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Health Aid Governance in Fragile States: The Global Fund Experience

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Fragile states represent key challenges for global health governance. This study analyzes Global Fund grant data from 122 recipient countries as an initial exploration into how well these grants are performing in fragile states as compared to other countries. Since 2002, the Global Fund has invested nearly US$ 5 billion in 41 fragile states, and most grants have been assessed as performing well. Nonetheless, statistically significant differences in performance exist between fragile states and other countries, which were further pronounced in states with humanitarian crises. This indicates that further investigation of this issue is warranted: variations in performance may be unavoidable given the complexities of health governance in fragile states, but may also have implications for how the Global Fund and others provide aid. For example, faster aid disbursements might allow for a better response to rapidly changing contexts, and there may need to be more of a focus on building capacity and strengthening health governance in these countries.
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Health Aid Governance in Fragile States: The Global Fund
Experience
Olga Bornemisza, Jamie Bridge, Michael Olszak-Olszewski, George Sakvarelidze, and
Jeffrey V Lazarus
Fragile states represent key challenges for global health governance. This study
analyzes Global Fund grant data from 122 recipient countries as an initial
exploration into how well these grants are performing in fragile states as compared
to other countries. Since 2002, the Global Fund has invested nearly US$ 5 billion in
41 fragile states, and most grants have been assessed as performing well.
Nonetheless, statistically significant differences in performance exist between
fragile states and other countries, which were further pronounced in states with
humanitarian crises. This indicates that further investigation of this issue is
warranted: variations in performance may be unavoidable given the complexities
of health governance in fragile states, but may also have implications for how the
Global Fund and others provide aid. For example, faster aid disbursements might
allow for a better response to rapidly changing contexts, and there may need to be
more of a focus on building capacity and strengthening health governance in these
countries.
INTRODUCTION
State fragility remains one of the most significant challenges for the well-being of
affected populations, progress towards the Millennium Development Goals, and
health and development donors. Fragile statesbroadly definable as a state that
“cannot or will not deliver core functions to the majority of its people, including the
poor”1are home to one-sixth of the world’s population, but one-third of those living
on less than US$ 1 per day.2 These states often face the double challenges of
fractured health systems and reduced capacity to absorb external funding. Violence,
conflict, corruption, exclusion or discrimination of certain groups, and gender
inequalities are also common characteristics.3 These states carry a disproportionate
burden of many health problems including HIV/AIDS, tuberculosis and malaria. For
example, four fragile states (Democratic Republic of Congo, Nigeria, Sudan and
Uganda) together account for 45% of the estimated malaria deaths among children in
the world.4 The greatest burdens in terms of maternal and child health are also found
within fragile states.5 Health aid in these countries is increasing, but is often
fragmented between different donors and their programs.6 This underlines the
importance of effective health governance in these contexts. Health governance is
defined by the World Health Organization (WHO) in terms of various key health-
related state functions such as policy guidance, intelligence and oversight,
collaboration and coalition building, regulation and incentives, system design, and
accountability to the public.7
The Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund) was
established in 2002 to raise and disburse substantial funding in order to achieve
sustained impacts on the three diseases. By mid-2010, it had approved proposals
worth US$ 19.3 billion: supporting tuberculosis treatment for seven million people,
the distribution of 122 million insecticide-treated nets to prevent malaria, the
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distribution of 2.3 billion condoms, and the delivery of 120 million HIV testing and
counseling sessions. Global Fund-supported programs are also providing
antiretroviral therapy to 2.8 million people.8
Previous research and analysis has found that the performance of Global Fund
grants in fragile states is comparable to those in other recipient countries. In 2005,
an analysis of Global Fund grants found that the 19 grants in fragile states at that
time were performing comparably to the 55 grants in other recipient countries. None
of the grants in fragile states had been discontinued.
Eligibility for Global Fund grants
focuses on country income level and disease burdens rather than political factors,
meaning that large investments have been made in fragile states, making health
governance in these countries a key issue for the organization. The state has the main
responsibility for governance, but non-state actors, including multilateral, regional
and bilateral institutions as well as the private sector and civil society, are also
important because they often play a major role in funding and providing services.
9 Analysis in 2007 concluded
that the performance-based funding model used by the Global Fund was working in,
and did not penalize, fragile states and poorer countries.10 This conclusion was
reported again in 2010, with program results in fragile states “roughly in line with
the monetary commitment,” and grants in fragile states “performing only slightly less
well than grants in other countries.”11 However, one external analysis in 200612 did
find a link between grant implementation and political stability: countries with
greater political stability (as defined by the World Bank) were more likely to have
received a greater cumulative proportion of their total grant amount.13
This article presents an exploratory study to re-test the hypothesis that state
fragility itself is not a barrier to the successful delivery of Global Fund grants, and
discusses the significance of the findings for the Global Fund. In doing so, it builds
upon, and updates, previous research in order to provide further insight into the
Global Fund approach and health governance in fragile states.
Overall, these
previous studies suggest that state fragility itself may not be a barrier to the
successful delivery of Global Fund grants, but that other linked factors, such as
political stability and absorptive capacity, may be.
METHODOLOGY
A secondary analysis was conducted on routinely-collected Global Fund grant
data. Table 1 lists the 122 countries which had received Global Fund grants by mid-
2010 (excluding those that are only part of multi-country grants or grants that are
only for specific territories). These countries were then divided into two groups: 41
fragile states and 81 other recipient countries. There are several lists and definitions
of fragile states available in the international literature.14 For the purposes of this
analysis, fragile states included the 28 countries that have experienced humanitarian
crises in the last five years, as documented by ReliefWeb in April 2010.15 These crises
may include, for example, national or regional conflicts or natural disasters such as
earthquakes and floods. These 28 countries were then supplemented with the 13
additional countries which feature as “alerts” on the Failed States Index 2009
compiled by the Fund for Peace.16 The Failed States Index scores countries against 12
indicators such as chronic and sustained human flight, economic decline, and the
rise of factionalized elites. For each indicator, a score from 0 to 10 is allocated by the
Fund for Peace, and countries with an aggregate score of over 90 are termed as
“alerts.”17 The combination of these two sources of information was chosen primarily
for its concurrence with internal (and unpublished) indices of risk and fragility that
are used within the Global Fund for the purposes of grant management and strategic
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planning. This approach for the study was also favored for its inclusiveness of
different kinds of fragile state contexts. For the purposes of this analysis, countries
were assessed in terms of their current status as fragile or otherwise: no
consideration was given to changes in status since the Global Fund was founded in
2002, as these were perceived to be minimal. As a means of validation for this
approach, only four of the countries with humanitarian crises in the last five years
did not also appear as alerts” on the Failed States Index (Mauritania, Rwanda, the
Solomon Islands and Togo). In addition, 32 of the 37 entries on the World Bank’s
Harmonized List of Fragile Situations for 201018 are countries that have received
Global Fund grants, and 25 (78%) of these appear in the list adopted for this analysis.
The 41 fragile states were compared to the 81 other countries in terms of several
descriptive variables: World Bank data on country populations,19 UNAIDS data on
national HIV prevalence,20 World Health Organization data on national tuberculosis
and malaria burdens,21 and publically available Global Fund data in the grant
portfolio of each country.22
These data were selected to provide context for the
remainder of the analysis. In order to best assess the performance of Global Fund
grants, six different variables were selected upon which to compare fragile states with
other recipient countries, and also to explore differences within the list of fragile
states:
1. Percentage of Targets Reached: Each grant has a range of main program
indicator targets (such as the number of condoms distributed or the number
of people currently receiving antiretroviral therapy) against which the grant
implementers must report to the Global Fund. The achievements of active
grants with respect to these targets were analyzed (as an average percentage
across the main targets) using one-sided t-tests.
2. Disbursement Rating: At the time of each funding disbursement, the Global
Fund Secretariat rates each grant as A1 or A2 (exceeded or met expectations),
B1 (performed adequately), B2 (potential demonstrated) or C (unacceptable).
This rating is based on a range of factors including the achievements made
against the grant targets, but also contextual considerations and the efforts
that have been made to improve performance where needed. This rating then
informs the decision to disburse additional funding. For the purposes of this
study, grants were allocated into two groups based on their latest
disbursement ratings, with A1, A2 or B1 indicating good performance, and B2
or C indicating weaker performance. Data were analyzed using Pearson’s
goodness of fit chi-square tests.
3. Phase Two Rating: All Global Fund grants are approved for an initial two-year
period (Phase One) and then receive major reviews in their second year to
inform decisions for further funding for the next three years (Phase Two). As
at disbursement, each grant is rated as A, B1, B2 or C, and these ratings
inform decisions to continue or discontinue funding at this stage. All grants
(active and closed) which had reached their Phase Two review were included
in this analysis and were divided into two groups: those performing well (i.e.
receiving A or B1 ratings at Phase Two) and those performing less well (i.e.
receiving B2 or C ratings). Data were subjected to Pearson’s goodness of fit
chi-square tests.
4. Continued Funding: After the five-year lifespan of a grant, applications can be
made for continued funding for successful programs (through what is known
as the Rolling Continuation Channel). The success rates of applications for
continued funding were analyzed using one-sided t-tests.
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5. M&E Ratings: In addition to the variables above, each grant is also given a
rating by the Global Fund Secretariat in terms of the quality of monitoring and
evaluation (M&E) systems. Based on the latest ratings allocated, both active
and closed grants were divided into two groups: those performing well (i.e.
receiving A or B1 ratings) and those performing less well (i.e. receiving B2 or C
ratings). Data were analyzed using chi-square tests.
