Extent and Nature of Integration of HIV/AIDS programme and national health systems:

Case Study in Ghana

Daniel Degbotse, MoH Ghana

“Bridging the Divide: Inter-disciplinary Partnerships for HIV and Health Systems”

16th to 17th July 2010

“You cannot have centers of excellence (the programs) in the midst of degradation (health system).”

- National Government Stakeholder

Objectives & Methodology• Objectives: To document the

– Extent and Nature of Integration of HIV/AIDS programme into national health system

– Interactions between Global Fund supported programmes and national health systems

– System-wide effects of HIV/AIDS on National Health Systems

• Methodology– Field work undertaken Nov 2008 to Jan 2009– Semi-structured interviews with Key informants

• 36 informants interviewed• 2 regions visited

Ghana: Contextual BackgroundDemographic/Socio-economic• Population: 24.2 million (2009 projections) • 46% Urban; concentrated in 3 regions• Literacy: 57.9% (2000 Census)• Political: Multiparty democracy restored in 1992• Economy:• National economy / GDP growing at 5 -6%• GNI per Capita Int $ 1,480 (PPP)• HDI – 0.526;

– Ghana ranks 152 out of list of 182 countries in 2009

Health Profile: Ranking and Percentage contribution (Source: WHOSIS)

Mortality Morbidity (DALYs)

• HIV/AIDS 1 (13.7%) 1 (12.5%)• Malaria 3 (6.9%) 3 (7.7%)• Tuberculosis 7 (5.1%) 6 (4.0%)• Perinatal conditions 2 (8.3%) 2 (9.5%)

WESTERN

ASHANTI

BRONG AHAFO

CENTRAL

EASTERN

GREATER ACCRA

NORTHERN

VOLTA

UPPER EAST

UPPER WEST

200 0 200 400 600 Miles

NBurkina Faso

Ivory Coast

Togo

Gulf of Guinea

Map of Ghana showing The Regions

HIV/AIDS in Ghana• Estimated National HIV Prevalence – 1.9% (1.7% - 2.2%)

– Urban 2.3%; Rural 1.7%– Amongst MARPS (Sex Workers) 25.1% (reduced from 34% in 2006)

• Predominantly hetero-sexual transmission– Low risk (30.2%); Casual (15.5%); sex with partners of clients of sex workers

(23%);

• Awareness of HIV (2009) - Universal (98%) – Comprehensive knowledge – males 34%; females 28% (33% and 25% in 2006)

PLWHA (2009) 240,000

New HIV infections per year (estimated) 21,000

Deaths due to HIV/AIDS (2009) 17,000

Number of patients initiated on ART (2009) 33,745 (90% currently on ART)

ART coverage (2009) 40% (26% in children; 46% in adults)

Health Sector Reforms Initiative• Sectoral reforms initiated in 1990s

• Adoption of SWAp - 1997 – Medium Term Health Strategy developed with 5 year Programme of Work

• 1st 5 yr POW 1997-2001 – Building systems for improving health• 2nd 5 Yr POW 2002-2006 – Maximize the gains and develop new strategies • 3rd 5 Yr POW 2007-2001 – Creating Wealth Through Health

• 1997 – Act 525 was passed– MOH – Policy formulation and regulatory function– Ghana Health Services and other agencies – Service delivery and

implementation of programmes

• Introduction of NHIS - 2003– Innovation - VAT is charged at 15% (10% for general government revenue,

2.5% as an earmarked tax for education and 2.5% as an earmarked tax for health insurance).

