Abstract
BackgroundIn the rapid scale-up of human immunodeficiency virus (HIV) care and acquired immunodeficiency syndrome (AIDS) treatment, many donors have chosen to channel their funds to non-governmental organizations and other private partners rather than public sector systems. This approach has reinforced a private sector, vertical approach to addressing the HIV epidemic. As progress on stemming the epidemic has stalled in some areas, there is a growing recognition that overall health system strengthening, including health workforce development, will be essential to meet AIDS treatment goals. Mozambique has experienced an especially dramatic increase in disease-specific support over the last eight years. We explored the perspectives and experiences of key Mozambican public sector health managers who coordinate, implement, and manage the myriad donor-driven projects and agencies.MethodsOver a four-month period, we conducted 41 individual qualitative interviews with key Ministry workers at three levels in the Mozambique national health system, using open-ended semi-structured interview guides. We also reviewed planning documents.ResultsAll respondents emphasized the value and importance of international aid and vertical funding to the health sector and each highlighted program successes that were made possible by recent increased aid flows. However, three serious concerns emerged: 1) difficulties coordinating external resources and challenges to local control over the use of resources channeled to international private organizations; 2) inequalities created within the health system produced by vertical funds channeled to specific services while other sectors remain under-resourced; and 3) the exodus of health workers from the public sector health system provoked by large disparities in salaries and work.ConclusionsThe Ministry of Health attempted to coordinate aid by implementing a “sector-wide approach” to bring the partners together in setting priorities, harmonizing planning, and coordinating support. Only 14% of overall health sector funding was channeled through this coordinating process by 2008, however. The vertical approach starved the Ministry of support for its administrative functions. The exodus of health workers from the public sector to international and private organizations emerged as the issue of greatest concern to the managers and health workers interviewed. Few studies have addressed the growing phenomenon of “internal brain drain” in Africa which proved to be of greater concern to Mozambique’s health managers.
Highlights
In the rapid scale-up of human immunodeficiency virus (HIV) care and acquired immunodeficiency syndrome (AIDS) treatment, many donors have chosen to channel their funds to non-governmental organizations and other private partners rather than public sector systems
Research activities were organized into three phases: 1) In order to identify aid flows to the health sector at national, provincial and district levels, researchers reviewed core Ministry of Health (MOH) planning documents including the Poverty Reduction Action Plan, the 2008 Health Sector Strategic Plan, the 2008 Economic and Social Plan, and routine annual reports; 2) Interviews to identify the scope of external technical assistance provided to the MOH were conducted with key directors in relevant national MOH departments including HIV/AIDS, malaria, tuberculosis, cooperation, pharmacy, human resources, and planning; and 3) Health managers at each level of the health system were selected for indepth qualitative interviews conducted from September to December, 2008
Sample and data collection Based on document review and preliminary interviews described above, two provinces and four districts within those two provinces were chosen for inclusion in this study because of their extensive history and experience with international support, and current presence of a significant number of international partners, such as non-governmental organizations (NGOs) and foreign universities
Summary
In the rapid scale-up of human immunodeficiency virus (HIV) care and acquired immunodeficiency syndrome (AIDS) treatment, many donors have chosen to channel their funds to non-governmental organizations and other private partners rather than public sector systems This approach has reinforced a private sector, vertical approach to addressing the HIV epidemic. The rapid increase in funding for human immunodeficiency virus (HIV) care and treatment over the last 10 years has presented both great opportunities and new dilemmas for improving health service delivery in many African countries Because this new wave of large-scale funding is primarily disease-specific, it is typically directed toward “vertical” projects through separate and parallel systems designed to improve HIV-related programs, often without strengthening other sectors of health systems [1,2,3,4,5]. A qualitative examination of health workers’ perspectives can complement quantitative approaches to health services research to reveal additional costs and benefits of vertical funding to health systems strengthening in Africa while suggesting further avenues of inquiry
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