Key informants articulated that the Global Fund’s financing has allowed the national HIV/AIDS response “to grow, to expand, and to learn”, but stakeholders had to work on the process “with a lot of pain, headaches, [and] hiccups” (R04). Results are organized around the six building blocks – A-F, as described below and shown in Table 1.
Summary of result findings by health system building blocks
Sub-themes and major concepts
- Largest funding source for HIV/AIDS response
- Criticism of “zero cash flow policy”
- Reliance of donor funding and limited domestic financial resource
Leadership and governance
- Alignment and coordination between donors, public sector, NGOs and civil society
- Trigger of important policy changes
- Engagement of NGOs and civil society in service delivery and national coordination
- Challenge in keeping all stakeholders involved and decision-making, especially at township level
- Main supplier for related medicine
- Parallel procurement and supply chain system created inefficiency in medicine provision
Health information system
- Improved data management and monitoring capacity of Ministry of Health and Sports
- Improved monitoring and evaluation capacity of implementing agencies
- Limited capacity at township level
- Lack of staffing in public sector hindered scale-up of interventions
- Frequent turnover and lack of power for recruitment and deployment in hospitals
- Limited funding for workforce training
- Prevention activities lacked focus on men who have sex with men and challenges in implementing harm reduction activities
- Care and support activities with challenges in stigma and hard-to-reach population
- Treatment scale-up: benefit and challenges of decentralization
- Fragmented service delivery system and inefficient coordination between public and non-public stakeholders
All respondents acknowledged the crucial role of the Global Fund in financing the national response for HIV/AIDS as the single largest funding source. However, some respondents voiced criticism on Global Fund’s “zero cash flow policy”, which made the financing in “a bit of convoluted way”: “cash doesn’t come to the government programs” and “somebody else in the parallel process [is] managing finances for them” (R03). Some international organizations utilize a system of disbursement called “the Managed Cash Flow” where they deploy a cadre of staff, called field finance assistants, in every state and region. Having cash in hand, those staff make direct disbursement to service providers in the public sector through advance payment or offer cash reimbursement (based on the work-plan and implementation of activities). Some respondents observed constraints of this system at the operational level, especially when the field finance assistants were not able to check with service providers about the eligibility of expense reimbursement.
She [field finance assistant] reimbursed straightly to the staff or sometimes into the hands of Township Medical Officer [TMO]. Reimbursement was a hundred percent… I am not sure what kind of vouchers they show to the finance staff… But she [finance staff] cannot argue with the TMO. If there is a problem, she can be, I mean, she can be sacked. That is a kind of threatening. (R07)
Respondents also commented that the Global Fund’s zero cash flow policy did not help the MOHS improve their financial management capacity and accountability. While the government has increased its investment in HIV/AIDS in recent years, the level of the government’s financing remains low in terms of the overall health expenditure. Respondents voiced concerns over Myanmar’s excessive reliance on Global Fund and other foreign donors, which posed great challenge for financial sustainability of the current activities. One respondent (R06) remarked that “the government does not have sufficient tax income to fund their own AIDS response.” This indicated the government’s inability to sustain the current momentum of the national HIV/AIDS response with its own financial resources.
It is not going to be sustainable in the near future; that’s for sure unless Myanmar suddenly becomes a huge oil nation or whatever. I don’t see that happening. (R06)
B. Leadership and governance
According to the respondents, in addition to finance, the most notable effect of Global Fund on the national HIV/AIDS response was on strengthening its leadership and governance, specifically in four key areas.
B.1. Alignment and coordination
Key informants explained that the Global Fund played an important role in improving alignment and coordination between donors, the public sector, NGOs and CSOs. They emphasized that the Global Fund’s HIV/AIDS financing was aligned with the NSP. Respondents explained that, program reviews conducted by the executive working group of Myanmar Health Sector Coordinating Committee or one of its Technical and Strategy Groups ensured the alignment and harmonization between the programs funded by the Global Fund and the national priorities and plans.
