Mounier-Jack S.  Rudge J.  Phetsouvanh R.  Chanthapadith C.  Coker R. 

November 2010

Health Policy and Planning  25 (suppl 1): i37i42

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London School of Hygiene & Tropical Medicine (LSHTM)

Integration, Global Fund, health system strengthening, Lao

Case study analysis

To assess the extent of integration of national HIV, tuberculosis (TB) and malaria programmes with the general health system; the integration of the Global Fund-portfolios within the national disease programmes; and system-wide effects on the health system in Lao Peoples Democratic Republic (Lao PDR).

Literature review and use of a Systematic Rapid Assessment Toolkit (SYSRA) for gathering information about structures and modes of operation of complex health systems. 35 interviews with government health officials, partners and civil society actors at national, regional and district levels. The SYSRA toolkit proposed six health systems functions: stewardship and governance, financing, planning, service delivery, monitoring and evaluation, and demand generation. These were subdivided into 25 elements, for which the level of integration was classified as not integrated, partly integrated or fully integrated, through iterative analysis and triangulation of the collected data.

Lao PDR remains a low prevalence country (<0.2%) for HIV. Strategic interventions primarily target high-risk groups situated in urban areas through specialized health care services rather than the general population. Recent investments by the Global Fund have permitted an extension of the network of facilities delivering HIV/AIDS services at local level, resulting in greater integration with primary care and improved access for patients. This includes improved access to voluntary counseling and testing (VCT) at district levels and better access to antiretroviral treatment (ART) in a higher number of provinces. New initiatives have been devised to ensure better coordination and collaboration between disease programmes functions and general health system operation. The HSS components of the Global Fund Round 8 HIV Proposal will set up common infrastructure and procedures for a drug delivery mechanism, while a new M&E strategy will aim for greater consistency in data collection and reporting. The level of integration of the Global Fund with national disease programmes is high (with the exception of M&E) partly because the Global Fund has become the main funder of these programmes. The Global Fund is a major player in Lao PDR, financing 60% of the HIV/AIDS programme, raising important sustainability concerns.

Wider effects of the Global Fund on the health system included:

• Improved access to services at lower levels of care because of better equity and affordability (HIV services are free of charge and patients received specific payment to cover food and transport costs).
• Capacity-building for staff, institutional strengthening and contribution to the management of other infectious diseases (training funded by the Global Fund) has enhanced generic staff management capacity.
• The Global Funds Country Coordinating Mechanism has positively influenced the health agenda policy (e.g. men who have sex with men is now a more prominent health issue), and multi-stakeholder representation has reportedly influenced other governance models in the health sector.
• Wider condom distribution and social marketing through the HIV/AIDS programme, and the delivery of add-on services at community level with the support of Global Fund programme staff and equipment.
• Negative effects primarily concern weaker areas of the health system, where the Global Fund has tended to set up parallel and often costly management systems such as procurement and drug supply and M&E systems.