6. OSDV Ratings: Finally, the Global Fund also commissions independent third
parties to perform on-site data verification (OSDV) exercises to assess data
quality and reporting systems. Ratings of A, B1, B2 or C are allocated based on
deviations. As above, active and closed grants were allocated into two groups:
those whose latest available OSDV rating was A or B1, and those whose latest
rating was B2 or C. Data were analyzed using chi-square tests.
RESULTS
The 41 fragile states (Table 1) were home to around 1.24 billion people or 19% of the
world’s population in 2008. However, these countries have a disproportionate
burden of disease. It is estimated that 38% of the people living with HIV in 2007
(12.5 million out of 33.2 million people) resided in fragile states. Similarly, in 2008,
these states accounted for 44% of the global tuberculosis prevalence, or an estimated
4.8 million cases (Table 2).
Global Fund Grant Portfolio
As of May 2010, there were 489 active Global Fund grants, of which 198
(40%) were in fragile states. The overall share of approved grants allocated to fragile
states had not changed significantly since the Global Fund was established in 2002.
Both fragile states and other recipient countries averaged between four and five
active grants per country. Fragile states were twice as likely to have a multilateral
organization, such as the United Nations Development Programme (UNDP),
administering their grants than other recipient countries (Table 3). Further analysis
identified 741 Global Fund grants for which disbursements had been made
(including active and closed grants): 42% (314) in fragile states, collectively
accounting for 46% of the total Global Fund disbursements by the end of May 2010.
The remaining 58% (427) of grants were in other recipient countries and collectively
accounted for 54% of the total Global Fund disbursements (Table 3). Grants in fragile
states spent more on cost categories such as health products, infrastructure,
medicines and procurement, and spent less on, for example, monitoring and
evaluation, planning, technical administration and training (Figure 1).
Global Fund Grant Performance
In fragile states, active grants were, on average, achieving 83% of their agreed
targets for main program indicatorsslightly below the average for other recipient
countries, which were achieving 88% of their targets. This difference was statistically
significant, and was slightly more pronounced when considering grants in fragile
states with humanitarian crises in the last five years (which achieved 80% of their
agreed targets) (Table 4).Grant ratings at disbursement were available for 348 active
grants, of which 137 (39%) were in fragile states. Among fragile states, 79% of grants
had been rated as performing well (rated A1, A2 or B1), and 21% had been rated as
B2 or C. Overall, grants in other recipient countries were rated as performing slightly
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better, with 85% of grants rated as A1, A2 or B1 and 15% rated as B2 or C. This
difference was nearly statistically significant (p=0.051). There was a significant
difference between fragile states with humanitarian crises and non-fragile countries,
the former accounting for 92 grants of which 69 (75%) were rated as performing well
and 23 (25%) were not (Table 4). A total of 445 grants (including both active and
closed grants) had undergone a Phase Two review: 176 (40%) from fragile states and
269 (60%) from other recipient countries. In fragile states, 123 grants (70%) were
rated as performing well, and 53 (30%) grants received B2 or C ratings. Of these,
seven grants (4%) had their funding discontinued at this stage. Among other
recipient countries, 220 grants (82%) were rated as performing well, and 49 grants
(18%) received either B2 or C ratings, of which three grants (1%) were discontinued.
These differences were statistically significant, and even more pronounced when
considering fragile states with humanitarian crises, which had 115 grants assessed,
35% of which were rated as B2 or C, and five of which were discontinued (Table 4).
A total of 209 grants had also applied for continued funding after their five-
year lifespan (through the Rolling Continuation Channel): 79 (38%) from fragile
states and 130 (62%) from other recipient countries. In fragile states, 14 of these
applications (18%) were approved for funding beyond the initial five years, compared
to 42 (32%) of the applications from other countries. This difference was statistically
significant, and, again, was even more pronounced when considering fragile states
with humanitarian crises, among which 55 grants had applied for continued funding,
just seven (13%) of which were approved (Table 4).
In fragile states, the M&E systems of 96 disease programs from 37 countries
had been assessed by May 2010. Forty-five of these programs (47%) received either A
or B1 ratings, whereas 51 (53%) received either B2 or C ratings. In other recipient
countries, the M&E systems of 132 disease programs from 62 countries were
assessed: 89 (67%) received either A or B1 ratings and 43 (33%) received either B2 or
C ratings. This difference in performance was statistically significant, with fragile
states two times more likely to receive lower ratings (OR 2.3, 95% CI 1.44.0) (Table
4). Finally, from the fragile states listed in Table 1, ratings for 484 programmatic
indicators were available from on-site data verification exercises in 32 countries.
From other recipient countries, ratings for 815 indicators from 63 countries were
available. Analysis showed that the fragile states were twice as likely to have
indicators rated as B2 or C (indicating poor data quality) compared to other recipient
countries (OR = 2.0, 95% CI 1.62.6) (Table 4). This finding was repeated when
analysis was applied individually to HIV/AIDS, tuberculosis and malaria grants
(although statistical significance was not reached for malaria grants).
DISCUSSION
This study clearly demonstrates that fragile states are an important set of countries
for the Global Fund. By mid-2010, the Global Fund had disbursed 46% of its overall
funding to these states, which appears to be proportionate to the reported disease
burden. Fragile states represent 34% of Global Fund recipient countries, but
accounted for 40% of all active grants including more than half of the malaria grants,
as many high malaria burden countries are also fragile states.
The study also demonstrates that Global Fund grants in fragile states,
including those in states that have experienced recent humanitarian crises, were
performing well overall across all six variables explored. This indicates that
successful large-scale health programs, and the accountability and transparency that
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this requires, can be achieved in fragile states (including countries with
humanitarian crises), and that the Global Fund approach does not necessarily
disadvantage these countries. For example, grants in fragile states were, on average,
achieving 83% of their agreed targets in terms of main program indicators. This is
similar to the previous findings from the Global Fund.23
Contrary to previous analyses, however, this study identified statistically
significant differences in performance between grants in fragile states and those in
other recipient countries. Grants in fragile states were reaching, on average, a smaller
proportion of their main agreed targets, were performing less well in their second-
year review ratings, were less likely to be approved for funding after the initial five-
year period, and were more likely to receive lower ratings for their M&E systems and
data quality. In addition, a smaller percentage of grants in fragile states were rated as
performing well at the time of funding disbursements and, of the ten grants that had
been discontinued after the second year by the Global Fund (as of May 2010), seven
were in fragile states. The outcome of this exploratory analysis may vary from that of
previous findings due to differences in how fragile states were defined. Also, previous
research tended to focus solely on Phase Two review ratings as a measure of
performance (rather than the six variables employed here), and the Global Fund
grant portfolio itself has grown considerably since 2005, meaning that statistical
differences in performance may have only recently become apparent.
This study also showed that
there was no difference between fragile states (including countries with
humanitarian crises) and other recipient countries in terms of the percentage of
submitted proposals which were approved by the Global Fund (Table 4)implying
that capacity exists within fragile states for proposal development and long-term
strategic planning (although the role of multilateral partners and consultant proposal
writers must also be acknowledged).
The differences in grant performance identified in this study became more
pronounced in the fragile states with humanitarian crises in the last five years, many
of which are conflict-affected. For example, of the ten grants that had been
discontinued after the second year, half were in countries with humanitarian crises.
By contrast, those countries within the fragile states without humanitarian crises in
the last five years appeared to be performing as well as, if not better than, other non-
fragile recipient countries. It is, however, important to note that the majority of
grants in fragile states with humanitarian crises were still performing well: they were
reaching, on average, 79.6% of their agreed targets, and three quarters of them
received A or B1 ratings at the disbursements stage. Further analysis is required to
better explore factors within the 41 fragile states that may impact on grant
performance, such as the degree or duration of state fragility or the type of crises
being experienced. However, based on the exploratory analysis presented in this
article, some initial hypotheses are discussed below.
Possible Reasons for Differential Performance
There could be several explanations for the differences found between fragile states
and other recipient countries in grant performance. However, it is not possible from
this preliminary and univariate data analysis to ascertain precisely why this may be
the case: multivariate analyses should be employed to try to develop our
understanding. For example, does the type of organization implementing the grant
(such as a governmental body as opposed to an international third party) make a
difference to grant performance? What aspects of state fragility, such as conflict or
recurrent natural disasters, have an impact on performance? Previous research has
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identified links between the improved implementation of Global Fund grants and
greater political stability in low-income countries.24
Another explanation for differential performance could be that fragile states
are more likely to experience corruption. For example, corruption is often a “by-
product of poverty.”
This would suggest that
countries in conflict, which are inherently politically unstable, would perform worse
than those with natural disasters.
25 and poverty is closely associated with state fragility. This can
be expected to impact program management, delivery and performance. By 2010, so-
called “firm action” (such as grant suspensions or early grant terminations) had been
taken by the Global Fund in four of the 41 fragile states: Chad, Mauritania, Myanmar
and Uganda. By contrast, only two of the 81 other recipient countries had been the
subject of such action (the Philippines and Zambia).26
Links between Global Fund grant performance and health governance at the
country level also warrant exploration. This study suggests that humanitarian crises,
many of which are conflict related, may be one of the key factors in grant
performance. It is well documented that conflict can have a major impact on disease
burdens, and mortality in conflict areas can be two or three times more than in non-
conflict areas.
