Chima Charles Chikodili, Homedes Nuria
The University of Texas Health Science Center at Houston, School of Public Health, Houston, Texas, USA.
J Glob Health. 2015 Jun;5(1):010407. doi: 10.7189/jogh.05.010407.
Three global health initiatives (GHIs) - the US President's Emergency Plan for AIDS Relief, the Global Fund to Fight AIDS, Tuberculosis and Malaria, and the World Bank Multi-Country HIV/AIDS Program - finance most HIV services in Nigeria. Critics assert that GHIs burden fragile health systems in resource-poor countries and that health system limitations in these countries constrain the achievement of the objectives of GHIs. This study analyzed interactions between HIV GHIs and the Nigerian Health System and explored how the impact of the GHIs could be optimized.
A country case study was conducted using qualitative methods, including: semi-structured interviews, direct observation, and archival review. Semi-structured interviews were held with key informants selected to reach a broad range of stakeholders including policymakers, program managers, service providers, representatives of donor agencies and their implementing partners; the WHO country office in Nigeria; independent consultants; and civil society organizations involved in HIV work. The fieldwork was conducted between June and August 2013.
HIV GHIs have had a mixed impact on the health system. They have enhanced availability of and access to HIV services, improved quality of services, and strengthened health information systems and the role of non-state actors in health care. On the negative end, HIV donor funding has increased dependency on foreign aid, widened disparities in access to HIV services, done little to address the sustainability of the services, crowded out non-HIV health services, and led to the development of a parallel supply management system. They have also not invested significantly in the production of new health workers and have not addressed maldistribution problems, but have rather contributed to internal brain drain by luring health workers from the public sector to non-governmental organizations and have increased workload for existing health workers. There is poor policy direction, strategic planning and coordination, and regulation of externally-financed HIV programs by the government and this poses a great limitation to the optimal use of HIV-specific foreign aid in Nigeria.
A few reforms are necessary to improve the strengthening effect of GHIs and to minimize their negative and unintended consequences. This will require stronger leadership from the Nigerian government with regards to better coordination of externally-financed health programs. Also, donors need to play a greater role in addressing the negative consequences of foreign aid. The findings highlight important unintended consequences and system-wide impacts that get little attention in traditional program evaluation.
三项全球卫生倡议——美国总统艾滋病紧急救援计划、全球抗击艾滋病、结核病和疟疾基金以及世界银行多国艾滋病毒/艾滋病项目——为尼日利亚的大多数艾滋病毒服务提供资金。批评者称，全球卫生倡议给资源匮乏国家脆弱的卫生系统带来负担，且这些国家的卫生系统限制因素制约了全球卫生倡议目标的实现。本研究分析了艾滋病毒全球卫生倡议与尼日利亚卫生系统之间的相互作用，并探讨了如何优化全球卫生倡议的影响。
采用定性方法开展了一项国别案例研究，包括：半结构化访谈、直接观察和档案审查。与选定的关键信息提供者进行了半结构化访谈，以涵盖广泛的利益相关者，包括政策制定者、项目管理人员、服务提供者、捐助机构及其实施伙伴的代表；世界卫生组织驻尼日利亚国家办事处；独立顾问；以及参与艾滋病毒工作的民间社会组织。实地调查于2013年6月至8月进行。
艾滋病毒全球卫生倡议对卫生系统产生了好坏参半的影响。它们提高了艾滋病毒服务的可及性和可得性，改善了服务质量，加强了卫生信息系统以及非国家行为体在医疗保健中的作用。负面的是，艾滋病毒捐助资金增加了对外国援助的依赖，扩大了获得艾滋病毒服务的差距，在解决服务可持续性方面成效甚微，排挤了非艾滋病毒卫生服务，并导致了一个平行供应管理系统的发展。它们也没有在新卫生工作者的培养方面进行大量投资且未解决分布不均问题，反而通过将公共部门的卫生工作者吸引到非政府组织而导致了人才外流，并增加了现有卫生工作者的工作量。政府对外部资助的艾滋病毒项目缺乏政策指导、战略规划和协调以及监管，这对尼日利亚最佳利用特定艾滋病毒外国援助构成了重大限制。
需要进行一些改革，以提高全球卫生倡议的强化效果，并尽量减少其负面和意外后果。这将需要尼日利亚政府发挥更强有力的领导作用，以更好地协调外部资助的卫生项目。此外，捐助者需要在应对外国援助的负面后果方面发挥更大作用。研究结果突出了传统项目评估中很少受到关注的重要意外后果和全系统影响。
