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
Oriented global health initiatives (GHIs) addressing the HIV/AIDS epidemic, including the PresidCelnetm’s EetmAersgkehneciymP,laKnrfiosrtiAnIDHSegRgeleinef,(EPiEvPinFAdRE)n, hgaevberseutcsceens**sfully contributed to reducing HIV/AIDS related morbidity and mortality
While some studies have demonstrated President’s Emergency Plan for AIDS Relief (PEPFAR) was associated with effective task-shifting, improved in-service training, and higher job satisfaction,[5,6,18] other studies have noted an internal brain-drain of doctors from the public sector to HIV programs run by non-governmental organizations (NGOs), work interruption for training, and overburdening of a health workforce already spread thin.[3,4,5,6,9,17,19]
District Health Officer Perceptions and Experiences We interviewed DHOs about how health systems and health facilities in their district were managed, including their current situation (2010/2011) and their best recall of two periods in the past (2005/2006, 2007/2008) with regard to the seven health system components described in the Methods section
Summary
Oriented global health initiatives (GHIs) addressing the HIV/AIDS epidemic, including the PresidCelnetm’s EetmAersgkehneciymP,laKnrfiosrtiAnIDHSegRgeleinef,(EPiEvPinFAdRE)n, hgaevberseutcsceens**sfully contributed to reducing HIV/AIDS related morbidity and mortality. Some researchers have observed positive effects on primary care,[8,13] increased vaccination rates, antenatal care coverage, malaria diagnoses, and treatment of sexually transmitted diseases.[13,14,15,16] There is evidence, health service providers have shifted focus from primary care duties, leading some to challenge the reports of positive PEPFAR spillover.[11,12,17] While some studies have demonstrated PEPFAR was associated with effective task-shifting, improved in-service training, and higher job satisfaction,[5,6,18] other studies have noted an internal brain-drain of doctors from the public sector to HIV programs run by non-governmental organizations (NGOs), work interruption for training, and overburdening of a health workforce already spread thin.[3,4,5,6,9,17,19] Despite this burgeoning body of literature analyzing the interactions between PEPFAR and health systems, few researchers have asked public sector health managers in low-income countries what they think about how PEPFAR influenced the health system. We hypothesized DHOs would perceive PEPFAR implementation prompted the movement of health workers out of the public sector and focused attention on HIV programming at the expense of primary healthcare delivery
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