Health system lessons from the global fund-supported procurement and supply chain investments in Zimbabwe: a mixed methods study.

BACKGROUND: The Global Fund partnered with the Zimbabwean government to provide end-to-end support to strengthen the procurement and supply chain within the health system. This was accomplished through a series of strategic investments that included infrastructure and fleet improvement, training of personnel, modern equipment acquisition and warehouse optimisation. This assessment sought to determine the effects of the project on the health system. METHODS: This study employed a mixed methods design combining quantitative and qualitative research methods. The quantitative part entailed a descriptive analysis of procurement and supply chain data from the Zimbabwe healthcare system covering 2018 - 2021. The qualitative part comprised key informant interviews using a structured interview guide. Informants included health system stakeholders privy to the Global Fund-supported initiatives in Zimbabwe. The data collected through the interviews were transcribed in full and subjected to thematic content analysis. RESULTS: Approximately 90% of public health facilities were covered by the procurement and distribution system. Timeliness of order fulfillment (within 90 days) at the facility level improved from an average of 42% to over 90% within the 4-year implementation period. Stockout rates for HIV drugs and test kits declined by 14% and 49% respectively. Population coverage for HIV treatment for both adults and children remained consistently high despite the increasing prevalence of people living with HIV. The value of expired commodities was reduced by 93% over the 4-year period. Majority of the system stakeholders interviewed agreed that support from Global Fund was instrumental in improving the country's procurement and supply chain capacity. Key areas include improved infrastructure and equipment, data and information systems, health workforce and financing. Many of the participants also cited the Global Fund-supported warehouse optimization as critical to improving inventory management practices. CONCLUSION: It is imperative for governments and donors keen to strengthen health systems to pay close attention to the procurement and distribution of medicines and health commodities. There is need to collaborate through joint planning and implementation to optimize the available resources. Organizational autonomy and sharing of best practices in management while strengthening accountability systems are fundamentally important in the efforts to build institutional capacity.

Corruption is making people sick.

According to Transparency International, of the US$7.5 trillion spent globally on health each year, US$500 billion is lost to corruption.1 This article deals with the topic of corruption in the health sector in sub-Saharan Africa with a focus on how it affects persons living with HIV and their families. It begins with a definition of corruption and outlines the types of activities, people and institutions that fall within that definition in the context of HIV/AIDS. Examples are provided of what happens in practice and the types of persons (in terms of their societal roles) who yield to corruption, and how and why they commit it. The effects of corruption in health and in the fight against HIV/AIDS are then considered, drawing on published research on the costs to institutions and society. For example, HIV prevalence among women is higher than men, yet their reliance on health services plagued by corruption makes them vulnerable to abuse, blocking access to vital contraceptive, HIV testing, and reproductive and child health services. Attention is then focused on the factors that encourage the adoption of corrupt practices and what approaches have been taken to try to counter them. This includes a review and analysis of the steps that have been taken to strengthen compliance, governance and accountability and why attempts to deal with corruption have met with little success. This article suggests a new approach - harnessing digitalisation - to combat corruption more quickly and effectively, pointing out that corruption is both a major factor contributing to inefficiency and is harming peoples' health. This article aims to raise interest and renew efforts in fighting corruption in health.

Price, quality, and market dynamics of malaria rapid diagnostic tests: analysis of Global Fund 2009-2018 data.

BACKGROUND: Rapid diagnostic tests (RDTs) for malaria are a vital part of global malaria control. Over the past decade, RDT prices have declined, and quality has improved. However, the relationship between price and product quality and their larger implications on the market have yet to be characterized. This analysis used purchase data from the Global Fund together with product quality data from the World Health Organization (WHO) and Foundation for Innovative New Diagnostics (FIND) Malaria RDT Product Testing Programme to understand three unanswered questions: (1) Has the market share by quality of RDTs in the Global Fund's procurement orders changed over time? (2) What is the relationship between unit price and RDT quality? (3) Has the market for RDTs financed by the Global Fund become more concentrated over time? METHODS: Data from 10,075 procurement transactions in the Global Fund's database, which includes year, product, volume, and price, was merged with product quality data from all eight rounds of the WHO-FIND programme, which evaluated 227 unique RDT products. To describe trends in market share by quality level of RDT, descriptive statistics were used to analyse trends in market share from 2009 to 2018. A generalized linear regression model was then applied to characterize the relationship between price and panel detection score (PDS), adjusting for order volume, year purchased, product type, and manufacturer. Third, a Herfindahl-Hirschman Index (HHI) score was calculated to characterize the degree of market concentration. RESULTS: Lower-quality RDTs have lost market share between 2009 and 2018, as have the highest-quality RDTs. No statistically significant relationship between price per test and PDS was found when adjusting for order volume, product type, and year of purchase. The HHI was 3,570, indicating a highly concentrated market. CONCLUSIONS: Advancements in RDT affordability, quality, and access over the past decade risk stagnation if health of the RDT market as a whole is neglected. These results suggest that from 2009 to 2018, this market was highly concentrated and that quality was not a distinguishing feature between RDTs. This information adds to previous reports noting concerns about the long-term sustainability of this market. Further research is needed to understand the causes and implications of these trends.

