Articles tagged as "Close the resource gap"

Subsidized insurance scheme has unintended consequences for access to essential health care in Colombia

Health insurance for the poor decreases access to HIV testing in antenatal care: evidence of an unintended effect of health insurance reform in Colombia.

Ettenger A, Barnighausen T, Castro A. Health Policy Plan. 2014 May;29(3):352-8. doi: 10.1093/heapol/czt021. Epub 2013 Apr 18.

Prevention of mother-to-child transmission of HIV was added to standard antenatal care (ANC) in 2000 for Colombians enrolled in the two national health insurance schemes, the 'subsidized regime' (covering poor citizens) and the 'contributory regime' (covering salaried citizens with incomes above the poverty threshold), which jointly covered 80% of the total Colombian population as of 2007. This article examines integration of HIV testing in ANC through the relationship between ordering an HIV test with the type of health insurance, including lack of health insurance, using data from the nationally representative 2005 Colombia Demographic and Health Survey. Overall, health-care providers ordered an HIV test for only 35% of the women attending ANC. We regressed the order of an HIV test during ANC on health systems characteristics (type of insurance and type of ANC provider), women's characteristics (age, wealth, educational attainment, month of pregnancy at first antenatal visit, HIV knowledge, urban vs. rural residence and sub-region of residence) and children's characteristics (birth order and birth year). Women enrolled in the subsidized regime were significantly less likely to be offered and receive an HIV test in ANC than women without any health insurance (adjusted odds ratio = 0.820, P < 0.001), when controlling for the other independent variables. Wealth, urban residence, birth year of the child and the type of health-care provider seen during the ANC visit were significantly associated with providers ordering an HIV test for a woman (all P < 0.05). Our findings suggest that enrolment in the subsidized regime reduced access to HIV testing in ANC. Additional research is needed to elucidate the mechanisms through which the potential effect of health insurance coverage on HIV testing in ANC occurs and to examine whether enrolment in the subsidized regime has affected access to other essential health services.

Abstract   Full-text [free] access

Editor’s notes: This paper describes an unintended effect of insurance reform in Colombia. It highlights the importance of considering structural barriers and patient costs in policy-making and implementation. The authors compare the likelihood of having an HIV test ordered in antenatal care for women with subsidized insurance, contributory insurance, and no insurance. After controlling for other confounding factors such as age, wealth, and education, authors find that women with subsidized insurance are less likely to have an HIV test ordered than women with contributory insurance or no insurance. 

This surprising result is contrary to the intended effect of the subsidized insurance scheme. It was introduced in order to increase access to essential health services. However, the authors propose that the reduced likelihood of ordering a test is related to the structure of the subsidized scheme. The scheme requires written authorization for an HIV test. In comparison, women with no insurance do not require authorization. The additional administrative tasks and patient travel costs associated with obtaining this authorization impose structural barriers. These should be further investigated in order to improve access to essential health care. 

HIV testing
Latin America
Colombia
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Refusal bias in HIV prevalence estimates from nationally-representative surveys: small overall effects may conceal substantial bias for certain subgroups

Refusal bias in the estimation of HIV prevalence.

Janssens W, van der Gaag J, Rinke de Wit TF, Tanovic Z. Janssens W, van der Gaag J, Rinke de Wit TF, Tanović Z. Demography. 2014 May 2. [Epub ahead of print]

In 2007, UNAIDS corrected estimates of global HIV prevalence downward from 40 million to 33 million based on a methodological shift from sentinel surveillance to population-based surveys. Since then, population-based surveys are considered the gold standard for estimating HIV prevalence. However, prevalence rates based on representative surveys may be biased because of nonresponse. This article investigates one potential source of nonresponse bias: refusal to participate in the HIV test. We use the identity of randomly assigned interviewers to identify the participation effect and estimate HIV prevalence rates corrected for unobservable characteristics with a Heckman selection model. The analysis is based on a survey of 1 992 individuals in urban Namibia, which included an HIV test. We find that the bias resulting from refusal is not significant for the overall sample. However, a detailed analysis using kernel density estimates shows that the bias is substantial for the younger and the poorer population. Nonparticipants in these subsamples are estimated to be three times more likely to be HIV-positive than participants. The difference is particularly pronounced for women. Prevalence rates that ignore this selection effect may be seriously biased for specific target groups, leading to misallocation of resources for prevention and treatment.

