Ana B. Amaya

After the Global Fund: Who can sustain the HIV/AIDS response in Peru and how?

Peru has received around

What’s in a word? The framing of health at the regional level: ASEAN, EU, SADC and UNASUR

70 million from Global Fund to fight AIDS, Tuberculosis and Malaria (Global Fund). Recent economic growth resulted in grant ineligibility, enabling greater government funding, yet doubts remain concerning programme continuity. This study examines the transition from Global Fund support to increasing national HIV/AIDS funding in Peru (2004–2012) by analysing actor roles, motivations and effects on policies, identifying recommendations to inform decision-makers on priority areas. A conceptual framework, which informed data collection, was developed. Thirty-five in-depth interviews were conducted from October to December 2011 in Lima, Peru, among key stakeholders involved in HIV/AIDS work. Findings show that Global Fund involvement led to important breakthroughs in the HIV/AIDS response, primarily concerning treatment access, focus on vulnerable populations and development of a coordination body. Nevertheless, reliance on Global Fund financing for prevention activities via non-governmental organisations, compounded by lack of government direction and weak regional governance, diluted power and caused role uncertainty. Strengthening government and regional capacity and fostering accountability mechanisms will facilitate an effective transition to government-led financing. Only then can achievements gained from the Global Fund presence be maintained, providing lessons for countries seeking to sustain programmes following donor exit.

A critical analysis of Peru's HIV grant proposals to the Global Fund

The Association of Southeast Asian Nations, the European Union, the Southern African Development Community and the Union of South American Nations have increasingly been involved in health diplomacy in the past decade, yet little is known about how they frame health as a foreign policy issue and how this has an impact on their prioritisation of policies. For this, we conducted a review of existing grey and peer-reviewed literature that address regional integration and health, as well as a documentary review according to security, development, trade, human rights, moral/ethical reasonings and global public goods frames identified in the literature. The policy frames identified responded to the challenges these regions currently face. The Association of Southeast Asian Nation’s struggle with re-emerging diseases has led to favouring a securitisation approach to health, the European Union approaches health as a cross-cutting policy issue, the Southern African Development Community presents health as a driver for development, and while the Union of South American Nations emphasises health as a human right and addresses the social determinants of health as an ethical imperative. Overall, these policy frames were useful in analysing the framing of health in foreign policy at the regional level. However, within our analysis, we identified a new frame that approaches health as an intersectoral issue. The impact of regional organisations’ forward will depend on their ability to harness their convening power and speak in a coherent voice on health matters.

Drivers of health system strengthening: learning from implementation of maternal and child health programmes in Mozambique, Nepal and Rwanda

Peru has applied to six of the Global Fund to Fight AIDS, Tuberculosis and Malaria (the Global Fund) rounds for funding, achieving success on four occasions. The process of proposal development has, however, been criticised, especially concerning the use of evidence, relevance/consistency and performance indicators. We aimed to analyse the Peruvian Global Fund proposals according to those dimensions, providing feedback to improve future local efforts and inform global discussions around Global Fund procedures. We analysed the content of four HIV-focused proposals (rounds 2, 5, 6 and 8) regarding epidemic context, needs identification and prioritisation and monitoring and evaluation systems. Peruvian proposals submitted after round 1 were described as resulting from collaborative inputs involving formerly unrepresented sectors, principally ‘vulnerable populations’. However, difficulties arose regarding the amount and quality of evidence about the epidemiological context; limited consideration of social determinants of the epidemic; lack of theory-driven interventions, and little synergy across projects and the inclusion of weak monitoring and evaluation systems, with poor indicators and measurement procedures. Prioritising the development of analytical and technical skills to generate Global Fund proposals would enhance the countrys capacity to produce and utilise evidence, improve the technical-political interface, strengthen information systems and lead to more informed decision making and accountability.

The European Union and transnational health policy networks: a case study of interaction with the Global Fund

Abstract There is a growing understanding that strong health systems are crucial to sustain progress. Health systems, however, are complex and much of their success depends on factors operating at different levels and outside the health system, including broader governance and political commitment to health and social development priorities. Recognizing these complexities, this article offers a pragmatic approach to exploring the drivers of progress in maternal and child health in Mozambique, Nepal and Rwanda. To do this, the article builds on a semi‐systematic literature review and case study findings, designed and analysed using a multi‐level framework. At the macro level, governance with effective and committed leaders was found to be vital for achieving positive health outcomes. This was underpinned by clear commitment from donors coupled by a significant increase in funding to the health sector. At the meso level, where policies are operationalized, inter‐sectoral partnerships as well as decentralization and task‐shifting emerged as critical. At micro (service interface) level, community‐centred models and accessible and appropriately trained and incentivized local health providers play a central role in all study countries. The key drivers of progress are multiple, interrelated and transversal in terms of their operation; they are also in a constant state of flux as health systems and contexts develop. Without seeking to offer a blueprint, the study demonstrates that a ‘whole‐system’ approach can help elicit the key drivers of change and potential pathways towards desirable outcomes. Furthermore, understanding the challenges and opportunities that are instrumental to progress at each particular level of a health system can help policy‐makers and implementers to navigate this complexity and take action to strengthen health systems.

Multi-Level Pro-Poor Health Governance, Statistical Information Flows, and the Role of Regional Organizations in South-America and Southern Africa

This article examines the nature of the engagement between the European Union and the Global Fund created to combat HIV/AIDS, tuberculosis and malaria. The authors reveal that in relations between the EU and the Fund, influence is reciprocal although asymmetrical with the EU commanding more leverage. They also contend that the EU considers its engagement with the Global Fund as successful to the extent that the success of this interaction is contingent on the Global Funds capacity for implementation. They conclude that the relationship between the EU and the Fund will continue for the foreseeable future.