How countries cope with competing demands and expectations: perspectives of different stakeholders on priority setting and resource allocation for health in the era of HIV and AIDS

BMC Public Health

David Plummer³  Mbela Kiyombo⁶  Victor Mwapasa⁵  Andriamampianina Ralisimalala⁴  Fuseini Sataru²  Seni Kouanda⁷  Lucie Blok¹  Anne Coolen¹  Georges Tiendrebeogo¹  Françoise Jenniskens¹ 

[1] Royal Tropical Institute, Amsterdam, The Netherlands;Centre for Health and Social Services, Accra, Ghana;James Cook University & Queensland Health, Townsville, Australia;Department of Community Health, National Institute of Public and Community Health (INSPC), Antananarivo, Madagascar;College of Medicine, University of Malawi, Blantyre, Malawi;Ecole de Santé Publique, Kinshasa, Democratic Republic of Congo;Biomedical and Public health Department, Institute of Research in Health Science (IRSS), Ouagadougou, Burkina Faso

关键词: Sub-Saharan Africa;    Sector-wide approaches;    Needs and priorities;    Priority setting;    Health systems strengthening;    HIV and AIDS;   

Others  :  1162737
DOI  :  10.1186/1471-2458-12-1071

 received in 2012-07-03, accepted in 2012-11-13,  发布年份 2012

【 摘 要 】

Background

Health systems have experienced unprecedented stress in recent years, and as yet no consensus has emerged as to how to deal with the multiple burden of disease in the context of HIV and AIDS and other competing health priorities. Priority setting is essential, yet this is a complex, multifaceted process. Drawing on a study conducted in five African countries, this paper explores different stakeholders′ perceptions of health priorities, how priorities are defined in practice, the process of resource allocation for HIV and Health and how different stakeholders perceive this.

Methods

A sub-analysis was conducted of selected data from a wider qualitative study that explored the interactions between health systems and HIV and AIDS responses in five sub-Saharan countries (Burkina Faso, the Democratic Republic of Congo, Ghana, Madagascar and Malawi). Key background documents were analysed and semi-structured interviews (n = 258) and focus group discussions (n = 45) were held with representatives of communities, health personnel, decision makers, civil society representatives and development partners at both national and district level.

Results

Health priorities were expressed either in terms of specific health problems and diseases or gaps in service delivery requiring a strengthening of the overall health system. In all five countries study respondents (with the exception of community members in Ghana) identified malaria and HIV as the two top health priorities. Community representatives were more likely to report concerns about accessibility of services and quality of care. National level respondents often referred to wider systemic challenges in relation to achieving the Millennium Development Goals (MDGs). Indeed, actual priority setting was heavily influenced by international agendas (e.g. MDGs) and by the ways in which development partners were supporting national strategic planning processes. At the same time, multi-stakeholder processes were increasingly used to identify priorities and inform sector-wide planning, whereby health service statistics were used to rank the burden of disease. However, many respondents remarked that health system challenges are not captured by such statistics.

In all countries funding for health was reported to fall short of requirements and a need for further priority setting to match actual resource availability was identified. Pooled health sector funds have been established to some extent, but development partners′ lack of flexibility in the allocation of funds according to country-generated priorities was identified as a major constraint.

Conclusions

Although we found consensus on health priorities across all levels in the study countries, current funding falls short of addressing these identified areas. The nature of external funding, as well as programme-specific investment, was found to distort priority setting. There are signs that existing interventions have had limited effects beyond meeting the needs of disease-specific programmes. A need for more comprehensive health system strengthening (HSS) was identified, which requires a strong vision as to what the term means, coupled with a clear strategy and commitment from national and international decision makers in order to achieve stated goals. Prospective studies and action research, accompanied by pilot programmes, are recommended as deliberate strategies for HSS.

