Policy change and micro-politics in global health aid: HIV in South Africa.

Efforts to improve the effectiveness of global health aid rarely take full account of the micro-politics of policy change and implementation. South Africa's HIV/AIDS epidemic is a case in point, where the US President's Emergency Plan for AIDS Relief (PEPFAR) has provided essential support to the national AIDS response. With changing political context, PEPFAR has shifted focus several times-most recently reversing the policy of 'transition' out of direct aid to a policy of re-investing in front-line services in priority districts to improve aid effectiveness. However, this policy shift has not led to the expected impact on health services. This paper reports the findings of a study on the implementation of the recent policy through interviews at randomly selected sites in high HIV-burden districts of South Africa that capture the experiences of public-sector health leaders. We find little evidence to support the explanation that the new aid policy displaced government staff and resources. Instead, our findings suggest that legacies of the previous policy remained as local aid managers did not shift funding and practice at sufficient scale to drive the planned service delivery expansion. Human resource support, the main PEPFAR contribution to service delivery at front-line facilities, was not adequate or distributed based on the size of the HIV programme, leaving notable gaps in outreach, defaulter tracing, and community service delivery. Instead, services that better fit the previous policy paradigm, like training and data-sharing, are common at site-level but provide diminishing returns. Together, our findings suggest opportunities for PEPFAR South Africa to revisit its model and increase service delivery intensity, in particular through community-based services. More broadly, this case illustrates the need for greater attention to the multiple actors with discretion in the policy system of health aid and the mechanisms through which political priority is translated into programming as policy shifts are made.