Abstract access 

Editor’s notes: Refusal bias in HIV prevalence estimates from nationally representative surveys has been a contested issue ever since UNAIDS made a downward revision of its estimates to accommodate the evidence from such surveys. Most authors nowadays agree that an adjustment of estimates based on unobserved characteristics – for example, prior knowledge of one’s HIV status – is necessary. The Heckman sample selection model with the interviewer identities as the instrumental variable is often used for that. Results from Heckman models have not always been conclusive however, and this study is no exception. The authors take the lack of significant bias as a starting point for exploring the characteristics of nonparticipants and their relative contribution to HIV prevalence estimates in greater detail. They conclude that even though the impact of refusal on national-level HIV prevalence estimates may be small, it could lead to substantial downward bias of HIV prevalence estimates for certain subgroups, in this case women, younger individuals and the poor.

Africa
Namibia
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Real-world costing of HIV treatment in Zambia highlights difference between national guidelines and actual resource use

Retention in care, resource utilization, and costs for adults receiving antiretroviral therapy in Zambia: a retrospective cohort study.

Scott CA, Iyer HS, McCoy K, Moyo C, Long L, Larson BA, Rosen S. BMC Public Health. 2014 Mar 31;14(1):296. doi: 10.1186/1471-2458-14-296.

Background: Of the estimated 800 000 adults living with HIV in Zambia in 2011, roughly half were receiving antiretroviral therapy (ART). As treatment scale up continues, information on the care provided to patients after initiating ART can help guide decision-making. We estimated retention in care, the quantity of resources utilized, and costs for a retrospective cohort of adults initiating ART under routine clinical conditions in Zambia.

Methods: Data on resource utilization (antiretroviral [ARV] and non-ARV drugs, laboratory tests, outpatient clinic visits, and fixed resources) and retention in care were extracted from medical records for 846 patients who initiated ART at ≥15 years of age at six treatment sites between July 2007 and October 2008. Unit costs were estimated from the provider's perspective using site- and country-level data and are reported in 2011 USD.

Results: Patients initiated ART at a median CD4 cell count of 145 cells/μL. Fifty-nine percent of patients initiated on a tenofovir-containing regimen, ranging from 15% to 86% depending on site. One year after ART initiation, 75% of patients were retained in care. The average cost per patient retained in care one year after ART initiation was $243 (95% CI, $194-$293), ranging from $184 (95% CI, $172-$195) to $304 (95% CI, $290-$319) depending on site. Patients retained in care one year after ART initiation received, on average, 11.4 months' worth of ARV drugs, 1.5 CD4 tests, 1.3 blood chemistry tests, 1.4 full blood count tests, and 6.5 clinic visits with a doctor or clinical officer. At all sites, ARV drugs were the largest cost component, ranging from 38% to 84% of total costs, depending on site.

Conclusions: Patients initiate ART late in the course of disease progression and a large proportion drop out of care after initiation. The quantity of resources utilized and costs vary widely by site, and patients utilize a different mix of resources under routine clinical conditions than if they were receiving fully guideline-concordant care. Improving retention in care and guideline concordance, including increasing the use of tenofovir in first-line ART regimens, may lead to increases in overall treatment costs.

 Abstract  Full-text [free] access

Editor’s notes: This article highlights the importance of conducting ‘real-world’ economic evaluations for HIV-related services.  The authors found that practical implementation of national policy was not universal. This finding had important implications on the observed retention in care and cost of providing services. The observed use of some resources, e.g. drugs, for people retained in care, were lower than expected, while the number of clinical consultations was higher than recommended in the guidelines. These findings suggest that it may not be appropriate to assume that guidelines and practice will be identical for the purposes of programme planning and budgeting.  

Africa
Zambia
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The do’s and don’ts for human resource strategies as external financing makes its exit: lessons from Namibia

Confronting 'scale-down': Assessing Namibia's human resource strategies in the context of decreased HIV/AIDS funding.

Cairney LI, Kapilashrami A. Glob Public Health. 2014 Jan-Feb;9(1-2):198-209. doi: 10.1080/17441692.2014.881525. Epub 2014 Feb 6.

