The impact of donor agency funding strategies on national responses:

1

• The impact of donor agency funding strategies on
  national responses
• the case of Lesotho
• Regien Biesma2, Elsie Makoa1, Philip Odonkor1,
  LineoTsekoa1, Regina
• Mmpemi1, Ruairi Brugha2
• 1Faculty of Health Sciences, National University
  of Lesotho
• 2Department of Epidemiology and Public Health
  Medicine, Royal College of Surgeons in Ireland
• IAS Cape Town 2009

2
RCSI
Irish Aid Danida
LSHTM
USAID
U.S. SWEF Health 20/20
3
The size of the problem in Lesotho From the
number of PLHIV to the number of people on ART

KYS effect?158,882 tested in 2007 (28 are
positive)
270,000 People living with HIV
(15-49)(2007SPECTRUM estimates)
81,270 In need of ART (2007 estimates)
People on ART 21,710 (Dec.07)
50,000 Knew their status in 2004 (DHS)(78 are
positive)
4
Source UNGASS, 2008
5
National HIV/AIDS expenditure
US
Source NASA, 2009
6
Main donors in Lesotho
7
Who is funding what in HIV/AIDS?
8
Successes so far- what is being scaled-up?
PMTCT
HIV/AIDS treatment ART
Global coverage 2007 33
Global coverage 2007 31

• However, despite significant scale-up
• of women, men and children with advanced HIV
  infection
• receiving ART 80 (2010-2011)
• of HIV-positive pregnant women who received
  antiretroviral
• therapy to reduce the risk of mother-to-child
  transmission 80 (2010-2011)
• Source HIV and AIDS National Strategic Plan
  2006-2011

9

• Research questions
• What are the main challenges in Lesotho in
  scaling-up HIV/AIDS interventions?
• Methodology
• The study is based on national level data in
  Lesotho collected between July 2008 and April
  2009 through
• Document review
• 24 in-depth key informant interviews at the
  national level
• Government
• Civil society
• Donor representatives
• Research institutions
• Topic guide (key thematic areas health system)
• Thematic analysis (Atlas Ti)
• Triangulation of data
• Validation session planned Lesotho
• Peer review by AIDS and health systems experts,
  including researchers, policymakers, and program
  implementers, and senior staff at each donor
  organization

10

• Analytical framework
• for understanding constraints to improving access
  to priority health interventions, by level
• Community level
• Health service delivery level
• Health sector policy and strategic management
  level
• Issues related to donor behaviour
• Adapted from Hanson et al. (2003) and de Renzio
  (2005)

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Findings barriers to use effective HIV/AIDS
interventions

• Community level
• Physical barriers geography of Lesotho
  (highlands)
• Roads, public transport, long distance to
  clinics
• High mobility of population
• Poverty
• Food insecurity no ARVs on an empty stomach
• Cultural/ stigma HIV/AIDS
• PMTCT role of mother-in-law to breastfeeding/
  formula feeding stigmatizes HIV positive women
• Role of traditional healer
• KYS campaign, visibility of HIV/AIDS services,
  discrimination PLWHA
• Public needs empowerment to demand for health
• Lack of male involvement

12
Health service delivery level

• Shortage of health workers!!!!
• Extremely high attrition
• HIV/AIDS illness and deaths
• external migration- mainly to South Africa
• Internal migration rural-urban and govt to
  donor-funded activities
• Poor working conditions rural areas (poor
  compensation package and workload)
• Poor accessibility of health services
• Mountain areas underserved (despite recent
  efforts donors)
• Scheduling of serviced delivery (vertical
  approach no supermarket model)
• Lack of equipment and infrastructure
• Inadequate drugs and medical supplies
• Cold chain management a challenge
• Stock out drugs (change of drugs not documented)

13
Health sector policy and strategic management
level

• Overly centralised system for planning and
  management
• Ministry of Health overstretched- lack of
  capacity
• Decentralisation not really taken off (MCA since
  Sept 2008)
• Long procurement processes
• Low absorptive capacity funding
• Slow disbursement of grants
• Under-budgeting shortage of funds (Global Fund
  project proposals)
• Workshops and training
• Health policies in place, but
• lacks mechanisms to define policy priorities
  (leadership)
• No capacity to implement
• Coordination challenges HIV/AIDS
• Overlap role MOH-NAC
• High turnover of personnel at NAC

14
Constraints generated by donor behaviour

• Fragmented interventions
• Multiple donors imposing uncoordinated and
  burdensome practices through small, dispersed
  projects
• Heavy transaction costs, taking time and
  resources away
• Lack of donor harmonization
• Intention is there , but no follow-through
• No trust (yet) donors in pooling funds
• (budget support, SWAp)
• Donor driven priorities

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What can be done to increase scale-up?
Hhighly effective Mmedium Llow
Adapted from Hanson et al. (2003) and
Oliveira-Cruz (2003)
16

• Conclusions
• Progress in foundations in Lesotho for scale-up
• User free HIV/AIDS interventions
• Increased donor funding available
• Policy environment has improved
• Scale-up being rolled out to health facility
• Public financial management improving
• Main challenge to scale-up
• Not enough competent HR at various levels of
  implementation,
• starting at community level, district, regional
  and central
• Not sufficient donor-flexibility to address
  systems weaknesses and strengthen implementation
  capacity, especially in HR at all levels.

17
Recommendations

• Additional funding will resolve some constraints
  but not all!
• HR
• - Hire, train and retain (incl civil servants)
• - Increase capacity educational institutions
• Partners and government need to work together to
  operationalise the agenda at country level
• GoL drivers seat
• Long-term donor commitments
• SWAp solution to multiple projects?
• More evidence needed
• - Most effective delivery approach for the short
  and long term best suited to Lesotho?
• -Optimal sequence of interventions?

18
Acknowledgements

• All key informants for their willingness to
  participate
• Special thanks to
• MoHSW
• Phiny Hanson and dr Givens Ateka (Irish Aid
  Lesotho)
• Yvonne Byrne (Pricewaterhouse Coopers)

• This work was funded by

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Limitations

• Very limited ability to uncover effects
  primarily describes interactions and possible
  implications so more hypothesis generating than
  hypothesis testing
• Way in which donor programs are implemented in
  the three countries might not be representative
  of donor practice elsewhere
• Sometimes difficult to triangulate data when
  researchers receive conflicting reports about
  donor activities from key informantsvalidity
  issues