Health systems and HIV: Priorities for civil societyPriorities for civil society advocacy

Mi h ll MMichelle Munro Interagency Coalition on AIDS and Development

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OverviewOverview

• GTAG civil society and health systemsGTAG, civil society and health systems advocacy

• Health systems and health systems• Health systems and health systems strengthening (HSS)H did HS t t i i t t ?• How did HS get to a crisis state?

• Key advocacy issues – health workers, HIV for HSS, funding

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GTAGGTAG• Coalition of CanadianCoalition of Canadian

CSOs who advocate on global HIV issues and the right to health

• ICAD is a founding member

• 2003, 2006 & 2009 l f i l dplatforms include

health systems

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Why is HSS a priority for civil y ysociety HIV advocates?

In the countries most affected by HIV, none of the health Millennium Developmentof the health Millennium Development Goals are unlikely to be achieved (UN 2008 MDG Report)

Weak health systems are the major reason for poor progress:

WHO 20084

WHO, 2008

Was GTAG’s health systems y‘ask’ coherent with our universal access and GFATMuniversal access and GFATM asks?

• HIV investments had exposed HS weaknessesHS weaknesses

• GTAG would adopt a ‘Do no harm’ approachharm approach.

• better understanding of how HIV can best support HSS

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can best support HSS

What’s in a health system?What s in a health system?Health services and care

Equity?Health workers – health human resources

Gender?CS Role?

resources

Information systems

Medicines, supplies, vaccines, technologies & infrastructure

Financing

6Leadership and governance

Health systems strengthening

Health systems strengthening is building capacity in critical health system components to achieve more equitableand sustained improvements across health services and outcomes

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How did health systemsHow did health systems get to a crisis state?

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MacroeconomicsMacroeconomics

Structural adjustment – ↓ Public sectorStructural adjustment pay off debt

↓ Public sector expenditure for HS

Health sector reform to Unsuccessful inHealth sector reform to reduce HS costs – user fees private sector

Unsuccessful in countries with weak HS ↓ equity accessfees, private sector

involvement, systemsHS, ↓ equity, access & CS participation in governancegovernance

Globalization Exacerbate all of the ti ff t

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negative effects

Where was Primary Health C ( C)?Care (PHC)?

• Alma Ata 1978: Health for AllAlma Ata 1978: Health for All– Equity, the right to health

A comprehensive package– A comprehensive package– CS participation

Inter sectoral cooperation– Inter-sectoral cooperation• But PHC quickly became selective and

ti l d thi h thvertical – and this approach was then applied to entire health systems

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Islands of sufficiencyIslands of sufficiency

11Illustration © Gorik Ooms & Marc Bestgen

Other effects of the ‘island’Other effects of the island

• little development of transferrable• little development of transferrable capacity

• inequity • duplication of effort and reportingduplication of effort and reporting• weak governance

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Aid effectiveness?Aid effectiveness?• Paris Declaration, 2005: Harmonisation,

country ownership, shared accountability• Sector Wide Approaches (SWAps) & DirectSector Wide Approaches (SWAps) & Direct

Budget Support/Programme Based Approaches (PBA)Approaches (PBA)

• But managing a SWAp or programme is a huge task doubly so where HS capacity ishuge task, doubly so where HS capacity is already weak (eg Malawi)The stigmatised can be excluded• The stigmatised can be excluded…

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How does gender weigh in?How does gender weigh in?When HSs are weak there is:When HSs are weak there is:• ↓ capacity to collect & analyse

gender disaggregated datagender disaggregated data –↓ understanding of gender iissues

• ↓ reproductive health funding• ↓ internal gender mainstreaming

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Key HIV advocacy issues for Civil SocietyHealth systems and HSS are complex, crisis

is not new & there are no easy answers.1. Health workers2. HIV’s role in HSS2. HIV s role in HSS3. Funding

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HIV & the health workforceHIV & the health workforce

