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Promoting Country Ownership and Stewardship of Health Programs: The Global Fund Experience

Atun, Rifat MBBS, MBA, DIC, FRCGP, FFPH; Kazatchkine, Michel MD, PhD

JAIDS Journal of Acquired Immune Deficiency Syndromes: November 2009 - Volume 52 - Issue - p S67-S68
doi: 10.1097/QAI.0b013e3181bbcd58
Supplement Article

The Global Fund to Fight AIDS, Tuberculosis and Malaria was established in 2002 to provide large-scale financing to middle- and low-income countries to intensify the fight against the 3 diseases. Its model has enabled strengthening of local health leadership to improve governance of HIV programs in 5 ways. First, the Global Fund has encouraged development of local capacity to generate technically sound proposals reflecting country needs and priorities. Second, through dual-track financing-where countries are encouraged to nominate at least one government and one nongovernment principal recipient to lead program implementation-the Global Fund has enabled civil society and other nongovernmental organizations to play a critical role in the design, implementation, and oversight of HIV programs. Third, investments to strengthen community systems have enabled greater involvement of community leaders in effective mobilization of demand and scale-up for services to reach vulnerable groups. Fourth, capacity building outside the state sector has improved community participation in governance of public health. Finally, an emphasis on inclusiveness and diversity in planning, implementation, and oversight has broadly enhanced country coordination capacity. Strengthening local leadership capacity and governance are critical to building efficient and equitable health systems to deliver universal coverage of HIV services.

From the *Strategy, Performance and Evaluation Cluster, The Global Fund to Fight AIDS, Tuberculosis and Malaria, Geneva, Switzerland, and Professor, International Health Management, Imperial College London, UK; and †The Global Fund to Fight AIDS, Tuberculosis and Malaria, Geneva, Switzerland.

Correspondence to: Rifat Atun, MBBS, MBA, DIC, FRCGP, FFPH, The Global Fund to Fight AIDS, Tuberculosis and Malaria, Chemin de Blandonnet 8, 1214 Vernier, Geneva, Switzerland (e-mail: rifat.atun@theglobalfund.org).

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INTRODUCTION

The Global Fund to Fight AIDS, Tuberculosis and Malaria was established in 2002 to intensify the global response to fight this trio of major pandemics. The Global Fund has succeeded in rapidly providing substantial external financing to low- and middle-income countries to fight these pandemics and further efforts to reach the health-related Millennium Development Goals.

At its inception, the Global Fund was designed as an inclusive partnership, with explicit emphasis on country ownership, demand-driven program development, and performance-based funding-features that have distinguished the Global Fund from other health-financing agencies. The countries are at the heart of this partnership, with the Country Coordinating Mechanism bringing together government and the public sector, civil society, multilateral and bilateral agencies, the private sector, affected communities, persons living with or affected by the disease, and marginalized groups to form a partnership platform at the country level.

The Global Fund has rapidly expanded its operations, successfully raising and investing substantial financial resources to become the leading multilateral investor of funds to fight AIDS, tuberculosis, and malaria. By July 2009, the Global Fund had mobilized approximately US $21 billion, approved US $16.2 billion for nearly 600 programs in 140 countries, and disbursed approximately US $8.1 billion. By the end of 2008, it had provided some 57% of all external international financing for tuberculosis, 60% for malaria, and 23% for HIV/AIDS. To date, approximately 60% of the approved Global Fund investments (US $9.7 billion) have been for HIV/AIDS. In addition to targeted funding for the 3 diseases, and based on country demand, the Global Fund has regularly directed around 35% of its investments in health systems and community systems strengthening to sustain and expand services in the countries it supports.

These achievements are remarkable. Programs supported by the Global Fund have rapidly scaled up service delivery in countries affected by the HIV epidemic, such that by end of 2008, through these programs, 2 million HIV-infected people were receiving antiretroviral treatment-an increase of 560,000 since December 2007. Through Global Fund-supported programs, by 2008, 62 million people have accessed HIV counseling and testing; 445,000 HIV-infected pregnant women have received antiretroviral treatment to prevent mother-to-child transmission of the HIV virus; 91 million people have been reached with community outreach services for HIV; and 3.2 million vulnerable children orphaned due to AIDS have been provided with basic care and support.1

Increasingly, results from a selected number of countries that receive substantial Global Fund financing-including Malawi2-6 and Ethiopia7-suggest early evidence of impact on HIV outcomes with a decline in incidence and AIDS-related mortality at population level or in target groups.

In many countries, Global Fund investments have also helped transform the way the HIV epidemic has been addressed by expanding involvement at multiple levels of nonstate actors in the design, implementation, monitoring, and oversight of HIV prevention, treatment, and care programs.8

Although no specific study has systematically analyzed the ways in which Global Fund investment has affected country stewardship of HIV programs, early evidence points to positive benefits and a catalytic effect of Global Fund investments in building the capacity of local health leadership to improve governance of HIV programs. This has been achieved in 5 ways. First, the Global Fund model, which finances country priorities identified in successful proposals has encouraged development of local capacity to generate quality demand through the Country Coordinating Mechanisms-whose inclusive nature has ensured that this demand reflects priorities of broad set of stakeholders. Consequently, quality demand, as measured by the financial scale of proposals recommended to the Global Fund Board for approval by the independent Technical Review Panel, quadrupled between 2006 and 2008, reaching to around US $3.2 billion in 2008.1 This in itself suggests strengthened planning capacity in countries.

