Health Policy and Planning
Volume 29 Issue 8 December 2014
http://heapol.oxfordjournals.org/content/current

The emergence, growth and decline of political priority for newborn survival in Bolivia
Stephanie L Smith*
Author Affiliations
School of Public Administration, University of New Mexico, Albuquerque, NM 87131-0001, USA
Accepted September 16, 2013.
Abstract
Bolivia is expected to achieve United Nations Millennium Development Goal Four, reducing under-five child mortality by two-thirds between 2021 and 2025. However, progress on child mortality reduction masks a disproportionately slow decline in newborn deaths during the 2000s. Bolivia’s neonatal mortality problem emerged on the policy agenda in the mid-1990s and grew through 2004 in relationship to political commitments to international development goals and the support of a strong policy network. Network status declined later in the decade. This study draws upon a framework for analysing determinants of political priority for global health initiatives to understand the trajectory of newborn survival policy in Bolivia from the early 1990s. A process-tracing case study methodology is used, informed by interviews with 26 individuals with close knowledge of newborn survival policy in the country and extensive document analysis. The case of newborn survival in Bolivia highlights the significance of political commitments to international development goals, health policy network characteristics (cohesion, composition, status and key actor support) and political transitions and instability in shaping agenda status, especially decline—an understudied phenomenon considering the transitory nature of policy priorities. The study suggests that the sustainability of issue attention therefore become a focal point for health policy networks and analyses.

Global Fund investments in human resources for health: innovation and missed opportunities for health systems strengthening
Diana Bowser1, Susan Powers Sparkes1, Andrew Mitchell1,2, Thomas J. Bossert1, Till Bärnighausen1, Gulin Gedik3 and Rifat Atun1,4,*
Author Affiliations
1Harvard School of Public Health, Boston, MA 02115, USA, 2Office of the U.S. Global AIDS Coordinator, Washington, DC, 20520, 3World Health Organization, 1211 Geneva 27, Switzerland and 4Imperial College Business School and Faculty of Medicine, London, SW7 2AZ, UK
Accepted September 16, 2013.
Abstract
Background
Since the early 2000s, there have been large increases in donor financing of human resources for health (HRH), yet few studies have examined their effects on health systems.
Objective To determine the scope and impact of investments in HRH by the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund), the largest investor in HRH outside national governments.
Methods
We used mixed research methodology to analyse budget allocations and expenditures for HRH, including training, for 138 countries receiving money from the Global Fund during funding rounds 1–7. From these aggregate figures, we then identified 27 countries with the largest funding for human resources and training and examined all HRH-related performance indicators tracked in Global Fund grant reports. We used the results of these quantitative analyses to select six countries with substantial funding and varied characteristics—representing different regions and income levels for further in-depth study: Bangladesh (South and West Asia, low income), Ethiopia (Eastern Africa, low income), Honduras (Latin America, lower-middle income), Indonesia (South and West Asia, lower-middle income), Malawi (Southern Africa, low income) and Ukraine (Eastern Europe and Central Asia, upper-middle income). We used qualitative methods to gather information in each of the six countries through 159 interviews with key informants from 83 organizations. Using comparative case-study analysis, we examined Global Fund’s interactions with other donors, as well as its HRH support and co-ordination within national health systems.
Results
Around US$1.4 billion (23% of total US$5.1 billion) of grant funding was allocated to HRH by the 138 Global Fund recipient countries. In funding rounds 1–7, the six countries we studied in detail were awarded a total of 47 grants amounting to US$1.2 billion and HRH budgets of US$276 million, of which approximately half were invested in disease-focused in-service and short-term training activities. Countries employed a variety of mechanisms including salary top-ups, performance incentives, extra compensation and contracting of workers for part-time work, to pay health workers using Global Fund financing. Global Fund support for training and salary support was not co-ordinated with national strategic plans and there were major deficiencies in the data collected by the Global Fund to track HRH financing and to provide meaningful assessments of health system performance.
Conclusion
The narrow disease focus and lack of co-ordination with national governments call into question the efficiency of funding and sustainability of Global Fund investments in HRH and their effectiveness in strengthening recipient countries’ health systems. The lessons that emerge from this analysis can be used by both the Global Fund and other donors to improve co-ordination of investments and the effectiveness of programmes in recipient countries.

Aid for health in times of political unrest in Mali: does donors’ way of intervening allow protecting people’s health?
Elisabeth Paul1,*, Salif Samaké2, Issa Berthé2, Ini Huijts3, Hubert Balique4 and Bruno Dujardin5
Author Affiliations
1Université de Liège, Changement Social et Développement, and Research Group on the Implementation of the Agenda for Aid Effectiveness in the Health Sector (GRAP-PA Santé), Boulevard du Rectorat 7, Bât B31, bte 8, 4000 Liège, Belgium, 2Planning and Statistics Unit, Ministry of Health, BP232, Koulouba, Bamako, Mali, 3International Heath Expert, Bamako, Mali, 4Laboratoire de Santé Publique, Faculté de Médecine de Marseille 27, Bd Jean Moulin, 13385 Marseille CEDEX 05, France and 5Ecole de Santé Publique, Université Libre de Bruxelles, Campus Erasme, CP596, Route de Lennik 808, 1070 Bruxelles, Belgium
Accepted September 27, 2013.
Abstract
Mali has long been a leader in francophone Africa in developing systems aimed at improving aid effectiveness, especially in the health sector. But following the invasion of the Northern regions of the country by terrorist groups and a coup in March 2012, donors suspended official development assistance, except for support to NGOs and humanitarian assistance. They resumed aid after transfer of power to a civil government, but this was not done in a harmonized framework. This article describes and analyses how donors in the health sector reacted to the political unrest in Mali. It shows that despite its long sector-wide approach experience and international agreements to respect aid effectiveness principles, donors have not been able to intervene in view of safeguarding the investments of co-operation in the past decade, and of protecting the health system’s functioning. They reacted to the political unrest on a bilateral basis, stopped working with their ministerial partners, interrupted support to the health system which was still expected to serve populations’ needs and took months before organizing alternative and only partial solutions to resume aid to the health sector. The Malian example leads to a worrying conclusion: while protecting the health system’s achievements and functioning for the population should be a priority, and while harmonizing donors’ interventions seems the most appropriate way for that purpose, donors’ management practices do not allow for reacting adequately in times of unrest. The article concludes by a number of recommendations.