Weaker capacity

Global HW shortage: 4 3 million

HIV ↑

p y4.3 million

HIV ↑workload & ↓ # of

HWsWeak HS &

HW capacity

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The countries with more diseases have fewer health workers, and less health investment

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HIV’s impact: the health worker crisis

• HIV has brought investment but alsoHIV has brought investment but also increased demand eg less stigma, more health seekingg

• Incentives allow for scale up of HIV but unintentionally draw health workers from yother health programs

• Task shifting (devolving work to less g ( ghighly trained workers or volunteers) may help to manage the load but needs to be

l dproperly managed18

Advocacy messages: health workers

• CS to monitor incentivesCS to monitor incentives• Task shifting needs policies, training,

supervision & remunerationsupervision & remuneration• NGOs & multi-laterals to adopt ethical

recruitment & human resource strategiesrecruitment & human resource strategies (see NGO Code of Conduct for HS)

• GoC & provinces to develop & fund aGoC & provinces to develop & fund a health HR policy

• No active recruitment by the private sector19

No active recruitment by the private sector• Gender mainstreaming

HIV as a HSS strategyHIV as a HSS strategy• Diagonal approaches – combiningDiagonal approaches combining

disease focused with systems approaches may be the way forwardmay be the way forward

• Some early but positive examples – Haiti, Cambodia RwandaCambodia, Rwanda

• GFATM has a health systems window that is separate & in addition to fundingis separate & in addition to funding windows for the three diseases

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Use HIV investments to improve the entire health system

21Illustration © Gorik Ooms & Marc Bestgen

Advocacy messages: HIV f d f HSSHIV funds for HSS

• Resources for BOTH HIV & HSS• SWAps +: specific HIV & equity indicators• CIDA & GoC: transparency on investments• CIDA & GoC: transparency on investments,

protect HSS & HIV at the WHAGFATM l t it HSS i t t• GFATM: evaluate its HSS investments

• ‘Do no harm’ in all investments• Private sector: equity & promote gender

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y• More evidence on HSS & what works

Funding & the financial crisisFunding & the financial crisis

• Long term under-investment by bothLong term under investment by both governments and donors - worsened by the current crisisthe current crisis

• Amount invested in health often unrealistically lowunrealistically low

• Most HS funds come from developing t i t dcountries – not donors

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African governments committed to investing 15% of total expenditure on health in 2001 (Abuja p ( jDeclaration)Government Health Spending as a Share of Total Expenditures Selected African Countries 2005Expenditures, Selected African Countries, 2005

MauritaniaAngola

Cote d'IvoireCongo, Republic

EritreaGuineaNigeriaBurundi

Abuja Target

GhanaComoros

KenyaSenegal

NigerCongo DRC

SudanTogo

Guinea BissauGambia

Mauritania

EthiopiaBenin

UgandaCape VerdeMadagascar

ChadMozambique

ZimbabweTanzania

Sierra LeoneGhana

DjiboutiBotswana

LesothoMali

ao Tome and PrincipeCameroon

ZambiaSwaziland

South AfricaCentral African

Ethiopia

240% 2% 4% 6% 8% 10% 12% 14% 16% 18%

RwandaBurkina Faso

GabonNamibiaDjibouti

Financing innovations

• Insurance where the tax base is lowAd d M k t C it t (AMC )• Advanced Market Commitments (AMCs): assured markets for new vaccines &

ibl d f l t d dipossibly drugs for neglected diseases or those that affect the poor

• Airline levy for HIV drugs

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Advocacy messages : Funding• 0.7% of GNI0.7% of GNI• Double GFATM contributions• Honour UN and G8 commitments to• Honour UN and G8 commitments to

Universal Access• Help Southern partners hold their• Help Southern partners hold their

governments accountable for Abuja• Cancel debt and remove conditionalities• Cancel debt and remove conditionalities• Watch innovative funding & financing tools

S pport CSOs so that the can hold26

• Support CSOs so that they can hold governments accountable

Questions?Questions?Comments?

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Thank youThank youwww.icad-csid.com

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