If it's not broken, then make it better

Submitted by Arin Dutta

Now that we've all heard at IAC'08 and after: disease-specific programs do no harm to health systems and may in fact help them, what's on the agenda for integration and health system strengthening? An analysis of a recent piece by Daniel Low Beer from the Global Fund reveals some hints of what is on the horizon.

Being that this is a Health Systems blog, we do bring our 20/20 vision to bear quite often on the important issues of horizontal integration &/or diagonality. Recently, you read a post on this blog which discussed what were the "Positive Synergies" between the global HIV/AIDS response and health systems strengthening (let's call this HSS for short). A recent piece by Daniel Low Beer of the 'Strategic Information & Evaluation' unit of the Global Fund to Fight AIDS, TB and Malaria (the Global Fund) provides an official coda to the debates on horizontality vs. verticality. The Global Fund has issued a flyer which illustrates the talking points and summarizes the positive synergies. The three most important synergies according to them are:

Global Fund financing allows flexible investment in health systems through disease programs
Disease programs reduce mortality among health workers
Tackling the causes of diseases reduces the health burden of hospitals

The Global Fund flyer summarizes in a clear way the good things that are being done. But the issue of verticality vs. horizontality has been a complex one for those in the field. At HealthSystems 20/20, we have been looking at the issue of Global Fund financing for disease specific programs and the potential 'systemwide effects' (or SWEF) on the health sector of a recipient country. With a two year pilot study in Ethiopia, Benin, and Malawi, we found that the effects of disease-specific funding were complex, and sometimes positive and sometimes negative, depending on the country and the specific component of the health system. An exhaustive, component-by-component study (e.g., from pharmaceuticals to human resources to policy processes), reveals that care may yet need to be exerted on how disease-specific funds and priorities are pushed through low-capacity settings. We invite you to read the SWEF reports here on this website.

One of the many positives discovered in the SWEF - which may or may not have been well-known two years ago - was that Global Fund grants include a HSS component. This has become quite an important talking point for the fund. There are two specific sources of HSS funds:

The 35% of disease-specific funding that is spent on health systems
Separate funding for 'cross-cutting actions', up to US$363 million in 2007 approved

The image below displays how the US$363 million in 2007 was spent: the emphasis is on human resources and on M&E systems: Copyright, GFATM

This leaves us with some agenda items to discuss and potentially take up for action:

Integrate HSS-related technical assistance into country CCMs for Global Fund proposals such that there is a well-thought out method to ask for, receive, and utilize the HSS funds flowing from the two sources within the Fund (above). This directly targets one of the issues raised at the IAC (see previous post). It is important that the CCMs, which are usually consultative bodies with different actors, now also include the 'wider' health system's actors for the HSS grants component. The next step will be to better integrate such thinking towards PEPFAR processes beyond what is already being done.
The Global Fund has talked of 'Performance Management' - tying funding to health outcomes broadly, not just for TB/Malaria/HIV-specific outcomes, but for child mortality, maternal health, etc. Outcomes as could be seen if health system strengthening efforts were successful. How better could we monitor such pathways of results from HSS funding to intervention outputs, on to ultimate outcomes? The upshot is: we need more in-process evaluations of 'cross-cutting' funding, more formative evaluations before new interventions begin, and innovative designs of new interventions which learn from both success and failure.
We can use the SWEF methodology as a tool which may help monitor system-wide effects of the disease-specific flows of funds: PEPFAR as well as Global Fund, and use the monitoring data to 'tune' the effects on the wider health system. Just like a smooth-running car needs continuous tuning and maintenance, the SWEF can be used to provide in-process adjustments to disease-specific programs. For example, the process can be used to check the availability of health workers in horizontal settings such as MCH service delivery, or policymaker 'bandwidth' available for other health outcomes. Do no harm, and do more good than you first imagined.

Translating successful cross-cutting HSS interventions from context to context. How can funding levels and interventions which work in one setting be modified to provide the same measurable success in another context? Now that HSS in the Fund and PEPFAR is well-established, it is time that we share our big wins. We need global learning in order to achieve these global successes.

As they say: if it (disease-specific funding and HSS) ain't broke - don't fix it. But they didn't say we can't make it better.

Tags: SWEF, Health System Strengthening, PEPFAR, The Global Fund

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