Global Health Initiatives
Encyclopedia
Global Health Initiatives (GHIs) are humanitarian initiatives that raise and disburse additional funds for infectious diseases, such as AIDS
, Tuberculosis
and Malaria
; for immunization
; and for strengthening health systems in developing countries. Examples of GHIs are the President’s Emergency Plan for AIDS Relief
(PEPFAR), the Global Fund to fight AIDS, Tuberculosis and Malaria (Global Fund), and the World Bank
’s Multi-country AIDS Programme (MAP), all of which focus on HIV
/AIDS
. The GAVI Alliance (formerly The Global Alliance for Vaccines and Immunisation) focuses on immunization, particularly with respect to child survival.
between the United States and a recipient of its development aid for HIV/AIDS – typically an international non-government organisation INGO
or a recipient country’s government. The Global Fund, established in 2002, and the GAVI Alliance, launched in 2000, are public-private partnerships that raise and disburse funds to treat AIDS, Tuberculosis and Malaria, and for immunization and vaccines. The World Bank
is an International financial institution. It is the largest funder of HIV/AIDS within the United Nations system and has a portfolio of HIV/AIDS programmes dating back to 1989. In 1999, the Bank launched the first phase of its response to HIV/AIDS in Sub-Saharan Africa – the MAP. This came to an end in 2006 when a second phase – Agenda for Action 2007-11 – came into effect.
Since 1989, the World Bank has committed approximately US$4.2bn in loans and credits for programs, and has disbursed US$3.1bn. Of this total, the Bank's MAP has committed US$ 1.9bn since 2000. Through bilateral contributions to HIV/AIDS and Tuberculosis programmes and donations to the Global Fund, PEPFAR has donated approximately US$ 25.6bn since 2003. In July 2008, the U.S Senate re-authorised a further US$48 bn over five years for PEPFAR II, of which US$6.7bn has been requested for FY 2010. During the period 2001-2010, donors have pledged US$21.1bn to the Global Fund, of which US$15.8bn has been paid paid by donors to the Fund. Gavi has approved US$3.7bn for the period 2000-2015
has also been very active in its analysis of GHIs, particularly PEPFAR financing. The Center's HIV/AIDS Monitor is essential reading for researchers of GHIs. With hubs in London and Dublin, the Global Health Initiatives Network (GHIN) has been coordinating and supporting research in 22 countries on the effects of GHIs on existing health systems.
Knowledge of the effects of GHIs on specific diseases and on health systems comes from multiple sources.Longitudinal studies enable researchers to establish baseline data and then track and compare GHI effects on disease control or country health systems over time. In addition to Abt Associates' SWEF studies, additional early examples of this type of analysis were three-year, multi-country studies of the Global Fund in Mozambique, Tanzania, Uganda and Zambia. In 2009, research findings were published from tracking studies in Kyrgyzstan, Peru and Ukraine that sought to identify the health effects of the Global Fund at national and sub-national levels.
In contrast to longitudinal studies, multi-country analyses of GHIs can provide a ‘snapshot’ of GHI effects but are often constrained by “aggressive timelines”. The Maximising Positive Synergies Academic Consortium, for example, reported in 2009 on the effects of the Global Fund and PEPFAR on disease control and health systems, drawing on data from 20 countries. Most GHI evaluations – both internally and externally commissioned – rely on this type of short-term analysis and, inevitably, there is often a trade-off between depth and breadth of reporting.
Synthesis of data from multiple sources is an invaluable resource for making sense of the effects of GHIs. Early synthesis studies include a 2004 synthesis of findings on the effects of the Global Fund in four countries by researchers at the London School of Hygiene and Tropical Medicine (LSHTM), a 2005 study by McKinsey & Company
and an assessment of the comparative advantages of the Global Fund and World Bank AIDS programs. Two wide-ranging studies were published in 2009: a study of interactions between GHIs and country health systems commissioned by the World Health Organisation and a study by researchers from LSHTM and the Royal College of Surgeons in Ireland
. The latter study - The effects of global health initiatives on country health systems: a review of the evidence from HIV/AIDS control – reviewed the literature on the effects of the Global fund, the World Bank MAP and PEPFAR 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 (Table 2).
investments had improved, accountability was weak.
Findings from two evaluations of GAVI’s support for Health Systems Strengthening (HSS) were published in 2009. An external evaluation by HLSP found insufficient technical support provided to countries applying for GAVI grants,an under-performing Independent Review Committee (IRC), and weaknesses in GAVI’s monitoring of grant activities. The study also found that countries were using GAVI grants for ‘downstream’ short-term HSS fixes rather than ‘upstream’ and long-term structural reform.
