakers, beneficiaries
• Literature review
– Country GHI documents, health plans, etc.
Methodology
• Action-oriented research
– provide ‘bottom-up’ perspective
– apply findings in real time through GHI pathways
• PEPFAR 5-year Partnership frameworks
• Global Fund National Strategy Application ‘learning
wave’ and Round 9
• Dual-track financing
• IHP+ participants
• Feedback and dissemination strategies in country
Findings
GHIs expose HS weaknesses, illuminate
opportunities for advancement
A massive shortage in the number of health workers including doctors,
nurses, lab technicians and pharmacists, as well as community health
workers
Weaknesses in procurement and supply chain management resulting in
stock-outs; procurement of unnecessary medicines
Civil society participation and impact often weak, fragmented
Inadequate remuneration and benefits (including suitable worker
housing) for professional and community health workers
The need for improved health facility infrastructure such as the
provision of electricity, safe water, and sufficient space
Lack of equipment such as x-ray machines, CD4 count machines, and
other essential laboratory equipment
Findings
GHIs addressing health system weaknesses
Health worker trainings on disease-specific topics viewed as beneficial
Improved information and tracking systems are leading to improved
supply chains (although still problems with parallel systems)
GHI funding for health workforce has lead to increased primary care in
some settings (ie increased direct cervical visualization) – PEPFAR
and GFATM have posted new health professionals and supported
country level implementation of task-shifting.
GHIs have improved medical record and laboratory systems through
training and equipment support (large “spillover” effect-- lab
equipment isn’t only used for AIDS!)
Findings
Preventing exacerbation of systems weaknesses
Internal brain drain caused by low salaries in public sector/salary
differentials.
Large international NGOs have better access to GHI funding streams;
no mechanism to systematically increase local capacity of
indigenous organizations
Findings
Community priorities for GHIs
– Health workforce production and retention – call for GHIs to focus on
pre-service training as well
– Equipping health system with essential commodities - call for scale
up
– Social determinants of health –GHIs have started addressing these (ie
school uniforms and fees, Kenya)
– Right to health: GHIs should promote human/health rights literacy
Opportunities for more effective civil society engagement in priority
setting, decision making
– National plans more critical, GHIs and Nat’l Govt’s should set
minimum percentages of independent participation of CSO and
patient groups
– Country ‘compacts,’ IHP+, National Strategy Applications
– Increasing focus on coordination with national plans, but plans range
in quality, inclusion, alignment with community priorities
Findings
Complex implementation systems
– Irregular access to funds
– Public sector bureaucracy and lack of GHI
transparency is a barrier to CSOs – and to health
– System for streamlined access for civil society needed
Variable civil society capacity
– Inadequate opportunity for GHI priority setting by civil
society, particularly at district level
– Governance: accountability, advocacy, consultation,
transparency
– Implementation: Proposal development, M&E
Areas for Action
Overall
-GHIs represent powerful actors in health system
strengthening
-More investments needed for GHIs to accelerate
disease specific work concurrent with urgent expansion
of HSS work
-GHIs should support creation of better national
information systems and metrics needed to measure
HSS and continue quality improvement measures
-Civil society is a key player in disease-specific and HSS
work, but will need additional resources and technical
assistance to optimize contributions
Areas for action
Health workforce
– Use GHIs to tackle production, retention, remuneration,
deployment problems
– Create enabling GHI policy environment that catalyzes country
demand
• reconsider Global Fund HSS window
• common HSS target on health worker density; production
– Community health workers: training, integration, payment
– Expanding fiscal space
Civil society
– Use GHIs to build stronger community systems
– Scale up investment in capacity building for priority setting,
planning, monitoring, proposal development
– Rapid, direct, flexible access by civil society to GHI funds
– Focus on indigenous civil society capacity building
– National planning must prioritize civil society involvement
References
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