27 Conflict can also cause or exacerbate health inequalities.28 For
example, conflict situations are closely linked to inequalities among refugees and
displaced populations, groups which were only accounted for in a minority of Global
Fund grants in these countries, according to a recent external analysis.29
Against this context of increased disease burden and inequity, conflict poses
complex challenges for health governance. Conflict isolates and demotivates health
professionals, and greatly weakens government institutions and non-state actors
(such as civil society organizations and academic institutions) that help to set policy
and regulate, finance and manage health service delivery. These situations are also
often associated with fluid and rapidly altering political contexts and changes in
leadership.
30
Global Fund policy requires multilateral organizations to administer grants in
countries which lack local capacities.
Such institutional weaknesses may hinder Global Fund grant
management, service delivery and capacity, and help explain why Global Fund grants
in countries with humanitarian emergencies performed less well than grants in other
countries.
31 UNDP in particular has a standing
arrangement with the Global Fund as a “last resort” grant recipient.32 This helps
explain why two-thirds of grants in fragile states were run by multilateral
organizations compared to 32% of grants in other recipient countries (Table 3). In
these cases, the multilateral organization is normally expected to strengthen local
capacities and then hand over administrative responsibilities to national bodies once
sufficient progress and capacity was established (as has been the case in Burkina
Faso, Central African Republic, Cote d’Ivoire and Guinea-Bissau). However, working
with third parties such as multilateral agencies is likely to have implications for
health governance at the country level, as institutional capacity could remain weak
when state institutions are not fully engaged.33 There is a lack of consensus on
whether or not the engagement of international third parties as opposed to
governments is the best way forward in settings of lower political stability.34 It should
also be noted that the governance of Global Fund grants does not necessarily reflect
the capacity of the overall health governance system at the country level, as a strong
Principal Recipient35 can exist in a weak governance environment. More work should
be done on whether and how institutional capacity is developed by the presence of
multilateral organizations as grant implementers in fragile states; this work requires
a long-term perspective, as institutional and economic recovery can take decades.36
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Finally, it must be acknowledged that it is perhaps inevitable for some grants
in fragile states to perform less well, regardless of the funding model or approach
taken, due to their inherently difficult operating environments. Fragile states,
especially those experiencing humanitarian crises, may opt for a more reactive,
responsive approach to health governance: one focused on immediate emergencies
and challenges rather than longer-term strategizing and development. This may
make it more difficult to implement five-year health programs such as those
supported by the Global Fund.
Implications for the Global Fund
Overall, the findings from this study raise important questions for the Global
Fund in terms of how it can improve its aid and support for fragile states. However,
this is just an initial and exploratory analysis of grant data and further work is
required to better understand the findings. This should, for example, examine how
health governance, especially the institutional capacities of state and non-state
partners, relates to Global Fund grant performance. For instance, how does the
capacity of Country Coordination Mechanisms,37 the Ministry of Health, multilateral
organizations and other key non-state actors affect the planning, implementing and
monitoring of grant performance? This work ties into the broader debate around
state-building in the health sector and how support to the health sector can help
strengthen the relationships between state and society, and possibly enhance state
stability.38
Although the majority of grants were performing well, the significant
differences in grant performance present a challenge for the Global Fund. It is well
documented that fragile state contexts require sustained and carefully tailored
approaches,
39 but there has been much debate about the best ways to engage with
and provide support to these countries, particularly to improve health governance.40
Despite a lack of consensus, the risk of failure in these countries is clearly overridden
by the potential costs of inaction,41 especially as improvements in governance and
service capacity may help to reduce state fragility itself.42 With this in mind, the
OECD Development Assistance Committee (DAC) has developed a series of
Principles for Good International Engagement in Fragile States and Situations,43
many of which are congruous with the Global Fund’s founding principles.44 For
example, the DAC principles 1 (“Take context as a starting point”) and 7 (“Align with
local priorities”) appear to fit well with the Global Fund focus on country-driven
demand: in almost all cases, proposals to the Global Fund are developed and
submitted by multi-stakeholder Country Coordinating Mechanisms. Similarly, the
DAC principle of continued, predictable engagement and funding fits well with the
five-year life-span and regular disbursement of Global Fund grants. Sometimes,
however, the DAC Principles may be difficult to adhere to. For example, with regards
to Principle 6 (“Promote non-discrimination [of women, youth, and minority groups]
as a basis for inclusive and stable societies”), refugees and internally displaced
populations are currently discriminated against as they are not included in disease
strategies and are under-represented in proposals to the Global Fund.45 In addition,
for Principle 9 (“Act fast”), the average time between approval for grant funding and
first disbursement is currently 11 months. If Global Fund processes were improved to
better reflect all of the DAC principles, this could better serve fragile states. For
example, it has been recommended that HIV/AIDS programs from all donors in
conflict-affected countries focus on basic prevention and treatment services through
simplified and accelerated funding processes,46 and the same message could easily be
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extended to tuberculosis and malaria as well. It has also been recommended that the
Global Fund promote the inclusion of refugees and internally displaced populations
into national disease strategies and Global Fund proposals, and allow for greater
flexibility to prioritize and transfer funds to these populations as needed (for
instance, in response to new rounds of displacement due to outbreaks of fighting or
natural disasters).47
Limitations
This exploratory study has a number of important limitations. First, it relies on the
secondary, univariate analysis of routinely collected grant data. Such data can
present an indication of the situation in countries, but not with the same depth as
qualitative assessments or field work.48 Second, this study is based on a list of fragile
states drawn from ReliefWeb and the Fund for Peace, which were chosen and
combined to closely reflect internal indices of risk and fragility that are used within
the organization. There are several lists and definitions of fragile states available in
the international literature, with most donor agencies having their own,49
but no
universal consensus on the best list to use. Different results would likely have been
obtained if an alternative fragile states list had been compiled or used. Third,
differences in grant performance (as reported here) do not necessarily translate into
numbers of services delivered or people reached. A Global Fund grant that is
performing well against its targets is not necessarily providing more (or better
quality) services than a grant which is not, as each grant has country-set targets
designed for the local context.
CONCLUSION
In conclusion, the Global Fund has invested heavily in fragile state, with nearly US$
5 billion disbursed by mid-2010. The majority of these grants, including those in
countries with recent humanitarian crises, are performing well and are reaching a
large proportion of their targets. This indicates that demand-driven, performance-
based financing, such as that provided by the Global Fund, can be successfully used
to support the delivery of critical health programs in fragile states. Nonetheless, it
would also appear that the performance of grants in fragile states, and particularly
those with humanitarian crises, is lower than that of grants in other recipient
countries. Weak performance may be caused by myriad challenges and complexities
of health governance in fragile states. This has implications for the Global Fund as it
seeks to provide better support in fragile state contexts. For example, more focus
could be given to speeding up aid disbursement, allowing grants to be more
responsive and opportunistic to changing contexts and crises, and to building
capacity and strengthening the governance of health systems in these countries.
Further exploration, including multivariate analyses and fieldwork, is required
in order to better assess the implications for the Global Fund, its partners and other
stakeholders, and to inform discussions about potential responses and actions that
need to be taken. International aid is just one component of efforts in fragile states,50
but the performance of these investments has many implications for the fight against
HIV/AIDS, tuberculosis and malaria, for global health governance, and for the race
to achieve the Millennium Development Goals by 2015.
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Olga Bornemisza, MSc, MEDes, is the Senior Technical Officer for Health
Systems Strengthening at the Global Fund to Fight AIDS, Tuberculosis and
Malaria. Prior to this, she conducted research on health issues and fragile states
while at the London School of Hygiene and Tropical Medicine, examining topics
such as the role of the health sector in state-building, and the links between foreign
policy, national security, and development aid.
Jamie Bridge, MSc, is a Program Officer for the Technical Publications and
Learning Team at the Global Fund to Fight AIDS, Tuberculosis and Malaria. He has
a background in HIV prevention for people who use drugs, having worked
previously for the International Harm Reduction Association and managed a
needle and syringe program in England.
Michael Olszak-Olszewski, PhD, is Senior Information Management Officer for
the Country Programs Cluster at the Global Fund to Fight AIDS, Tuberculosis and
Malaria. His main background is in statistics and he also holds a position of
Lecturer in Statistics at the University of Geneva.
George Sakvarelidze, MD, MPH, is a Senior Technical Officer for the Monitoring
and Evaluation Support Team at the Global Fund to Fight AIDS, Tuberculosis and
Malaria. Earlier, he worked with UNICEF coordinating research in Central and
Eastern Europe and the development of socioeconomic databases.
Jeffrey Victor Lazarus, PhD, MIH, MA, is the Senior Policy Officer, Strategy,
Performance and Evaluation, at the Global Fund to Fight AIDS, Tuberculosis and
Malaria. He also holds positions as Affiliated Professor at the Medical School in
Porto University and External Lecturer in international health at Copenhagen
University.
This article does not necessarily represent the views of the Global Fund.
The authors wish to thank several colleagues for their invaluable support and
advice in the preparation of this paper, including Dr Paul Spiegel from the Office of
the United Nations High Commissioner for Refugees (UNHCR), Andrew Kennedy,
Jami Johnson and Ryuichi Komatsu from the Global Fund to Fight AIDS,
Tuberculosis and Malaria, and the members of the Global Fund’s internal working
group on fragile states.