Health Financing: Trends in contribution by source

GOG SBP NHIF User Fees Earmarked• Item 1(Personal Emoluments) 93% 3% 4%• Item 3: (Service Expenses) 3% 11% 64% 23% • Item 4: (Investment Expenses 10% 7% 33% 35%

Key System related challenges

• High disease burden – Communicable diseases - including HIV & Malaria, burden of Neglected tropical Diseases, high Maternal and child mortality; rising trend of NCDs

• Health financing– Large proportion of government funds allocated to salaries– Item 3 of budget – for service delivery – donor fund dependent (34%)

• 99% of CD control budget comes either from SBS (7%) / Earmarked funds (93%)– NHIS – roll out and management of NHIS

• Human resource availability and distribution– High attrition rate, mal-distribution in numbers and by skill mix

• Governance and Performance Management

Integration and Synergies of HIV/AIDS Program and national health systems

Financing of HIV/AIDS Response

• Increasing investments in HIV/AIDS– US$ 28 million in 2005– US$ 52 million in 2007– US$ 38 million in 2008

• Global Fund HIV grants (Rd 1, 5 and 8)– Total approved funding US$ 160 M– Total disbursed US$ 112 M– 67% of expenditure is towards

procurement of health products/ commodities/ equipments

• Global Fund accounted for 82% of external funding in 2007

Public, 13.70%

Private, 2.40%

External

Resources,

83.90%

Extent of IntegrationNational Regional District

Stewardship & Governance

HIV/AIDS Program NAC & NACP Oversight by RHD

Oversight by DHO

Global Fund Grants

CCM Oversight by RHD

Oversight by DHO

FinancingHIV/AIDS Program Pooled Pooled Pooled

Global Fund Grants

Earmarked Earmarked Earmarked

Planning

HIV/AIDS Program Done by NAC/ NACP; aligned with National Strategic Plan

Component of Regional Plans

Component of District Annual Plans

Global Fund Grants

In line with National Strategic Plan; varying cycles – rounds based

Activities determined by approved funding

Activities determined by approved funding

Highly Integrated Moderate Integration Limited Integration Not Integrated

Extent of Integration

National Regional District

Service delivery (HR/ Infrastructure/ PSM)

HIV/AIDS ProgramGlobal Fund Grants

M&E

HIV/AIDS Program

Feeds into National MIS

Global Fund Grants

Uses same parallel system

Uses same parallel system

Uses same parallel system

Demand Generation

HIV/AIDS Program

Coordinated with Health Promotion Unit

Global Fund Grants

Activities out-sourced to agencies/ NGOs

Highly Integrated Moderate Integration Limited Integration Not Integrated

Factors influencing Integration• Positive influences

– Strong Political Commitment– Epidemiological situation - Generalized epidemic – Underlying SWAp programme– A relatively strong Government Public Health system and leadership

• Challenges– Disproportionate availability of funds to few priority interventions

influencing underlying governance structures– Role of CCM

• viewed as an additional layer and duplication of national structures for sector coordination and oversight;

• sub-optimal oversight function performed by CCM – Ever increasing global demand for information and reporting for the

priority interventions– Project/ Round based nature of donor commitments leading to piece-

meal approach to addressing disease strategy/ planning

Perceptions of Stakeholders

‘The 3 disease control programmes due to the abundance of resources have grown bigger and pushed the disease control unit into oblivion.

Now their offices are separate and much bigger than the ministry’

“Programmes are too strong. They are a State within a State”

“Every disease is under the management of public health officer be it national, regional or district level. If this system is distorted, it would affect the whole structure. … … The delegation of responsibility of

implementing and monitoring the programme to programme officers does not absolve the senior officers from being accountable. Lapses

are individualistic and not a system related issue. ”

What has been achieved?

Number of clients accessing CT services Number of HIV positive clients detected from CT services

Cumulative totals of clients on HIV clinical care and those receiving ART

System-Wide Effects• Positive effects

– On System inputs – health products, commodities/ equipment– Improved collaboration with other sectors and programs – On M&E – growing recognition of need for strong HMIS

• Limited evidence– Human resource availability or distribution (salary top-ups limited

to national program staff)– Institutional capacity (other than Disease program units)

• Challenges– Re-enforcement of parallel disease reporting systems– Continued use of ear-marked (non-pooled) funding – Effects on Governance structures/ arrangements

“As you painfully improve the performance, the system would push itself to maintain the current levels of performance. Even if additional funding ceases, and if basic supplies (drugs/ vaccines) are ensured the system

would be able to deliver”

THANK YOU