The Global Fund introduced coordination mechanisms into the National AIDS Programme and optimized coordination for planning, proposal preparation (including that for the Global Fund), and NSP preparation and reviews. Respondents expressed their positive experiences of improved planning and coordination in the MOHS:
[W]e remind everyone in the room, not just the government; we have to remind ourselves—wait! Remember last year when we submitted the concept note, we received this feedback. Let’s think about how we can incorporate these interventions to strengthen our program to address, you know, the technical guidance provided to us… I think it is a good check-and-balance. (R01)
Respondents perceived that the coordination mechanisms of National AIDS Programme have greatly improved transparency and information sharing among the stakeholders over time. This process also helped stakeholders gain the each other’s trust and develop a culture of working together. A respondent (R10) from non-public agency indicated the change in the nature of collaboration between government hospitals and civil society.
[R]ight now, when we are going to organize trainings in a hospital, the hospital may arrange for it. They arrange a room for the training. They invite us. They welcome us. They collaborate with us in organizing some events. They also tell us to contact them directly if necessary and to tell them directly if we have so and so issues. (R10)
B.2. Policy development: the Global Fund makes it possible
Respondents pointed out that the Global Fund’s financing triggered several important policy changes regarding HIV/AIDS in the recent years. With “push and pull” from the Global Fund, the NSP has been updated and regularly monitored and evaluated. For example, the updated NSP allowed for broader participation of stakeholders, most notably the civil society, in governance of the national response. Recent updates (2014) of the NSP and the national guidelines for clinical management of HIV/AIDS have also signaled significant policy changes in terms of the country’s emphasis on treatment, especially scaling up ART, through standardization of essential service packages and simplification of the ART regimens. A respondent explained this catalytic effect of the Global Fund’s financing:
[I]t can be the leverage—so a bit like judo, you know; use the weight to the other. They [the Global Fund] put their money in. Because of that, we needed to reform the guidelines on treatment in the country. (R03)
Key informants also remarked that the country has gained positive experiences of grant implementation in compliance with the Global Fund’s requirements and standards over time. Domestic stakeholders are willing and ready to accept technical guidance and inputs provided to them. Respondents remarked that the Global Fund’s financing triggered such policy developments in the public sector that would substantially improve welfare of the people infected or affected by HIV/AIDS.
B.3. Engagement of stakeholders: NGOs and civil society
The Country Coordinating Mechanism of the Global Fund ensures involvement of NGOs and CSOs in proposal preparation and governance of the national response to HIV/AIDS. Along with the scaling-up of interventions funded by the Global Fund, participants noted that the role of local NGOs and CSOs has also been escalating. In the past, the role of local NGOs was mainly limited to providing counseling and home-based care, but now they have become engaged in providing services such as testing, and patient follow-up. Additionally, representatives from the local NGOs became more and more engaged and confident in discussing various issues at the Myanmar Health Sector Coordinating Committee. A key informant of a local NGO explains:
In the past, we took a seat and were just sitting and listening. We didn’t dare to talk in front of the Chair—the Minister… Right now, we have to talk when it is really necessary… So gradually our participation became meaningful. (R09)
B.4. Challenges in planning and coordination
Respondents discussed the challenges related to coordination, notably ensuring that all stakeholders were well-informed and engaged in discussions and the decision-making process, which was described as time consuming and occasionally unclear. Participants explained that this lack of coordination was frustration, especially for non-governmental stakeholders:
There are plenty of challenges in terms of ensuring that everybody has to say and everybody is informed… You know this proverb: “If you want to go fast, go alone. If you want to go far, go together.” … So given that, we try to get as many stakeholders as possible involved; it takes a long time. (R06)
Though the National AIDS Programme has established 47 teams in 2014 and holds quarterly planning and coordination meetings to oversee and coordinate activities at the state/regional level and the district/township level 5, many respondents observed that stakeholder coordination seemed to be more challenging at township level. A key informant (R05) commented that the public sector’s commitment seemed to diminish at the more local township level. However, the same respondent (R05) also clarified the opinion that “it is not because people [TMOs] do not want to do the business, but [because] they need support.” TMOs, who bear the responsibility for the implementation of different vertical programs, are sometimes not fully aware of all of the plans. In such cases, non-public partners face some constraints to coordinate their activities with the public sector at the township level.
