Has global funding for HIV accelerated or slowed down progress towards the Health MDGs? or Can health systems research produce useful evidence for policy makers and practitioners? Ruairí Brugha Royal College of Surgeons in Irelandand Irish Forum for Global Health 16 th June 2010

Presentation 1.Health systems analysis framework helping to situate where we are all working 2.Illustrations from GHIN (Global HIV Initiative Network) research What effects have the increased funding to HIV had on progress towards the Health and HIV/AIDS MDGs? 3.Research networks New ways for Northern (Irish) researchers to work with researchers from the South

Health Systems Framework GHI Investment Government Expenditure Private Expenditure Other External Expenditure Epidemiological Demographic Political Social / Cultural Legal / human rights Technological Environmental Economic Governance / Coordination Financing Health Workforce Health information Systems Health Technologies Communities Civil Society DELIVERYDELIVERY Health Outcomes Fairness of Financing Access Responsive- ness Historical

Global Fund and PEPFAR HIV funding to Malawi and Zambia Global FundPEPFAR AllocatedDisbursedAllocated Malawi Round 1$342.6m$229.6m (Dec 09)$14.5m (2004) Round 5$17.6m$13.0m (Oct 09)$15.2m (2005) Round 5 (HSS)*$ 52.0m$21.3m (Aug 09)$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$128.0m$126m (2005) Round 8$129.4m$147m (2006) $216m (2007) $269.2m (2008)

HIV/AIDS assistance: levels of funding by global health initiatives Ethiopia Uganda

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

ZAMBIA: Scale up in HIV and AIDS services across the three districts:

Staff trends Zambia: (29 facilities) Health worker category Urban Rural TOTAL Doctors Nurses Clinical Officers & Medical Assistants Total Clinical Staff: Doctors, Clinical Officers, medical assistants and nurses Technicians (lab + pharmacy) Health Surveillance Assistants + Dedicated HIV counsellors TOTAL

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

PMTCT coverage (12 facilities with complete data)

Reproductive Health Service coverage : % of women of child-bearing age (15-49 years) registered for antenatal care and family planning

Infant vaccination and ART trends,

Intrafacility correlations in service trends between HIV and non-HIV services, (Spearman rank correlations > 0.3 highlighted) Facilities reporting Clients for two services Number of facilities Spearman Rank Correlation (positive unless otherwise stated) ART and Antenatal Clinic ART and Family Planning Clinic ART and DPT 3 vaccine ART and BCG vaccine PMTCT and Antenatal Clinic PMTCT and Family Planning Clinic PMTCT and DPT 3 vaccine PMTCT and BCG vaccine VCT and Antenatal Clinic VCT and Family Planning Clinic VCT and DPT 3 vaccine VCT and BCG vaccine

Correlation in ART and Family Planning service trends,

Conclusions 1.HIV service scale-up (MDG 6) is happening (or was up to 2008 – is this still the case??) 2.Some evidence that other priority services (MDG 4 – children and 5 – maternal health) are benefiting this hypothesis needs to be explored / tested 3.But... Health workers are increasingly being stretched, especially in rural areas A failure of policy and strategic responses by governments and donors alike

Research Funders Country Studies Research Partners Network (GHIN) Funders OSI 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

Network Aims: Promote comparability through common research protocols and tools 2.Share expertise across country study teams and build research capacity 3.Generate multi-country comparisons and context specific lessons 4.Coordinate dissemination of findings/recommendations at global level Thank you Irish Aid!

Acknowledgement 1.All of the GHIN study teams ―esp Gill Walt and London (LSHTM) team 2.Zambian colleagues: ―Joseph Simbaya and Phillimon Ndubani 3.Aisling Walsh