BORNEMISZA, ET AL, HEALTH AID GOVERNANCE IN FRAGILE STATES 11
GLOBAL HEALTH GOVERNANCE, VOLUME IV, NO. 1 (FALL 2010) http://www.ghgj.org
Table 1. Fragile States and Other Global Fund Recipient Countries
Fragile States Other Recipient Countries
Afghanistan* Albania Jordan
Bangladesh Algeria Kazakhstan
Burkina Faso Angola Kyrgyzstan
Burundi* Argentina Lao (People’s Democratic
Cameroon Armenia Lesotho
Central African Republic* Azerbaijan Macedonia (Former Yugoslav
R bli )
Chad* Belarus Madagascar
Congo (Democratic
Belize Maldives
Congo* Benin Mali
Côte d'Ivoire* Bhutan Mauritius
Eritrea* Bolivia (Plurinational State) Mexico
Ethiopia Bosnia and Herzegovina Moldova (Republic)
Georgia Botswana Mongolia
Guinea* Brazil Montenegro
Guinea-Bissau* Bulgaria Morocco
Haiti* Cambodia Mozambique
Iran (Islamic Republic) Cape Verde Namibia
Iraq* Chile Nicaragua
Kenya* China Panama
Korea (Democratic People’s Republic)
Colombia Papua New Guinea
Liberia* Comoros Paraguay
Malawi Costa Rica Peru
Mauritania* Croatia Philippines
Myanmar Cuba Romania
Nepal* Djibouti Russian Federation
Niger Dominican Republic Sao Tome and Principe
Nigeria Ecuador Senegal
Pakistan* Egypt Serbia
Rwanda* El Salvador South Africa
Sierra Leone* Equatorial Guinea Suriname
Solomon Islands* Estonia Swaziland
Somalia* Fiji Syrian Arab Republic
Sri Lanka* Gabon Tanzania (United Republic)
Sudan* Gambia Thailand
Tajikistan Ghana Tunisia
Timor-Leste* Guatemala Turkey
Togo* Guyana Turkmenistan
Uganda* Honduras Ukraine
Uzbekistan India Viet Nam
Yemen* Indonesia Zambia
Zimbabwe* Jamaica
Notes: Multi-country grants and grants in territories were excluded. * indicates a
country that has experienced a humanitarian crisis in the last five years.51
Source: Global Fund Grant Portfolio,
http://portfolio.theglobalfund.org (accessed
May 2010).
BORNEMISZA, ET AL, HEALTH AID GOVERNANCE IN FRAGILE STATES 12
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Table 2. Descriptive Characteristics of Fragile States versus Other
Recipient Countries
Fragile States Other Recipient
Countries
Number of countries (% total) 41 (34%) 81 (66%)
Population 1.238,838,237 4,276,217,411
Share of world population 19% 64%
People living with HIV 1 12,534,500 19,047,900
Share of global HIV prevalence 1 38% 57%
Prevalence of tuberculosis 4,815,250 6,204,231
Share of global tuberculosis
prevalence 44% 56%
Reported, positive malaria cases 1 15,974,898 13,061,798
1 Data were not available for all 122 countries in the analysis.
BORNEMISZA, ET AL, HEALTH AID GOVERNANCE IN FRAGILE STATES 13
GLOBAL HEALTH GOVERNANCE, VOLUME IV, NO. 1 (FALL 2010) http://www.ghgj.org
Figure 1. Cumulative Expenditures of Global Fund Grants by Cost
Category (as of May 2010)
BORNEMISZA, ET AL, HEALTH AID GOVERNANCE IN FRAGILE STATES 14
GLOBAL HEALTH GOVERNANCE, VOLUME IV, NO. 1 (FALL 2010) http://www.ghgj.org
Table 3. Global Fund Grant Portfolio Analyses: Fragile States versus
Other Recipient Countries
Fragile States Other Recipient
Countries
Number of countries (% total) 41 (34%) 81 (66%)
Number of active Global Fund grants
(% total) 198 (40%) 291 (60%)
Percentage of total HIV grants 37.14% 62.86%
Percentage of total tuberculosis
grants 41.95% 58.05%
Percentage of total malaria grants 50.96% 49.04%
Average number of active grants per
country 4.95 4.16
Percentage of grants where the
Principal Recipient is:
Civil society or private sector body 35.68% 64.32%
Governmental body 37.89% 62.11%
Multilateral organization 68.00% 32.00%
Number of Global Fund grants with
previous disbursements (% total) 314 (42%) 427 (58%)
Disbursements as of May 2010 (US$) 4,867,424,598 5,802,365,241
Share of total disbursements as of May
2010 46% 54%
Average total disbursements per
country as of May 2010 (US$) 118,717,673 73,447,661
Source: Global Fund Grant Portfolio, http://portfolio.theglobalfund.org (accessed
May 2010).
BORNEMISZA, ET AL, HEALTH AID GOVERNANCE IN FRAGILE STATES 15
GLOBAL HEALTH GOVERNANCE, VOLUME IV, NO. 1 (FALL 2010) http://www.ghgj.org
Table 4. Performance Ratings of Global Fund Grants
“Non-
fragile”
recipient
countries
“Fragile” recipient countries
All
Fragile states
with
humanitarian
crises in the
last five years
Other fragile
states
Number of countries
(% total recipient countries) 81
(66%) 41
(34%) 28
(23%) 13
(11%)
Percentage of submitted
proposals approved for
funding 43% 42% 42% 41%
Average percentage of main
program indicator targets
being reached by active grants 88.1% 82.7%* 79.6%* 89.3%
Percentage of grants with
performance rated A or B1 for
latest disbursement 84.8% 78.9% 75%* 86.7%
Percentage of grants rated A or
B1 at major review in second
year 81.8% 69.9%* 64.7%* 80%
Grants with funding
discontinued after second year
review 3 7* 5* 2
Percentage of assessed grants
approved for continued
funding after five-year grant
period
32.3% 17.7%* 12.7%* 29.2%
Disease programs with
performance ratings for
monitoring and evaluation
systems
A or B1 89 (67.4%) 45 (46.9%)*
B2 or C 43 (32.6%) 51 (53.1%)*
Indicators rated through on-
site data verification
exercises
A or B1 637 (78.2%) 308 (63.6%)*
B2 or C 178 (21.8%) 176 (36.4%)*
* indicates that there is a statistically significant difference (p < 0.05, or 95% confidence level)
between the group tested and the “non-fragile” recipient countries.
BORNEMISZA, ET AL, HEALTH AID GOVERNANCE IN FRAGILE STATES 16
GLOBAL HEALTH GOVERNANCE, VOLUME IV, NO. 1 (FALL 2010) http://www.ghgj.org
1 DFID, Why We Need to Work More Effectively in Fragile States (London: UK Department for
International Development, 2005).
2 OECD, Ensuring Fragile States Are Not Left Behind (Paris: Organisation for Economic Co-operation
and Development, 2007).
3 OECD, Service Delivery in Fragile Situations (Paris: Organisation for Economic Co-operation and
Development, 2008).
4 WHO, World Malaria Report 2008 (Geneva: World Health Organization, 2008).
5 Andrew Branchflower et al., How Important Are Difficult Environments to Achieving the MDGs?
(London: UK Department for International Development, 2004).
6 Paolo Piva and Rebecca Dodd, “Where did all the aid go? An in-depth analysis of increased health aid
flows over the past 10 years,” Bulletin of the World Health Organization 87 (2009):930-939.
7 WHO, Everybody’s Business: Strengthening Health Systems to Improve Health Outcomes: WHO’s
Framework for Action (Geneva: World Health Organization, 2007); Sameen Siddiqi et al.,
“Framework for assessing governance of the health system in developing countries: Gateway to good
governance,” Health Policy 90 (2009): 13-25.
8 Global Fund, “2.8 Million People on AIDS Treatment through Global Fund Investments,” Global
Fund to Fight AIDS, Tuberculosis and Malaria,
http://www.theglobalfund.org/en/pressreleases/?pr=pr_100608.
9 Global Fund, Global Fund Investments in Fragile States: Early Results (Geneva: Global Fund to
Fight AIDS, Tuberculosis and Malaria, 2005).
10 Daniel Low-Beer et al., “Making performance based funding work for health,” PLoS Medicine 4
(2007): e219.
11 Global Fund, The Global Fund 2010: Innovation and Impact (Geneva: Global Fund to Fight AIDS,
Tuberculosis and Malaria, 2010), 48.
12 Chunling Lu et al., “Absorptive capacity and disbursements by the Global Fund to Fight AIDS,
Tuberculosis and Malaria: Analysis of grant implementation,” The Lancet 368 (2006): 483-488.
13 The disbursement of funding from the Global Fund to countries is linked to an assessment of
performance of the grant. Information on this process is available at:
www.theglobalfund.org/en/performancebasedfunding
14 Olga Bornemisza et al., “Promoting health equity in conflict-affected fragile states,” Social Science
and Medicine 70 (2010): 80-88.
15 ReliefWeb, “Countries and Emergencies,” http://www.reliefweb.int.
16 Fund for Peace, “Failed States Index 2009,”
http://www.fundforpeace.org/web/index.php?option=com_content&task=view&id=391&Itemid=549
.
17 Fund for Peace, “Failed States Index FAQ,”
http://www.fundforpeace.org/web/index.php?option=com_content&task=view&id=102&Itemid=891
.
18 The World Bank, “Harmonized List of Fragile Situations FY10”,
http://siteresources.worldbank.org/EXTLICUS/Resources/511777-
1269623894864/Fragile_Situations_List_FY10_Mar_26_2010_EXT.pdf.