Trends in access to anti-malarial treatment in the formal private sector in Uganda: an assessment of availability and affordability of first-line anti-malarials and diagnostics between 2007 and 2018.

BACKGROUND: Malaria is the single largest cause of illness in Uganda. Since the year 2008, the Global Fund has rolled out several funding streams for malaria control in Uganda. Among these are mechanisms aimed at increasing the availability and affordability of artemisinin-based combination therapy (ACT). This paper examines the availability and affordability of first-line malaria treatment and diagnostics in the private sector, which is the preferred first point of contact for 61% of households in Uganda between 2007 and 2018. METHODS: Cross-sectional surveys were conducted between 2007 and 2018, based on a standardized World Health Organization/Health Action International (WHO/HAI) methodology adapted to assess availability, patient prices, and affordability of ACT medicines in private retail outlets. A minimum of 30 outlets were surveyed per year as prescribed by the standardized methodology co-developed by the WHO and Health Action International. Availability, patient prices, and affordability of malaria rapid diagnostic tests (RDTs) was also tracked from 2012 following the rollout of the test and treat policy in 2010. The median patient prices for the artemisinin-based combinations and RDTs was calculated in US dollars (USD). Affordability was assessed by computing the number of days' wages the lowest-paid government worker (LPGW) had to pay to purchase a treatment course for acute malaria. RESULTS: Availability of artemether/lumefantrine (A/L), the first-line ACT medicine, increased from 85 to100% in the private sector facilities during the study period. However, there was low availability of diagnostic tests in private sector facilities ranging between 13% (2012) and 37% (2018). There was a large reduction in patient prices for an adult treatment course of A/L from USD 8.8 in 2007 to USD 1.1 in 2018, while the price of diagnostics remained mostly stagnant at USD 0.5. The affordability of ACT medicines and RDTs was below one day's wages for LPGW. CONCLUSIONS: Availability of ACT medicines in the private sector medicines retail outlets increased to 100% while the availability of diagnostics remained low. Although malaria treatment was affordable, the price of diagnostics remained stagnant and increased the cumulative cost of malaria management. Malaria stakeholders should consolidate the gains made and consider the inclusion of diagnostic kits in the subsidy programme.

The Global Fund: why anti-corruption, transparency and accountability matter.

BACKGROUND: The creation of the Global Fund to Fight AIDS, Tuberculosis and Malaria, also known as the Global Fund, was prompted by the lack of a timely and effective global response, and the need for financing to fight against three devastating diseases: HIV/AIDS, tuberculosis, and malaria. During the formation of the Global Fund, necessary anti-corruption, transparency, and accountability (ACTA) structures were not put in place to prevent fraud and corruption in its grants, which resulted in the misuse of funds by grant recipients and an eventual loss of donor confidence in 2011. The Global Fund has instituted various ACTA mechanisms to address this misuse of funding and the subsequent loss of donor confidence, and this paper seeks to understand these implementations and their impacts over the past decade, in an effort to probe ACTA more deeply. RESULTS: By restructuring the governing committees in 2011, and the Audit and Finance; Ethics and Governance; and Strategy Committees in 2016, the Global Fund has delineated committee mandates and strengthened the Board's oversight of operations. Additionally, the Global Fund has adopted a rigorous risk management framework which it has worked into all aspects of its functioning. An Ethics and Integrity Framework was adopted in 2014 and an Ethics Office was established in 2016, resulting in increased conflict of interest disclosures and greater considerations of ethics within the organization. The Global Fund's Office of the Inspector General (OIG) has effectively performed internal and external audits and investigations on fraud and corruption, highlighted potential risks for mitigation, and has implemented ACTA initiatives, such as the I Speak Out Now! campaign to encourage whistleblowing and educate on fraud and corruption. CONCLUSIONS: From 2011 onwards, the Global Fund has developed a number of ACTA mechanisms which, in particular, resulted in reduced grant-related risks and procurement fraud as demonstrated by the decreased classification from high to moderate in 2017, and the reduction of investigations in 2018 respectively. However, it is crucial that the Global Fund continues to evaluate the effectiveness of these mechanisms; monitor for potential perverse impacts; and make necessary changes, when and where they are needed.