A study by John Snow, Inc
praised the multi-year, flexible and country-driven characteristics of GAVI HSS grant funding and encouraged GAVI to continue this support. But also found weak M&E of grant activity, low Civil Society involvement in the HSS proposal development process, unclear proposal writing guidelines, and over-reliance by countries on established development partners for assistance in implementing health system reform.
found that PEPFAR had made significant progress in reaching its targets for prevention, treatment and care but also reported that budget allocations "limit the Country Teams ability to harmonize PEPFARs activities with those of the partner government and other donors", and PEPFARs ABC (Abstinence, Be faithful, and correct and consistent Condom use) priorities "fragment the natural continuum of needs and services, often in ways that do not correspond with global standards".
AIDS
Acquired immune deficiency syndrome or acquired immunodeficiency syndrome is a disease of the human immune system caused by the human immunodeficiency virus...
, Tuberculosis
Tuberculosis
Tuberculosis, MTB, or TB is a common, and in many cases lethal, infectious disease caused by various strains of mycobacteria, usually Mycobacterium tuberculosis. Tuberculosis usually attacks the lungs but can also affect other parts of the body...
and Malaria
Malaria
Malaria is a mosquito-borne infectious disease of humans and other animals caused by eukaryotic protists of the genus Plasmodium. The disease results from the multiplication of Plasmodium parasites within red blood cells, causing symptoms that typically include fever and headache, in severe cases...
; for immunization
Immunization
Immunization, or immunisation, is the process by which an individual's immune system becomes fortified against an agent ....
; and for strengthening health systems in developing countries. Examples of GHIs are the President’s Emergency Plan for AIDS Relief
President's Emergency Plan For AIDS Relief
The President's Emergency Plan For AIDS Relief was a commitment of $15 billion over five years from United States President George W. Bush to fight the global HIV/AIDS pandemic...
(PEPFAR), the Global Fund to fight AIDS, Tuberculosis and Malaria (Global Fund), and the World Bank
World Bank
The World Bank is an international financial institution that provides loans to developing countries for capital programmes.The World Bank's official goal is the reduction of poverty...
’s Multi-country AIDS Programme (MAP), all of which focus on HIV
HIV
Human immunodeficiency virus is a lentivirus that causes acquired immunodeficiency syndrome , a condition in humans in which progressive failure of the immune system allows life-threatening opportunistic infections and cancers to thrive...
/AIDS
AIDS
Acquired immune deficiency syndrome or acquired immunodeficiency syndrome is a disease of the human immune system caused by the human immunodeficiency virus...
. The GAVI Alliance (formerly The Global Alliance for Vaccines and Immunisation) focuses on immunization, particularly with respect to child survival.
GHI Functions
In terms of their institutional structure, GHIs have little in common with each other. In terms of their function – specifically their ability to raise and disperse funds, provide resources, and coordinate and/or implement disease control in multiple countries – GHIs share some common ground, even if the mechanisms through which each of these functions is performed are different. PEPFAR (an initiative established in 2003 by the Bush Administration) and PEPFAR II (PEPFAR’s successor in 2009 under the Obama Administration) are bilateral agreementsBilateralism
Bilateralism consists of the political, economic, or cultural relations between two sovereign states. For example, free trade agreements signed by two states are examples of bilateral treaties. It is in contrast to unilateralism or multilateralism, which refers to the conduct of diplomacy by a...
between the United States and a recipient of its development aid for HIV/AIDS – typically an international non-government organisation INGO
Ingo
Ingo is a first name in contemporary Scandinavia and Germany, and a historical name in France. It is the male version of the name Inga, used in the same region, and as a name for a tropical plant....
or a recipient country’s government. The Global Fund, established in 2002, and the GAVI Alliance, launched in 2000, are public-private partnerships that raise and disburse funds to treat AIDS, Tuberculosis and Malaria, and for immunization and vaccines. The World Bank
World Bank
The World Bank is an international financial institution that provides loans to developing countries for capital programmes.The World Bank's official goal is the reduction of poverty...
is an International financial institution. It is the largest funder of HIV/AIDS within the United Nations system and has a portfolio of HIV/AIDS programmes dating back to 1989. In 1999, the Bank launched the first phase of its response to HIV/AIDS in Sub-Saharan Africa – the MAP. This came to an end in 2006 when a second phase – Agenda for Action 2007-11 – came into effect.