C. Medical supply
With vertical programs supported by the Global Fund, the two Principal Recipients, the UNOPS and Save the Children International, run their procurement and supply chain systems in parallel. Several respondents highlighted the overall need of the public sector for strengthening the medical supply chain and logistics system, along with capacity building of the staff. At the township level, a key informant commented that inventory management systems were paper-based, creating a challenge at the local level for ensuring a consistent supply of key medications. One key informant explained that the Global Fund should make it a priority to assist township hospitals by creating a clear and coordinated system for managing supplies of key materials.
In some places medicines may be piled up in stocks, but in other places, medicines are in shortage. The government’s medical supply chain for the whole country is based on the central store. The central store delivers [medical supply] upon request. So in some cases, there is no order and no delivery. I think there are also some constraints in this part…The Global Fund is important because the Global Fund has been supporting the medicines provided by NAP until now. And the Global Fund is also supporting all patients in the NGO sector. So we can say that the Global Fund is supporting more than 100,000 patients currently receiving ART. (R12).
D. Health information system
According to the key informants, the Global Fund has improved the availability and reliability of strategic information about the HIV/AIDS epidemic. Data management and monitoring capacity of the implementing agencies have improved because of the Global Fund’s emphasis on data quality and monitoring. This also reflects willingness and ability of domestic agencies to adapt themselves and comply with the Global Fund’s fundamental requirements over time. A respondent (R04) remarked:
[T]en years ago you could not talk about data. Ten years ago, many people from outside or inside didn’t trust the data that we have or from MOHS. Now all partners trust the data we have because there are [is] transparency of the way of working. (R04)
Key informants also acknowledged the Global Fund’s monitoring & evaluation mechanism in improving the capacity of implementing agencies in health information systems. The interviewee said:
They [the Global Fund] are very precise about data. They check everything including the sources. As they are doing so, I would say that the skills of the volunteers, of our staff at different levels, and of staff from the health department have improved than before… They are always monitoring us and also teaching us for improving the quality. (R13)
At the township-level, however, monitoring and evaluation system in the public sector remains paper-based and needs to be improved. Respondents noted that that application of modern technology (e.g. electronic database, computers, and internet) is limited at the township level due to lack of human resources, equipment, and technical support.
E. Health workforce
Respondents agreed that lack of adequate staffing and capacity building, most notably in the public sector at the sub-national level, remain one of the most demanding health system issues and hindered the scaling-up and expansion of key HIV/AIDS interventions. According to respondents, MOHS officials at the central level were often burdened with outsized responsibilities for undertaking parallel or multiple tasks. At the township hospitals, the shortage of health workforce was even more pronounced. Respondents explained that many township hospitals lack key personnel – including pharmacists to oversee medicine stocks, and specific monitoring & evaluation personnel to manage database operations. In most cases, these specialized tasks fall to doctors and nurses:
We have built hospitals. Equipment is provided. We have labs but there are no technicians. It is because the soft component [human resources] is totally deficient. (R10)
Key informants also highlighted other challenges in township hospitals, such as frequent turnover of medical doctors (especially in remote areas). Turnover is exacerbated by the fact that township hospitals do not have the authority to recruit and deploy medical staff, making it difficult to fill positions and ensure adequate staffing. These staffing challenges have hampered timely and effective rolling-out of key programs:
So, just after we have given them trainings, they move [to another place]. What happens is that we give them trainings, and then they move. (R14)
The Global Fund invested a tiny portion of its funds to health workforce training. For example, in 2012, less than 0.1% funds were spent on capacity building for health workers 11. Respondents commented that trainings supported by the Global Fund enabled health care workers and volunteers to acquire some skills and capacity. Some respondents were critical of donors’ hesitancy (including the Global Fund) to invest in long-term human capacity development and concerned about programmatic sustainability.
