review of the evidence from HIV/AIDS control.

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

This paper reviews country-level evidence about the impact of global health initiatives, which have had profound effects on recipient country health systems in middle- and low- income countries. Biesma and colleagues have selected three initiatives that account for an estimated two-thirds of external funding earmarked for HIV 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 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 monitoringand evaluation systems. Sub-national and district studies are needed to assess the degree to which global health initiatives are learning to align with and build the capacities of countries to respond to HIV; whether marginalized populations access and benefit from global health initiatives-funded programmes; and about the cost-effectiveness and long-term sustainability of the HIV programmes funded by the global health initiatives. Three multi-country sets of evaluations, which will be reporting in 2009, will answer some of these questions.