GHI Funding
Tracking funding from GHIs is not easy. However, it is possible to determine the amounts of funding GHIs commit and disperse from sources such as the OECD CRS online database, as well as data provided by individual GHIs (Figure 1).Since 1989, the World Bank has committed approximately US$4.2bn in loans and credits for programs, and has disbursed US$3.1bn. Of this total, the Bank's MAP has committed US$ 1.9bn since 2000. Through bilateral contributions to HIV/AIDS and Tuberculosis programmes and donations to the Global Fund, PEPFAR has donated approximately US$ 25.6bn since 2003. In July 2008, the U.S Senate re-authorised a further US$48 bn over five years for PEPFAR II, of which US$6.7bn has been requested for FY 2010. During the period 2001-2010, donors have pledged US$21.1bn to the Global Fund, of which US$15.8bn has been paid paid by donors to the Fund. Gavi has approved US$3.7bn for the period 2000-2015
Impact of GHIs on Country Health Systems
There is much discussion about the extent to which the volume of these additional funds creates multiple effects that impact – positively and negatively – on health outcomes for specific diseases and also on health systems themselves. Assessing the impact of GHIs on specific diseases and health systems is also notoriously difficult, not least because of the problem of attributing particular effects to individual GHIs. A common response in evaluations of GHIs, therefore, is to acknowledge the inherent limitations of establishing causal chains in what is a highly complex public health environment, and to base conclusions on adequacy statements resulting from trends that demonstrate substantial growth in process and impact indicators.Research on the effects of GHIs
A small number of institutions have shaped, and continue to shape, research on GHIs. In 2003, researchers at Abt Associates devised an influential framework for understanding the system-wide effects of the Global fund which has informed much subsequent research, including their own studies of system-wide effects of the Global Fund in Benin, Ethiopia, Georgia and Malawi - often referred to as the 'SWEF' studies. Abt continues to support ongoing research on the effects of GHIs in multiple countries. The Washington-based Center for Global DevelopmentCenter for Global Development
The Center for Global Development is a non-profit think tank based in Washington, D.C. that focuses on international development. It was founded in November 2001 by former senior U.S. official Edward W. Scott, director of the Peterson Institute for International Economics, C. Fred Bergsten, and...
has also been very active in its analysis of GHIs, particularly PEPFAR financing. The Center's HIV/AIDS Monitor is essential reading for researchers of GHIs. With hubs in London and Dublin, the Global Health Initiatives Network (GHIN) has been coordinating and supporting research in 22 countries on the effects of GHIs on existing health systems.
Knowledge of the effects of GHIs on specific diseases and on health systems comes from multiple sources.Longitudinal studies enable researchers to establish baseline data and then track and compare GHI effects on disease control or country health systems over time. In addition to Abt Associates' SWEF studies, additional early examples of this type of analysis were three-year, multi-country studies of the Global Fund in Mozambique, Tanzania, Uganda and Zambia. In 2009, research findings were published from tracking studies in Kyrgyzstan, Peru and Ukraine that sought to identify the health effects of the Global Fund at national and sub-national levels.
In contrast to longitudinal studies, multi-country analyses of GHIs can provide a ‘snapshot’ of GHI effects but are often constrained by “aggressive timelines”. The Maximising Positive Synergies Academic Consortium, for example, reported in 2009 on the effects of the Global Fund and PEPFAR on disease control and health systems, drawing on data from 20 countries. Most GHI evaluations – both internally and externally commissioned – rely on this type of short-term analysis and, inevitably, there is often a trade-off between depth and breadth of reporting.
Synthesis of data from multiple sources is an invaluable resource for making sense of the effects of GHIs. Early synthesis studies include a 2004 synthesis of findings on the effects of the Global Fund in four countries by researchers at the London School of Hygiene and Tropical Medicine (LSHTM), a 2005 study by McKinsey & Company
McKinsey & Company
McKinsey & Company, Inc. is a global management consulting firm that focuses on solving issues of concern to senior management. McKinsey serves as an adviser to many businesses, governments, and institutions...
and an assessment of the comparative advantages of the Global Fund and World Bank AIDS programs. Two wide-ranging studies were published in 2009: a study of interactions between GHIs and country health systems commissioned by the World Health Organisation and a study by researchers from LSHTM and the Royal College of Surgeons in Ireland
Royal College of Surgeons in Ireland
The Royal College of Surgeons in Ireland , is a Dublin-based medical institution, situated on St. Stephen's Green. The college is one of the five Recognised Colleges of the National University of Ireland...
. The latter study - The effects of global health initiatives on country health systems: a review of the evidence from HIV/AIDS control – reviewed the literature on the effects of the Global fund, the World Bank MAP and PEPFAR 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 (Table 2).
