UCOBAC (Uganda) Alice Kayongo Layolah Muhwemza GROOTS Kenya Esther Jael Amati

1. Maximizing positive synergies at the front lines of global healthOverview 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

2. UCOBAC (Uganda) Alice Kayongo LayolahMuhwemza GROOTS Kenya Esther Jael Amati Esther Mwaura-Miuru Ruth Kihiu Reach Trust Malawi Lot Nyirenda TchakaNdhlovu 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 civil society consortium

3. 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

4. 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)?

5. Assumption Civil society and community groups are the front line actors andprimary 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

6. 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

7. Civil society in health systems

8. Building community systems

9. community systems strengthening advocacy optimizing GHIs community led demand creation Advancing comprehensive primary health care

10. 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

11. 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

12. 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

13. Maximizing Positive Synergies civil society consortium global advisory network

14. Civil society consortium

15. 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.

16. 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

17. 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

18. 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!)

19. 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

20. 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

21. 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

22. 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

23. 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

24. References • Wouters E, Van Damme W, van Rensburg D et al. Impact of baseline health and community support on antiretroviral treatment outcomes in HIV patients in South Africa. AIDS. 22(18): 2545-2548. 2008. • Medicins San Frontiers, Achieving and Sustaining Universal Access to Antiretrovirals in Rural Areas: The Primary Health Care Approach to HIV Services in Lusikisiki, East Cape, 1-19 (2006). http://www.equinetafrica.org/bibl/docs/MEDaids.pdf • Patcharanarumol, W. Global health initiatives and health system: Experiences of Thailand. Presentation in Geneva, 29 May 2008. • Amazigo, U. Defeating River Blindness and strengthening health systems in Africa. Presentation in Geneva. May 2008. • The Global Fund to Fight AIDS, Tuberculosis and Malaria. Progress Report 2006. http://www.theglobalfund.org/en/funds_raised/reports/ Accessed 30 August 2008. • PEPFAR. All countries: Partner and sub-partner counts by local status, organization type and program area (FY 2005). http://www.state.gov/s/gac/progress/other/data/partners/60363.htm. Accessed 30 August 2008. • Global Fund and International HIV/AIDS Alliance, Civil Society Success on the Ground: Community System Strengthening and Dual-track Financing: Nine Illustrative Case Studies (2008). • UNAIDS. The Three Onesin Action: Where we are and where we go from here. http://data.unaids.org/publications/irc-pub06/jc935-3onesinaction_en.pdf. Accessed 30 August, 2008. • UNDP. Governance for human development. UNDP Strategy Paper. February 2000. • Hannah Brown, Community workers key to improving Africa’s primary care, 370 Lancet 115-17 (Sept. 29, 2007) http://download.thelancet.com/pdfs/journals/lancet/PIIS0140673607614937.pdf • Global Fund for AIDS, Tuberculosis and Malaria. Investing in impact: Mid-year results report 2006. • Hsu, L. Building democratic governance and HIV-resilient societies. UNDP. January 2004. • Bhan A et al. Grand challenges in global health: Engaging civil society organizations in biomedical research in developing countries. PLoS Medicine. 4(9):e272. 2007