Global fund: Analyzing 10 Years of bridging health inequalities.

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 strategies 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.

Global Fund financing and human resources for health investments in the Eastern Mediterranean Region.

BACKGROUND: Despite the large investments in donor-related health activities in areas of the globe prone to tension and conflict, few studies have examined in detail the role of these donor investments in human resources for health (HRH). METHODS: We used a mixed-methods research methodology comprising both quantitative and qualitative analyses to analyze the Enhanced Financial Reporting System of the Global Fund to Fight AIDS, Tuberculosis and Malaria budget and expenditure data from 2003 to 2017 for 13 countries in the Eastern Mediterranean Region (EMR). We analyzed additional detailed budgetary data over the period 2015-2017 for a sub-set of these countries. Two country-case studies were conducted in Afghanistan and Sudan for a more in-depth understanding of the HRH-related activities that occurred as a result of Global Fund grants. RESULTS: The results show that US$2.2 billion Global Fund dollars had been budgeted and US$1.6 billion were expended over the period 2003-2017 in 13 Eastern Mediterranean countries. The average expenditures for human resources for health (training and human resources) as a percentage of total expenditure are 28%. Additional detailed budgetary data analysis shows a more conservative investment in HRH with 13% of total budgets allocated to "direct" HRH activities such as salaries, training costs, and technical assistance. HRH-related activities supported by the Global Fund in Afghanistan and Sudan were similar, including pre-service and in-services training, hiring of program coordinators and staff, and top-ups for clinical staff. CONCLUSIONS: HRH remains a key issue in strengthening the health systems of low- and middle-income countries. While this study suggests that Global Fund's HRH investments in the EMR are not lagging behind the global average, there appears to be a need to further scale up these investments considering this region's unique HRH challenges.

Incorporating operational research in programmes funded by the Global Fund to Fight AIDS, Tuberculosis and Malaria in four sub-Saharan African countries.

BACKGROUND: The current study builds upon a previous situation analysis of the extent to which grants from the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund) are being utilized to support operational research and implementation research (OR/IR) activities in recipient countries. The objective of this follow-up study was to identify approaches and pathways to implement an OR component into grants to the Global Fund, in four sub-Saharan African countries. Special focus was given to the Structured Operational Research and Training IniTiative (SORT IT). METHODS: The conceptual framework was based on an analysis to identify elements supporting and blocking the integration of OR, called force field analysis, and a behavioural change assessment covering aspects such as opportunity, motivation, capability and triggers to do the integration. Data were collected through online surveys and stakeholder interviews both via telephone/online conference tools and in person in four countries with a high burden of malaria and tuberculosis. These countries were Ghana, Sierra Leone, the United Republic of Tanzania and Zimbabwe. The stakeholders included programme managers, implementation partners, representatives from international organisations, academic and governmental research institutions and other individuals involved in the countries' needs assessment and National Strategic Plan development. RESULTS: We identified opportunities to integrate OR into the countries' programmes during the funding process, the country's needs assessment being the most important one, including the need of OR-related capacity. Both the force field analysis and the behavioural change assessment showed that the necessary elements to integrate OR were present in the countries. Motivation, capability and efficiency were found to be a managerial value omnipresent across stakeholders. However, those elements were influenced by the tendency to favour tangible assets over any abstract ones, such as increasing organisational capacity in OR. CONCLUSIONS: In each of the countries assessed, there is potential to integrating OR into the programmes supported by the Global Fund. However, given the relative lack of OR-related capacity and skills encountered, a capacity strengthening tool, such as SORT IT, would be of benefit helping to identify and carry forward OR activities sustainably.

Inclusive engagement for health and development or 'political theatre': results from case studies examining mechanisms for country ownership in Global Fund processes in Malawi, Tanzania and Zimbabwe.