Evaluations of GHIs
Each of the four GHIs summarised has been evaluated at least once since 2005 and all four produce their own annual reports.World Bank MAP
A comprehensive study of MAP programs published in 2007 reviewed whether MAP was implemented as designed, but did not evaluate MAP or assess its impact. In addition, there have been two evaluations that provide important additional insight into the effectiveness of the Bank's HIV/AIDS programmes (though not specifically MAP focused). In 2005, the Bank conducted an internal evaluation - Committing to Results: Improving the Effectiveness of HIV/AIDS Assistance - which found that National AIDS strategies were not always prioritised or costed; supervision, and monitoring and evaluation (M&E), were weak; civil society had not been engaged; political commitment and capacity had been overestimated, and mechanisms for political mobilisation were weak; and bank research and analysis, whilst perceived to be useful, was not reaching policy makers in Africa. In 2009, a hard-hitting evaluation of the Bank’s Health, Nutrition and Population support – Improving Effectiveness of Outcomes for the Poor in Health, Nutrition and Population – found that a third of the Bank’s HNP lending had not performed well, and that while the performance of the Bank’s International Finance CorporationInternational Finance Corporation
The International Finance Corporation promotes sustainable private sector investment in developing countries.IFC is a member of the World Bank Group and is headquartered in Washington, D.C., United States....
investments had improved, accountability was weak.
Global Fund
A five-year, comprehensive evaluation of the Global Fund published a synthesis report in 2009 of findings from three Study areas. The Fund’s Technical Evaluation Research Group (TERG) Five Year Evaluation (5YE) of the Global Fund drew on data from 24 countries to evaluate the Fund’s organisational effectiveness and efficiency, partnership environment and impact on AIDS, TB and Malaria. The Evaluation highlighted the possible decline in HIV incidence rate in some countries, and rapid scale up of funding for HIV/AIDS, access and coverage, but also identified major gaps in support for national health information systems, and poor drug availability.GAVI Alliance
In 2008, an evaluation of GAVI’s vaccine and immunization support - Evaluation of the GAVI Phase 1 performance - reported increased coverage of HepB3, Hib3 and DTP3 and increased coverage in rural areas but also a lack of cost data disaggregated by vaccine that prevented GAVI from accurately evaluating the cost effectiveness of its programs and vaccines, and an “unrealistic” reliance by GAVI on the market to reduce the cost of vaccines. The same year, a study of the financial sustainability of GAVI vaccine support - Introducing New Vaccines in the Poorest Countries: What did we learn from the GAVI Experience with - found that although GAVI funding equated to $5 per infant in developing countries per year for the period 2005-10, resource need was accelerating faster than growth in financing.Findings from two evaluations of GAVI’s support for Health Systems Strengthening (HSS) were published in 2009. An external evaluation by HLSP found insufficient technical support provided to countries applying for GAVI grants,an under-performing Independent Review Committee (IRC), and weaknesses in GAVI’s monitoring of grant activities. The study also found that countries were using GAVI grants for ‘downstream’ short-term HSS fixes rather than ‘upstream’ and long-term structural reform.
A study by John Snow, Inc
John Snow, Inc
John Snow, Inc. is a public health research and consulting firm in the United States and around the world. Named after the English physician John Snow, JSI, along with its nonprofit partner JSI Research & Training Institute, Inc., provides technical and managerial assistance to public health...
praised the multi-year, flexible and country-driven characteristics of GAVI HSS grant funding and encouraged GAVI to continue this support. But also found weak M&E of grant activity, low Civil Society involvement in the HSS proposal development process, unclear proposal writing guidelines, and over-reliance by countries on established development partners for assistance in implementing health system reform.
PEPFAR
A quantitative study by Stanford University in 2009 – The President's Emergency Plan for AIDS Relief in Africa: An Evaluation of Outcomes – calculated a 10.5% reduction in the death rate in PEPFAR’s 12 focus countries, equating to 1.2 million lives saved at a cost of $2450 per death averted. In 2007, an evaluation of PEPFAR by the Institute of MedicineInstitute of Medicine
The Institute of Medicine is a not-for-profit, non-governmental American organization founded in 1970, under the congressional charter of the National Academy of Sciences...
found that PEPFAR had made significant progress in reaching its targets for prevention, treatment and care but also reported that budget allocations "limit the Country Teams ability to harmonize PEPFARs activities with those of the partner government and other donors", and PEPFARs ABC (Abstinence, Be faithful, and correct and consistent Condom use) priorities "fragment the natural continuum of needs and services, often in ways that do not correspond with global standards".