19 The World Bank, “Data,” http://data.worldbank.org.
20 UNAIDS, “Estimated number of people living with HIV by country, 1990-2007”, Joint United
Nations Programme on HIV/AIDS,
http://www.unaids.org/en/KnowledgeCentre/HIVData/Epidemiology/latestEpiData.asp.
21 WHO, “Estimated epidemiological burden of TB (best estimates, lower and upper bounds), all
forms, 1990–2008”, World Health Organization,
http://www.who.int/tb/publications/global_report/2009/update/a-1_full.pdf; WHO, World Malaria
Report 2009 (Geneva: World Health Organization, 2009), Annex 3A.
22 Global Fund, “Grant Portfolio,” Global Fund to Fight AIDS, Tuberculosis and Malaria,
http://portfolio.theglobalfund.org.
23 Global Fund, Global Fund Investments in Fragile States: Early Results (Geneva: Global Fund to
Fight AIDS, Tuberculosis and Malaria, 2005); Daniel Low-Beer et al., “Making performance based
funding work for health,” PLoS Medicine 4 (2007): e219; Global Fund, The Global Fund 2010:
Innovation and Impact (Geneva: Global Fund to Fight AIDS, Tuberculosis and Malaria, 2010), 48.
24 Chunling Lu et al., “Absorptive capacity and disbursements by the Global Fund to Fight AIDS,
Tuberculosis and Malaria: Analysis of grant implementation,” The Lancet 368 (2006): 483-488.
25 Transparency International, Working Paper #2: Poverty and Corruption (Berlin: Transparency
International, 2008)
BORNEMISZA, ET AL, HEALTH AID GOVERNANCE IN FRAGILE STATES 17
GLOBAL HEALTH GOVERNANCE, VOLUME IV, NO. 1 (FALL 2010) http://www.ghgj.org
26 Bernard Rivers, “Is the Global Fund Living Up to Its Principles?,” Aidspan,
http://www.aidspan.org/index.php?issue=127&article=4.
27 Benjamin Coghlan et al, “Mortality in the Democratic Republic of Congo: A nationwide survey,” The
Lancet 367 (2006): 4451.
28 Olga Bornemisza et al., “Promoting health equity in conflict-affected fragile states,” Social Science
and Medicine 70 (2010): 80-88.
29 Paul B Spiegel et al., “Conflict-affected displaced persons need to benefit more from HIV and
malaria national strategic plans and Global Fund grants,” Conflict and Health 4 (2010): 2.
30 Brent W Hanson et al., “Refocusing and prioritizing HIV programmes in conflict and post-conflict
settings: funding recommendations,” AIDS 22 Supplement 2 (2008): S95-S103; Margaret E Kruk,
Lynn P Freedman, Grace A Anglin and Ron J Waldman, “Rebuilding health systems to improve health
and promote statebuilding in post-conflict countries: a theoretical framework and research agenda,”
Social Science & Medicine 70 (2010): 89–97.
31 Global Fund, The Global Fund 2010: Innovation and Impact (Geneva: Global Fund to Fight AIDS,
Tuberculosis and Malaria, 2010), 47.
32 Global Fund, Global Fund Investments in Fragile States: Early Results (Geneva: Global Fund to
Fight AIDS, Tuberculosis and Malaria, 2005).
33 Margaret E Kruk, Lynn P Freedman, Grace A Anglin and Ron J Waldman, “Rebuilding health
systems to improve health and promote statebuilding in post-conflict countries: a theoretical
framework and research agenda,” Social Science & Medicine 70 (2010): 89–97.
34 OECD, Service Delivery in Fragile Situations (Paris: Organisation for Economic Co-operation and
Development, 2008).
35 ‘Principal Recipient’ refers to the nongovernmental organization, public entity, private sector
organization or development agency that works with the Global Fund Secretariat to develop and
implement grants. Once a grant agreement has been signed, funds are disbursed to, and managed by,
the Principal Recipient.
36 Lise Chauvet and Paul Collier, Development Effectiveness in Fragile States: Spillovers and
Turnarounds (Oxford: Centre for the Study of African Economies, Oxford University, 2004).
37 The ‘Country Coordinating Mechanism’ is a national partnership of stakeholders composed of
representatives from both the public and private sectors including government bodies, multilateral
and bilateral agencies, nongovernmental organizations, academic institutions, the private sector, and
people living with the diseases. It is responsible for developing and submitting grant proposals based
on country needs, nominating the Principal Recipient and providing oversight to grant
implementation.
38 DFID, Building the State and Securing the Peace: Emerging Policy Paper (London: UK
Department for International Development, 2009); Jack Eldon and Dean Gunby, States in
Development: State Building and Service Delivery Final Report (London: HLSP, 2009).
39 OECD, Service Delivery in Fragile Situations (Paris: Organisation for Economic Co-operation and
Development, 2008).
40 OECD, Service Delivery in Fragile Situations (Paris: Organisation for Economic Co-operation and
Development, 2008); Olga Bornemisza et al., “Promoting health equity in conflict-affected fragile
states,” Social Science and Medicine 70 (2010): 80-88; DFID, Why We Need to Work More
Effectively in Fragile States (London: UK Department for International Development, 2005).
41 The World Bank, “Fragile and Conflict-Affected Countries,”
http://go.worldbank.org/BNFOS8V3S0.
42 OECD, Service Delivery in Fragile Situations (Paris: Organisation for Economic Co-operation and
Development, 2008).
43 OECD, Monitoring the Principles for Good International Engagement in Fragile States and
Situations (Paris: Organisation for Economic Co-operation and Development, 2010).
44 Global Fund, The Framework Document of the Global Fund to Fight AIDS, Tuberculosis and
Malaria (Geneva: Global Fund to Fight AIDS, Tuberculosis and Malaria, 2002).
45 Paul B Spiegel et al., “Conflict-affected displaced persons need to benefit more from HIV and
malaria national strategic plans and Global Fund grants,” Conflict and Health 4 (2010): 2.
46 Brent W Hanson et al., “Refocusing and prioritizing HIV programmes in conflict and post-conflict
settings: funding recommendations,” AIDS 22 Supplement 2 (2008): S95-S103.
47 Paul B Spiegel et al., “Conflict-affected displaced persons need to benefit more from HIV and
malaria national strategic plans and Global Fund grants,” Conflict and Health 4 (2010): 2.
BORNEMISZA, ET AL, HEALTH AID GOVERNANCE IN FRAGILE STATES 18
GLOBAL HEALTH GOVERNANCE, VOLUME IV, NO. 1 (FALL 2010) http://www.ghgj.org
48 Dominique Behague et al., “Evidence-based policy-making: The implications of globally-applicable
research for context-specific problem-solving in developing countries,” Social Science and Medicine
69 (2009): 1539-1546.
49 Olga Bornemisza et al., “Promoting health equity in conflict-affected fragile states,” Social Science
and Medicine 70 (2010): 80-88.
50 OECD, Ensuring Fragile States Are Not Left Behind (Paris: Organisation for Economic Co-
operation and Development, 2007).
51 ReliefWeb, “Countries and Emergencies,” http://www.reliefweb.int.
... Macro International (2009), French Ministry of Foreign Affairs (2013), Norwegian Min-istry of Foreign Affairs (2013), DFID (2016)). A substantial scientific literature, predominantly published in The Lancet, has covered different aspects of its business model, such as performance-based funding ( Katz et al., 2010;Fan et al., 2013Fan et al., , 2014Glassman et al., 2013), its impact on health systems ( Samb et al., 2009;Bowser et al., 2014), involvement of civil society ( Harmer et al., 2012;Bridge et al., 2016), drug pricing ( Stover et al., 2011;Zelman et al., 2014), its role in fragile countries ( Bornemisza et al., 2010), and the promotion of implementation research and management learning (van Szlezák, 2006, 2010). However, the literature tends to focus on individual components of the Global Fund without linking them to the institution's key design principles, and without considering how they might interact to explain the apparent success of the Fund. ...
... Countries thus learned that rigorous programs would be funded, which spurred increased high-quality demand for funding [DPs 1, 4, and 5]. Global Fund-supported programs have performed well in complex operating environments of fragile countries ( Bornemisza et al., 2010). Evaluations by the TERG supported implementation research by technical partners to fill knowledge gaps, such as the design of outcome and impact criteria in malaria-control programs ( Nahlen and Low-Beer, 2007). ...
... This diminished the discretion of countries and the TRP to set funding volumes, so we limit our analysis to the rounds-based mechanism. Several studies have investigated the performance of Global Fund grants ( Lu et al., 2006;Radelet and Siddiqi, 2007;Macro International, 2009;Katz et al., 2010;), including in fragile countries ( Bornemisza et al., 2010;Patel et al., 2015), and their impact on health systems ( Atun et al., 2011;Car et al., 2012;iERG, 2014;Samb et al., 2009). There has been no systematic assessment of the role of the TRP. ...
