International Journal of Health Policy and Management

International Journal of Health Policy and Management

District Health Officer Perceptions of PEPFAR’s Influence on the Health System in Uganda, 2005-2011

Document Type : Original Article

Authors
Nathaniel Lohman 1
Amy Hagopian 1, 2
Samuel Abimerech Luboga 3
Bert Stover 2
Travis Lim 4
Frederick Makumbi 3
Noah Kiwanuka 3
Flavia Lubega 3
Assay Ndizihiwe 4
Eddie Mukooyo 5
Scott Barnhart 1
James Pfeiffer 1, 2
1 Department of Global Health, University of Washington, Seattle, WA, USA
2 Department of Health Services, University of Washington, Seattle, WA, USA
3 Faculty of Health Sciences, Makerere University, Kampala, Uganda
4 Division of Global HIV and Tuberculosis, Atlanta, GA, USA
5 Resource Center for the Uganda Ministry of Health, Uganda Ministry of Health, Nakasero, Uganda
10.15171/ijhpm.2016.98
Abstract
Background
Vertically oriented global health initiatives (GHIs) addressing the HIV/AIDS epidemic, including the President’s Emergency Plan for AIDS Relief (PEPFAR), have successfully contributed to reducing HIV/AIDS related morbidity and mortality. However, there is still debate about whether these disease-specific programs have improved or harmed health systems overall, especially with respect to non-HIV health needs.
 
Methods
As part of a larger evaluation of PEPFAR’s effects on the health system between 2005-2011, we collected qualitative and quantitative data through semi-structured interviews with District Health Officers (DHOs) from all 112 districts in Uganda. We asked DHOs to share their perceptions about the ways in which HIV programs (largely PEPFAR in the Ugandan context) had helped and harmed the health system. We then identified key themes among their responses using qualitative content analysis.
 
Results
Ugandan DHOs said PEPFAR had generally helped the health system by improving training, integrating HIV and non-HIV care, and directly providing resources. To a lesser extent, DHOs said PEPFAR caused the health system to focus too narrowly on HIV/AIDS, increased workload for already overburdened staff, and encouraged doctors to leave public sector jobs for higher-paid positions with HIV/AIDS programs.
 
Conclusion
Health system leaders in Uganda at the district level were appreciative of resources aimed at HIV they could often apply for broader purposes. As HIV infection becomes a chronic disease requiring strong health systems to manage sustained patient care over time, Uganda’s weak health systems will require broad infrastructure improvements inconsistent with narrow vertical health programming.

Highlights

 

 

Watch the Video Summary here. 

 

Keywords
President’s Emergency Plan for AIDS Relief (PEPFAR)
Health System Strengthening
Global Health Initiatives (GHIs)
District Health Officers (DHOs)
Uganda
HIV
Subjects

 

 