BACKGROUND: For many countries, including Malawi, Tanzania and Zimbabwe, 2017 was a transition year for support from the Global Fund to Fight AIDS, Tuberculosis and Malaria as one funding cycle closed and another would begin in 2018. Since its inception in 2001, the Global Fund has required that countries demonstrate ownership and transparency in the development of their funding requests through specific processes for inclusive, deliberative engagement led by Country Coordinating Mechanisms (CCMs). In reporting results from case study research, the article explores whether, in the context of the three countries, such requirements continue to be fit-for-purpose given difficult choices to be made for financing and sustaining their HIV programmes. RESULTS: The findings show how complex, competing priorities for limited resources increasingly strain processes for inclusive deliberation, a core feature of the Global Fund model. Each country has chosen expansion of HIV treatment programmes as its main strategy for epidemic control relying almost exclusively on external funding sources for support. This step has, in effect, pre-committed HIV funding, whether available or not, well into the future. It has also largely pre-empted the results of inclusive dialogue on how to allocate Global Fund resources. As a result, such processes may be entering the realm of 'political theatre,' or processes for processes' sake alone, rather than being important opportunities where critical decisions regarding priorities for national HIV programmes and how they are funded could or should be made. CONCLUSION: To address this, the Global Fund has begun an initiative to shore-up the capabilities of CCMs, with specialised technical and financial support, so that they can both grasp and influence the overall financing and sustainability of HIV programmes, rather than focussing on Global Fund programmes alone. What stronger CCMs could achieve, given the growing HIV-treatment-related commitments in these three countries, remains to be seen. Starting in 2020, the three countries will discover what resources the Global Fund will have for them for the 2021-2023 period. The resource needs for expanding HIV treatment programmes for this period are already foreseeable leaving few if any options for future deliberation should funding from the Global Fund and others not grow at a similar pace.

Challenges and opportunities for eliminating tuberculosis - leveraging political momentum of the UN high-level meeting on tuberculosis.

BACKGROUND: As demonstrated by the United Nations High-Level Meeting on tuberculosis (TB) held in September 2018, the political momentum for TB has been increasing. The aim of this study was to analyze the current challenges and opportunities for global TB control and, with specific focus on policies surrounding TB control, to reveal what kinds of efforts are needed to accelerate global TB control. METHODS: We organized two expert meetings with the purposes of assessing the current situation and analyzing challenges regarding TB control. By applying Shiffman and Smith's framework which contains four categories; Actor, Ideas, Political context, and Issue characteristics, we analyzed the challenges and opportunities for global TB control based on the findings from the two expert meetings. RESULTS: In the Actor Category, we found that although there has already been active engagement by non-governmental organizations (NGOs), civil society organizations (CSOs) and private sectors, there still remained an area with room for improvement. In particular, the complexities behind varying drug regulatory and procurement systems per country hindered the active participation of the private sector in this area. As for the Ideas category, due to an increasing threat of antimicrobial resistance and growing number of global migrations, TB is now widely recognized as a health security issue rather than a purely health issue. This makes TB an easier target for political attention. As for the Political category, having the UN High-Level Meeting itself is not enough; such meetings must be followed up by actual commitments from heads of states. Lastly the issue characteristic indicates that the amount of funding for R&D for new drugs, vaccines and diagnostics for TB is not at an adequate level, and investment in childhood TB and missing cases are particularly in need. CONCLUSIONS: This study provides important insight into the current status of global efforts toward end TB epidemic. The outcomes from the UN high-level meeting on TB need to be closely monitored will be crucial for the progress towards this goal.

A global biodiversity fund to implement distributive justice for genetic resources.

This article examines the question of who has a right to control and benefit from genetic resources globally. To this end it draws on different accounts in the resource rights literature with a focus on the specific features that distinguish genetic resources from other types of natural resources. It will be argued that due to the intangible and non-territorial nature of genetic resources, territorial rights over these resources are difficult to maintain. Moreover, the vulnerability of genetic resources implies that much cost and effort is required to protect them. I will argue that not only benefits resulting from the use of genetic resources but also these costs associated with their protection should be an object of distributive justice. To accommodate these two points I will introduce the model of a global biodiversity fund that could replace the bilateral access and benefit sharing negotiations suggested by the Convention on Biological Diversity.

Securitizing HIV/AIDS: a game changer in state-societal relations in China?

