The rapid increase in funding for human immunodeficiency virus (HIV) care and treatment over the last 10 years has presented both great opportunities and new dilemmas for improving health service delivery in many African countries. Because this new wave of large-scale funding is primarily disease-specific, it is typically directed toward “vertical” projects through separate and parallel systems designed to improve HIV-related programs, often without strengthening other sectors of health systems [1–5]. Many donors have chosen to channel most of their funds to non-governmental organizations (NGOs) and other partners rather than to public sector systems, further reinforcing vertical approaches. However, the challenges associated with scale-up of HIV care services, especially anti-retroviral treatment (ART), has led to growing recognition that overall health system strengthening will be essential to meet acquired immunodeficiency syndrome (AIDS) treatment goals [3, 6, 7].
Health workforce capacity building is a vital component of health system strengthening in developing countries. It is now widely accepted that the shortage of health workers in many African countries is among the most significant constraints to achieving the three health-related Millennium Development Goals (MDGs) [8–10]. While the scale of new vertical HIV-specific funding is significantly larger than most other health sector donor funding in many African countries, its impact on existing public sector systems and workforce has been understudied . There is even less in the literature that highlights the views, experiences, and working conditions of public sector health workers themselves as they attempt to manage health services within this new environment. A qualitative examination of health workers’ perspectives can complement quantitative approaches to health services research to reveal additional costs and benefits of vertical funding to health systems strengthening in Africa while suggesting further avenues of inquiry.
Since Mozambique has experienced an especially dramatic increase in disease-specific support over the last eight years it provides an ideal site to examine health worker experiences. Mozambique’s Primary Health Care (PHC) system, first established after independence in 1975, suffered through a protracted civil war and budget cuts mandated by a World Bank/International Monetary Fund (IMF) structural adjustment program during the 1980s . Since the war’s end in 1992, hundreds of international NGOs and agencies have been recruited by donors and have become major actors in the health sector [13, 14]. Beginning in the early 2000s, Mozambique experienced an especially large surge of aid funding primarily for HIV (and to a lesser extent malaria and tuberculosis) from donors including the President’s Emergency Plan for AIDS Relief (PEPFAR), the Global Fund to Fight AIDS, Malaria, and TB, the Clinton Presidential Foundation, the World Bank, and a range of others. Overall health sector spending increased from US$165 million in 2001 to an estimated US$591 million by 2008 [15, 16]. Much of this additional funding has supported new and existing foreign NGOs leading to an expansion of their involvement in the health sector. However, even with this rapid growth in funding, the MOH continues to suffer a severe workforce shortage with a population/physician ratio of 34,579: 1, and a population/nurse ratio of 4,441:1, among the worst in the world . Most support from major donors for human resources in many developing countries continues to focus on short-term in-service training rather than pre-service training that might alleviate workforce shortages .
Vertical funding takes two major forms in Mozambique. Some support is provided to programs within the Ministry of Health (MOH) itself that focus on specific diseases. A much larger proportion of vertical support is channeled directly to NGOs that center on specific projects whose funding, planning, and implementation are conducted outside the MOH. In both forms, vertical funds have generally not supported cross-cutting human resources, administration, logistics costs, or basic training institutions of the MOH [18, 19]. “Non-vertical” aid funds that flow to the MOH itself are either channeled into the general state health budget under direct MOH control or into a mechanism known as the “Common Fund” (managed through a Sector Wide Approach to planning, or SWAp) where donor funds are jointly managed with the MOH. From 2001 to 2008 the MOH state budget doubled from US$70 million to US$138 million and the Common Fund increased from US$17 million to US$74 million. However, vertical funds channeled outside of the MOH to NGOs and other agencies quadrupled from $75 million to an estimated $300 million, accounting for over 58% of all health sector spending by 2008, while the common fund constituted about 15% and the general state budget contributed 27% [15, 16]. By 2011, vertical funding still constituted nearly 50% of all health sector spending, while common fund contributions accounted for 22% . The great majority of this vertical funding continues to come from PEPFAR, which had increased its support to US$269 million by 2011 . None of the PEPFAR funding has been channeled through the common fund and is primarily allocated to NGO implementing partners. The Global Fund is the second largest contributor and had experimented with channeling resources through the common fund but changed strategies in July 2008 to vertical support . The United States (USA) President’s Malaria Initiative (PMI) has been growing as a major vertical donor since 2007, and by 2012 was contributing about US$30 million . Foreign NGOs had already been major actors in the health sector before the increase in HIV-related funding , but now continue to dominate the civil society involvement in the health sector in part because of the major vertical funding that has been channeled to them from PEPFAR, PMI, and other donors .
The primary objective of this study was to solicit and identify perspectives on vertical aid among key Mozambican public sector health managers who must coordinate, implement, and manage the myriad projects, agencies, and resource flows that the increase in vertical funding has produced amid these continued severe workforce staffing shortages. While these interviews were conducted in 2008 and are now somewhat dated they represent an important historical record to orient and guide future research. Specific aims of the project included identification of manager perspectives on the value of international aid funding and technical assistance, the impact of vertical funding on health system function, health system relationships with vertically-funded NGO projects, and the influence of vertical funding on work conditions within respondents’ respective sectors of the health system.