  1. Bendavid E, Bhattacharya J. The President's Emergency Plan for AIDS Relief in Africa: an evaluation of outcomes. Ann Intern Med. 2009;150(10):688-695. doi:10.7326/0003-4819-150-10-200905190-00117
  2. Bass E. The two sides of PEPFAR in Uganda. Lancet. 2005;365(9477):2077-2078. doi:10.1016/s0140-6736(05)66717-7
  3. Hanefeld J. How have Global Health Initiatives impacted on health equity? Promot Educ. 2008;15(1):19-23.
  4. Yu D, Souteyrand Y, Banda MA, Kaufman J, Perriëns JH. Investment in HIV/AIDS programs: Does it help strengthen health systems in developing countries? Global Health. 2008;4(1):8.
  5. Biesma RG, Brugha R, Harmer A, Walsh A, Spicer N, Walt G. 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):239-252. doi:10.1093/heapol/czp025
  6. Samb B, Evans T, Dybul M, et al. An assessment of interactions between global health initiatives and country health systems. Lancet. 2009;373(9681):2137-2169. doi:10.1016/s0140-6736(09)60919-3
  7. De Cock KM, El-Sadr WM, Ghebreyesus TA. Game changers: why did the scale-up of HIV treatment work despite weak health systems? J Acquir Immune Defic Syndr. 2011;57 Suppl 2:S61-63. doi:10.1097/QAI.0b013e3182217f00
  8. Rasschaert F, Pirard M, Philips MP, et al. Positive spill-over effects of ART scale up on wider health systems development: evidence from Ethiopia and Malawi. J Int AIDS Soc. 2011;14 Suppl 1:S3. doi:10.1186/1758-2652-14-S1-S3
  9. Oomman N, Bernstein M, Rosenzweig S. Seizing the opportunity on AIDS and health systems. Washington, DC: Center for Global Development; 2008.
  10. Shiffman J. Has donor prioritization of HIV/AIDS displaced aid for other health issues? Health Policy Plan. 2008;23(2):95-100.
  11. Marchal B, Cavalli A, Kegels G. Global health actors claim to support health system strengthening: is this reality or rhetoric? PLoS Med. 2009;6(4):e1000059. doi:10.1371/journal.pmed.1000059
  12. Grepin KA. HIV donor funding has both boosted and curbed the delivery of different non-HIV health services in sub-Saharan Africa. Health Aff (Millwood). 2012;31(7):1406-1414. doi:10.1377/hlthaff.2012.0279
  13. Price JE, Leslie JA, Welsh M, Binagwaho A. Integrating HIV clinical services into primary health care in Rwanda: a measure of quantitative effects. AIDS Care. 2009;21(5):608-614. doi:10.1080/09540120802310957
  14. Assefa Y, Jerene D, Lulseged S, Ooms G, Van Damme W. Rapid scale-up of antiretroviral treatment in Ethiopia: successes and system-wide effects. PLoS Med. 2009;6(4):e1000056. doi:10.1371/journal.pmed.1000056
  15. Janssens B, Van Damme W, Raleigh B, et al. Offering integrated care for HIV/AIDS, diabetes and hypertension within chronic disease clinics in Cambodia. Bull World Health Organ. 2007;85(11):880-885.
  16. Matsubayashi T, Manabe YC, Etonu A, et al. The effects of an HIV project on HIV and non-HIV services at local government clinics in urban Kampala. BMC Int Health Hum Rights. 2011;11 Suppl 1:S9. doi:10.1186/1472-698x-11-s1-s9
  17. Hanefeld J, Musheke M. What impact do Global Health Initiatives have on human resources for antiretroviral treatment roll-out? A qualitative policy analysis of implementation processes in Zambia. Hum Resour Health. 2009;7:8. doi:10.1186/1478-4491-7-8
  18. Makombe SD, Jahn A, Tweya H, et al. A national survey of the impact of rapid scale-up of antiretroviral therapy on health-care workers in Malawi: effects on human resources and survival. Bull World Health Organ. 2007;85(11):851-857.
  19. Cailhol J, Craveiro I, Madede T, et al. Analysis of human resources for health strategies and policies in 5 countries in Sub-Saharan Africa, in response to GFATM and PEPFAR-funded HIV-activities. Global Health. 2013;9:52. doi:10.1186/1744-8603-9-52
  20. Nankumbi J, Groves S, Leontsini E, Kyegombe N, Coutinho A, Manabe Y. The impact on nurses and nurse managers of introducing PEPFAR clinical services in urban government clinics in Uganda. BMC Int Health Hum Rights. 2011;11 Suppl 1:S8. doi:10.1186/1472-698x-11-s1-s8