Thesis
The world has experienced unprecedented growth in average per capita incomes over the last 50 years, but many countries continue to face deep economic, social, and/or environmental challenges. These include persistent extreme poverty, poor outcomes in human health and education, widespread malnutrition, high inequality measured by income or other characteristics, poor access to infrastructure, growing water stress, the degradation of terrestrial and marine ecosystems, pollution, and climate change. Under business-as-usual trajectories the environmental challenges in particular are expected to worsen significantly. Enhanced international policy coordination and cooperation around shared goals is required to reverse these trends, and many developing countries require more external financial assistance. In response governments have adopted international development goals, including the Millennium Development Goals (MDGs) and their successors, the Sustainable Development Goals (SDGs), which are to be achieved by 2030. These goals complement earlier tools for international policy coordination, notably the environmental conventions, such as the United Nations Framework Convention on Climate Change and the Convention on Biological Diversity. This thesis contributes to the need to understand how progress towards the SDGs can be monitored, how investment needs for climate-resilient development and the SDGs can be estimated, and what lessons can be drawn for international financing mechanisms in support of the SDGs from the experience of the health sector under the MDGs. These issues represent important contemporary questions in the scientific and policy literature, as evidenced by the rapidly growing scientific literature on the SDGs to which this thesis contributes. Chapter 2 introduces a novel SDG Index and Dashboards that combines official and science-based metrics to establish an SDG baseline for the 149 countries for which sufficient data are currently available. The SDG Index and Dashboards measure countries’ distance from achieving the goals, assess overall performance, and identify implementation priorities for each country. We find that many countries’ development models are imbalanced in favor of economic development and at the expense of social inclusion and environmental sustainability. We demonstrate the SDG Index’ usefulness as an explanatory variable in studying policy objectives, such as subjective well-being and in identifying policy priorities. Moreover, the chapter identifies major data gaps for monitoring the SDGs and suggests ways in which these can be closed in coming years. In Chapter 3 we consider the combined investment needs of development objectives in low-income country settings, as exemplified by the MDGs, and measures to adapt to a changing climate. Drawing on consensus investment needs for the MDGs in Africa, as established by the MDG Africa Steering Group, and the literature on investment needs for climate change adaptation, we propose and apply a methodology for integrating these assessments. The chapter reviews major line items in financing the MDGs and considers the nature and extent of additional measures to adapt to climate change, as well as associated financing needs. We find that climate change adaptation may increase total investment needs by some 40 percent. The analysis shows that development and adaptation measures need to be integrated along sectoral lines in order to facilitate implementation by governments. Chapter 4 extends this analysis to propose an analytical framework for SDG needs assessments that translates the 17 SDGs into eight investment areas and introduces a preliminary score to assess the quality and suitability of needs assessment studies. Using this framework, published sector needs assessments are analyzed, harmonized, and consolidated to arrive at a first assessment of private and public investment needs for the SDGs in low- and lower-middle-income countries. Incremental spending needs in these countries are estimated at $1.3-1.4 trillion per year. Approximately half of these incremental investments can be privately financed. Domestic resource mobilization can increase significantly, leaving an external financing gap of perhaps $152-163 billion per year (equivalent to 0.22-0.26% of high-income countries’ GDP) that must be met through international public finance, including Official Development Assistance. Globally, an incremental 1.5-2.5% of world GDP needs to be invested each year by the public and private sectors to achieve the SDGs in every country. Turning to the financing of the SDGs, Chapter 5 investigates the experience of the Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria in financing the rapid scaling up of proven health interventions observed since 2002. The chapter identifies 8 key design principles of the Global Fund that set the institution apart from other multilateral financing mechanisms. It then considers to what extent these design principles have enabled rapid progress in combating the three infectious diseases in a broad range of operating environments, including fragile countries and countries with poor governance. The chapter concludes that the Global Fund has performed better than expected at inception, and that the key design principles explain this success. Adopting these principles may help multilateral grant financing mechanisms focusing on other SDG priorities – such as education; access to energy, water, and sanitation; nutrition; and smallholder agriculture – improve the effectiveness of resource use and accelerate progress towards the goals. In the Chapter 6, we investigate the Global Fund’s Technical Review Panel (TRP) to determine whether it had succeeded in reconciling the competing needs of country ownership of development programs and the need to ensure effective use of scarce resources. We also investigate whether the demand-based application process generated funding allocations that were in line with the Global Fund’s objective to direct funds towards the countries most in need. To answer these questions, we construct a novel dataset and conduct four sets of regression analysis using ordinary least squares and ordered logistic regression models. The chapter finds that the TRP operated in line with the Global Funds’ objectives and allocated funding to countries most in need, though we find evidence that countries with large populations suppressed the volume of financing requested from the Global Fund. The evidence suggests that the TRP promoted learning on how to scale up disease control programs and that the Global Fund operated equally well across different country environments, including fragile and poorly governed countries. The chapter closes by considering the policy implications for financing the SDGs in health and other areas. The concluding chapter summarizes the research findings and critically discusses the methodologies and data used in this thesis. It outlines suggestions for further research and summarizes policy implications for monitoring, implementing, and financing the SDGs.
... Although partnerships and health initiatives provide an opportunity for health sector development, the variety of their funding levels, instruments for engagement with countries, focus, and scope of support creates challenges for the recipient countries [9][10][11][12][13][14][15][16]. The large number of health partnerships and initiatives also generates a wide range of issues and concerns in ensuring that they are aligned to sector priorities, and in preventing overburdening of government officials with extra demands [17][18][19][20][21][22][23]. GHIs are renowned for their large funding to countries. ...
... There has been growing concern in various African countries over the alignment of GHI objectives with those of the national strategic plans [2,17,19,21]. One school of thought is that by nature, GHIs with their specific earmarked funding, inevitably will influence the countries that are highly donor dependent. ...
... Studies conducted in Malawi, Benin and Zambia showed that opportunities provided by GFATM strengthened public-private collaboration through allowing NGOs to establish umbrella organisations that helped to channel funds through principal recipients to sub-recipients [57]. There are still gaps, however, in the involvement of the private sector, and perceptions about how well GHIs are working with other stakeholders are contradictory [19]. There is evidence that some of the NGOs and CSOs do not have the capacity to implement GHI activities or absorb their funds [55]. ...
Article
Full-text available
Background The advent of global health initiatives (GHIs) has changed the landscape and architecture of health financing in low and middle income countries, particularly in Africa. Over the last decade, the African Region has realised improvements in health outcomes as a result of interventions implemented by both governments and development partners. However, alignment and harmonisation of partnerships and GHIs are still difficult in the African countries with inadequate capacity for their effective coordination. Method Both published and grey literature was reviewed to understand the governance, priorities, harmonisation and alignment of GHIs in the African Region; to synthesise the knowledge and highlight the persistent challenges; and to identify gaps for future research. Results GHI governance structures are often separate from those of the countries in which they operate. Their divergent funding channels and modalities may have contributed to the failure of governments to track their resources. There is also evidence that basically, earmarking and donor conditions drive funding allocations regardless of countries’ priorities. Although studies cite the lack of harmonisation of GHI priorities with national strategies, evidence shows improvements in that area over time. GHIs have used several strategies and mechanisms to involve the private sector. These have widened the pool of health service policy-makers and providers to include groups such as civil society organisations (CSOs), with both positive and negative implications. GHI strategies such as co-financing by countries as a condition for support have been positive in achieving sustainability of interventions. Conclusions GHI approaches have not changed substantially over the years but there has been evolution in terms of donor funding and conditions. GHIs still largely operate in a vertical manner, bypassing country systems; they compete for the limited human resources; they influence country policies; and they are not always harmonised with other donors. To maximise returns on GHI support, there is need to ensure that their approaches are more comprehensive as opposed to being selective; to improve GHI country level governance and alignment with countries’ changing epidemiologic profiles; and to strengthen their involvement of CSOs.
... Studies have reported that Global Fund grants in fragile states did not perform as well as in stable resourcepoor countries [61], with weak governance, corruption and poor leadership consistently identified as constraints in conflict-affected countries [36,51,61]. We could identify no studies providing evidence on specific ways in which GHIs seek to strengthen governance and leadership within the health system. ...
... Studies have reported that Global Fund grants in fragile states did not perform as well as in stable resourcepoor countries [61], with weak governance, corruption and poor leadership consistently identified as constraints in conflict-affected countries [36,51,61]. We could identify no studies providing evidence on specific ways in which GHIs seek to strengthen governance and leadership within the health system. ...
... Concerns over the governance and management arrangements of GHIs themselves in conflict-affected countries were also raised in the literature [61,62]. The Global Fund does not have an in-country presence in any recipient country and potential limitations with this arrangement may be especially acute in conflict-affected countries. ...
Article
Full-text available
Global Health Initiatives (GHIs) respond to high-impact communicable diseases in resource-poor countries, including health systems support, and are major actors in global health. GHIs could play an important role in countries affected by armed conflict given these countries commonly have weak health systems and a high burden of communicable disease. The aim of this study is to explore the influence of two leading GHIs, the Global Fund and the GAVI Alliance, on the health systems of conflict-affected countries. This study used an analytical review approach to identify evidence on the role of the Global Fund and the GAVI Alliance with regards to health systems support to 19 conflict-affected countries. Primary and secondary published and grey literature were used, including country evaluations from the Global Fund and the GAVI Alliance. The WHO heath systems building blocks framework was used for the analysis. There is a limited evidence-base on the influence of GHIs on health systems of conflict-affected countries. The findings suggest that GHIs are increasingly investing in conflict-affected countries which has helped to rapidly scale up health services, strengthen human resources, improve procurement, and develop guidelines and protocols. Negative influences include distorting priorities within the health system, inequitable financing of disease-specific services over other health services, diverting staff away from more essential health care services, inadequate attention to capacity building, burdensome reporting requirements, and limited flexibility and responsiveness to the contextual challenges of conflict-affected countries. There is some evidence of increasing engagement of the Global Fund and the GAVI Alliance with health systems in conflict-affected countries, but this engagement should be supported by more context-specific policies and approaches.