Second, by expanding the number and capacity of nongovernmental actors involved in HIV control, the Global Fund has helped develop broad country leadership in this area. Through dual-track financing-under which the Global Fund strongly encourages countries to nominate at least one government and one nongovernment principal recipient to lead program implementation-the Global Fund has enabled civil society organizations, nongovernmental institutions, faith-based entities, and community-based organizations to develop and play a critical role in the design, implementation, and oversight of HIV programs. Indeed, performance of Global Fund-supported programs implemented by civil society organizations exceeds those implemented by government agencies.1

Third, investments in local leadership have been critical in generating community demand for services. In many settings, investments to develop stronger community systems have encouraged greater involvement of community leaders to effectively mobilize demand for services and to successfully scale up programs to reach the poor and the vulnerable. For example, community mobilization in Ethiopia has enabled provision of strengthened counseling and testing in more than 650 health facilities, scaled up improved clinical management of HIV infection, expanded management of sexually transmitted diseases in over 350 clinics across the country, and improved the safety of medical practices through strict application of universal precautions in health facilities. Similarly, a comprehensive partnership of government, civil society, and faith-based organizations in Zambia illustrates how greater engagement of the civil society and the community along with government actors has helped to effectively address the AIDS epidemic by expanding provision of prevention, treatment, and care at community level. Alongside the government program, civil society now forms an essential part of Zambia's health system, which by the end of 2008 supported 172,000 people on antiretroviral drugs.1 Zambia provides a good example of community systems strengthening, an area of investment that countries can request in their proposals to the Global Fund.

Fourth, expansion of community involvement has helped improve health governance. With around one-half of Global Fund resources now invested in programs that are implemented by nonstate actors, accountability of service providers to the communities served and to nongovernment organizations has increased. The Global Fund contribution toward building capacity outside the state sector has improved community participation in the governance of public health.9

Finally, mechanisms that have emphasized inclusiveness and diversity in planning, proposal development, and oversight have helped enhance country coordination capacity. The recently completed Five Year Evaluation of the Global Fund concluded that Country Coordinating Mechanisms had emerged as the core partnership mechanism at the country level, and had succeeded in mobilizing multilateral institutions, bilateral agencies, and other organizations investing in health development for submission of proposals.10

Early evidence suggests that Global Fund financing and flexibilities have promoted development of strong in-country leadership capacity and stewardship of health programs. The observed improvements in leadership capacity at all levels are laudable, but much work needs to be done. Country demand for Global Fund investments has targeted activities aimed at addressing immediate bottlenecks to service delivery and expanding access. Sustaining the acceleration in the scale-up of services to fight HIV/AIDS will require increased investment, which also emphasizes further strengthening in-country ownership, leadership, and coordination capacity. This is critical if the objective of building efficient and equitable health systems to deliver universal coverage for HIV is to be achieved.8

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REFERENCES

1. The Global Fund to Fight AIDS. Tuberculosis and Malaria. Scaling Up for Impact: The Global Fund Results Report 2009. Geneva, Switzerland: The Global Fund to Fight AIDS, Tuberculosis and Malaria; 2009.
2. Joint United Nations Programme on HIV/AIDS (UNAIDS). 2008 Progress Reports: UNGASS Reports Submitted by Countries: Malawi. Geneva: UNAIDS; 2008. Available at: http://www.unaids.org/en/KnowledgeCentre/HIVData/CountryProgress/2007CountryProgressAllCountries.asp. Accessed July 9, 2009.
3. Makombe SD, Jahn A, Tweya H, et al. A national survey of the impact of rapid scale-up of antiretroviral therapy on health-care workers in Malawi: effects on human resources and survival. Bull World Health Organ. 2007;85:851-857.
4. Makombe SD, Jahn A, Tweya H, et al. A national survey of teachers on antiretroviral therapy in Malawi: access, retention in therapy and survival. PLoS One. 2007;2:e620. doi:10.1371/journal.pone.0000620.
5. Banda AC, Makomba SD, Jahn A, et al. Antiretroviral therapy in the Malawi defence force: access, treatment outcomes and impact on mortality. PLoS One. 2008;3:e1445. doi:10.1371/journal.pone.0001445.
6. Jahn A, Floyd S, Crampin AC, et al. Population-level effect of HIV on adult mortality and early evidence of reversal after introduction of antiretroviral therapy in Malawi. Lancet. 2008;371:1603-1611.
7. Reniersa G, Arayad T, Daveyd G, et al. Steep declines in population-level AIDS mortality following the introduction of antiretroviral therapy in Addis Ababa, Ethiopia. AIDS. 2009;23:511-518.
8. Piot P, Kazatchkine M, Dybul M, et al. AIDS: lessons learnt and myths dispelled. Lancet. 2009;374:260-263. doi:10.1016/S0140-6736(09)60321-4.
9. World Health Organization Maximizing Positive Synergies Collaborative Group. An assessment of interactions between global health initiatives and country health systems. Lancet. 2009;373:2137-2169.
10. Sherry J, Mookherji S, Ryan L. The Five-Year Evaluation of the Global Fund to Fight AIDS, Tuberculosis and Malaria. Synthesis of Study Areas 1, 2 and 3. March 2009. Calverton, MD: Macro International; 2009. Available at: http://www.theglobalfund.org/documents/terg/TERG_Synthesis_Report.pdf. Accessed July 10, 2009.
Keywords:

HIV/AIDS; aid effectiveness; governance; Global Fund

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