  21. Williams EI, McGill D. Effects of PEPFAR on beneficiaries' determinants of health: perspectives from a beneficiary community in Gaza province, Mozambique. Int Q Community Health Educ. 2010;31(3):265-278. doi:10.2190/IQ.31.3.e
  22. Cohn J, Russell A, Baker B, Kayongo A, Wanjiku E, Davis P. Using global health initiatives to strengthen health systems: a civil society perspective. Glob Public Health. 2011;6(7):687-702. doi:10.1080/17441692.2010.521165
  23. Bilimoria NF. Lessons learned from a decade of partnership between PEPFAR and the Global Fund: a case study from Tanzania. Health Aff (Millwood). 2012;31(7):1415-1421. doi:10.1377/hlthaff.2012.0229
  24. Atun R, Pothapregada SK, Kwansah J, Degbotse D, Lazarus JV. Critical interactions between the Global Fund-supported HIV programs and the health system in Ghana. J Acquir Immune Defic Syndr. 2011;57 Suppl 2:S72-76. doi:10.1097/QAI.0b013e318221842a
  25. Bermejo A. Global Fund at risk of alienating civil society. Lancet. 2012;380(9854):1646. doi:10.1016/s0140-6736(12)61946-1
  26. Biesma R, Makoa E, Mpemi R, Tsekoa L, Odonkor P, Brugha R. The implementation of a global fund grant in Lesotho: applying a framework on knowledge absorptive capacity. Soc Sci Med. 2012;74(3):381-389. doi:10.1016/j.socscimed.2011.07.020
  27. Bowser D, Sparkes SP, Mitchell A, et al. Global Fund investments in human resources for health: innovation and missed opportunities for health systems strengthening. Health Policy Plan. 2013. doi:10.1093/heapol/czt080
  28. Desai M, Rudge JW, Adisasmito W, Mounier-Jack S, Coker R. Critical interactions between Global Fund-supported programmes and health systems: a case study in Indonesia. Health Policy Plan. 2010;25 Suppl 1:i43-i47. doi:10.1093/heapol/czq057
  29. Drager S, Gedik G, Dal Poz MR. Health workforce issues and the Global Fund to fight AIDS, Tuberculosis and Malaria: an analytical review. Hum Resour Health. 2006;4:23. doi:10.1186/1478-4491-4-23
  30. Galarraga O, Bertozzi SM. Stakeholders' opinions and expectations of the Global Fund and their potential economic implications. Aids. 2008;22 Suppl 1:S7-S15. doi:10.1097/01.aids.0000327618.01362.6a
  31. Gomez EJ, Atun R. The effects of Global Fund financing on health governance in Brazil. Global Health. 2012;8:25. doi:10.1186/1744-8603-8-25
  32. Hanefeld J. The Global Fund to Fight AIDS, Tuberculosis and Malaria: 10 years on. Clin Med. 2014;14(1):54-57. doi:10.7861/clinmedicine.14-1-54
  33. Hanvoravongchai P, Warakamin B, Coker R. Critical interactions between Global Fund-supported programmes and health systems: a case study in Thailand. Health Policy Plan. 2010;25 Suppl 1:i53-57. doi:10.1093/heapol/czq059
  34. Mounier-Jack S, Rudge JW, Phetsouvanh R, Chanthapadith C, Coker R. Critical interactions between Global Fund-supported programmes and health systems: a case study in Lao People's Democratic Republic. Health Policy Plan. 2010;25 Suppl 1:i37-42. doi:10.1093/heapol/czq056
  35. Ooms G, Van Damme W, Baker BK, Zeitz P, Schrecker T. The 'diagonal' approach to Global Fund financing: a cure for the broader malaise of health systems? Global Health. 2008;4:6. doi:10.1186/1744-8603-4-6
  36. Rudge JW, Phuanakoonon S, Nema KH, Mounier-Jack S, Coker R. Critical interactions between Global Fund-supported programmes and health systems: a case study in Papua New Guinea. Health Policy Plan. 2010;25 Suppl 1:i48-52. doi:10.1093/heapol/czq058
  37. Taylor EM, Harper I. The politics and anti-politics of the global fund experiment: understanding partnership and bureaucratic expansion in Uganda. Med Anthropol. 2014;33(3):206-222. doi:10.1080/01459740.2013.796941
  38. Wafula F, Marwa C, McCoy D. Implementing Global Fund programs: a survey of opinions and experiences of the Principal Recipients across 69 countries. Global Health. 2014;10:15. doi:10.1186/1744-8603-10-15