In Namibia, support through the Global Fund and President’s Emergency Plan for AIDS Relief has facilitated an increase in access to HIV and AIDS services over the past 10 years. In collaboration with the Namibian government, these institutions have enabled the rapid scale-up of prevention, treatment and care services. Inadequate human resources capacity in the public sector was cited as a key challenge to initial scale-up; and a substantial portion of donor funding has gone towards the recruitment of new health workers. However, a recent scale-down of donor funding to the Namibian health sector has taken place, despite the country’s high HIV and AIDS burden. With a specific focus on human resources, this paper examines the extent to which management processes that were adopted at scale-up have proven sustainable in the context of scale-down. Drawing on data from 43 semi-structured interviews, we argue that human resources planning and management decisions made at the onset of the country’s relationship with the two institutions appear to be primarily driven by the demands of rapid scale-up and counter-productive to the sustainability of interventions.

Abstract access 

Editor’s notes: Some countries graduate to higher income categories and become ineligible for funding from major donors, such as the Global Fund and PEPFAR. As this happens, it is increasingly important to draw lessons on how to manage this transition from international to domestic financing and ownership. Using the case of human resource management, this study underscores the need to establish exit strategies early on. It also emphasises the need to ensure the integration of management processes within government systems. These are deemed necessary if high service coverage rates are to be maintained. The case study documents how additional health professionals were recruited at higher salaries than government salaries through a parallel recruitment system.  This was done in order to meet the needs of service scale-up. However, that approach led to an unsustainable situation. Sudden salary cuts jeopardised service continuity and the expectation that these staff would be absorbed on to the government payroll. There appears to be a trade-off between certain structures to enable rapid scale-up and programme sustainability. These ought to be planned for at an early stage of funding partnerships.   

Africa
Namibia
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Sustaining HIV responses in a post-Global Fund era: lessons from Peru

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

Amaya AB, Caceres CF, Spicer N, Balabanova D. Glob Public Health. 2014 Jan-Feb;9(1-2):176-97. doi: 10.1080/17441692.2013.878957. Epub 2014 Feb 5.

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

Abstract access 

Editor’s notes: Some countries graduate to higher income categories and become ineligible for funding from major donors, such as the Global Fund and PEPFAR. As this happens,it is important to learn how the transition from international to domestic financing and ownership is managed. This study complements the previous paper, and documents the case of Peru and the impending exit of Global Fund support. The national and regional coordination bodies initially created for inter-sectoral dialogue and planning around Global Fund grant applications appear to be enabling factors for programme sustainability. As Peru started aligning Global Fund HIV activities with local priorities early on, this has helped set the stage for a smoother integration of such efforts in the national response. The authors highlight, however, that the predominant role of NGOs as implementers of prevention activities could become a limiting factor for sustainability.  This is so, given that they will become dependent on government funding, and may have a weakened ability to be able to hold the government to account. 

Latin America
Peru
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Provider-initiated partner notification of HIV is potentially cost-effective in sub-Saharan Africa

Cost-effectiveness of provider-based HIV partner notification in urban Malawi.

Rutstein SE, Brown LB, Biddle AK, Wheeler SB, Kamanga G, Mmodzi P, Nyirenda N, Mofolo I, Rosenberg NE, Hoffman IF, Miller WC. Health Policy Plan 2014 Jan;29(1):115-26. doi: 10.1093/heapol/czs140. Epub 2013 Jan 15.

Provider-initiated partner notification for HIV effectively identifies new cases of HIV in sub-Saharan Africa, but is not widely implemented. Our objective was to determine whether provider-based HIV partner notification strategies are cost-effective for preventing HIV transmission compared with passive referral. We conducted a cost-effectiveness analysis using a decision-analytic model from the health system perspective during a 1-year period. Costs and outcomes of all strategies were estimated with a decision-tree model. The study setting was an urban sexually transmitted infection clinic in Lilongwe, Malawi, using a hypothetical cohort of 5 000 sex partners of 3 500 HIV-positive index cases. We evaluated three partner notification strategies: provider notification (provider attempts to notify indexes' locatable partners), contract notification (index given 1 week to notify partners then provider attempts notification) and passive referral (index is encouraged to notify partners, standard of care). Our main outcomes included cost (US dollars) per transmission averted, cost per new case identified and cost per partner tested. Based on estimated transmissions in a 5 000-person cohort, provider and contract notification averted 27.9 and 27.5 new infections, respectively, compared with passive referral. The incremental cost-effectiveness ratio (ICER) was $3 560 per HIV transmission averted for contract notification compared with passive referral. Provider notification was more expensive and slightly more effective than contract notification, yielding an ICER of $51 421 per transmission averted. ICERs were sensitive to the proportion of partners not contacted, but likely HIV positive and the probability of transmission if not on antiretroviral therapy. The costs per new case identified were $36 (provider), $18 (contract) and $8 (passive). The costs per partner tested were $19 (provider), $9 (contract) and $4 (passive). We conclude that, in this population, provider-based notification strategies are potentially cost-effective for identifying new cases of HIV. These strategies offer a simple, effective and easily implementable opportunity to control HIV transmission.

