Positive Synergies and the Health Workforce
Andrew L Ellner M.D., M.Sc.Global Health Delivery Project
Brigham and Women’s HospitalHarvard Medical School
Policy Question
How can global health initiatives and national health systems optimize their interactions to capitalize on positive synergies and minimize negative impacts, thereby achieving their common goal of improving health outcomes?
WHO Positive Synergies Initiative
• WHO-led initiative for G8 Summit, Italy 2009
• 3 consortia: – Academic – Civil society– Implementers
• Fifteen academic partners from Africa, Asia, Europe, and the U.S.
Institute of Tropical Medicine, Antwerp
Kenyatta University
Public Health Foundation of India
Royal College of Surgeons, Ireland
The AIDS Support Organization (TASO)
University of Pretoria
University of the Western Cape
University of Yaoundé
Imperial College, London
Heartfile, Pakistan
George Washington University
Dakar University Teaching Hospital
Center for Global Development
Agence Nationale de Recherche sur le Sida
Harvard University
Academic Consortium
WHO Health Systems Building Blocks
Adapted from: WHO six building blocks and RA Atun et al, 2006
Health Outcomes
Fairness of Financing
Responsiveness
GHI investment
Health workforce
Governance
Monitoring and Evaluation
Health Technologies
D
E
L
I
V
E
R
Y
Privateexpenditure
Governmentexpenditure
Financing
Other externalexpenditure
Epidemiological
PoliticalDemographic
Environmental
Technological
Social
Economic
Legal
Communities/Civil Society
Conceptual Framework
Pathways to Impact
Health Outcomes
Fairness of Financing
Responsiveness
GHI investment
Health workforce
Governance
M & E
Technologies
D
E
L
I
V
E
R
Y
Privateexpenditure
Governmentexpenditure
Financing
Other externalexpenditure CSO/Communities
Country-level mixed methods analysis
Cross-country quantitative analysis
Provider-unit level analysis
Levels of Analysis
Identify relationships
Understand relationships
Understand the impact
WHO Positive SynergiesResearch Questions
How do GHI-funded programmes interact with health systems in varied country contexts?
WHO Positive SynergiesMethods
InstitutionsNational AIDS Control Council
WHOPEPFAR
Global Fund for AIDS, Malaria, and Tuberculosis
USAIDCDC
UNAIDSAAR Private Healthcare
National NewspaperMinistry of Health
Treasury DepartmentFamily Health InternationalAidspan GFATM watchdog
Ministry of Public Health and SanitationAIDS NGO Consortium
• Qualitative and quantitative case studies• Key informants:
WHO Positive Synergies Research Questions
How do different health system designs and specific implementation strategies influence the coverage of targeted and non-targeted interventions?
WHO Positive SynergiesMethodsFacility Assessment Tool
WHO Positive Synergies Timeline
Summer2008
Fall2008
Winter2008-2009
Spring2009
Summer2009
May 29-30:1st Consultation, Geneva
July 15 – 16:Drs. Carissa Etienne & Badara Samb visit Harvard
August 4:WHO Satellite Panel
August 5:2nd Consultation, Mexico City
August 15:Prof. Rifat Atun visits Harvard
• October 2 - 3:3rd Consultation, Geneva
• November 3 - 4:Dr. Badara Samb visits Harvard
• Nov - Dec:Data collection begins
• August 5:2nd Consultation, Mexico City
• August 15:Prof. Rifat Atun visits Harvard
• Jan - Feb:Data collection continues
• February 16 - 17:Lancet special issue mtg, Rome
• March 9:Consortium submits preliminary results
• March 20:Draft circulated to consortium
• March 26 - 27:4th Consultation, Geneva
• March 28:Working meeting of Academic Consortium, Gva.
