influence of ghis on mozambique public health system
DESCRIPTION
presentation by Baltazar Chilundo and Tavares MadedeTRANSCRIPT
INFLUENCE OF GHIs ON MOZAMBIQUE PUBLIC HEALTH SYSTEM
GHIs in AFRICA funded by the EU 6th frameworkINCO-DEV program. INCO contract no. 032371
Beijing - October 31st 2012By: Prof. Baltazar Chilundo (MD, PhD)
Dr. Tavares Madede (MD, Research fellow)
DEPARTMENT OF COMMUNITY HEALTH, FACULTY OF MEDICINE, EDUARDO MONDLANE UNIVERSITY, MOZAMBIQUE
BackgroundParameters Value
Total Population (in million – projection based on 2007 census) 23.7
Children (population below 19 years of age) (in million – projection based on 2007 census)
12.3
People living below the poverty line (%) (Mozambique MDG report, 2010)
54%
Under five mortality rate/1,000 live births (MICS 2008) 138
Maternal mortality ration/100,000 live births (2007 Census) 500.1
HIV prevalence rate among pregnant women (INSIDA, 2009) 11.5%
Malaria parasitaemia among children under five (MIS, 2007) 38.5%
TB prevalence rate/100,000 people (WHO, 2008) 504
Proportion of aid by external partners in 2008 (MISAU, 2008) 73%
Research Questions• What are the GHIs operating in Mozambique?• What are the current implications of selected
GHIs on health systems strengthening at both national and sub-national levels?– Has the availability of services increased due to
GHIs?– How have GHIs affected health workers availability
and performance in the public health sector, particularly at the facility level?
– What is the influence of GHIs on financial system, HMIS and M&E?
Research Methods• Qualitative at the national level (2008 - 2010)– Documents review– 22 interviews with key informants (MISAU authorities
and managers, partners’ representatives, NGOs…) • Qualitative and quantitative at the Sub-national
level (2010 - 2011)– Administrative health data – 66 interviews to provincial, district and health unit
authorities and NGO representatives• Nampula (Nampula & Nacala-porto) - Northern• Zambézia (Mocuba & Quelimane) - Central• Gaza (Xai-Xai & Chókwe) - Southern
What are the GHIs operating in Mozambique?
Malaria
Tuberculosis
HIV/AIDS
Vaccination
US President’s Malaria Initiative
GFATM
MultiCountry AIDS Programme (WB)
Catalytic Initiative
Health Problems/Issues GHIs
Stop TB Initiative
Treatment Acceleration Programme (WB)
US PEPFAR
Bill and Melinda Gates FoundationMaternal and Child Health
Clinton Foundation
Health Systemsstrengthening
GAVI
R2 & 7
R2, 6 & 9
R8
RED
RED
PEPFAR II
Has the availability of services increased due to GHIs?
Source: Administrative data_HMIS_MoH, Mozambique
2007 2008 2009 2010 20110%
10%
20%
30%
40%
50%
60%
70%
80%
11.2% 10.0% 11.1%
24.0% 23.0%
54.0%
51.9%55.1%
64.0% 63.0%
24.0%
47.0%
68.0%
69.0% 69.0%
Trends of selected MCH indicators: PMTCT coverage (GHI funded) compared to coverage of institutional deliveries and family planning
2007-2011Coverage of new clients on Family Planning Coverage of Institutional deliveries
PMTCT
Institutional de-liveries
Family Planning
How have GHIs affected health worker availability and performance in the public health
sector?
Health partners funded by PEPFAR/GFATM tend to be more attractive in terms of incentives and are hiring the most experienced qualified staff coming from the public sector• Official figures from MISAU headquarters (2010) say 56.5% (14/23) of
MD with Master or PhD moved to outside the public system, with 71.4% (10/14) from the National Directorate of Public Health
Still recently NGOs (e.g. ITECH funded by PEPFAR) are providing support to MISAU for in-service and pre-service training mainly oriented to the areas of their interest
HRH – Remarks from the national and subnational interviews
The latest health sector human resource development plan (2008 2015) clearly lays out strategies that can be used to ‐strengthen the workforce in terms of motivation, retention, availability and so, for better performance…but it demands funding that could come from GHIs
The rapid "scale up" of ART services had negative effect on the quality of services provided by the health system due to work overload as the level of HRH availability did not change at all
2009 2010 2011
Performed 61 63.4 67
Planned 60 63 65
Minimum WHO standard 230 230 230
25
75
125
175
225
Ratio of health workers of specific health areas of medicine, nursing and MCH per 100,000 inhabitants . Source: BdPES DRH
2012
2009 2010 2011
Performed 1525 2170 1688
Planned NaN 2321 1650
Needs expressed in HRH plan
2263.745 3266.7525 3146.5
1250
1750
2250
2750
3250
# of new cadres graduated (basic and medium) of specific health
career. Source: BdPES DRH 2012
HRH: Gap between needs and capacity
Source: Hilde De Graeve,
Bert Schreuder.
What is the influence of GHIs on Financial system, HMIS and
M&E?• Low capacity of MoH officials to
demonstrate accountability• Inability of the MoH to promptly satisfy
the recommendations from financial auditors
• Data quality remains a big issue (this was also found by GFATM external data auditors)
• Geo-discrepancy on service delivery and around M&E:– funding partners targeting specific
provinces– Within each province an agency often
covers only one or a few districts– PEPFAR seems to promote parallel HMIS
and M&E relying on their implementing partners’ systems
Final Remarks• GHIs increased services scale up for the specific
health programs (HIV+++, Malaria++ and TB+)
• No evidence of GHI interventions negatively affecting other health related services
• GHIs do affect HRH availability and performance both negatively and positively
• Existing financial accountability and M&E/HMIS are still weak and being stressed by GHIs
• The collective efforts of GHIs would have resulted in better health outcomes if they had targeted the health system as a whole in a coherent manner.
Kudos for me: I am Becoming 40 today!Thanks a lot
Obrigado谢谢
A health post from Nampula, Mozambique