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Report of Isabel Craveiro (IHMT) presented at the COHRED forum 2012 on the INCO-GHI research project

Report of Isabel Craveiro (IHMT) presented at the COHRED forum 2012 on the INCO-GHI research project

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    GHI Angola overview GHI Angola overview Presentation Transcript

    • Instituto de Higiene e Medicina Tropical WHO Collaborating Centre for Health Workforce Policy and Planning Universidade Nova de Lisboa-Portugal Global Health Initiatives and health system in Angola Craveiro, I.; Dussault, G; Vicente, N. COHRED Global Forum 2012 Cape Town, 23 April 20121
    • Outline Background Research questions Methods Findings  Human Resources for Health  Financing of health systems  Donor harmonization and Global Health Initiative  Civil Society and NGOs Final Remarks 2
    • Selected Social, Economic and HealthIndicators for Angola Parameters ValueTotal Population (in million – UNDATA, 2011) 19.08Proportion of population below $1 (PPP) per day (%) (Angola, MDG report, 54,32011)Under five mortality rate/1,000 live births (2009) (UNDATA, 2011) 160,5Maternal mortality ratio/100,000 live births (2008) (UNDATA, 2011) 610Prevalence of HIV, total (% of population ages 15-49 (2007) (UNDATA, 2.1Distribution of causes of death among children aged <5 years (%) – Malaria2011) 9.7(WHO, 2004)Prevalence of TB (2007) (WHO, 2008) 294Proportion of aid by external partners (%) (Oliveira, 2010) 14• Angola has one of the lowest HIV prevalence rates in sub-Saharan Africa.• Tuberculosis (TB) is a major public health problem in Angola.• Malaria is the leading cause of morbidity and mortality in Angola, accounting for 60% of under five hospital admissions, 35% of under five deaths and 10,000 deaths a year. It’s the first cause of under-5 deaths and case fatality rate varies between 15-30% (MINSA, 2005) 3
    • The National Health Service in Angola is organized in three levels of cares Administrativ e levels • Health service delivery is divided 3rd level into three levels of care (primary, Nation Centra CENTRAL HOSPITALS 8 secondary, and tertiary) corresponding to the three levels al l (National Referral)Provincial Health of government (district, provincial,Directorate s 18 Regions 2nd level PROVINCIAL HOSPITAL 32 and national). Municipal Health 228  The MINSA carries out its Centres / Municipal HospitalsMunicipalDirectorat Health Interventi 1st level Health Centres - Rural Company stewardship and technical guidance role, namely through es on areas - Urban Health Units Heath Posts Private Health clinics 1.453 national vertical health Community programmes supported by Volunteer health workers, traditional partners such as the EU, UN agencies and the US government. midwives, therapists 4 Source: Adapted from the Research, Planning and Statistical Office of the Ministry of Health (2007)
    • Background - health policyAbsence of a concrete guiding sector policy, despite the steps taken towards consolidating the national health policy - national health plan is “under construction”Country only have specific plans:  Human Resources Development Plan (The first strategic plan elaborated by the health sector – weak implementation)  Strategic Plan for the Accelerated Reduction of Maternal and Infant Mortality Rates in Angola  PAV – “Immunization Program”  TB strategic plan  Malaria strategic plan  HIV-AIDS 5
    • Donors disbursement Donor Period Value Area Health SystemEU 2004-2010 €21M (US$ 28M) RevitalizationGHI 2010 US$40M HIV-AIDSGlobal Fund   US$78M MalariaGAVI 2003-2010 US$17M Penta vaccinesUNDP-GF On-going US$31M  World Bank 2006-2011 US$21M Malaria / HIV / TB(MAP-HAMSET) Source: USAID, 2010• Angolas experience with global health initiatives (GHIs) is relatively recent.• About six global health initiatives are present in Angola, namely GAVI, GFATM, PMI, Polio Eradication, Stop TB and PEPFAR (since 2009).• In Angola GHIs are mainly located in Luanda (the capital) 6
    • Research questions How GHI’s influenced the organization of the health services system in Angola (and vice-versa)? Which are the limitations to and the potentialities of a more effective integration of GHI’s? Which are the effects of GHI’s on HRH planning, distribution, retention and management ? 7
    • Methods NATIONAL LEVEL PROVINCIAL LEVEL Data were collected through individual Data were collected through individual semi-structured interviews - conducted semi-structured interviews - conducted between April and June 2009 between March and September 2011 12 participants at national level: - total of 30 participants at provincial • 3 NGO’s level • 3 (advisors from the Ministry of Health / PAV-MINSA “program on immunization”) • 5 (donors) • Minister of Health HRH – Focus Group • November 20106 participants of national and provincial level – HRH managers: 4 HR Department - MINSA 1 Military Health Service 1 Clinical Director - Provincial Hospital 8
    • HUMAN RESOURCES FOR HEALTH How did GHIs and MINSA respond to the following themes HRH workingHRH supply conditions HRH performance HRH education management 9
    • GHI IMPACT ON HRH - National level findings Increased transparency in public management - required to comply with the procedures of the GHI’s Management burden related with GHI’s funding Better coordination of training between GHI’s and public sector Creation of national institutions for human resources training - to harmonize HRH Salaries harmonization between NGO’s and public sector Better supervision for GHI’s funded, but with more difficulties at provincial level 10
    • There is a paradox:On one hand, “there is always HRH shortages” –especially in remote areas.“ We have a laboratory in a Municipal Hospital, but it does notwork because we do not have trained technicians”But on the other hand, in the provincial capital there is asurplus“due to war, health workers concentrated in the provincialcapital and no one wants to go back to municipalities of theinterior.” 11