BACKGROUND: China has experienced unprecedented economic growth since the 1980s. Despite this impressive economic development, this growth exists side by side with the human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) and severe acute respiratory syndrome (SARS) crises and the persisting deficiencies in public health provision in China. Acknowledging the prevailing health problems, the Chinese government has encouraged the development of health non-governmental organizations (NGOs) to respond to the health challenges and address the gaps in public health provision of the government. HIV/AIDS-focused NGOs have been perceived as the most outstanding civil society group developed in China. Considering the low priority of health policies since the economic reform, the limitation of the "third sector" activity permitted in authoritarian China, together with the political sensitivity of the HIV/AIDS problem in the country, this article aims to explain the proliferation of HIV/AIDS-focused NGOs in China with the usage of the securitization framework in the field of international relations (IR). METHODS: The research that underpins this article is based on a desk-based literature review as well as in-depth field interviews with individuals working in HIV/AIDS-focused NGOs in China. Face-to-face interviews for this research were conducted between January and May in 2011, and between December 2016 and January 2017, in China. Discourse analysis was in particular employed in the study of the security-threat framing process (securitization) of HIV/AIDS in China. RESULTS: This article argues that the proliferation of HIV/AIDS-related NGOs in China is largely attributed to the normative and technical effects of HIV/AIDS securitization ushered in by the United Nations Security Council (UNSC) and supported by the Global Fund to Fight AIDS, Tuberculosis, and Malaria (hereinafter Global Fund) observed in China. Despite depicting a positive scenario, the development of HIV/AIDS-focused NGOs in China generated by the international securitization efforts is largely limited. An internal and external factor was identified to verify the argument, namely (1) the reduction of international financial commitments, as well as (2) the fragmentation of HIV/AIDS-focused NGO community in China. CONCLUSIONS: This article shows that international securitization weakened with the rise of Chinese commitment on HIV/AIDS interventions. In other words, HIV/AIDS-related responses delivered by the national government are no longer checked by the global mechanism of HIV/AIDS; thus it is unclear whether these NGOs would remain of interest as partners for the government. The fragmentation of the HIV/AIDS community would further hinder the development, preventing from NGOs with the same interest forming alliances to call for changes in current political environment. Such restriction on the concerted efforts of HIV/AIDS-related NGOs in China would make achievement of the Sustainable Development Goals (SDGs) to foster stronger partnerships between the government and civil society difficult, which in turn hindering the realization of ending HIV/AIDS in the world by 2030.

A social systems analysis of implementation of El Salvador's national HIV combination prevention: a research agenda for evaluating Global Health Initiatives.

BACKGROUND: Global Health Initiatives (GHIs) have been instrumental in the rapid acceleration of HIV prevention, treatment access, and availability of care and support services for people living with HIV (PLH) in low and middle income countries (LMIC). These efforts have increasingly used combination prevention approaches that include biomedical, behavioral, social and structural interventions to reduce HIV incidence. However, little research has evaluated their implementation. We report results of qualitative research to examine the implementation of a national HIV combination prevention strategy in El Salvador funded by the Global Fund to Fight AIDS, Tuberculosis and Malaria. METHODS: We conducted in-depth interviews with principal recipients of the funding, members of the Country Coordinating Mechanism (CCM) and front line peer outreach workers and their clients. We analyzed the data using a dynamic systems framework. RESULTS: El Salvador's national HIV combination prevention strategy had three main goals: 1) to decrease the sexual risk behaviors of men who have sex with men (MSM), commercial sex workers (CSW) and transgender women (TW); 2) to increase HIV testing rates among members of these populations and the proportion of PLH who know their status; and 3) to improve linkage to HIV treatment and adherence to antiretroviral therapy (ART). Intervention components to achieve these goals included peer outreach, community prevention centers and specialized STI/HIV clinics, and new adherence and retention protocols for PLH. In each intervention component, we identified several factors which reinforced or diminished intervention efforts. Factors that negatively affected all intervention activities were an increase in violence in El Salvador during implementation of the strategy, resistance to decentralization, and budget constraints. Factors that affected peer outreach and sexual risk reduction were the human resource capacity of grassroots organizations and conflicts of the national HIV strategy with other organizational missions. CONCLUSIONS: Overall, the national strategy improved access to HIV prevention and care through efforts to improve capacity building of grass roots organizations, reduced stigma, and improved coordination among organizations. However, failure to respond to environmental and organizational factors limited the intervention's potential impact.

What happened to anti-malarial markets after the Affordable Medicines Facility-malaria pilot? Trends in ACT availability, price and market share from five African countries under continuation of the private sector co-payment mechanism.

