Donors Officials Discuss HIV/AIDS Monitor Report on Health Systems at the 2008 International AIDS Conference

From Aug 2-9, the Center for Global Development's HIV/AIDS Monitor team and its research partners from Mozambique and Uganda attended the international AIDS Conference in Mexico City. In addition to taking advantage of the fantastic opportunity for learning and exchange with the over 23,000 participants committed to addressing HIV/AIDS globally, our team also launched its new paper "Seizing the Opportunity on AIDS and Health Systems." This turned out to be a very timely piece of research, as discussions on health systems strengthening dominated much of the conference.While many of these discussions centered around whether or not HIV/AIDS money was strengthening or weakening health systems, our research and the panel discussion between our researchers and donors sought instead to examine how HIV/AIDS donors could better take advantage of important opportunities to strengthen health systems which are necessary for expanded and sustainable achievements both in HIV/AIDS and in general health outcomes. It is clear to us that the future of the HIV/AIDS response and health systems cannot be considered independently. Regardless of the cause, a weak health system is a problem for achieving all health outcomes, including HIV/AIDS specific ones. Therefore, it is the responsibility of all actors concerned with health issues, including those with HIV/AIDS specific mandates, to address weak health systems. The important issues for discussion are then NOT if they should or whether they are, but how they are and how it can be done better.This was the focus of the research evidence presented in the "Seizing the Opportunities" report. Our panel discussion in Mexico City was an important and unique opportunity to get three major HIV/AIDS donor heads to engage in depth on the specific interactions in the sub-systems of health information systems, medicine supply chains, and health human resources. To start the panel, Nandini Oomman, the Director of the HIV/AIDS Monitor, presented an overview of the "Seizing the Opportunity on AIDS and Health Systems" report.Steve Morrison, the Director of the HIV/AIDS task force for CSIS in Washington D.C., then moderated a panel discussion among our researchers to draw out specific examples of donor programs’ interactions with health subsystems in their three countries. Freddie Ssengooba, our Principal Investigator in Uganda who is a Lecturer at Makerere University School of Public Health, discussed the example of a highly effective information system management (Monitoring and Evaluation of Emergency Plan Progress) used in Uganda by PEPFAR for their HIV/AIDS programs. He recommended that the lessons learned from this effective information system should be expanded and applied by the donors and national stakeholders to improve the currently dysfunctional national health information system, which many of the donors really on for some key information on national progress against HIV/AIDS.William Okedi, our Field Director from Kenya, discussed the weaknesses of the health workforce in Zambia, (in lieu of Caesar Cheelo, our Principal Investigator in Zambia and lecturer at the University of Zambia) and the lack of health workers for general health needs. He recommended that the long term solution would be for the World Bank, the Global Fund, and PEPFAR to work with the governments and national stakeholders to develop, fund and implement national human resources for health policies that would include policies for human resources for HIV/AIDS. He also recommended that in the short term donors' policies on compensations and incentives needed to ensure that donor policies guarantee that performance for all health tasks are rewarded and not just for AIDS. Dirce Costa, our Principal Investigator in Mozambique and an Economist at Austral-COWI Consulting, discussed how in Mozambique while the ARV supply chain was highly successful the supply chain for essential medicines was failing, with regular stock outs. She recommended that the capacity for the ARV supply chain be expanded to include other health commodities, staring with medicines for HIV/AIDS related opportunitistic diseases and then to include all essential medicines.Following these illustrative examples, Steve then moderated a discussion among the donors and the researchers about how the opportunities identified in the report could be acted upon. Mark Dybul, the U.S. Global AIDS Coordinator and PEPFAR Administrator, admitted there were still many areas where donors need to do a better job strengthening the national health systems, including creating feedback loops for performance monitoring, breaking through bureaucratic barriers to unify supply chain management systems within and across U.S. government agencies, and learning more about what the right mix of health workers is needed for an effective tiered national health workforce that can address both HIV/AIDS and general health needs. He also argued that HIV/AIDS actors had been more successful than any other area of development in dealing with difficult operational challenges such as harmonized and aligned M&E systems. Debrework Zewdie, Director of the Global HIV/AIDS Programs in the World Bank Human Development Network, explained that the World Bank had taken a “learning by doing approach” in their HIV/AIDS programs, and made significant progress in the early days strengthening of civil society, though still needed to improve their operational research, how they share information at the country level, and willingness (or capacity) of recipients to invest 15% of funds on M&E as the World Bank has suggested.Michel Kazatchkine, the Executive Director of The Global Fund to Fight AIDS, Tuberculosis and Malaria, was concerned that the important role of civil society and the responsibilities of governments were under-emphasized in the report, and also called for more research in countries where HIV/AIDS responses were failing. He discussed how getting the balance right between useful performance monitoring and large reporting burdens required harmonization at the country level around national plans and associated indicators that link broad health systems targets and disease specific targets (they are currently working on this, and expect to have guidance on these indicators in a year). He also often argued that taking advantage of opportunities for health systems strengthening was really up to the countries’ themselves to pursue and include in proposals. The discussion then progressed, with the HIV/AIDS monitor research partners following up with some tough questions, leading to an interesting and constructive exchange with the donor heads. You can watch this exchange in the following video clip:There were quite a few other sessions which also focused on similar issues:

• a panel organized by the [World Health Organization] entitled "Positive Synergies between Health Systems and Global Health Initiatives,"
• presentations of research papers on ["Global Health Initiatives: The Impact of Vertical Funding on Health Systems and Community Priorities"],
• a special session on "Financing for Sustainable National Health Care" that examining national case studies from around the world,
• a special session on "Strengthening Health Systems Through the AIDS Response" where panelists represented differing perspectives on this issue.
• and of course, [our panel discussion with donors] to elicit and engage with their responses to the findings of our report about how their programs are interacting with national health systems and where there are opportunities for them to do better.