1. 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 www.ghinet.orgwww.ghinet.org Irish Forum for Global Health 16 th June 2010

2. 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

3. 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

4. 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)

5. www.cgdev.org/content/publications/detail/13029 HIV/AIDS assistance: levels of funding by global health initiatives Ethiopia Uganda

6. 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 69

7. ZAMBIA: Scale up in HIV and AIDS services across the three districts: 2004-07

8. Staff trends Zambia: 2004-07 (29 facilities) Health worker category200420072004200720042007 Urban Rural TOTAL Doctors 1623662229 Nurses 38438161 445442 Clinical Officers & Medical Assistants 766716159282 Total Clinical Staff: Doctors, Clinical Officers, medical assistants and nurses 4764718382 559553 Technicians (lab + pharmacy) 51624115573 Health Surveillance Assistants + Dedicated HIV counsellors 475616216377 TOTAL 574589103114677703

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

10. PMTCT coverage 2004-07 (12 facilities with complete data)

11. Reproductive Health Service coverage 2004-07: % of women of child-bearing age (15-49 years) registered for antenatal care and family planning

12. Infant vaccination and ART trends, 2004-07

13. Intrafacility correlations in service trends between HIV and non-HIV services, 2005-07 (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 90.22 ART and Family Planning Clinic 90.83 ART and DPT 3 vaccine 90.00 ART and BCG vaccine 90.27 PMTCT and Antenatal Clinic120.50 PMTCT and Family Planning Clinic120.33 PMTCT and DPT 3 vaccine12 - 0.11 PMTCT and BCG vaccine120.14 VCT and Antenatal Clinic110.12 VCT and Family Planning Clinic110.38 VCT and DPT 3 vaccine110.15 VCT and BCG vaccine11 - 0.30

14. Correlation in ART and Family Planning service trends, 2005-07

15. 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

16. 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

17. Network Aims: 2006-10 1.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!

18. 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