Abstract access 

Editor’s notes: Partner notification of HIV status is a way to identify new HIV cases and prevent transmission. Provider-initiated partner notification has had success in high-income countries, but is not widely implemented in sub-Saharan Africa. This study is the first cost-effectiveness analysis of provider-initiated partner notification in sub-Saharan Africa. The authors use a decision-tree model based on trial data from Malawi, to identify the incremental cost-effectiveness of provider notification, and contract notification, against the current standard of care (passive referral). 

The findings of this study indicate that provider referral may be a cost-effective and affordable way to identify new HIV cases and link patients to care earlier. The cost per infection averted as compared to passive referral ($3 560 for contract notification and $4 106 for provider notification) compares favourably with that of using nevirapine for prevention of mother-to-child transmission of HIV. Further research into the possible costs of adverse outcomes from provider notification (including dissolution of partnership or violence) is needed.

Africa
Malawi
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Gender, structural determinants and vulnerability

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

Cáceres CF, Amaya AB, Sandoval C, Valverde R. Glob Public Health. 2013 Dec;8(10):1123-37. doi: 10.1080/17441692.2013.861859

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

Abstract access 

Editor’s notes: This is a useful paper that dissects one country’s Global Fund proposals over 10 years (2002-2012) to assess the use of evidence, the consistency and appropriateness of proposed activities and the adequacy of its monitoring and evaluation framework. Although only one country, Peru, is scrutinised in this paper, many of the findings will be relevant to the development and implementation of Global Fund proposals in other countries.

It was encouraging to learn that the use of evidence improved over time. However the lack of appropriate surveillance data meant that proposals were not always found to be evidence-based. The paper highlights in particular the need to use epidemiological evidence that is related to specific population sub-categories to address “vulnerability” and ensure that interventions are effectively targeted.

Consistency and continuity across proposals was sometimes lacking, possibly reflecting the Global Fund’s mechanistic funding process via “rounds”. The paper notes that at times, programmes could appear to be a juxtaposition of activities rather than a well thought out comprehensive strategy. It would be interesting to see whether the Global Fund's new funding model based on the national HIV/AIDS strategy in the future leads to a more continuous and consistent flow of activities.

Another key point in the paper is the inadequacy of the proposals’ monitoring and evaluation (M&E) framework to monitor grants and evaluate results. As the paper notes, the information system will need to be strengthened for the M&E to deliver a more evidence based strategy.

Latin America
Peru
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Does global procurement and price negotiation through the Global Fund reduce HIV commodity costs?

Trends in procurement costs for HIV commodities: a seven-year retrospective analysis of Global Fund data across 125 countries. 

Wafula F, Agweyu A, Macintyre K. J Acquir Immune Defic Syndr. 2013 Nov 20. [Epub ahead of print]

Background: Nearly 40% of Global Fund money goes towards procurement. However, no analyses have been published to show how costs vary across regions and time, despite the availability of procurement data collected through the Global Fund's price and quality reporting (PQR) system.

Methodology: We analyzed data for the three most widely procured commodities for the prevention, diagnosis and treatment of HIV. These were male condoms, HIV rapid tests, and the ARV combination of lamivudine/nevirapine/zidovudine. The compared costs, first across time (2005-2012), then across regions, and finally, between individual procurement reported through the PQR and pooled procurement reported through the Global Fund's voluntary pooled procurement (VPP) system. All costs were adjusted for inflation and reported in US dollars.