BACKGROUND: The private sector supplies anti-malarial treatment for large proportions of patients in sub-Saharan Africa. Following the large-scale piloting of the Affordable Medicines Facility-malaria (AMFm) from 2010 to 2011, a private sector co-payment mechanism (CPM) provided continuation of private sector subsidies for quality-assured artemisinin combination therapies (QAACT). This article analyses for the first time the extent to which improvements in private sector QAACT supply and distribution observed during the AMFm were maintained or intensified during continuation of the CPM through 2015 in Kenya, Madagascar, Nigeria, Tanzania and Uganda using repeat cross-sectional outlet survey data. RESULTS: QAACT market share in all five countries increased during the AMFm period (p < 0.001). According to the data from the last ACTwatch survey round, in all study countries except Madagascar, AMFm levels of private sector QAACT availability were maintained or improved. In 2014/15, private sector QAACT availability was greater than 70% in Nigeria (84.3%), Kenya (70.5%), Tanzania (83.0%) and Uganda (77.1%), but only 11.2% in Madagascar. QAACT market share was maintained or improved post-AMFm in Nigeria, Tanzania and Uganda, but statistically significant declines were observed in Kenya and Madagascar. In 2014/5, QAACT market share was highest in Kenya and Uganda (48.2 and 47.5%, respectively) followed by Tanzania (39.2%), Nigeria (35.0%), and Madagascar (7.0%). Four of the five countries experienced significant decreases in median QAACT price during the AMFm period. Private sector QAACT prices were maintained or further reduced in Tanzania, Nigeria and Uganda, but prices increased significantly in Kenya and Madagascar. SP prices were consistently lower than those of QAACT in the AMFm period, with the exception of Kenya and Tanzania in 2011, where they were equal. In 2014/5 QAACT remained two to three times more expensive than the most popular non-artemisinin therapy in all countries except Tanzania. CONCLUSIONS: Results suggest that a private sector co-payment mechanism for QAACT implemented at national scale for 5 years was associated with positive and sustained improvements in QAACT availability, price and market share in Nigeria, Tanzania and Uganda, with more mixed results in Kenya, and few improvements in Madagascar. The subsidy mechanism as implemented over time across countries was not sufficient on its own to achieve optimal QAACT uptake. Supporting interventions to address continued availability and distribution of non-artemisinin therapies, and to create demand for QAACT among providers and consumers need to be effectively implemented to realize the full potential of this subsidy mechanism. Furthermore, there is need for comprehensive market assessments to identify contemporary market barriers to high coverage with both confirmatory testing and appropriate treatment.

The Role of Civil Society Organizations in Monitoring the Global AIDS Response.

Civil society organizations (CSOs) are recognized as playing an exceptional role in the global AIDS response. However, there is little detailed research to date on how they contribute to specific governance functions. This article uses Haas' framework on global governance functions to map CSO's participation in the monitoring of global commitments to the AIDS response by institutions and states. Drawing on key informant interviews and primary documents, it focuses specifically on CSO participation in Global AIDS Response Progress Reporting and in Global Fund to Fight AIDS, Tuberculosis and Malaria processes. It argues that the AIDS response is unique within global health governance, in that CSOs fulfill both formal and informal monitoring functions, and considers the strengths and weaknesses of these contributions. It concludes that future global health governance arrangements should include provisions and resources for monitoring by CSOs because their participation creates more inclusive global health governance and contributes to strengthening commitments to human rights.

Operational and implementation research within Global Fund to Fight AIDS, Tuberculosis and Malaria grants: a situation analysis in six countries.

BACKGROUND: Operational/implementation research (OR/IR) is a key activity to improve disease control programme performance. We assessed the extent to which malaria and tuberculosis (TB) grants from the Global Fund to Fight AIDS, Tuberculosis and Malaria ("Global Fund") include support for OR/IR, and discuss the implications of the current Global Fund operating mechanisms for OR/IR support. METHODS: The situation analysis focussed on malaria and TB, while HIV was excluded. Stakeholder interviews were conducted at the Global Fund secretariat and in six purposefully selected high disease burden countries, namely the Democratic Republic of the Congo, Ethiopia, India, Indonesia, Myanmar and Zimbabwe. Interviewed in-country stakeholders included the relevant disease control programme managers, project implementation partners, representatives from international organisations with a stake in global health, academic and governmental research institutions, and other relevant individuals such as members of the country coordination mechanism. Additionally, documentation of grants and OR/IR obtained from the Global Fund was reviewed. RESULTS: The Global Fund provides substantial resources for malaria and TB surveys, and supports OR/IR if such support is requested and the application is well justified. We observed considerable variations from one country to another and between programmes with regards to need, demand, absorption capacity and funding for OR/IR related to malaria and TB. Important determinants for the extent of such funding are the involvement of national research coordination bodies, established research agendas and priorities, human and technical research capacity, and involvement of relevant stakeholders in concept note development. Efforts to disseminate OR/IR findings were generally weak, and the Global Fund does not maintain a central OR/IR database. When faced with a need to choose between procurement of commodities for disease control and supporting research, countries tend to seek research funding from other donors. The Global Fund is expected to issue more specific guidance on the conditions under which it supports OR/IR, and to adapt administrative procedures to facilitate research. CONCLUSIONS: The importance of OR/IR for optimising disease control programmes is generally accepted but countries vary in their capacity to demand and implement studies. Countries expect guidance on OR/IR from the Global Fund. Administrative procedures specifically related to the budget planning should be modified to facilitate ad-hoc OR/IR funding. More generally, several countries expressed a need to strengthen capacity for planning, negotiating and implementing research.