To address these issues, some short-term arrangements have been made to meet the need at the township hospitals. For example, technical staff (such as technical officers, pharmacists, and logisticians) were hired through the WHO and some NGOs and supported the related services in the township hospitals. This approach provided temporary support for the ART provision at the township hospital but does not address the overall staffing issues in the public sector.
F. Service delivery on HIV/AIDS
Global Fund’s financing significantly improved HIV interventions, especially in scaling-up and decentralization of key interventions, such as ART. However, respondents commented that the government failed to fully utilize the funding from the Global Fund to ensure coverage of prevention, care and support, and treatment for vulnerable populations due to challenges as described below.
As guided by the NSP, prevention has focused on key populations including people who inject drugs (PWID), sex workers and their clients, and men who have sex with men. Main preventive care includes harm reduction for PWID (e.g. distributing sterile needles and syringes to break the chain of HIV transmission among PWID), condom promotion, prevention of mother to child transmission (PMTCT), awareness and education, etc. In 2013, nearly US$ 11 million (20 % of the total expenditure on HIV/AIDS) was spent on prevention and the Global Fund contributed US$ 3.8 million.
Respondents commented that most governmental prevention programs were tailored toward the general population (e.g. condom promotion, education campaign,) and lacked programs targeting men who have sex with men. Some respondents felt that - even for general population - current programs on awareness and mobilization were inadequate, and the level of public awareness about HIV/AIDS remained low. One respondent explained that this situation exacerbated the existing burden of HIV/AIDS-related stigma in the community (R10).
Several key informants highlighted challenges in implementing harm reduction. One respondent noted that the idea of distributing needles and syringes “may be not traditionally accepted by the government” (R01). Current governmental programs prioritize methadone maintenance therapy over harm reduction interventions for drug users.
They are not showing their leadership on the issue… Some government officials want to work on methadone. Sorry! This doesn’t stop you sharing the needles… First line has to be needle-syringe program. (R03)
In some cases, local communities are reluctant to distribute needles and syringes, fearing it could promote injecting drug use in their area. Subsequently, several respondents suggested MOHS to “re-think” its approach towards prevention among drug users.
F.2. Care and support: promoting the patients’ welfare
Self-help groups and civil society networks are the main providers of peer supports at the community level. However, some volunteers faced constraints in conducting home-based follow-up because of the stigma.
[W]hen we organized volunteers and told them to follow up our new patients, they said that the whole town had already known them (patients) as HIV-positive people.” (R13)
Respondents working for the networks also commented on challenges to reach patients in migrant and mobile populations:
[M]igrant and mobile populations do not stay in a township [for long]. Sometimes, the places they live are really away; they move far away from villages. They may live in woodlands. (R13)
F.3. Treatment: scaling-up provision of ART
The Global Fund contributed 46% of its funding to support ART scaling-up in 2013, approximately equivalent to 70 % of the country’s total spending on ART in the year (23), mainly in the public sector. At the end of 2014, more than 85,000 people living with HIV (47%) received ART 5.
Supported by the Global Fund, the public sector adopted a two-pronged approach for ART scaling-up: increasing the number of main ART center countrywide and decentralizing some service provision to lower level health facilities. The main ART centers, located mostly at specialist hospitals or hospitals at state/regional and district levels, are primary facilities for enrollment of new patients, initiation of treatment, and management of complex cases, whereas the township hospitals are facilities that provide follow-up services to stable patients for continuation of treatment. In this way, patient loads could be relieved at the main ART centers and patients may have convenient access to the treatment at nearby places after their conditions were stable. Some respondents witnessed that, providing ART treatment in township hospitals helped patients save time and costs of accessing care.
[W]hen some patients arrived there [decentralized site], they realized it was near to their home. For those who used to get up at two in the morning, they might get up at six in the morning to go there… They got the same medication… So, some [patients] became satisfied. As they felt satisfied, the information was spread from one to another, and a few more patients showed up. (R14)
Respondents described this process of decentralization in service delivery as an important but challenging. A number of barriers to effective decentralization of treatment to township hospitals were raised by the respondents including limited human resources, concerns about the quality of treatment in township settings, limited laboratory and medical supply chain and stock management capacity, and overall weak communication links with main ART centers, referral labs, and regional medical stores.