• Mid-April:Monograph submitted
• April - May:Final analyses conducted
• Mid-May:Full-length report submitted
• August 4:WHO Satellite Panel
• August 5:2nd Consultation, Mexico City
• August 15:Prof. Rifat Atun visits Harvard
• June:Publication of monograph & case study library
• July 8 - 10:Results presented at G8 Summit, Italy
• Mid-May:Full-length report submitted
• August 4:WHO Satellite Panel
Existing Evidence & Emerging Themes
Potential impacts:• Distortions in health labor market• Uncompensated increases in workload• Trainings compromising service delivery
(See e.g. Banteyerga 2005, 2006; Gbangbadthore 2006; Mtonya 2005, 2006; Schott 2005)
WHO Positive Synergies Project
GHIsLearning institutions
Early in major GHI implementation
Few countries
Cross-sectional
Mostly Qualitative
????
PEPFAR: 6 years of evidenceGFATM: 7 years of evidence
## countries
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Mixed Methods Approach
Rationale for New Research
New Evidence &Emerging Themes
Potential Synergies:• Strategic top-ups, QOL incentives,
infrastructure improvements• Building capacity through training and
task-shifting• Flexible GHI funding for health workforce
(See e.g. Oomman 2007; Sepulveda 2007; Samb 2008; Atun 2009; Brenzel 2009)
1. Time2. Time3. Time4. Qualitative methods5. Sampling strategy6. Data Availability
WHO Positive SynergiesChallenges
• Global network/Public-private-academic partnerships
• GHIs: learning institutions• Improved health
WHO Positive SynergiesPromise
References• Atun R, Shakarishvili G, Kley N, Blakely M, Godfrey-Faussett P, Boillot F, Lansang MA 2009. Country demand for Health Systems
Strengthening: Analysis of Proposals to the Global Fund to Fight Against AIDS, Tuberculosis and Malaria.
• Banteyerga H, Kidenu A, Bennet S & Stillman K. 2005. The System-Wide Effects of the Global Fund in Ethiopia: Baseline Study Report. The Partners for Health Reformplus, Abt Associates, Inc.
• Banteyerga H, Kidenu A, & Stillman K. 2006. The System-Wide Effects of the Global Fund in Ethiopia: Final Study Report. The Partners for Health Reformplus, Abt Associates, Inc.
• Brenzel L and Waddington C. Health System Strengthening (HSS) Support from the GAVI Alliance: Early Experience and Lessons.
• Gbangbadthore S, Hounsa A & Miller-Franco L. 2006. System-Wide Effects of the Global Fund in Benin: Final Report. Health Sytems20/20 Project, Abt Associates, Inc.
• Mtonya B, Mwapasa V & Kadzandira J. 2005. The System-Wide Effects of the Global Fund in Malawi: Baseline Study Report. The Partners for Health Reformplus, Abt Associates, Inc.
• Mtonya B & Chizimbi, S. 2006. The System-Wide Effects of the Global Fund in Malawi: Final Report. The Partners for Health Reformplus, Abt Associates, Inc.
• Oomman N, Bernstein M & Rosenzweig S. 2007. Following the Funding for HIV/AIDS: a comparative analysis of funding practices of PEPFAR, the Global Fund and World Bank MAP in Mozambique, Uganda and Zambia. Center for Global Development.
• Schott W, Stillman K, & Bennett S. 2005. Effects of the Global Fund on reproductive health in Ethiopia and Malawi: baseline findings. The Partners for Health Reformplus, Abt Associates, Inc.
• Sepulveda J, Carpenter C, Curran J et al 2007. PEPFAR Implementation: Progress and Promise. Institute of Medicine.
Thank you
It is not a case of either or: we do not have this option… it is about making sure that all available resources produce the maximum possible benefits in improving the lives & well-beings of our people.
-Dr. Carissa EtienneAssistant Director-GeneralHealth Systems & ServicesWorld Health Organization
• Develop sampling matrix in consultation with partners:– Geographical representation– GHI investment as a percentage of total
health expenditure– High burden of GHI-targeted disease– Existing connections with partner institutions
WHO Positive SynergiesCountry Selection