Key findings: There were 2 337 entries from 578 grants in 125 countries. The procurement cost for the ARV dropped substantially over the period, whereas those for condoms and HIV tests remained relatively stable. None of the commodity prices increased. Regional variations were pronounced for HIV tests, but minimal for condoms and the ARV. The unit cost for the three-table ARV combination, for instance, varied between US$0.15 and US$0.23 in South Asia and the Eastern Europe/Central Asia regions respectively, compared to a range of $0.23 (South Asia) - $1.50 (Eastern Europe/Central Asia) for a single diagnostic test. Pooled procurement lowered costs for condoms, but not the other commodities.

Conclusion: We showed how global procurement costs vary by region and time. Such analyses should be done more often to identify and correct market insufficiencies.

Abstract access 

Editor’s notes: With the flatlining of HIV resources, it is important that HIV investments are optimally used, and achieve good value for money. The Global Fund has played a major role in financing HIV programmes, with over a half of the US$23 billion given since 2002 going to HIV. A large proportion of Global Fund grants go towards the procurement of pharmaceuticals and other health products. The global fund uses its (and partners, such as PEPFAR and Clinton Health Access Initiative) bulk purchasing power to negotiate lower commodity prices for countries.  It has also set up systems to support countries to negotiate costs and identify cheap suppliers. This paper uses information from the Global Fund across time and recipient countries, to explore how costs of 3 HIV related commodities have changed over time, and/or vary regionally. The trends observed reflect a variety of market factors, and the increasingly global nature of commodity markets. The reduction in antiretroviral therapy (ART) costs are likely to result from increased competition across suppliers, the move to generic drug use, and the joint negotiation in cost reductions, and there may be scope for further price reductions. In contrast, the limited variation in costs for HIV tests and male condoms suggest that markets for these commodities have stabilized, leaving limited room for negotiation. 

Africa, Asia, Europe, Latin America, Oceania
South Africa
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Modelling finds early treatment of HIV discordant couples is cost-effective in India and South Africa

Cost-effectiveness of HIV Treatment as Prevention in Serodiscordant Couples.

Walensky RP, Ross EL, Kumarasamy N, Wood R, Noubary F, Paltiel AD, Nakamura YM, Godbole SV, Panchia R, Sanne I, Weinstein MC, Losina E, Mayer KH, Chen YQ,Wang L, McCauley M, Gamble T, Seage GR 3rd, Cohen MS, Freedberg KA. N Engl J Med. 2013 Oct 31;369(18):1715-25. doi: 10.1056/NEJMsa1214720.

Background: The cost-effectiveness of early antiretroviral therapy (ART) in persons infected with human immunodeficiency virus (HIV) in serodiscordant couples is not known. Using a computer simulation of the progression of HIV infection and data from the HIV Prevention Trials Network 052 study, we projected the cost-effectiveness of early ART for such persons.

Methods: For HIV-infected partners in serodiscordant couples in South Africa and India, we compared the early initiation of ART with delayed ART. Five-year and lifetime outcomes included cumulative HIV transmissions, life-years, costs, and cost-effectiveness. We classified early ART as very cost-effective if its incremental cost-effectiveness ratio was less than the annual per capita gross domestic product (GDP; $8,100 in South Africa and $1,500 in India), as cost-effective if the ratio was less than three times the GDP, and as cost-saving if it resulted in a decrease in total costs and an increase in life-years, as compared with delayed ART.

Results: In South Africa, early ART prevented opportunistic diseases and was cost-saving over a 5-year period; over a lifetime, it was very cost-effective ($590 per life-year saved). In India, early ART was cost-effective ($1,800 per life-year saved) over a 5-year period and very cost-effective ($530 per life-year saved) over a lifetime. In both countries, early ART prevented HIV transmission over short periods, but longer survival attenuated this effect; the main driver of life-years saved was a clinical benefit for treated patients. Early ART remained very cost-effective over a lifetime under most modelled assumptions in the two countries.

Conclusions:  In South Africa, early ART was cost-saving over a 5-year period. In both South Africa and India, early ART was projected to be very cost-effective over a lifetime. With individual, public health, and economic benefits, there is a compelling case for early ART for serodiscordant couples in resource-limited settings.

