HOW can HIV funding strengthen health systems Evidence from Malawi and Zambia Ruairí Brugha Royal College of Surgeons in Irelandand GHIN Network XV111International.

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HOW can HIV funding strengthen health systems Evidence from Malawi and Zambia Ruairí Brugha Royal College of Surgeons in Irelandand GHIN Network XV111International AIDS Conference Vienna 21 st July 2010

Summary of Global Fund and PEPFAR funding to HIV in Malawi and Zambia: Global FundPEPFAR AllocatedDisbursedAllocated Malawi Round 1$342.6m$230m$14.5m (2004) Round 5$17.6m$ 13.0m$15.2m (2005) Round 5 (HSS)*$ 52.0m$ 21.3m$16.4m (2006) Round 8$15.1m$18.9m (2007) $23.9m (2008) Zambia Round 1$90.3m$ 81.9m$82m (2004) Round 4$236.3m$128m$126m (2005) Round 8$129.4m$147m (2006) $216m (2007) $269.2m (2008)

Research Methods MALAWIZAMBIA District samplingurban: 3 2 probability in Malawi rural: 6 1 small + purposive in Zambia 2006 and 2008 Facility record reviews: Probability sampling of facilities Similar data extraction tools Cross-checked + supplemented by routine HIS data Structured questionnaires to health workers and managers Topic-guided interviews

Numbers of clients receiving ART, PMTCT, VCT + outpatient visits: Malawi and Zambia ( )

Staff trends Malawi: (52 facilities) Mar-06Mar-08Mar-06Mar-08 Mar 06_Mar 08_ Mar-06Mar-08 Urban Rural District TOTAL Doctors Nurses Clinical Officers Medical Assistants Total Clinical staff Lab + Pharmacy HSAs (Health Surveillance Assists) TOTAL

Staff trends Zambia: (29 facilities) Health worker category Urban Rural TOTAL Doctors Nurses Clinical Officers & Medical Assistants Total Clinical staff Technicians Dedicated HIV counsellors TOTAL

Country-driven Health Systems Strengthening (HSS) approaches Global Fund (+ UK DfID) agreed to re-allocation of MALAWI Round 1 grant, which enabled Malawi to start to implement its Emergency Human Resource Programme –Doubling in training of new health workers –Hiring 10,000 new staff (mainly HSAs) –Salary supplements ZAMBIA’s National Human Resources Strategic Plan lacked concerted donor support for hiring new health workers 1.Recipient governments (and their partners) need to prioritise the development of HSS strategies 2.Donors can then be encouraged (pressurised) to fund them

Research Funders Country Studies Research Partners Network (GHIN) Funders OSI Open Society Institute Kyrgyzistan Ukraine Zambia LSHTM (UK) EU INCODEV Mozambique Angola South Africa x 2 Lesotho RCSI (Ireland) Belgium Portugal Vietnam Sweden Alliance for Health Policy and Systems Research Tanzania Uganda Peru China Georgia Malawi Ethiopia Benin Malawi Irish Aid DANIDA USAID SWEF Health 20/20 RCSI LSHTM

MALAWI : average clinical staff- outpatient workload 45facilities (6 urban, 6 district hospital, 13 rural health centre)

Zambia: average clinical staff- outpatient workload 22 facilities (9 urban 13 rural)