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Health Policy and Planning Advance Access published online on June 2, 2009
Health Policy and Planning, doi:10.1093/heapol/czp025
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Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine © The Author 2009; all rights reserved.
The online version of this article has been published under an open access model. Users are entitled to use, reproduce, disseminate, or display the open access version of this article for non-commercial purposes provided that: the original authorship is properly and fully attributed; the Journal and Oxford University Press are attributed as the original place of publication with the correct citation details given; if an article is subsequently reproduced or disseminated not in its entirety but only in part or as a derivative work this must be clearly indicated. For commercial re-use, please contact journals.permissions@oxfordjournals.org

The effects of global health initiatives on country health systems: a review of the evidence from HIV/AIDS control

Regien G Biesma1,*, Ruairí Brugha1,2, Andrew Harmer2, Aisling Walsh1, Neil Spicer2 and Gill Walt2

1Division of Population Health Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland.
2Department of Public Health and Policy, London School of Hygiene and Tropical Medicine, UK.

* Corresponding author. Department of Epidemiology and Public Health Medicine, Division of Population Health Sciences, Royal College of Surgeons in Ireland, St Stephens Green 120, Dublin 2, Ireland. Tel: +353 1 402 8584. Fax: +353 1 402 2764. E-mail: rbiesma{at}rcsi.ie

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.

Key Words: Global health initiatives, HIV/AIDS, health system strengthening, aid

Accepted for publication 20 April 2009.


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