The impact of Global Health Initiatives at national and sub-national level - a policy analysis of their role in implementation processes of antiretroviral treatment (ART) roll-out in Zambia and South Africa.

Global Health Initiatives (GHIs), such as the President's Emergency Plan For AIDS Relief (PEPFAR) and the Global Fund to Fight AIDS, TB and Malaria (the GFATM), have emerged as new mechanisms for development assistance in health. By 2008, GHIs were providing two-thirds of all external funding for HIV/AIDS globally. In Zambia and South Africa over the past five years, PEPFAR and the GFATM have provided significant funding for the public sector provision of anti-retroviral treatment (ART). GHIs are a feature of a new global health governance. A study of their role in implementation helps to explore some of the challenges of this new system of governance at national and sub-national level. This paper draws on policy analysis research that involved 150 interviews with policy-makers at national, provincial and district level in both countries, conducted as part of Ph.D. fieldwork between August 2007 and June 2008. Research findings show that GHIs impacted on policy-implementation processes at national and sub-national level, on aspects of the ART programme and the wider health system. Study results highlight GHIs impact both through funding and the mechanisms, and processes by which their support is provided. Evidence suggests that while GHIs have contributed significantly to enabling the rapid scale-up of ART in both the countries, they may also have had a negative impact on coordination, the long-term sustainability of treatment programmes and equity of treatment access. In addition, their programmes may have contributed to disconnect between HIV prevention and treatment initiatives. The comparative findings from Zambia and South Africa highlight some of the challenges in implementation of GHI programmes at country and sub-country level that need to be addressed urgently, to mediate against negative consequences for the health systems and policy processes in both countries.