The Global Fund's paradigm of oversight, monitoring, and results in Mozambique.

BACKGROUND: The Global Fund is one of the largest actors in global health. In 2015 the Global Fund was credited with disbursing close to 10 % of all development assistance for health. In 2011 it began a reform process in response to internal reviews following allegations of recipients' misuse of funds. Reforms have focused on grant application processes thus far while the core structures and paradigm have remained intact. We report results of discussions with key stakeholders on the Global Fund, its paradigm of oversight, monitoring, and results in Mozambique. METHODS: We conducted 38 semi-structured in-depth interviews in Maputo, Mozambique and members of the Global Fund Board and Secretariat in Switzerland. In-country stakeholders were representatives from Global Fund country structures (eg. Principle Recipient), the Ministry of Health, health or development attachés bilateral and multilateral agencies, consultants, and the NGO coordinating body. Thematic coding revealed concerns about the combination of weak country oversight with stringent and cumbersome requirements for monitoring and evaluation linked to performance-based financing. RESULTS: Analysis revealed that despite the changes associated with the New Funding Model, respondents in both Maputo and Geneva firmly believe challenges remain in Global Fund's structure and paradigm. The lack of a country office has many negative downstream effects including reliance on in-country partners and ineffective coordination. Due to weak managerial and absorptive capacity, more oversight is required than is afforded by country team visits. In-country partners provide much needed support for Global Fund recipients, but roles, responsibilities, and accountability must be clearly defined for a successful long-term partnership. Furthermore, decision-makers in Geneva recognize in-country coordination as vital to successful implementation, and partners welcome increased Global Fund engagement. CONCLUSIONS: To date, there are no institutional requirements for formalized coordination, and the Global Fund has no consistent representation in Mozambique's in-country coordination groups. The Global Fund should adapt grant implementation and monitoring procedures to the specific local realities that would be illuminated by more formalized coordination.

[Analysis on the performance evaluation of the Global Fund Malaria Programme in China from 2003 to 2013].

Objective: To analyze the performance of the 5 Global Fund Malaria Programmes in China from 2003 to 2013. Methods: All of the proposals, summaries, progress reports, survey reports, Monitoring& Evaluation reports, and performance rating reports of the 5 Global Fund Malaria Programmes in China and the epidemic data of program areas were collected for statistical analysis from 2012 to 2014. Symposiums were held with relevant experts from national and provincial Centers for Disease Control and Prevention, program managers and staffs from national and provincial Global Fund Malaria Programme offices. The completion of the relevant programme indicators (including the general grant information such as program areas, beneficiaries and funding; the implementation of malaria control measures; the performance of malaria control measures; the malaria incidence in the program areas; the prevalence of malaria parasites; and program management and performance evaluation) were analyzed, and the results: of the symposiums were summarized. Results The implementation period of the 5 Global Fund Malaria Programs were as follows: Round 1 from 2003 to 2008, Round 5 from 2006 to 2010, Round 6 from 2007 to 2012, Round 10 from 2012 to 2013, and National Strategy Application (NSA) from 2010 to 2012. Under the support of all the Global Fund Malaria Programs, a total of 11 936 726 fever cases received microscopic tests, 1 485 915 confirmed and suspected malaria cases were treated, 1 579 773 Long Lasting Insecticide-treated Nets were distributed, 3 414 633 regular nets were treated by insecticide, 40 298 284 primary and middle school students received health education on malaria control. Compared with the baseline value, the completion rates of each indicator increased after the implementation of the programs. The growth value ranged from 12.83% to 83.11%, among which the biggest growth was the value of the indicator'Percentage of households with at least one LLIN/ITN in target areas', and it increased from 9.2% (baseline value of 2006) to 92.31% (value of 2012). The malaria incidence in program areas has dropped significantly year by year, the annual reported malaria incidence in Yunnan and Hainan provinces decreased from 1 950/100 000, 3 850/100 000 in 2002 to 3.31/100 000, 0.15/100 000 in 2012, the P. falciparum malaria incidence in target counties in Hainan province decreased from 90.6/100 000 in 2002 to 0/100 000 in 2012. As from the implementation of NSA grant in 2010 to 2012, the annual reported malaria incidence in 92% of the 75 Type 1 counties was less than 1 per 10 000, 60.00% of Type 1 counties and 98.69% of the 687 Type 2 counties reported zero locally transmitted malaria cases. The Global Fund Secretariat had conducted a total of 37 performance evaluations, of which 9 have been rated as A1, 4 rated as A2, 19 rated as B1 and 5 rated as B1. Conclusions: The Global Fund Malaria Program in China has been closely integrated with the goal and task of National Malaria Control Program, reducing malaria burden in target areas, and pushing Chinese malaria control efforts to move from control to elimination.

