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      Global Health Initiatives and aid effectiveness: insights from a Ugandan case study

      research-article
      Author(s): 1 , , 2
      Publication date (Electronic):
      Journal: Globalization and Health
      Publisher: BioMed Central

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          Abstract

          Background

          The emergence of Global Health Initiatives (GHIs) has been a major feature of the aid environment of the last decade. This paper seeks to examine in depth the behaviour of two prominent GHIs in the early stages of their operation in Uganda as well as the responses of the government.

          Methods

          The study adopted a qualitative and case study approach to investigate the governance of aid transactions in Uganda. Data sources included documentary review, in-depth and semi-structured interviews and observation of meetings. Agency theory guided the conceptual framework of the study.

          Results

          The Ugandan government had a stated preference for donor funding to be channelled through the general or sectoral budgets. Despite this preference, two large GHIs opted to allocate resources and deliver activities through projects with a disease-specific approach. The mixed motives of contributor country governments, recipient country governments and GHI executives produced incentive regimes in conflict between different aid mechanisms.

          Conclusion

          Notwithstanding attempts to align and harmonize donor activities, the interests and motives of the various actors (GHIs and different parts of the government) undermine such efforts.

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          Most cited references18

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          An assessment of interactions between global health initiatives and country health systems.

          (2009)
          Since 2000, the emergence of several large disease-specific global health initiatives (GHIs) has changed the way in which international donors provide assistance for public health. Some critics have claimed that these initiatives burden health systems that are already fragile in countries with few resources, whereas others have asserted that weak health systems prevent progress in meeting disease-specific targets. So far, most of the evidence for this debate has been provided by speculation and anecdotes. We use a review and analysis of existing data, and 15 new studies that were submitted to WHO for the purpose of writing this Report to describe the complex nature of the interplay between country health systems and GHIs. We suggest that this Report provides the most detailed compilation of published and emerging evidence so far, and provides a basis for identification of the ways in which GHIs and health systems can interact to mutually reinforce their effects. On the basis of the findings, we make some general recommendations and identify a series of action points for international partners, governments, and other stakeholders that will help ensure that investments in GHIs and country health systems can fulfil their potential to produce comprehensive and lasting results in disease-specific work, and advance the general public health agenda. The target date for achievement of the health-related Millennium Development Goals is drawing close, and the economic downturn threatens to undermine the improvements in health outcomes that have been achieved in the past few years. If adjustments to the interactions between GHIs and country health systems will improve efficiency, equity, value for money, and outcomes in global public health, then these opportunities should not be missed.
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            The effects of global health initiatives on country health systems: a review of the evidence from HIV/AIDS control.

            Regien Biesma, Ruairí Brugha, Andrew Harmer … (2009)
            This paper reviews country-level evidence about the impact of global health initiatives (GHIs), which have had profound effects on recipient country health systems in middle and low income countries. We have selected three initiatives that account for an estimated two-thirds of external funding earmarked for HIV/AIDS control in resource-poor countries: the Global Fund to Fight AIDS, TB and Malaria, the World Bank Multi-country AIDS Program (MAP) and the US President's Emergency Plan for AIDS Relief (PEPFAR). This paper draws on 31 original country-specific and cross-country articles and reports, based on country-level fieldwork conducted between 2002 and 2007. Positive effects have included a rapid scale-up in HIV/AIDS service delivery, greater stakeholder participation, and channelling of funds to non-governmental stakeholders, mainly NGOs and faith-based bodies. Negative effects include distortion of recipient countries' national policies, notably through distracting governments from coordinated efforts to strengthen health systems and re-verticalization of planning, management and monitoring and evaluation systems. Sub-national and district studies are needed to assess the degree to which GHIs are learning to align with and build the capacities of countries to respond to HIV/AIDS; whether marginalized populations access and benefit from GHI-funded programmes; and about the cost-effectiveness and long-term sustainability of the HIV and AIDS programmes funded by the GHIs. Three multi-country sets of evaluations, which will be reporting in 2009, will answer some of these questions.
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              The President's Emergency Plan for AIDS Relief in Africa: an evaluation of outcomes.

              Eran Bendavid, Jayanta Bhattacharya (2009)
              Since 2003, the President's Emergency Plan for AIDS Relief (PEPFAR) has been the most ambitious initiative to address the global HIV epidemic. However, the effect of PEPFAR on HIV-related outcomes is unknown. To assess the effect of PEPFAR on HIV-related deaths, the number of people living with HIV, and HIV prevalence in sub-Saharan Africa. Comparison of trends before and after the initiation of PEPFAR's activities. 12 African focus countries and 29 control countries with a generalized HIV epidemic from 1997 to 2007 (451 country-year observations). A 5-year, $15 billion program for HIV treatment, prevention, and care that started in late 2003. HIV-related deaths, the number of people living with HIV, and HIV prevalence. Between 2004 and 2007, the difference in the annual change in the number of HIV-related deaths was 10.5% lower in the focus countries than in the control countries (P = 0.001). The difference in trends between the groups before 2003 was not significant. The annual growth in the number of people living with HIV was 3.7% slower in the focus countries than in the control countries from 1997 to 2002 (P = 0.05), but during PEPFAR's activities, the difference was no longer significant. The difference in the change in HIV prevalence did not significantly differ throughout the study period. These estimates were stable after sensitivity analysis. The selection of the focus countries was not random, which limits the generalizability of the results. After 4 years of PEPFAR activity, HIV-related deaths decreased in sub-Saharan African focus countries compared with control countries, but trends in adult prevalence did not differ. Assessment of epidemiologic effectiveness should be part of PEPFAR's evaluation programs. Agency for Healthcare Research and Quality.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Global Health
                Title: Globalization and Health
                Publisher: BioMed Central
                ISSN (Electronic): 1744-8603
                Publication date Collection: 2011
                Publication date (Electronic): 4 July 2011
                Volume: 7
                Page: 20
                Affiliations
                [1 ]Department of Global Health and Development, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
                [2 ]Institute for International Health and Development, Queen Margaret University, Edinburgh, Musselburgh, EH21 6UU, UK
                Article
                Publisher ID: 1744-8603-7-20
                DOI: 10.1186/1744-8603-7-20
                PMC ID: 3148970
                PubMed ID: 21726431
                SO-VID: a64803c2-82aa-4129-9a18-8083aed1db5c
                Copyright © Copyright ©2011 Cruz and McPake; licensee BioMed Central Ltd.
                License:

                This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                Date received : 29 October 2010
                Date accepted : 4 July 2011
                Categories
                Subject: Research

                ScienceOpen disciplines: Health & Social care
                Data availability:
                ScienceOpen disciplines: Health & Social care

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