Global Health Initiatives Scale-Up and its Effect on Private Health Institutional Systems Capacity: Selected Cases from Nigeria

Rationale: New Global Health Initiatives (GHI) in a number of countries in the developing world has often followed a vertical approach in a bid to increase significantly the number of treatment beneficiaries in a relatively short time. Increased funding from global initiatives such as the Global Fund for AIDS TB and Malaria (GFATM) and the US President's Emergency Plan for AIDS Relief (PEPFAR) has mostly gone to purchase of diagnostics and treatment health inputs and little focus has been put on strengthening internal systems and management processes that are essential for long term sustainability of these programs. In some cases these programs are threatening to weaken further institutional systems capacities. Objectives: The objective of this paper is to demonstrate the unequal investment in rapid scale up of Anti Retroviral Treatment programs at some hospitals in Nigeria at the expense of systems capacity in these institutions. Methodology: Systems capacities of 3 hospitals in Nigeria were mapped following a generic in-put-process-output-intermediate model. Additionally service configuration of ART programs within the general hospital operations was also assessed to establish any systems linkages and support during the programming phase to establish whether these programs are considered as part of the strategic focus of these institutions since these programs are exclusively donor funded. While not the focus of the study, the effect these new programs are having on general service delivery was also investigated during the mapping and assessment exercise. A statistical analysis was also carried out to show the proportion of financing devoted to new programs versus the service load they represent within the broader context of hospital services delivery. Results: The results show that in all the 4 hospitals ART programs run as vertical stand alone programs. Further analysis of the strategic loci of these institutions showed that ART programming which requires a chronic disease management approach is not considered a core organizational business yet in all institutions these programs are taking up more physical space, staff time and other support services of the hospitals. HIV care and treatment programs funded by donors make up about 83% of total operating budget at one of the hospitals, 54% at another and 40% at the third. While in all the three hospitals HIV care and treatment funding represents a substantial proportion of total annual operating budgets; the proportion of inpatient cases attributed to HIV care make up only 25%, 33% and 18% at each of the three hospitals respectively. In all the three hospitals all HIV related funding is exclusively for HIV programming related activities with none devoted to general support indirect services. Relative to outpatient services, the proportion of HIV related outpatient visits was 65%, 25% and 40% respectively. At the hospital with high HIV patient visits, it was also established that other patients have selectively referred themselves out of the hospital due to longer waiting times and the general perception that the hospital was offering only HIV related services. About 50%of the staff complement at this hospital was paid for and working for the HIV program and the hospital has no plans for sustaining such staff costs post donor funding. At the other two hospital the proportion was 32% and 18% respectively. Even with the high contribution of HIV related funding there is no clear understanding of actual financial and cost implications of these programs. At all the 3 hospitals there were no operational plans and no linkage between funding and any form of planning. They also reported difficulties in prioritising activities versus available funding and decide to pay salaries as a way of absorbing such funds, lest they risk losing it. All expressed a need for support to develop management and institutional capacities to enable them integrate new programs and increase their institutional internal efficiencies. Conclusion: Assessing the full impact on systems capacity for provider individual health institutions will require a longitudinal approach over a number of years. Nevertheless, cross sectional analyses like the one under this study still go a long way to demonstrate current implications and can be a good pointer to what the long term impact will be. Funding vertical programs at small hospitals without equal focus on their internal systems and management processes will eventually have an adverse effect not only on those programs but the institutions as a whole.