【 授权许可】

   
2012 Jenniskens et al.; licensee BioMed Central Ltd.

【 参考文献 】

• [1]Primary health care: report of the International Conference on Primary Health Care, Alma-Ata, USSR, 6-12 September, 1978, jointly sponsored by the World Health Organisation and the United Nations Children’s Fund. Geneva: World Health Organisation; 1978. Health for All Series No 1
• [2]Lawn JE, Rohde J, Rifkin S, Were M, Paul VK, Chopra M: Alma-Ata 30 years on: revolutionary, relevant, and time to revitalise. Lancet 2008, 372(9642):917-927.
• [3]Skolnik R, Jensen P, Johnson R: Aid without impact: How the world bank and development partners are failing to improve health ThroughSWAps.. Washington: Advocacy to Control TB Internationally; 2010.
• [4]Vaillancourt D: Do health sector-wide approaches achieve results? Emerging evidence and lessons from six countries. Washington: Independent Evaluation Group; 2009. [IEG working papers series]
• [5]World Health Organization: Measuring health systems strengthening and trends: a toolkit for countries. Geneva, Switzerland: World Health Organization; 2008.
• [6]Atun R, Dybul M, Evans T, Kim JY, Moatti J-P, Nishtar S, Russell A: Venice statement on global health initiatives and health systems. Lancet 2009, 374(9692):783-784.
• [7]Murray CJ: Quantifying the burden of disease: the technical basis for disability-adjusted life years. Bull World Health Organ 1994, 72:429-445.
• [8]World Health Organization: The global burden of disease: 2004 update. Geneva: WHO; 2004.
• [9]Lopez A, Mathers CD, Ezzati M, Jamison DT, Murray CJ: Global burden of disease and risk factors. Disease control priorities project. Oxford, United Kingdom: Oxford University Press and the World Bank; 2006.
• [10]General Assembly of the United Nations: Declaration of commitment on HIV/AIDS. New York, USA: United Nations; 2001.
• [11]Sachs JD, Brundtland GH: Macroeconomics and health: investing in health for economic development. Report of the WHO commission on macroeconomics and health. Geneva: WHO; 2001.
• [12]UNAIDS: What countries need: investments for 2010 targets. UNAIDS/09.03E – JC1681E. Geneva, Switzerland: UNAIDS; 2009.
• [13]Shiffman J, Berlan D, Hafner T: Has aid for AIDS raised all health funding boats? J Acquir Immune Defic Syndr 2009, 52:S45-S48.
• [14]Adjei S, Nazzar A, Seddoh A, Blok L, Plummer D: The impact of HIV and AIDS funding and programming on health system strengthening in Ghana. Edited by Jenniskens F, Oosterhoff P, Tiendrebeogo G, Wolmarans L. Amsterdam: Royal Tropical Institute (KIT); 2011. [Health system research]
• [15]Bila-Ouédraogo B, Kouanda S, Ouédraogo A, Bocoum F, SangareCazal-Gamelsi S, Bocoum Y, De Jongh T, Tiendrebeogo G: VIH et renforcement des systèmes de santé: exploration des expériences afin de maximiser les synergies: cas de Burkina Faso. Edited by Blok L, Jenniskens F, Oosterhoff P, Wolmarans L. Amsterdam, Pays-Bas: Royal Tropical Institute (KIT); 2011. [Health system research]
• [16]Kiyombo M, Munyanga M, Konde NN, Mimboro L, Pero A, Tiendrebeogo G, Coolen A, Health System R: VIH et renforcement des systèmes de santé, Etudes de cas plurinationales pour la recherche de données probantes permettant d'optimiser les synergies - l'expérience de la république démocratique du Congo. Edited by Blok L, Jenniskens F, Oosterhoff P, Wolmarans L. Amsterdam: Royal Tropical Institute (KIT); 2011. [Health system research]
• [17]Mwapasa V, Kadzandira J, Jenniskens F, Plummer D, Wolmarans L: The impact of HIV and AIDS funding and programming on health system strengthening in malawi. Health system research series No. 4. Edited by Blok L, Oosterhoff P, Tiendrebeogo G. Amsterdam: Royal Tropical Institute (KIT); 2011.
• [18]Ranjalahy RJ, Ratsimbazafy MR, Blok L, Coolen A, Jenniskens F: VIH et renforcement des systèmes de santé: exploration des expériences afin de maximiser les synergies: cas de Madagascar. Health system research series No. 1. Edited by Oosterhoff P, Tiendrebeogo G, Wolmarans L. Amsterdam, Pays-Bas: Royal Tropical Institute (KIT); 2011.
• [19]Conseil National de Lutte Contre Le Sida et les Infections Sexuellement Transmissibles: Etude de cas. De l’expérience du Burkina Faso dans l’estimation des flux des ressources et dépenses de lutte contre le VIH/sida et les IST. Burkina Faso: CNLS/IST; 2007.
• [20]UNAIDS: Rapport de situation national à l’intention de l’UNGASS. Madagascar (période considérée: janvier 2008-décembre 2009). Geneva, Switzerland: UNAIDS; 2010.
• [21]Ministère de la Santé: Comptes nationaux de la santé et sous comptes paludisme, tuberculose et VIH/SIDA année 2009. Burkina Faso: Ministère de la Santé; 2011.
• [22]Programme National Multisectoriel de Lutte contre le VIH/SIDA: Rapport national de suivi UNGASS. DRC: Programme National Multisectoriel de Lutte contre le VIH/SIDA; Présidence de la République; 2008.