Abstract access

Editor’s notes: The HPTN 052 found that antiretroviral therapy (ART) can prevent onward HIV transmission. With this finding, countries in the North and South are faced with optimizing treatment protocols, for the direct clinical benefit of ART, and its impact on national HIV epidemics.  Walensky et al. draw on data from this clinical trial in India and South Africa to model the short (5 year) and long (cohort lifetime) term cost-effectiveness. The main study models cost-effectiveness with trial based parameters i.e., cd4+ count at presentation, virological suppression and failure, loss to follow up and transmission rates. They also estimate cost-effectiveness in routine care setting and worst case scenario to consider the robustness of findings.  In contrast to many model projections which find ART for prevention more cost effective over longer time frames, Walensky’s projections show very immediate (5 year) reductions in transmission and treatment costs attributable to preventing opportunistic infections.  In South Africa this results in short term cost-saving; as the cost of treating these are relatively lower in India, this is highly cost effective, albeit not cost saving. In the longer term their model shows that many of these transmissions are delayed rather than avoided altogether: in South Africa the 5 year reduction in transmission is 69% versus 13% over the cohort lifetime.  Evaluated against per capita GDP in each country, treatment as prevention is shown to be cost-effective in both settings.  These results are sensitive to retention in care and effective virological suppression, though would not change policy recommendations. However it does highlight critical role of both the health system and patients in reaping the optimal prevention benefits of treatment. 

Africa, Asia
India, South Africa
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‘Public’ and ‘hidden’ transcripts of the Global Fund in India

Transforming governance or reinforcing hierarchies and competition: examining the public and hidden transcripts of the Global Fund and HIV in India.

Kapilashrami A, McPake B. Health Policy Plan. 2013 Sep;28(6):626-35. doi: 10.1093/heapol/czs102. Epub 2012 Nov 11.

Global health initiatives (GHIs) have gained prominence as innovative and effective policy mechanisms to tackle global health priorities. More recent literature reveals governance-related challenges and their unintended health system effects. Much less attention is received by the relationship between these mechanisms, the ideas that underpin them and the country-level practices they generate. The Global Fund has leveraged significant funding and taken a lead in harmonizing disparate efforts to control HIV/AIDS. Its growing influence in recipient countries makes it a useful case to examine this relationship and evaluate the extent to which the dominant public discourse on Global Fund departs from the hidden resistances and conflicts in its operation. Drawing on insights from ethnographic fieldwork and 70 interviews with multiple stakeholders, this article aims to better understand and reveal the public and the hidden transcript of the Global Fund and its activities in India. We argue that while its public transcript abdicates its role in country-level operations, a critical ethnographic examination of the organization and governance of the Fund in India reveals a contrasting scenario. Its organizing principles prompt diverse actors with conflicting agendas to come together in response to the availability of funds. Multiple and discrete projects emerge, each leveraging control and resources and acting as conduits of power. We examine how management of HIV is punctuated with conflicts of power and interests in a competitive environment set off by the Fund protocol and discuss its system-wide effects. The findings also underscore the need for similar ethnographic research on the financing and policy-making architecture of GHIs.

Abstract access 

Editor’s notes: The paper presents results of a study on the implementation of the Global Fund fourth round HIV/AIDS grant in five states of India. It draws on Scott’s (1992) distinction between ‘dominant public transcripts’ –  official and documented statements describing principles, structures and activities - and ‘hidden transcripts’ meaning the unofficial practices and realities that are rarely acknowledged in official documents. While such a distinction is not new in the social sciences, for instance public and private accounts of experiences of health and illness are often contrasted, this framing provides a useful way to distinguish official rhetoric from interviewees’ discourses and observation of day-to-day practices of decision making and implementation. The study took an ethnographic approach between 2007 and 2009 to articulate these ‘hidden transcripts’ consisting of observations of meetings, document review and 70 ‘in-depth’ stakeholder interviews.

The paper reports on several aspects of the Indian experience that reinforce findings from previous studies of the effects of Global Fund HIV/AIDS programmes in other countries. These include limited involvement of local civil society organisations in grant application processes. Instead the application process was dominated by government, bilateral and multilateral agencies and large national/international civil society organisations. Country Coordination Mechanism (CCM) activities were confined to applying for grants rather than overseeing programme implementation. Demanding reporting requirements strained an already weak health system, created competition between implementers and impacted negatively on the continuity of interventions. The paper concludes that while the Global Fund claims to be a financial mechanism for country-driven programmes, its structures, rules and conditions create a highly regulating environment for programme implementation. 

Asia
India
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