“We reach to the township level decentralized sites, in most places we have only one doctor in township hospitals such as township medical officer. These guys- they also have other activities under their management. There is no kind of additional support in terms of human resources, let’s say in terms of benefits, salary – no, nothing. It is kind of like adding another burden over their shoulders and no significant support is received. So, there are some decentralized sites that are functioning well because they receive supports from the partners. But in some places, there is no collaborating partner, and most of these places are not functioning.” (R05)
“There might not be actual decentralization, I mean…. For example, if it is an actual decentralization, there must be transfer of responsibility and decision-making authority to the lower level. But the lower levels do not make any actual decisions and they don’t have any decision-making power. We concern that it may still be controlled by the central level, as usual.” (R11)
In addition, the Global Fund’s implementing agencies face the challenge and security risks for reaching the people with the greatest need, including the migrant population and those in remote and conflict-affected areas:
“Sometimes, INGOs [international non-governmental organizations] use illegal routes to get to the patients and could take a lot of risks to get there [conflict and border areas]. (R07)
In some cases, lack of information about availability of services widens the existing gaps of service utilization at the operational level. Due to these challenges, inequity in access to ART remains a significant challenge for the national HIV/AIDS response.
F.4. Other challenges
In addition to above issues, there were two more challenges in delivering prevention, care/support, and treatment: (1) fragmented service delivery system, and (2) inefficient coordinating between public sector and non-public stakeholders.
Fragmenting service delivery system due to vertical programs
The MOHS implements several vertical disease control programs (including HIV/AIDS funded by the Global Fund) and other public health programs through township health systems. These vertical programs, running in parallel to each other, have fragmented the health system at different levels. At the national level, the fragmentation has led to inefficiencies and weak coordination around cross-cutting issues, as a key informant illustrated:
[Y]ou will become kind of like a ping-pong ball. So, the different national programs will play you around the circle, and at the end of the day, you got frustrated. (R05)
At the operational level, some respondents pointed out that implementing parallel projects constrained provision of integrated services. Patients could not obtain all needed services at one delivery point, and they often have to go to other delivery points for different diseases. Health facilities in some areas are far from each other, which makes it very difficult for patients to obtain needed care. A respondent explained:
[I]n terms of time spent by the clients, it is really challenging… So, because of that, we have a lot of … dropouts between the referral facilities. (R05)
Inefficient coordinating between public and non-public stakeholders
NGOs and civil society have been playing substantial role in the national HIV/AIDS response stakeholders, especially in the places (e.g. conflict-affected areas) where the coverage of governmental health services is poor. They also play a prominent role in delivering and promoting HIV prevention among the key population groups. Therefore, coordinating the activities between the public and non-public stakeholders is important for efficiently delivering services.
Some key informants pointed out the issue of ownership in the public sector when NGOs filled the urgent gaps with temporary assistance: the township hospitals seem to shift their responsibility to NGOs. Respondents felt that the sense of ownership was vital to ensure sustainability of the programs in the public sector. Some key informants also pointed out the difficulties of collaboration at the local level.
[W]e tried to run a one-stop shop in [Township X]… When we talked about it at the central level, it was going well. They agreed to it. But when we talked about it at the field level, we were not able to negotiate with the respective the district medical officer [DMO]. (R12)
Respondents commented that intensive advocacy from the MOHS could mitigate the challenge. Respondents cited “the letter for collaboration” to be an effective tool for successfully running activities at the local level. “The letter for collaboration” refers to an official letter issued by the MOHS that instructs or informs local authorities to collaborate and support the non-public partners. One key informant said:
[T]he process becomes smooth because of their support letter for collaboration. It is a little bit [more] convenient and easy to do prevention activities and find our targets in places like KTV [Karaoke Television] lounges and brothels in the township if we get their approval. (R09)