• [23]Office of the President and Cabinet of the Republic of Malawi and UNAIDS: Malawi HIV and aids monitoring and evaluation report: 2008–2009. UNGASS country progress report. Reporting period: January 2008-december 2009. Lilongwe, Malawi: Government office; 2010.
• [24]Ghana Aids Commission: Ghana’s Progress report on the united nations general assembly special session (UNGASS) declaration of commitment on HIV and aids reporting period January 2008 – December 2009. Accra, Ghana: Ghana Aids Commission; 2010.
• [25]Asante F, Fenny A: Ghana national aids spending assessment 2007. Level and flow of resources and expenditures to confront HIV and aids. Accra, Ghana: Institute of Statistical, Social and Economic Research (ISSER), University; 2008.
• [26]Conseil National de Lutte Contre Le Sida et les Infections Sexuellement Transmissibles: Estimation des flux de ressources et de dépenses nationales de lutte contre le VIH et les IST, Burkina Faso. Ouagadougou, Burkina Faso: CNLCS; 2009.
• [27]Conseil National de Lutte Contre Le Sida et les Infections Sexuellement Transmissibles Burkina Faso et ONUSIDA: Rapport UNGASS 2010 du Burkina Faso. Suivie de la déclaration d’engagement sur le VIH/sida. Ouagadougou, Burkina Faso: CNLCS; 2010.
• [28]UNAIDS: Global report; UNAIDS report on the global AIDS epidemic 2010. Geneva, Switzerland: UNAIDS; 2010.
• [29]Travis P, Bennett S, Haines A, Pang T, Bhutta Z, Hyder AA, Pielemeier NR, Mills A, Evans T: Overcoming health-systems constraints to achieve the millennium development goals. Lancet 2004, 364(9437):900-906.
• [30]Yu D, Souteyrand Y, Banda MA, Kaufman J, Perriëns JH: Investment in HIV/AIDS programmes: does it help strengthen health systems in developing countries? Glob Healh 2008, 4:8. BioMed Central Full Text
• [31]England R: Lessons and myths in the HIV/AIDS response. Lancet 2009, 374(9702):1674. Author reply 1675–6. 2009. Retrieved from: http://www.ncbi.nlm.nih.gov/pubmed/19914508 webcite
• [32]World Health Organization: The world health report 2008, primary health care – Now more than ever. Geneva: World Health Organization; 2009.
• [33]Atun R, Lazarus J, Van Damme W, Coker R: Interactions between critical health system functions and HIV/AIDS, tuberculosis and malaria programs. Health Policy Plan 2010, 25:i1-3.
• [34]Coker R, Balen J, Mounier-Jack S, Shigayeva A, Lazarus J, Rudge J, Naik N, Atun R: A conceptual and analytical approach to comparative analysis of country case studies: HIV and TB control programs and health systems integration. Health Policy Plan 2010, 25:i21-31.
• [35]Baltussen R, Niessen L: Priority setting of health interventions: the need for multi-criteria decision analysis. Cost Eff Resour Alloc 2006, 4:14. BioMed Central Full Text
• [36]World Health Organization: An assessment of interactions between global health initiatives and country health systems. Lancet 2009, 373(9681):2137-2169.
• [37]Biesma RG, Brugha R, Harmer A, Walsh A, Spicer N: The effects of global health initiatives on country health systems: a review of the evidence from HIV/AIDS control. Health Policy Plan 2009, 24(4):239-52.
• [38]Reich MR, Takemi K: G8 And strengthening of health systems: follow-up to the toyako summit. Lancet 2009, 373:508-515.
• [39]Avila C, Menser N, McGreevey W: HIV and AIDS programs: How they support health system strengthening. Georgetown: Aids2031Financing Working Group and Result for Development Institute; 2009. [Aids2031 Working paper N0. 18]
• [40]Blok L, Plummer D, Tiendrebeogo G, Jenniskens F: Impact of HIV programs on Health system strengthening in five African countries; Methodological challenges in studying complex systems. In Capacity strengthening for knowledge generation: Experiences in the context of health and development, chapter 4.. Edited by Kwaak A, Hermen O, Annemiek R. Amsterdam: Royal Tropical Institute (KIT) Publishers; 2012.
• [41]Addai E, Gaere L: Capacity-building and systems development for sector wide approaches (SWAps): the experience of the Ghana health sector. 2001.
• [42]Government of Malawi, Office of the President and Cabinet, NAC: National HIV/aids policy: a call for renewed action. Lilongwe, Malawi: Office of the President; 2003.
• [43]Department of Planning, Ministry of Health of the Republic of Malawi: A health sector-wide approach (SWAp) [2004–2010]. Lilongwe, Malawi: Ministry of Health; 2004.
• [44]Présidence de la République, Madagascar: Madagascar action plan 2007–2011. Antananarivo: PRM; 2007.
• [45]République Démocratique du Congo – Ministère de la Santé Publique: Plan national de développement sanitaire PNDS 2011–2015. 2010.
• [46]Smith HJ: Ownership and capacity: Do current donor approaches help or hinder the achievement of international and national targets for education? Int J Educ Dev 2005, 25(4):445-455.
• [47]Swanson RC, Bongiovanni A, Bradley E, Murugan V, Sundewall J, Betigeri A, Nyonator F, Cattaneo A, Harless B, Ostrovsky A, Labonté R: Toward a consensus on guiding principles for health systems strengthening. PLoS Med 2010, 7(12):e1000385.