A coordinated response to HIV/AIDS remains one of the 'grand challenges' facing policy makers today [1
]. As the number of global health actors continues to proliferate exponentially, one particular set of actors - global health initiatives (GHIs) - has the potential both to facilitate and exacerbate coordination. New actors bring new resources for health, increased flexibility and creativity, all of which require coordination. However, the diversity and complexity of relations amongst multiple actors - a hallmark of GHIs - may also weaken already fragile health systems, thereby undermining their efficiency, effectiveness and equity [2
Whilst single country studies and broad-brush reviews are starting to reveal the complex relationship between GHIs and efforts to coordinate the HIV/AIDS response [6
], synthesis of primary data from multiple countries is required to identify cross-country challenges and lessons learned. This study fills this knowledge gap by presenting a synthesis of primary data from seven country studies on the effects of the Global Fund to Fight AIDS, Tuberculosis and Malaria, the President's Emergency Plan for AIDS Relief (PEPFAR), and the World Bank's HIV/AIDS programmes including the Multi-country AIDS Programme (MAP).
At the global level consensus has emerged about the need to improve coordination of health and HIV-specific programmes [8
]. Several initiatives have aimed at improving coordination (Table ). In 2004, the UNAIDS 'Three Ones' principles called for one national AIDS coordinating body, while in 2005 both the Paris Declaration on Aid Effectiveness and the Global Task Team on Improving AIDS Coordination among Multilateral Institutions and International Donors (GTT) reported on how actors within the new global health architecture might better coordinate their activities. Buoyant with a new-found enthusiasm for coordination, a flurry of international activity in 2007 led to the establishment of the Global Implementation Support Team, the Global Campaign for the Health MDGs, and the International Health Partnership (IHP) - all calling for better coordination to achieve improved health outcomes.
Global and country level initiatives, agreements and processes to promote coordination of health programmes
At the country level the need for a coordinated HIV/AIDS response is also recognised as urgent, and numerous country-level programmes and reforms have been implemented with varying degrees of success (Table ). Beginning in the late 1980s with the WHO's Global Programme on AIDS - the genesis of many current National AIDS Commissions (NAC) or their equivalents - efforts to coordinate were given a boost in 2002 with the introduction of the Global Fund's Country Coordinating Mechanism (CCM). Established to coordinate country-funding proposals and broaden cooperation and participation in decision-making, early experiences were mixed: some CCMs integrated with NACs, others developed complementary roles, and some were reported to be competing for the same resources [11
]. In 2006 the UN's report Delivering as One
added emphasis to the need for better country coordination by outlining a series of reforms to streamline the work of UN agencies operating at country level [13
], and by 2009 Country Health Sector Teams were being developed through the IHP as a way to bring civil society and non-state actors into the coordination process [14
The introduction of GHIs such as the Global Fund, PEPFAR and the World Bank's Multi-country AIDS Programme have important implications for these and other efforts at improving coordination of health programmes. While they have diverse governance arrangements - PEPFAR is a bilateral programme, the Global Fund is a public-private partnership and the World Bank is a multilateral agency - their common feature is the extent to which they have mobilised substantial resources for HIV/AIDS control in multiple countries. Brugha defines a GHI as: 'a blueprint for financing, resourcing, coordinating and/or implementing disease control across at least several countries in more than one region of the world
]. Indeed these GHIs have mobilised unprecedented levels of funds for diseases such as HIV/AIDS, malaria and tuberculosis and engendered increased political attention and widened stakeholder engagement for disease control [6
]. The Global Fund, for example, has rapidly scaled up its funding from less than 1% of total development assistance for health in 2002 to 8·3% in 2007, with total approved funding of 15.6B
3.8B in funds for HIV/AIDS programmes globally [19
Concerns have been raised about how well GHI programmes are coordinated and aligned with health systems, and whether they have exaggerated problems of weak health systems in some cases. Some GHIs have required countries receiving funds to establish new coordination structures, as in the case of the Global Fund; others, such as PEPFAR, have operated relatively independently of national coordination systems. In the first, and to date only, systematic review of GHIs, the Global Fund was credited with expanding stakeholder engagement, notably civil society participation in CCMs, although in some countries governments dominated CCM decision making while sideling civil society and private sector actors [6
]. While the Global Fund has since introduced tighter conditions stipulating the inclusion of these groups [20
], CCMs have also been criticised for duplicating existing coordination structures, thereby adding to an already complex health governance architecture, and for failing to engender effective communication and trust between members [11
