1. 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

2. Summary of Global Fund and PEPFAR funding to HIV in Malawi and Zambia: 2004-08 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)

3. Research Methods MALAWIZAMBIA District samplingurban: 3 2 probability in Malawi rural: 6 1 small + purposive in Zambia 2006 and 2008 Facility record reviews: 52 39 Probability sampling of facilities Similar data extraction tools Cross-checked + supplemented by routine HIS data Structured questionnaires to health workers and managers 571 234 Topic-guided interviews 153 61

4. Numbers of clients receiving ART, PMTCT, VCT + outpatient visits: Malawi and Zambia (2004-07)

5. Staff trends Malawi: 2006-08 (52 facilities) Mar-06Mar-08Mar-06Mar-08 Mar 06_Mar 08_ Mar-06Mar-08 Urban Rural District TOTAL Doctors 5965 25 8106980 Nurses 523651 221199 29532910391179 Clinical Officers Medical Assistants 13594 6785 103115305294 Total Clinical staff 717810 290289 40645414131553 Lab + Pharmacy 376511 244662112 HSAs (Health Surveillance Assists) 74158 456737 205381 7351276 TOTAL82810337471027 635881 22102941

6. Staff trends Zambia: 2004-07 (29 facilities) Health worker category 200420072004200720042007 Urban Rural TOTAL Doctors 1623662229 Nurses 38438161 445442 Clinical Officers & Medical Assistants 766716159282 Total Clinical staff 4764718382 559553 Technicians 51624115573 Dedicated HIV counsellors 47561621 6377 TOTAL 574589103114 677703

7. 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

8. 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

10. MALAWI : average clinical staff- outpatient workload 45facilities (6 urban, 6 district hospital, 13 rural health centre) 2006-08

11. Zambia: average clinical staff- outpatient workload 22 facilities (9 urban 13 rural) 2004-07