  39. Warren AE, Wyss K, Shakarishvili G, Atun R, de Savigny D. Global health initiative investments and health systems strengthening: a content analysis of global fund investments. Global Health. 2013;9(1):30. doi:10.1186/1744-8603-9-30
  40. Oomman N, Bernstein M, Rosenzweig S. Following the funding for HIV/AIDS: a comparative analysis of the funding practices of PEPFAR the Global Fund and World Bank MAP in Mozambique Uganda and Zambia. 2007.
  41. UNAIDS. AIDSinfo. Geneva; 2015.
  42. The World Factbook 2013-14. Washington DC: Central Intelligence Agency; 2013.
  43. World Health Statistics 2015. Geneva: World Health Organization; 2015.
  44. World Development Indicators 2015. Washington DC: The World Bank; 2015.
  45. McCoy D, Chopra M, Loewenson R, et al. Expanding access to antiretroviral therapy in sub-saharan Africa: avoiding the pitfalls and dangers, capitalizing on the opportunities. Am J Public Health. 2005;95(1):18-22.
  46. The HIV and AIDS Uganda Country Progress Report 2014. Kampala, Uganda: UNAIDS; 2015.
  47. Spicer N, Aleshkina J, Biesma R, et al. National and subnational HIV/AIDS coordination: are global health initiatives closing the gap between intent and practice. Global Health. 2010;6(3):1-16. doi:10.1186/1744-8603-6-3
  48. Sepulveda J, Carpenter C, Curran J, et al. PEPFAR implementation: progress and promise. Washington DC: National Academies Press; 2007.
  49. Brugha R, Cliff J, Donoghue M, et al. Global Fund tracking study: a cross-country comparative analysis. London: London School of Hygiene and Tropical Medicine; 2005.
  50. Luboga S, Stover B, Lim T, et al. Did PEPFAR investments result in health system strengthening in Uganda? A retrospective longitudinal study measuring non-HIV health service utilization at the District level. Health Policy Plan. doi:10.1093/heapol/czx009
  51. World Health Organization (WHO). Monitoring the building blocks of health systems: a handbook of indicators and their measurement strategies. Geneva: WHO; 2010.
  52. Bernard HR, Ryan GW. Analyzing Qualitative Data: Systematic Approaches. SAGE Publications; 2010.
  53. Improving Resource Management and Mobilization. http://www.pepfar.gov/about/strategy/global_context/133649.htm. Accessed December 14, 2014. Published 2009.
  54. Kruk ME, Jakubowski A, Rabkin M, et al. Association between HIV programs and quality of maternal health inputs and processes in Kenya. Am J Public Health. 2015;105(S2):S207-S210.
  55. Evaluation of PEPFAR. Chapter 9. Committee on the Outcome and Impact Evaluation of Global HIV/AIDS Programs Implemented Under the Lantos-Hyde Act of 2008. Washington DC: Institute of Medicine; 2013.
  56. Alcorn T. What has the US Global Health Initiative achieved? Lancet. 2012;380(9849):1215-1216.
  57. Pfeiffer J, Johnson W, Fort M, et al. Strengthening health systems in poor countries: a code of conduct for nongovernmental organizations. Am J Public Health. 2008;98(12):2134.
  58. Pfeiffer J, Robinson J, Hagopian A, et al. The end of AIDS and the NGO Code of Conduct. Lancet. 2014;384(9944):639-640. doi:10.1016/S0140-6736(14)61259-9
  59. PEPFAR 3.0: Delivering on the Promise of an AIDS-free Generation. The Office of the U.S. Global AIDS Coordinator; 2014.
  60. El-Sadr WM, Barker P, Rabkin M, Pillay Y, Birx D. Putting quality at the heart of HIV programs. AIDS. 2015;29:S119-S120.
  61. Kruk ME, Jakubowski A, Rabkin M, Elul B, Friedman M, El-Sadr W. PEPFAR programs linked to more deliveries in health facilities by African women who are not infected with HIV. Health Affairs. 2012;31(7):1478-1488.
International Journal of Health Policy and Management
Volume 6, Issue 2
2017
Pages 83-95

  • Received Date 28 December 2015
  • Revised Date 26 July 2016
  • Accepted Date 18 July 2016
  • First Published Date 01 February 2017
  • Published Date 01 February 2017