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

1. 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 2012
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2. 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
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3. Selected Social, Economic and Health
Indicators for Angola
Parameters Value
Total Population (in million – UNDATA, 2011) 19.08
Proportion of population below $1 (PPP) per day (%) (Angola, MDG report, 54,3
2011)
Under five mortality rate/1,000 live births (2009) (UNDATA, 2011) 160,5
Maternal mortality ratio/100,000 live births (2008) (UNDATA, 2011) 610
Prevalence of HIV, total (% of population ages 15-49 (2007) (UNDATA, 2.1
Distribution of causes of death among children aged <5 years (%) – Malaria
2011) 9.7
(WHO, 2004)
Prevalence of TB (2007) (WHO, 2008) 294
Proportion 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)
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4. 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
Hospitals
Municipal
Directorat
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)

5. Background - health policy
Absence 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
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6. Donors disbursement
Donor Period Value Area
Health System
EU 2004-2010 €21M (US$ 28M)
Revitalization
GHI
2010 US$40M HIV-AIDS
Global Fund
US$78M Malaria
GAVI 2003-2010 US$17M Penta vaccines
UNDP-GF On-going US$31M
World Bank
2006-2011 US$21M Malaria / HIV / TB
(MAP-HAMSET)
Source: USAID, 2010
• Angola's 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)
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7. 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 ?
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8. 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 2010
6 participants of national and provincial level –
HRH managers:
4 HR Department - MINSA
1 Military Health Service
1 Clinical Director - Provincial Hospital
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9. HUMAN RESOURCES FOR HEALTH
How did GHIs and MINSA respond to the following themes
HRH working
HRH supply
conditions
HRH performance
HRH education
management
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10. 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
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11. 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 not
work because we do not have trained technicians”
But on the other hand, in the provincial capital there is a
surplus
“due to war, health workers concentrated in the provincial
capital and no one wants to go back to municipalities of the
interior.”
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12. 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 in
specific sector,s promote a competition for funds and choose the best project.”
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13. FINANCING OF HEALTH SYSTEMS
Funds received by the municipal hospital comes directly from state budget -
MINSA.
Municipal hospital managers do not know the amount channeled by the
GHIs, nor which are the GHIs that finance the MINSA.
But at municipality level there is knowledge and valorization of the
contribution of the multilateral and bilateral partners – mainly because of
contributions to hospital material supplies and infrastructures (Centros de
Atendimento e Testagem Voluntária) - VCT
Provincial Hospital
level Material
National MINSA funding
level
13

14. DONOR HARMONIZATION AND GLOBAL HEALTH INITIATIVES
There are various initiatives to improve government capacity to develop
protocols and standards, and to help their implementation at the different
levels.
At national level
The Country Coordination Mechanism (CCM), which is responsible for the
coordination of technical proposals to the Global Fund , has matured notably
over the past five years and has a strong leadership.
At provincial level
There is not a provincial Coordination Mechanism. There is the UTCH –
Unidade de coordenação da ajuda humanitária (Government’s coordinating
body of NGO activities)
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15. National level findings
Harmonization
• A process still in its beginning in Angola;
• Leadership needs to be assumed by the Government
MINSA perception:
Advantages of GHI’s – resources; technical and management
transfer of knowledge; beginning of strategic planning in the
country
Disadvantages of GHI’s – competition with the MINSA for skilled
Human Resources
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16. National level findings
National policy development
• Leadership must be assumed by Ministry of Health
Donors 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 / GHI
Ministry of Health perception:
Intersectoral collaboration is still weak
Monitoring and evaluation
• Major weaknesses in monitoring and evaluation system
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17. CIVIL SOCIETY AND NGOs
Civil society is weak in Angola, and political and societal space for civil society is
limited.
NGOs lack capacity to prepare and articulate sound proposals that can attract
and meet the requirements of available funding sources.
Angolan authorities have not fully accepted civil society’s voice and control
functions. National NGOs have limited membership bases, and are dependent
on 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

18. CIVIL SOCIETY AND NGOS – Provincial level
NGOs
National
“NGOs have weak coordination and lack of transparency. If a NGO disappears in
the middle of a project and does not report their results to the donor and the NGOs
managers also disappear, the UTCH can do nothing.”
“If the NGOs disappear and do not fulfill the plan or project sketched, UTCH do not
act 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 or
thematic area also fulfills that mission.
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19. CIVIL SOCIETY AND NGOs – Provincial level
Before 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 projects
were available.”
There is internal migration of the NGOs staff to public sector.
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20. 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
GHI's.
 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.
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21.  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.
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22.  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.
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