... 13 Furthermore, the Global Fund adopts a demand-driven model for funds allocation with poor consideration of specific epidemiological profiles as it relates with individual countries. 11,14,15 There has also been lack of cooperation and synergy with partner institutions which has delayed the progress towards the unified goal. Another limitation being experienced is the poor risk management that has resulted in discrepancies of over US$4 million discovered in the Global Fund grants received by Nigeria as of 2016. ...
Article
The Global Fund is a non‐profit organization founded by Bill Gates, Melinda Gates, Kofi Annan, Amir Attaran, and Jeffrey Sachs on the 28th January, 2002. Each year, about US$ 4 billion is invested to support programs and organizations led by local experts in various communities towards developing strategies and ways in which these three (HIV/ AIDS, Malaria and Tuberculosis) diseases could be fought. The Global Fund has supported various innovative strate- gies used in tackling these infectious diseases. It is also worthy of note that 38 million lives have been saved through the Global Funds Partnership resulting in a 50% decline in mortality rate caused by tuberculosis, AIDS and Malaria in these reached countries. However, the Global Fund is not without its challenges as there has been lack of fund commitment from the G8 countries who instituted the idea in the first place. Another limitation being experienced is the poor risk management that has resulted in discrepancies of over US$4 million discovered in the Global Fund grants received by Nigeria as of 2016. This study discusses the current state of the Global Fund and suggests recommendations to policymakers that could be instrumental in strengthening health systems and achieving increased impact.
... Although individual case studies are often contested, with diverging views of their achievements and limitations, some general principles emerge, including the need for a real but realistic role for the Ministry of Health, which is widely shared by all parties; strong donor coordination and alignment to reduce transaction costs and fragmentation; participatory decision making across actors and levels of the health system; focusing on results and performance monitoring of health-sector activities using multiple data sources; increasing the reliability of aid flows, ideally for sufficient periods to support system strengthening; and ensuring a critical mass of individuals with the right experience and expertise being deployed at the right time and able to look beyond agency mandates and priorities to support sector reform and results (Dalil et al., 2014). These have also been highlighted in reviews of global health initiatives operating in FCAS settings (Bornemisza et al., 2010;Pearson et al., 2014;Witter and Pavignani, 2016). Given the challenge of legitimacy and capacity, it is particularly important that heath policies are not (nor seen as) externally devised (Gruber, 2009). ...
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Fragile and conflict affected settings (FCAS) present a growing challenge for achieving UHC and other developmental goals. In this paper, we examine core features of FCAS, which centre on deficits in capacity, legitimacy and security, and what this implies for health systems, but more specifically for health financing and in relation to the key messages and policy guidance currently offered by WHO. We explore common health financing constraints and opportunities and how policies have responded to these and draw out recommendations.
... Without foresight, both low income migrants and non-migrants living in the receiving communities may suffer from inadequate systems. Integrating the HEIA tool within health system policy planning could support more equitable health service provision and strengthen the overall healthcare system [15,[17][18][19]. ...
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Materials and methods: An international Delphi consensus process was used to identify policy approaches to improve health systems for populations affected by migration. Participants were leading migrant health experts from Americas, Europe, Middle East, Asia, and Australasia. We calculated average ranking scores and qualitatively analyzed open-ended questions. Results: Participants identified the following key areas as priorities for policy development: health inequities, system discrimination, migrant related health data, disadvantaged migrant sub-groups, and considerations for disadvantaged non-migrant populations. Highly ranked items to improve health systems were: Health Equity Impact Assessment, evidence based guidelines, and the International Organization for Migration annual reports. Discussion: Policy makers need tools, data and resources to address health systems challenges. Policies need to avoid preventable deaths of migrants and barriers to basic health services.
Chapter
The future of cancer and HIV/AIDS control in low- and middle-income countries (LMICs) lies in strategic international collaboration for opportunities in global equity in health, so as to mitigate high rates of premature death and suffering. This goal should be attainable through successful performance of the United Nations initiatives, including the Sustainable Development Goals, and performing in concert with funding agencies, such as the Global Fund, and health care promoting agencies including the Global Alliance for Vaccine Development, the United States National Institutes of Health and its subsidiaries, such as the Fogarty International Center. Other organizations already making remarkable contributions in global health (GH) outreach are Médicins Sans Frontières, the Bill and Melinda Gates Foundation and several other mainly US-based research agencies, working “in convergence” with academia and industry to resolve GH care challenges. Promotion of emerging GH partnerships between cancer care organizations in high-income countries (HICs) and LMICs promises to impact positively on the control of cancer and HIV/AIDS globally. Innovations are required in promoting resource-setting appropriate access to universal health coverage and supportive human resources development, while exploring ways to engage the political class to comprehend the basis of, and need for the control of factors that are responsible for premature death and suffering among their people. LMICs need vigorous advocacy of science as an instrument of human development, for the conquest of poverty and the containment of the ravages of diseases, so as to ensure the global dissemination of the US cancer Moonshot, and UNAID 90-90-90 goals.
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The independent Technical Review Panel (TRP) of the Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria is a unique mechanism to review funding proposals and to provide recommendations on their funding. Its functioning and performance have received little attention in the scientific literature. We aimed to identify predictors for TRP recommendations, whether these were in line with the Global Fund's ambition to give priority to countries most in need, and whether they correlated with grant performance. We combined data on proposals and applications under the Rolling Continuation Channel, TRP recommendations and grant implementation during the rounds-based mechanism (2002-2010) with country characteristics. Ordered logistic and OLS regressions were used to identify predictors for per-capita funding requests, TRP recommendations, Global Fund funding and grant performance ratings. We tested for financial suppression of large funding proposals and whether fragile or English-speaking countries performed differently from other countries. We found that funding requests and TRP recommendations were consistent with disease burden, but independent of other country characteristics. Countries with larger populations requested less funding per capita, but there is no evidence of financial suppression by the TRP. Proposals from fragile countries were as likely to be recommended as proposals from other countries, and resulting grants performed equally well except for lower performance of HIV/AIDS grants. English-speaking countries obtained more funding for TB and malaria than other countries. In conclusion, the independent TRP acted in line with the guiding principles of the Global Fund to direct funding to countries most in need without ex ante country allocation. The Global Fund appears to have promoted learning on how to design and implement large-scale programs in fragile and non-fragile countries. Other pooled financing mechanisms may consider TRP operating principles to generate high-quality demand, to promote learning and to direct resources to countries most in need.
Technical Report
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The International Health Partnership UHC 2030 Working Group on Support to Countries with a Fragile or Challenging Operational Environments aims to develop guidance for improved aid coordination and health systems strengthening in fragile settings. This led to the following review question: “What does existing peer- reviewed and selected grey literature evidence tell us about what works (and does not work) in health systems strengthening and actor coordination in countries with fragile or challenging operational environments, and how and why?” This report attempts to find answers to this question.
Technical Report
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Violence by states and non-state armed groups (NSAG) against health workers and those seeking medical aid is amongst the most serious of contemporary humanitarian issues. Yet empirically NSAG behaviour is extremely diverse when it comes both to healthcare and more generally to providing governance in areas under their control. While numerous non-state armed groups have systematically obstructed service provision or hindered humanitarian assistance though their predatory behaviour, many others have engaged in complex forms of assistance to the civilian populations. Groups as diverse as the FARC in Colombia, Hezbollah in the Lebanon, the LTTE in Sri Lanka, the CPN-M in Nepal, and the SPLM/A in Sudan and the KNLA in Burma have each held territory, regulated many aspects of CAERUS – D 2.2 NSAGs and Health – literature Review ii civilian life, managed relationships both with the international community and with their erstwhile enemies and provided or facilitated health assistance. Social scientists have tended to overlook or simplify the determinants of healthcare provision and obstruction by such groups, characterizing NSAGs either as greed-based warlords bent on exploiting lootable resources or as embryonic states simply aping the institutions and practices of formal states. In fact the literature tends to be almost exclusively focused on NSAG’s (admittedly frequent) negative impact on health outcomes. But the evidence suggests that groups don’t simply fall wholly into either category and that approaches to healthcare can evolve over time. Similarly, states and NSAGs can, but don’t always, simply engage in existential ‘total’ wars against one another. Similarly, rather than manifesting solely as situations of chaos without any forms of political order, civil conflicts can in fact reflect complex patterns of order shaped by formal or informal bargains and deals struck between the belligerents as well as commonly held norms that structure patterns of violence but also shape institutions of political authority and patterns of service delivery. Equally, NSAGs and state behaviour is shaped both by their respective degree of control over territory, their self interest in the delivery of particular services and their relationships with consumers and providers of healthcare. We therefore suggest that civil war, the demands of political and military survival, organisational formation and growth, levels of territorial control and state/NSAG co-operation and the demands of healthcare beneficiaries are interconnected. Our paper therefore attempts to identify some of the determinants of healthcare provision and obstruction by NSAGs and to situate this within the wider literature on political order in conflict situations. We argue that the ways in which NSAGs engage in health care delivery remains under theorized and caught in state centric heuristics that distort our understanding of political order that emerges in the midst of conflict situations. Understanding the dynamics of this NSAG engagement can be a first step to determining how health and healthcare can continue to be delivered during conflict and how NSAG health resources used by them during conflict can contribute to a post-conflict health system.