]. PEPFAR has been criticised in particular for limited transparency, and a lack of willingness to coordinate with other donors [26
], although the new Obama administration has pledged to revise PEPFAR's Country Operation Plans to ensure better coordination with country governments and donors [10
Ten years have passed since the launch of the World Bank's Multi-country AIDS Programme, and almost five years since PEPFAR was launched. The Global Fund's Technical Evaluation Reference Group (TERG) has just completed its Five Year Evaluation, and findings from primary research about the effects of GHIs on health systems at national and subnational levels are beginning to be reported [27
]. It is therefore an appropriate time to revisit and review the effects that GHIs providing large levels of funds to HIV/AIDS control are having on coordination efforts in-country. Most studies have been located in Africa and have focused on the national level. Now that GHIs are well established, knowledge is needed on their effects across more diverse country settings, and at subnational as well as national levels. This paper addresses some of these knowledge gaps by presenting a synthesis of empirical findings on the effects of three GHIs for HIV/AIDS across seven countries. While the results fill some gaps, what is striking from our findings is the paucity of data in some areas, in some countries, and for some - though not all - of the initiatives; but we argue that this is an important finding in its own right and that there remains an important need for ongoing studies on the effects of GHIs on country health systems as these initiatives mature.
Based on empirical evidence from country studies forming part of the Global HIV/AIDS Initiatives Network
, this paper explores the effects on subnational and national coordination structures of three GHIs for HIV/AIDS control that collectively contribute more than two thirds of external funding for HIV/AIDS programmes [40
]: the Global Fund, PEPFAR, and the HIV/AIDS programmes that form a part of the World Bank's Health Nutrition and Population (HNP) programme including the Multi-country AIDS Programme (MAP). Table summarises the key features of each of these initiatives. The paper synthesises empirical qualitative data from seven country studies: two from Europe (Georgia and Ukraine); two from Africa (Mozambique and Zambia); two from Asia (China and Kyrgyzstan); and one from Latin America (Peru). These country studies were selected on the basis that: a) they were members of the GHIN network, and b) they had explored coordination as part of their study. Reports for the studies conducted in the seven countries are accessible at http://www.ghinet.org/
]. Key reports are referenced fully in this article. The Peru research team has also published some of their findings at http://www.iessdeh.org/usuario/ftp/final%20ghin.pdf
The paper has the following objectives:
To assess progress towards the Three Ones principle of creating one national AIDS coordination authority by mapping national and subnational coordination structures with a remit for HIV/AIDS across the seven countries;
To identify how the above GHIs - where present - have affected national and subnational HIV/AIDS coordination structures including their creation, broad participation and effective functioning;
To assess what has been achieved in terms of the functioning of national and subnational coordination structures and identify what problems remain.
Table summarises GHI HIV/AIDS programmes in the seven countries together with selected indicators of HIV/AIDS; the table shows there is substantial diversity across these countries in terms of GHI country presence, epidemiological status (low level, concentrated or generalised epidemics) and amount of HIV/AIDS-related funding received.
GHI HIV/AIDS programmes in seven case study countries
The study embraces both deductive and inductive approaches to thematic analysis: we tested the importance of the key factors relating to the effective functioning of coordination structures identified in the literature in the seven country settings; additionally we identified and explored themes emerging from the country data. The literature to date defines the effective functioning of national coordination mechanisms including Global Fund CCMs in different ways [2
• inclusive stakeholder representation across government departments;
• strong civil society engagement;
• appropriate level of membership;
• strong and effective leadership;
• authority and strong country ownership;
• alignment with other coordination structures;
• clear functions and mandates;
• clarity over structure, operating procedures and terms of reference;
• sufficient secretariat capacity; and
• effective communication between members.
Informed by these studies and the major issues grounded in the findings of the seven country studies we developed a health systems analytical framework (Figure ) that captures a) GHIs and other financers of country HIV/AIDS programmes; b) aspects of the functioning of national and subnational coordination structures; c) and the effects of coordination structure functioning on programme coordination. Less data were available from these studies relating to c) the effects of coordination structures on programme delivery and health outcomes. While it has been widely accepted that improved coordination can lead to better efficiency, effectiveness, equity and sustainability of health and other programmes [2
], this remains an area where further research is required.
Framework for assessing the effects of global HIV/AIDS initiatives on country coordination structures.