    • FINANCING OF HEALTH SYSTEMS What about crowding out, dependency, negotiation capacity, sustainability, and priority-setting? There is no dependency on external funds - each partner complement s government actions related to the national strategic programs. At national level ,GHIs funds are directly channeled to MINSA and to UNDP as main sub-recipient in the case of GFATM funds for Malaria GHI MINSA PNUD NGOs At provincial level, direct financing to NGO predominates, which is not compatible with Angolan policy (Benguela) GHI NGOs“The GHIs should try to identify NGOs available in the province that intervene inspecific sector,s promote a competition for funds and choose the best project.” 12
    • FINANCING OF HEALTH SYSTEMSFunds received by the municipal hospital comes directly from state budget -MINSA.Municipal hospital managers do not know the amount channeled by theGHIs, nor which are the GHIs that finance the MINSA. But at municipality level there is knowledge and valorization of thecontribution of the multilateral and bilateral partners – mainly because ofcontributions to hospital material supplies and infrastructures (Centros deAtendimento e Testagem Voluntária) - VCT Provincial Hospital level Material National MINSA funding level13
    • DONOR HARMONIZATION AND GLOBAL HEALTH INITIATIVESThere are various initiatives to improve government capacity to developprotocols and standards, and to help their implementation at the differentlevels.At national levelThe Country Coordination Mechanism (CCM), which is responsible for thecoordination of technical proposals to the Global Fund , has matured notablyover the past five years and has a strong leadership.At provincial levelThere is not a provincial Coordination Mechanism. There is the UTCH –Unidade de coordenação da ajuda humanitária (Government’s coordinatingbody of NGO activities) 14
    • National level findingsHarmonization• A process still in its beginning in Angola;• Leadership needs to be assumed by the GovernmentMINSA perception:Advantages of GHI’s – resources; technical and management transfer of knowledge; beginning of strategic planning in the countryDisadvantages of GHI’s – competition with the MINSA for skilled Human Resources 15
    • National level findingsNational policy development• Leadership must be assumed by Ministry of HealthDonors perception: difference between war (emergency action) and current situation – need for dialogue with government / policy-makers; countries have to organize a platform that integrates international aid / GHIMinistry of Health perception:Intersectoral collaboration is still weakMonitoring and evaluation• Major weaknesses in monitoring and evaluation system 16
    • CIVIL SOCIETY AND NGOsCivil society is weak in Angola, and political and societal space for civil society islimited.NGOs lack capacity to prepare and articulate sound proposals that can attractand meet the requirements of available funding sources.Angolan authorities have not fully accepted civil society’s voice and controlfunctions. National NGOs have limited membership bases, and are dependenton foreign funding. 127 international 464 national 25 faith-based There are no NGOs NGOs organizations reliable numbers on how many CBOs UTCHA (Unidade Técnica de Coordenação da Ajuda Humanitária) - Government’s coordinating body of NGO activities, 2011 17
    • CIVIL SOCIETY AND NGOS – Provincial level NGOs National“NGOs have weak coordination and lack of transparency. If a NGO disappears inthe middle of a project and does not report their results to the donor and the NGOsmanagers also disappear, the UTCH can do nothing.”“If the NGOs disappear and do not fulfill the plan or project sketched, UTCH do notact like polices, their mission is going to coordinate and do not punish the NGO.The main reason for that is that the UTCH receives nothing from the GHIs”.UTCH has the responsibility of coordination and supervision, but each sector orthematic area also fulfills that mission. 18
    • CIVIL SOCIETY AND NGOs – Provincial levelBefore civil war Foreign aid - MINSA Funds NGOs After civil war Funds GHIs - NGOs MINSA“During the civil war ,NGOs were a small farm where everyone wants to work,because they paid relatively well, with most funds.Nowadays it change, people runaway from NGOs to work in the public sector,because it offers higher salaries than the NGOs.Most NGO‘s pay low salaries to their workers and sometimes don’t pay at all.”“People from NGOs used to work part-time during 2 hours and just when projectswere available.”There is internal migration of the NGOs staff to public sector. 19
    • Conclusions Angola is not a country dependent on external funds, The arrival of the GHIs was an opportunity to strengthen government capacity to lead the process of policy definition and to undertake strategic planning in health. Difficulties in terms of alignment and integration of aid remain. in general there were more positive than negative effects of GHIs.  On the negative side, short-term initiatives raise the issue of sustainability of their effects and they are less likely to have only limited development impact. 20
    •  GHIs contributed to weakening health services when they recruited qualified health technicians from the national health system – currently is changing “parallel information system” - was a way of GHIs deal with the weakness of heath information system of the country.  It contributed to the workload of health professionals who had to collect different kind of indicators and data.  GHIs did not opted for strengthening the national information system. At least, GHIs could simplify reporting procedures of GHIs and at the same time contribute to building information collection and analysis, and monitoring capacity. 21
    •  Efforts towards the harmonization between different global initiatives and government’s activities must continue,  with a shared objective of ensuring the sustainability of the various interventions which they support.  Thank you. 22