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In the past 15 or so years, the "evidence-based medicine" (EBM) framework has become increasingly institutionalized, facilitating its transfer across the globe. In the late 1990s, the basic principles of EBM began to have a marked influence in a number of non-clinical public policy arenas. Policy-makers working in these areas are now being urged to move away from developing policies according to political ideologies to a more legitimate approach based on "scientific fact," a process termed "evidence-based policy-making" (EBPM). The conceptual diffusion of EBM to non-clinical arenas has exposed epistemologically destabilizing views regarding the definition of "science," particularly as it relates to the demands of global versus national/sub-national policy-making. Using the maternal and neonatal subfield as an ethnographic case-study, this paper explores the effects of these divergences on EBPM in 5 developing countries (Bangladesh, Burkina Faso, Ghana, Malawi and Nepal). In doing so, our analysis aims to explain why EBPM has thus far had a limited impact in the area of context-specific programmatic policy-development and implementation at the national and sub-national levels. Results highlight that the political contexts in which EBPM is played out promote uniformity of methodological and policy approaches, despite the fact that disciplinary diversity is being called for repeatedly in the public health literature. Even in situations where national EBPM diverges from international priorities, national evidence-based policies are found to hold little weight in countering global policy interests, which some informants claim are themselves legitimated, rather than informed, by evidence. Informants also highlight the way interpretations of research findings are shaped by the broader political context within which donors set priorities and distribute limited resources - contexts that are driven by the need to provide generalisable research recommendations based on scientifically replicable methods. Added to this are clear rifts between senior and junior-level experts within countries that constrain national and sub-national research agendas from serving as tools for empowered knowledge production and problem-solving. We conclude by arguing for diverse forms of research that can more effectively address context-specific problems. While such diversity may render EBPM more conflict-ridden, debate is by no means an undesirable characteristic in any evolving system of knowledge, for it has the potential to foster critical insight and localized change.
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Governance is thought to be a key determinant of economic growth, social advancement and overall development, as well as for the attainment of the MDGs in low- and middle-income countries. Governance of the health system is the least well-understood aspect of health systems. A framework for assessing health system governance (HSG) at national and sub-national levels is presented, which has been applied in countries of the Eastern Mediterranean. In developing the HSG framework key issues considered included the role of the state vs. the market; role of the ministries of health vs. other state ministries; role of actors in governance; static vs. dynamic health systems; and health reform vs. human rights-based approach to health. Four existing frameworks were considered: World Health Organization's (WHO) domains of stewardship; Pan American Health Organization's (PAHO) essential public health functions; World Bank's six basic aspects of governance; and United Nations Development Programme (UNDP) principles of good governance. The proposed HSG assessment framework includes the following 10 principles-strategic vision, participation and consensus orientation, rule of law, transparency, responsiveness, equity and inclusiveness, effectiveness and efficiency, accountability, intelligence and information, and ethics. The framework permits 'diagnoses of the ills' in HSG at the policy and operational levels and points to interventions for its improvement. In the case of Pakistan, where the framework was applied, a positive aspect was the growing participation and consensus orientation among stakeholders, while weaknesses were identified in relation to strategic vision, accountability, transparency, effectiveness and efficiency and rule of law. In using the HSG framework it needs to be recognized that the principles are value driven and not normative and are to be seen in the social and political context; and the framework relies on a qualitative approach and does not follow a scoring or ranking system. It does not directly address aid effectiveness but provides insight on the ability to utilize external resources and has the ability to include the effect of global health governance on national HSG as the subject itself gets better crystallized. The improved performance of the ministries of health and state health departments is at the heart of this framework. The framework helps raise the level of awareness among policymakers of the importance of HSG. The road to good governance in health is long and uneven. Assessing HSG is only the first step; the challenge that remains is to carry out effective governance in vastly different institutional contexts.
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Performance-based funding provides powerful incentives to scale up the fight against HIV, TB, and malaria, argues a team of authors from the Global Fund.
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OBJECTIVE: To examine how health aid is spent and channelled, including the distribution of resources across countries and between subsectors. Our aim was to complement the many qualitative critiques of health aid with a quantitative review and to provide insights on the level of development assistance available to recipient countries to address their health and health development needs. METHODS: We carried out a quantitative analysis of data from the Aggregate Aid Statistics and Creditor Reporting System databases of the Organisation for Economic Co-operation and Development, which are the most reliable sources of data on official development assistance (ODA) for health from all traditional bilateral and multilateral sources and from partnerships such as the Global Fund to Fight AIDS, Tuberculosis and Malaria. FINDINGS: The analysis shows that while health ODA is rising and capturing a larger share of total ODA, there are significant imbalances in the allocation of health aid which run counter to internationally recognized principles of "effective aid". Countries with comparable levels of poverty and health need receive remarkably different levels of aid. Funding for Millennium Development Goal 6 (combat HIV/AIDS, malaria and other diseases) accounts for much of the recent increase in health ODA, while many other health priorities remain insufficiently funded. Aid is highly fragmented at country level, which entails high transaction costs, divergence from national policies and lack of coherence between development partners. CONCLUSION: Although political momentum towards aid effectiveness is increasing at global level, some very real aid management challenges remain at country level. Continued monitoring is therefore necessary, and we recommend that a review of the type presented here be repeated every 3 years.
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Issues around health equity in conflict-affected fragile states have received very little analysis to date. This paper examines the main factors that threaten health equity, the populations that are most vulnerable and potential strategies to improve health equity. The methods employed are a review of the published and grey literature, key informant interviews and an analysis of data on social determinants of health indicators. A new conceptual framework was developed outlining types of inequity, factors that influence equity and possible strategies to strengthen equity. Factors that affect equity include displacement, gender and financial barriers. Strategies to strengthen health equity include strengthening pro-equity policy and planning functions; building provider capacity to provide health services; and reducing access and participation barriers for excluded groups. In conclusion, conflict is a key social determinant of health. More data is needed to determine how conflict affects within-country and between-country equity, and better evaluated strategies are needed to reduce inequity.
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Violent conflicts claim lives, disrupt livelihoods, and halt delivery of essential services, such as health care and education. Health systems are often devastated in conflicts as health professionals flee, infrastructure is destroyed, and the supply of drugs and supplies is halted. We propose that early reconstruction of a functioning, equitable health system in countries recovering from conflict is an investment with a range of benefits for post-conflict countries. Building on the growing literature about health systems as social and political institutions, we elaborate a logic model that outlines how health systems may contribute not only to improved health status but also potentially to broader statebuilding and enhanced prospects for peace. Specifically, we propose that careful design of the core elements of the health system by national governments and their development partners can promote reliable provision of essential health services while demonstrating a commitment to equity, strengthening government accountability to citizens, and building the capacity of government to manage core social programs. We review the conceptual basis and extant empirical evidence for these mechanisms, identify knowledge gaps, and suggest a research agenda.
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Commencing in 1998, the war in the Democratic Republic of Congo has been a humanitarian disaster, but has drawn little response from the international community. To document rates and trends in mortality and provide recommendations for political and humanitarian interventions, we did a nationwide mortality survey during April-July, 2004. We used a stratified three-stage, household-based cluster sampling technique. Of 511 health zones, 49 were excluded because of insecurity, and four were purposely selected to allow historical comparisons. From the remainder, probability of selection was proportional to population size. Geographical distribution and size of cluster determined how households were selected: systematic random or classic proximity sampling. Heads of households were asked about all deaths of household members during January, 2003, to April, 2004. 19,500 households were visited. The national crude mortality rate of 2.1 deaths per 1000 per month (95% CI 1.6-2.6) was 40% higher than the sub-Saharan regional level (1.5), corresponding to 600,000 more deaths than would be expected during the recall period and 38,000 excess deaths per month. Total death toll from the conflict (1998-2004) was estimated to be 3.9 million. Mortality rate was higher in unstable eastern provinces, showing the effect of insecurity. Most deaths were from easily preventable and treatable illnesses rather than violence. Regression analysis suggested that if the effects of violence were removed, all-cause mortality could fall to almost normal rates. The conflict in the Democratic Republic of Congo remains the world's deadliest humanitarian crisis. To save lives, improvements in security and increased humanitarian assistance are urgently needed.
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The Global Fund to Fight AIDS, Tuberculosis and Malaria was launched in 2002 to attract and rapidly disburse money to fight these diseases. However, some commentators believe that poor countries cannot effectively use such resources to increase delivery of their health programmes-referred to as a lack of absorptive capacity. We aimed to investigate the major determinants of grant implementation in developing countries. With information available publicly on the Global Fund's website, we did random-effects analysis to investigate the effect of grant characteristics, types of primary recipient and local fund agent, and country attributes on disbursements that were made between 2003 and 2005 (phase one of Global Fund payments). To check the robustness of findings, regression results from alternative estimation methods and model specifications were also tested. Grant characteristics--such as size of commitment, lag time between signature and first disbursement, and funding round-had significant effects on grant implementation. Enhanced political stability was associated with high use of grants. Low-income countries, and those with less-developed health systems for a given level of income, were more likely to have a higher rate of grant implementation than nations with higher incomes or more-developed health systems. The higher rate of grant implementation seen in countries with low income and low health-spending lends support to proponents of major increases in health assistance for the poorest countries and argues that focusing resources on low-income nations, particularly those with political stability, will not create difficulties of absorptive capacity. Our analysis was restricted to grant implementation, which is one part of the issue of absorptive capacity. In the future, assessment of the effect of Global Fund grants on intervention coverage will be vital.
http://www.ghgj.org 1 DFID, Why We Need to Work More Effectively in Fragile States
  • Health Governance
  • Volume Iv
HEALTH GOVERNANCE, VOLUME IV, NO. 1 (FALL 2010) http://www.ghgj.org 1 DFID, Why We Need to Work More Effectively in Fragile States (London: UK Department for International Development, 2005).