Resource allocation and health financing

“If donors woke up tomorrow and said we can't fund you, what would we do?” A health system dynamics analysis of implementation of PMTCT option B+ in Uganda
Doherty T; Besada D; Goga A; Daviaud E; Rohde S; Raphaely N: Globalisation and Health 13(51) 2017

In October 2012 Uganda extended its prevention of mother to child HIV transmission (PMTCT) policy to Option B+, providing lifelong antiretroviral treatment for HIV positive pregnant and breastfeeding women. The rapid changes in and adoption of new PMTCT policies are argued by the authors to have not been accompanied by research to explore health system preparedness to implement such programmes. The implementation of Option B+ provides many lessons which can inform the shift to ‘Universal Test and Treat’, a policy which many sub-Saharan African countries are preparing to adopt, despite fragile health systems. This qualitative study of PMTCT Option B+ implementation in Uganda three years following the policy adoption, uses the health system dynamics framework to explore the impacts of this programme on ten elements of the health system. Qualitative data were gathered through rapid appraisal during in-country field work. Key informant interviews and focus group discussions (FGDs) were undertaken with the Ministry of Health, implementing partners, multilateral agencies, district management teams, facility-based health workers and community cadres. The authors conducted a simple manifest analysis, using the ten elements of a health system for grouping data into categories and themes. Of the ten elements in the health system dynamics framework, context and resources (finances, infrastructure and supplies, and human resources) were the most influential in the implementation of Option B+ in Uganda. Support from international actors and implementing partners attempted to strengthen resources at district level, but had unintended consequences of creating dependence and uncertainty regarding sustainability. The health system dynamics framework is argued to offer a novel approach to analysis of the effects of implementation of a new policy on critical elements of the health system. Its emphasis on relationships between system elements, population and context is helpful in unpacking impacts of and reactions to pressures on the system, which adds value beyond some previous frameworks.