Study Details

System-wide effects of Global Fund investments in Nepal


Tragard A.  Shrestha I. 


November 2010


Health Policy and Planning  25 (suppl 1): i58i62

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Institute of Medicine Kathmandu
Imperial College London


Nepal, health systems strengthening, financing, Global Fund

Study Type

Case study analysis


To assess the extent of integration of national HIV, tuberculosis (TB) and malaria programmes with the general health system; the integration of the Global Fund-portfolios within the national disease programmes; and system-wide effects on the health system in Nepal.


Literature review and use of a Systematic Rapid Assessment Toolkit (SYSRA) for gathering information about structures and modes of operation of complex health systems. 29 interviews with government health officials, partners and civil society actors at national, regional and district levels. The SYSRA toolkit proposed six health systems functions: stewardship and governance, financing, planning, service delivery, monitoring and evaluation, and demand generation. These were subdivided into 25 elements, for which the level of integration was classified as not integrated, partly integrated or fully integrated, through iterative analysis and triangulation of the collected data.


  • The Global Funds Country Coordinating Mechanism (CCM) has successfully attracted resources as well as demonstrated flexibility, proactive grant management and oversight to achieve results.
  • With limited government investments and frequent changes in leadership, the planning and financing of HIV activities remains highly fragmented.
  • Respondents perceived a missed opportunity in linking HIV prevention, care and support to the public health system resulting in lack of country ownership of the sector-wide response.
  • In terms of recruitment and retention of human resources, HIV was considered a one-off effort with limited plans for addressing capacity long-term.
  • Health management and information systems were considered weak, incomplete and unresponsive.

Conclusions /

The wider effects of disease-specific initiatives on health systems can be viewed as positive in a resource-constrained environment, especially by strengthening disease structures and systems and facilitating civil society involvement.

Sponsored by DFID, Danida, Irish Aid