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Maximizing Positive Synergies Project 1 and the Purpose of This Document Table of Contents Key Acronyms Introduction The maximizing positive synergies project 1 and the purpose of this document Burundi Building a health system together with Global 8 Health Initiatives, in the aftermath of war Johann Cailhol, Thuba Mathole, Annie Parsons, David Sanders, Denise Kandondo, Innocent Ndayiragije and Théodore Niyongabo Cameroon Evaluation of the national programme for access 20 to antiretroviral therapy Boyer S., Eboko F., Camara M., Abé C., Owona Nguini M.E., Koulla-Shiro S., Moatti J-P. Cameroon Impact of Global Health Initiatives on primary level health 31 care facilities: the case of Kumba and Limbe health districts Peter M. Ndumbe, Julius Atashili Central African Impact of the Global Health Initiatives 40 Republic on the health system: perceptions of informants Julius Atashili, Marie-Claire Okomo, Emilia Lyonga, Nayana Dhavan, Nikita Carney, Erin Sullivan, Peter Ndumbe China Impact of the Global Fund HIV/AIDS programmes on 50 coordination and coverage of financial assistance schemes for people living with HIV/AIDS and their families Zhang Xiulan, Pierre Miège and Zhang Yurong Georgia System-wide effects of the Global Fund on Georgia’s 59 health care systems Ketevan Chkhatarashvili, George Gotsadze, Natia Rukhadze Ghana Interactions between health systems and Global Fund-supported 65 TB and HIV programmes Sai Pothapregada, Rifat Atun Haiti Maximizing positive synergies between Global Health 74 Initiatives and the health system LC Ivers, JG Jerome, E Sullivan, JR Talbot, N Dhavan, M StLouis, W Lambert, J Rhatigan, JS Mukherjee India Exploring how disease-specific programmes in TB and 88 HIV/AIDS interact with health systems Krishna Dipankar Rao, Mathew Sunil George, Aarushi Bhatnagar, Babita Rajkumari, Maulik Chokshi, Preeti Kumar and Indrajit Hazarika Kenya The impact of Global Health Initiatives on the health system 97 Joseph Rhatigan, Erin Sullivan, Kileken ole-MoiYoi, George Kimathi, Nayana Dhavan, Ephantus Kabiru Kyrgyzstan Tracking global HIV/AIDS initiatives and their impact 107 on the health system Gulgun Murzalieva, Julia Aleshkina, Arnol Samiev, Neil Spicer, Gill Walt Malawi Global Health Initiatives and delivery of health care: 117 the case of the Global Fund Victor Mwapasa and John Kadzandira Pakistan Impact of the Global Polio Eradication Initiative on the 124 health system Sania Nishtar Peru Effects of the implementation of Global Fund-supported 134 HIV/AIDS projects on health systems, civil society and affected communities, 2004-2007 Carlos F. Cáceres, Maziel Girón, Clara Sandoval, Roberto López, José Pajuelo, Rocío Valverde, Patricia Vásquez, Alfonso Silva-Santisteban, Ana Maria Rosasco Rwanda Impact of Global Health Initiatives on the health system: 144 a mixed methods analysis Mukherjee JS, Jerome JG, Sullivan E, May MA, Mayfield A, Lambert W, Dhavan N, Carney N, Rhatigan J, Ivers LC Senegal Effects of Global Health Initiatives on the health system 160 Papa Salif Sow, Fatou Francesca Mbow, Aliou Diallo, Demba Dione, Marième Ba South Africa The effects of Global Health Initiative funding for HIV/AIDS 168 on the health system Thomas Bisika, Eric Buch, Thubelihle Mathole, Annie Parsons, David Sanders Uganda Expanding targeted services into primary health care 181 Dr. Bernard Michael Etukoit, Mr. Richard Wanyama Ukraine Effects of the Global Fund on the health system 192 Tetyana Semigina United Republic Strengthening the health system to address 201 of Tanzania the burden of HIV/AIDS and TB Thyra de Jongh, Rifat Atun Zambia Global HIV/AIDS initiatives and health system capacity to 209 cope with the scale-up of HIV services Phillimon Ndubani, Joseph Simbaya, Aisling Walsh, Ruairí Brugha Policy analysis of the impact of Global Health Initiatives on health systems: 218 policies and lessons learned from donor programmes Anne Rossier Markus, Seble Frehywot, Amie Heap, Alan Greenberg Conclusion Directions for future research on positive synergies 236 Annex 01 Data sources for tables in country case studies 240 Annex 02 Contributing Institutions 242 The named contributors alone are responsible for the views expressed in this publication. Key Acronyms1 AIDS (SIDA) Acquired immunodeficiency syndrome ANC Antenatal care ART Antiretroviral therapy ARVs Antiretrovirals CBO Community-based organization CCM Country coordinating mechanism CDC U.S. Center for Disease control CHW Community health worker CSO Civil society organization DFID U.K. Department for International Development DOTS Directly Observed Treatment, short-course FBO Faith-based organization GAVI Global Alliance for Vaccines and Immunization GHI Global health initiative Global Fund Global Fund to fight AIDS, Tuberculosis and Malaria GDP Gross domestic product HIPC Initiative Heavily Indebted