Health sector reform and STD/AIDS control in resource poor settings--the case of Tanzania

Investigating the interface between health system reform and HIV/AIDS in sub-Saharan Africa: an approach for improving the fight against the epidemic

During the period in which the HIV/AIDS epidemic has taken hold in sub-Saharan Africa, health system reforms have and continue to be introduced throughout the region. In spite of the multidisciplinary research undertaken, it can be questioned whether the relationships between processes of reform and some of the critical issues of HIV/AIDS response have been fully appreciated. This is particularly worrying since many countries in sub-Saharan Africa have already embarked on reform whilst concurrently and independently attempting to develop and manage effective responses to the overwhelming challenges posed by the HIV/AIDS epidemic. This paper explores the relationship between health system reform and HIV/AIDS, and argues that an interface approach is crucial for understanding the complexity of combating the epidemic whilst reforming health systems. The interface refers to the interacting processes between reform and the effects of the disease and attempts to respond to it. It includes the ways in which reforms, and such features as decentralisation and user fees, affect the capacity to fight HIV/AIDS, and conversely how the implications of the disease affect the performance of reformed health systems. Two sets of constraints in the interface are defined: internal and delivery constraints. The former are illustrated by deteriorating levels of human resources, poor integration of HIV/AIDS activities and problems faced by tiered health systems. The latter are illustrated by issues of access to relevant health services and rural-urban disparities. Issues in the interface need to be addressed by researchers and implementers in order to move forward in containing the epidemic.

Health systems and the implementation of disease programmes: case studies from South Africa

This paper analyses the transfer and implementation of two internationally formulated infectious disease strategies in South Africa, namely, directly observed therapy (DOTS) for TB and syndromic management (SM) for sexually transmitted infections (STIs). Using the tools of policy analysis, this paper seeks to draw conclusions from contrasting experiences with the two strategies. DOTS and SM differ with respect to styles of engagement by World Health Organization (WHO), the international agency promoting the ideas, in the following ways: continuity and networking between policy makers, practitioners and researchers nationally; and approaches to sub-national implementation. We show how these factors may have been important to national uptake, and conclude on the need for a context sensitive approach to policy transfer and a balance between bottom-up and top-down implementation strategies. These insights may have relevance for the current global wave of treatment programmes for HIV and other infectious diseases.

Collapsing the vertical-horizontal divide: an ethnographic study of evidence-based policymaking in maternal health

Using the international maternal health field as a case study, we draw on ethnographic research to investigate how public health researchers and policy experts are responding to tensions between vertical and horizontal approaches to health improvement. Despite nominal support for an integrative health system approach, we found that competition for funds and international recognition pushes professionals toward vertical initiatives. We also highlight how research practices contribute to the dominance of vertical strategies and limit the success of evidence-based policymaking for strengthening health systems. Rather than support disease-and subfield-specific advocacy, the public health community urgently needs to engage in open dialogue regarding the international, academic, and donor-driven forces that drive professionals toward an exclusive interest in vertical programs.

HIV/AIDS and TB: contextual issues and policy choice in programme relationships

Tuberculosis (TB) and HIV/AIDS affect each other closely. Given the rapid spread of the HIV-driven TB epidemic worldwide, the case for establishing some form of relationship between control activities for HIV/AIDS and TB is clear. However, the question 'how' has not been resolved satisfactorily. TB and HIV/AIDS programmes have traditionally maintained their own management, supervision, funding flows and specialist boundaries. This article explores opportunities and challenges for collaboration between the two, through drawing on the expertise in organization and management, policy analysis and disease control of both TB and HIV/AIDS. Based on an extensive literature review, the article investigates how contextual issues affect the design of a collaboration; what the organizational options are; and what impact a collaboration would have. A universal model for organizational change is unlikely and changes may present as both solutions and contradictions. Careful planning and consultation are required before implementing the changes, in order to avoid jeopardizing the function and effectiveness of both disease control programmes and the health service system.

AIDS and "shared sovereignty" in Tanzania from 1987 to 2000: a case study

After more than 15 years of foreign assistance to support HIV/AIDS prevention in Sub-Saharan Africa, HIV rates in the sub-continent remain high with only a few examples of reduced HIV incidence. This case study used the frame of "shared sovereignty" between nation-states and official development assistance agencies to analyze 13 years of technical assistance for HIV/AIDS programs in Tanzania from 1987 to 2000. The study draws on 21 key informant interviews and a systematic review of key program documents from the National AIDS Control Programme (NACP) and 14 other international agencies. Applying Jamison et al.'s (Lancet 351 (1998) 514) shared sovereignty framework, the analysis focused on fulfilled shared functions in moving Tanzania's NACP from dependence to independence. The analysis revealed an uneven and inconsistent level of technical assistance to the NACP with a rotation of multilateral and bilateral donors over the period of study. The Tanzanian government was often ambivalent toward agencies providing assistance towards its HIV/AIDS programs and toward its own NACP. Results are discussed in terms of implications for future strategic planning to mitigate the effects of HIV/AIDS. Determining roles, shared accountability and responsibility in a shared sovereignty framework remain a challenge in the governance of HIV/AIDS programs in Tanzania.

A code of best practice for disease control programmes to avoid damaging health care services in developing countries

How should we implement disease control programmes so as to strengthen existing health systems? To answer this question, we re-examined the integration of these programmes from a managerial perspective. Based on a literature review, we concluded that integration is essential in the majority of cases. We went on to examine the mechanisms whereby the integration of disease control activities can jeopardize health care delivery, resulting in low service utilization, low detection and cure rates, and patient delays. To do this we clustered disease control programmes into three categories and assessed the impact of each on local health care facilities. From these results, we suggest a series of measures designed to help aid agencies and national governments support local health care infrastructures or, as a minimum, avoid damaging them. Whilst some vertical programmes should never be integrated, two conditions are essential to the integration of others: (1) Disease control needs to be integrated with general health care delivery--which implies the possibility to deliver general practice/family medicine care in publicly oriented health services. (2) Integration of both operational and administrative aspects should take place simultaneously. Any health policies in developing countries tending to allocate disease control programmes to government facilities and general health care to private facilities preclude their integration. They risk unravelling the fabric on which both disease control and health care delivery depend.

Between intent and achievement in sector-wide approaches: staking a claim for reproductive health

Since 1995, sector-wide approaches (SWAps) to health development have significantly influenced health aid to developing countries. SWAps offer guidelines for new partnerships with international donors led by government, new relationships between donors and shared financing, development and implementation of agreed packages of health sector reforms. These structural and funding changes have significant implications for reproductive health. The early experience of SWAps suggests that the extent of donor commitment is constrained for administrative, philosophical and political reasons, with vertical programmes (including those relevant to reproductive health) protecting their 'core' business, and reproductive health, as an integrative concept, lacking strong advocates. Defining the sector in terms of government health systems focuses resources on building effective district health systems, but with uncertain outcomes for elements of reproductive health that depend on multi-sectoral strategies, e.g. safe motherhood. The context of the reforms remains a determining factor in their success, but despite savings available through increased efficiencies and coordinated services, the total per capita expenditure on health to ensure minimum clinical and public health services often remains beyond the budget available to least developed nations. Despite this, many of the elements of SWAps--government leadership, new donor relationships, better coordination, sectoral reform and service integration--offer the potential for more effective and efficient health services, including those for reproductive health.