Effect of global health initiatives on the health services system in Angola: perspectives of civil servants, donors, and non-governmental organisations

Abstract

BackgroundAngola is less dependent on external funds to finance health-care than most other countries in sub-Saharan Africa (government funding provides more than 80% of total health expenditure); nonetheless, global health initiatives exist in the country. How initiatives are aligned with national health policy is important because they can affect how policy is implemented and can strengthen or weaken the national health system. We documented key stakeholders' perceptions of the effects of global health initiatives on the national health system. MethodsWe collected national qualitative data from key informants through semi-structured interviews. We identified an initial pool of respondents (from the Ministry of Health, donors, and non-governmental organisations), who then identified other potential informants. We collected data between April, and May, 2011. We also interviewed 30 key informants in the provinces of Benguela and Bengo. We reviewed national health policy documents and documents provided by key informants. Interviews were recorded, transcribed, and analysed. FindingsWe did 41 interviews. Six global health initiatives exist in Angola (GAVI, the Global Fund to Fight AIDS, Tuberculosis, and Malaria, President's Malaria Initiative, Polio Eradication, Stop TB, and PEPFAR). They are mainly managed from the capital. Respondents thought that foreign aid had the potential to improve strategic planning in health and service provision; for example, by introduction of new vaccines with the support of GAVI. They also believed that they contribute to strengthening systems through staff training, expansion of services, and upgrade of laboratories. Government and donors' representatives said that it was desirable that the Ministry of Health provide a strategic plan, clear objectives, and measurable goals for health policy, and that external partners integrate and harmonise their interventions with national policies. According to respondents, for alignment to be strong, clear national policies are needed, which is not the case in Angola—the national health plan is still being written and only vertical plans exist, for human resources, maternal and child health, immunisation, tuberculosis, malaria, and HIV/AIDS. Global health initiatives stimulated the formulation of a health policy, plans, and strategies (eg, Human Resources Development Plan, Strategic Plan for the Accelerated Reduction of Maternal and Infant Mortality Rates in Angola, PAV immunisation programme, tuberculosis strategic plan, malaria strategic plan, and HIV/AIDS plan), but the country has yet to decide on its priorities for health. According to Ministry of Health representatives, intersectoral collaboration is weak. Furthermore, when global health initiatives use their own monitoring and assessment systems, they increase transparency, but these systems run in parallel to national systems, which increases the workload of health professionals and does little to strengthen national systems. Regional service managers lack knowledge of global health initiatives, although they judge the effect of external funds as positive, improving health infrastructures in the public sector and drug supply systems at municipal and provincial health units, and increasing training opportunities. The main effect of global health initiatives was to increase training opportunities and the number of workers engaged in HIV or other specific disease programmes, but they have not addressed the dilemma of attraction and retention of qualified personnel in provinces because the initiatives focused on their own needs. InterpretationBecause Angola is not dependent on external funding, national strategic programmes and service delivery and the interventions of global health initiatives work together well. This situation differs in other African countries such as Mozambique, which depends on external aid for roughly 70% of its health budget. FundingEuropean Union.