Poor Countries Initiative HIV Human immunodeficiency virus HMIS Health management information system IDU Injecting drug user ILO International Labour Organization M&E Monitoring and evaluation MDG Millennium Development Goal MDR-TB Multidrug-resistant tuberculosis MOH Ministry of Health MPS Maximizing Positive Synergies NACP National AIDS Control Programme NGO Nongovernmental organization ODA Official Development Assistance 1 All other abbreviations are spelled out in full in individual country case studies. OIs Opportunistic infections OVC Orphans and vulnerable children PEI Polio Eradication Initiative PEPFAR U.S. President's Emergency Plan for AIDS Relief PHC Primary Health Care PLWHA People living with HIV/AIDS PMTCT Prevention of mother-to-child transmission SWAp Sector Wide Strategic Approach SYSRA Systemic Rapid Assessment Toolkit TB Tuberculosis UN United Nations UNAIDS Joint United Nations Programme on HIV/AIDS UNDP United Nations Development Programme UNICEF United Nations Children's Fund USAID United States Agency for International Development VCT Voluntary counselling and testing WHO World Health Organization WHO NHA WHO National Health Accounts WHO SIS WHO Statistical Information System (WHOSIS) WHO WMR WHO World Malaria Report World Bank MAP Multi-Country HIV/AIDS Program Introduction: The Maximizing Positive Synergies project and the purpose of this document Over the last decade, Global Health Initiatives (GHIs) have mobilized substantial new resources for health action in many low- and middle-income countries. The expansion of key services, particularly the provision of HIV/AIDS treatment, has been striking, and millions of people have benefited. But the scale-up of selected services by GHIs has placed new demands on national health systems, revealed weaknesses in those systems, and rekindled debates on how countries can best combine disease-specific programmes with broader agendas to improve the health of their people. Addressing knowledge gaps—at a critical time In July 2009, policymakers of the G8 nations gathering in Italy will review policy and funding priorities for global health at a critical moment. As the 2015 target date of the Millennium Development Goals (MDGs) approaches, the global economic crisis threatens to slow recent health gains and inflict its harshest effects on the world’s poorest countries and people – the very communities that the MDGs were designed to help. Yet the opportunity exists to accelerate health progress by sustaining ambitious global investments in health and ensuring that resources are directed strategically for maximum impact. Understanding interactions between GHIs and health systems is crucial to reach this objective. Until recently, little solid evidence was available to guide policymakers and programme implementers seeking practical, proven ways to shape interactions between disease-specific programmes and health systems so as to achieve the greatest gains in health. In May 2008, the World Health Organization (WHO) launched a process to generate evidence-informed guidance on this issue for GHIs, countries, and global health partners. The “Maximizing Positive Synergies” (MPS) project has engaged stakeholders in a collaborative effort to build new knowledge on how GHI-supported programmes are impacting national health systems, and to harness this evidence for policy and implementation. This draft document presents an initial compilation of findings from MPS research partners who have analysed GHI-health systems interactions in more than 20 countries. It offers a new body of data to inform policy and guide strategic action by national authorities, GHIs and implementers. Research partners are continuing to analyse their data; the results summarized here are provisional. As analysis, validation and comparison proceed on the wealth of data gathered, MPS country studies will provide a robust evidence base to support WHO’s normative guidance on disease-specific programmes and health systems. In addition, the initial phase of MPS learning summarized here has clarified directions for future research that will continue to generate fresh evidence for policy. Structure of this report The introductory section of this document summarizes the main research questions, conceptual framework and methodologies used in MPS country-level research. It describes how countries were selected for inclusion in the MPS studies and indicates limitations of the work to date. The 1 core section of the document then presents 21 country case studies on GHI-health systems interaction, along with a comparative analysis of the internal structures and policies of four major GHIs: the GAVI Alliance (formerly the Global Alliance for Vaccines and Immunization), the Global Fund to Fight AIDS, TB and Malaria (Global Fund), the United
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