Instituto de Higiene e Medicina Tropical

WHO Collaborating Centre for Health Workforce Policy and Planning

Universidade Nova de Lisboa-Portugal

COHRED Global Forum 2012

Cape Town, 23 April 2012

Global Health Initiatives and health system in Angola

Craveiro, I.; Dussault, G; Vicente, N.

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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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Selected Social, Economic and Health Indicators for Angola

Parameters ValueTotal Population (in million – UNDATA, 2011) 19.08Proportion of population below $1 (PPP) per day (%) (Angola, MDG report, 2011)

54,3

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, 2011)

2.1

Distribution of causes of death among children aged <5 years (%) – Malaria (WHO, 2004)

9.7

Prevalence of TB (2007) (WHO, 2008) 294Proportion of aid by external partners (%) (Oliveira, 2010) 14

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• 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)

The National Health Service in Angola is organized in three levels of cares

CENTRAL HOSPITALS

(National

Referral)

3rd level

Community

8

32

228

1.453

PROVINCIAL HOSPITAL

Municipal Health Centres / Municipal

Hospitals

Health Centres

- Rural - Urban

Heath Posts

Company

Health Units

Private Health clinics

Volunteer health workers, traditional midwives, therapists

2nd level

1st level

Administrative levels

National

Central

Provincial Directorate

s18

HealthRegions

Municipal Directorat

es

HealthIntervention areas

Source: Adapted from the Research, Planning and Statistical Office of the Ministry of Health (2007)

• Health service delivery is divided into three levels of care (primary, secondary, and tertiary) corresponding to the three levels of government (district, provincial, and national).

The MINSA carries out its stewardship and technical guidance role, namely through national vertical health programmes supported by partners such as the EU, UN agencies and the US government.

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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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Donors disbursement

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Donor Period Value Area

EU 2004-2010 €21M (US$ 28M)Health System Revitalization

GHI

Global Fund2010 US$40M HIV-AIDS  US$78M Malaria

GAVI 2003-2010 US$17M Penta vaccinesUNDP-GF On-going US$31M  World Bank

(MAP-HAMSET)

2006-2011 US$21MMalaria / HIV / TB

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)

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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MethodsNATIONAL LEVEL

Data were collected through individual semi-structured interviews - conducted between April and June 2009

12 participants at national level: • 3 NGO’s • 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

PROVINCIAL LEVEL

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Data were collected through individual semi-structured interviews - conducted between March and September 2011 - total of 30 participants at provincial level

     HUMAN RESOURCES FOR HEALTH

How did GHIs and MINSA respond to the following themes

 HRH supply

HRH education

HRH working conditions

HRH performance management

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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 level10

GHI IMPACT ON HRH - National level findings

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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.”

FINANCING OF HEALTH SYSTEMS

What about crowding out, dependency, negotiation capacity, sustainability, and priority-setting?

 

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

“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.”

GHI MINSA

GHI NGOs

PNUD NGOs

There is no dependency on external funds - each partner complement s government actions related to the national strategic programs.

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At provincial level, direct financing to NGO predominates, which is not compatible with Angolan policy (Benguela)

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

FINANCING OF HEALTH SYSTEMS

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Provincial level

National level

MINSA funding

Hospital Material

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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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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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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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 NGOs

464 national NGOs

25 faith-based organizations

There are no reliable numbers on how many CBOs

UTCHA (Unidade Técnica de Coordenação da Ajuda Humanitária) - Government’s coordinating body of NGO activities, 2011

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“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.

CIVIL SOCIETY AND NGOS – Provincial level

NGOs

National

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“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.

Before civil war

After civil war

Funds

Funds

Foreign aid - NGOs

GHIs - NGOs

MINSA

MINSA

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CIVIL SOCIETY AND NGOs – Provincial level

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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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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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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