Study Details

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


Biesma R  Brugha R.  Harmer A.  Walsh A.  Spicer N.  Walt G. 


June 2009


Health Policy and Planning  24(4): 239-252.

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Global HIV/AIDS Initiatives Network (GHIN)
London School of Hygiene & Tropical Medicine (LSHTM)
Royal College of Surgeons in Ireland


HIV/AIDS Services; Health Systems strengthening; Human Resources; Governance; Funding; Civil Society; PEPFAR; Global Fund; World Bank MAP

Study Type

A systematic documentary review of original country-specific and cross-country articles and reports on the Global Fund, PEPFAR, and the World Banks MAP.


To review the literature on the effects of three GHIs on country health systems with respect to: 1) national policy; 2) coordination and planning; 3) stakeholder involvement; 4) disbursement, absorptive capacity and management; 5) monitoring & evaluation; and 6) human resources.


A comprehensive and systematic database search was conducted for the period 200207 for literature on the three GHIs. Inclusion criteria were devised and a dataset of 31 original documents derived. Analysis was conducted using a heath systems framework.


Presentation of findings of the effects at national and sub-national of the Global Fund, PEPFAR, and the World Bank's MAP, focusing on national policy, coordination and planning, stakeholder involvement, disbursement of funds, M&E, and human resources.

National policy:

  • Early reports showed GHIs failing to align behind government efforts to strengthen their health systems.
  • Since 2005, evidence suggests GHIs are beginning to learn from their mistakes and better alignment has been reported in various evaluations and studies.
  • Donor harmonisation was also weak to begin with, but GHIs especially GFATM are improving.
Coordination and planning:
  • Weaknesses in coordination structures such as GFATMs CCM, and NACs are highlighted in the literature, but comparable data on coordination processes are lacking across GHIs.
  • Feedback from GHIs on country proposals is beginning to improve, however.
Stakeholder involvement:
  • Each of the GHIs but particularly GFATM has boosted stakeholder engagement, although PEPFAR use of US NGOs has been at the expense of building government capacity.
  • 30% of GFATM grants are now allocated to CSOs.
  • Channeling funds through multiple different routes involving multiple stakeholders has proved difficult for governments to cope with.
  • GHIs have not invested sufficiently in strengthening NGO capacity for receiving and processing funds, or encouraging establishment of NGO accountability mechanisms.
Disbursement, absorptive capacity and management
  • There have been significant increases in aid flows to focal diseases.
  • However, different fiscal years, disbursement mechanisms, and unpredictable disbursements compound weak absorptive capacity in countries, and thus hamper government efforts to coordinate their national plans.
  • Duplication and parallelism in GHIs financial management systems continues to be an administrative burden for staff in-country, and is a source of fragmentation.
Monitoring & evaluation
  • National studies report having to prepare multiple M&E reports, in different formats, and for different deadlines for different donors.
  • GHIs are beginning to build capacity.
Human resources for health
  • Early reports identified staff shortages as a major impediment to development of strong health systems.
  • Follow-up studies show improvements but increases in GHI funding has added significantly to staff workloads resulting in some staff leakage from public to private sectors.
  • There is little evidence that GHIs are addressing the problem of staff workload and resulting problems of low staff motivation.
  • Whilst training is reported positively in GHI studies, management and M&E training are insufficiently supported.

Conclusions /

Engage more fully with the Paris Principles for Aid Effectiveness, specifically:

  • Promote country ownership through aligning GHI objectives with comprehensive national health (rather than only HIV/AIDS) priorities
  • Coordinate GHI investment to strengthen the capacity of national systems for financial management, M&E and reporting
  • Stronger coordination of donor investments to support countries national strategic health plans
  • GHIs should give recipient countries sufficient flexibility to address systems weaknesses and strengthen implementation capacity, especially in HR
  • GHIs need to provide long-term funding to address public sector health worker shortages a key determinant for successful scale up
  • GHIs should continue to encourage NGO participation
  • Country and global policy makers and donors should demand and fund the acquisition of better evidence on what is a complex and rapidly evolving arena

Sponsored by DFID, Danida, Irish Aid