A vision for the future of pastoralism.

Pastoral regions are challenged by social and ecological changes. Yet, there is increasingly robust evidence that pastoralism is a viable and sustainable livelihood and that pastoralists play a role in attaining the United Nations Sustainable Development Goals (SDGs). In this issue of the Scientific and Technical Review of the World Organisation for Animal Health (OIE), the authors take a broad view of pastoralism and pastoral livestock production from a number of different perspectives, taking into account societal and ecological viewpoints as well as issues of animal and human health. Thematic reviews are complemented by regional perspectives from Central Asia, China, Europe, East, Central and West Africa, and Latin America. The broader issues of pastoral livestock production and its potential for improving and sustaining animal health are of great interest to the OIE. Summarising the diverse contributions, it appears that pastoral socialecological systems are hotspots of cultural and biological diversity. They are multifunctional in that they generate diversified sources of income and contribute to sustained natural resource management. Pastoral populations require favourable institutional and legal frameworks, so governance structures must be improved and reformed through effective participation and the empowerment of pastoralists. To sustain functional pastoral production systems, the key ingredients are decentralised governance of natural resources, better locally adapted social services, and high flexibility for maintaining mobility. Young people should be actively encouraged to engage in pastoral livelihoods, which should be supported by improved legal systems for land use by all interested parties. There is still untapped potential to optimise extensive livestock production through adapted genetic improvement and better transformation, stocking and marketing of animal-source food. Modern concepts of disease surveillance and response, combining human and animal health as 'One Health', are particularly suited to pastoral systems. The OIE's interest in pastoralism is highly justified given its economic and environmental importance and its significance for livelihoods. Sustainable improvements require understanding and discussion of diverse social and ecological interactions, and it is to this discussion which the authors and editors of this issue of the Review have endeavoured to contribute.

Les régions d'élevage pastoral sont confrontées à des mutations tant sociales qu'écologiques. En même temps, des éléments factuels chaque fois plus nombreux démontrent que le pastoralisme constitue un moyen de subsistance viable et durable et que les pasteurs participent à la réalisation des Objectifs de développement durable fixés par les Nations Unies. Ce numéro de la Revue scientifique et technique de l'Organisation mondiale de la santé animale (OIE) propose une large vue d'ensemble sur le pastoralisme et l'élevage pastoral, examinés sous différents angles et en prenant en considération divers points de vue, tant sociétaux qu'écologiques, sans oublier les problématiques de la santé animale et publique. Les examens thématiques sont complétés par des études régionales portant sur l'Asie centrale, la Chine, l'Europe, l'Afrique de l'Est, centrale et de l'Ouest et l'Amérique latine. Les questions plus générales liées à l'élevage pastoral et à sa capacité potentielle d'améliorer et de promouvoir la santé animale présentent un grand intérêt pour l'OIE. Les diverses contributions réunies dans ce numéro font apparaître que les systèmes socio-écologiques pastoraux constituent des zones sensibles en termes de diversité biologique et culturelle. Ils exercent de multiples fonctions, dans la mesure où ils génèrent des sources de revenus diversifiées et contribuent à une gestion durable des ressources naturelles. Les populations pastorales doivent être soutenues par des cadres juridiques et institutionnels favorables, ce qui suppose d'améliorer et de moderniser les structures de gouvernance au moyen d'une participation effective des pasteurs eux-mêmes et de la prise en main de leur destin. Les ingrédients majeurs pour soutenir le bon fonctionnement des systèmes de production pastoraux sont la gouvernance décentralisée des ressources naturelles, la fourniture de services sociaux spécifiquement adaptés aux besoins des pasteurs et une grande flexibilité afin de préserver le nomadisme. Les jeunes devraient être activement encouragés à participer à l'économie pastorale, et celle-ci devrait bénéficier d'un soutien juridique afin que l'utilisation des terres par toutes les parties intéressées soit mieux encadrée. La production animale extensive présente une grande marge d'amélioration encore inexploitée, grâce à l'amélioration génétique et à des méthodes plus efficaces de transformation, de stockage et de commercialisation des denrées alimentaires d'origine animale. Les concepts modernes de surveillance des maladies et de réaction aux évènements sanitaires en faisant appel à une approche intégrée de la santé animale et humaine selon le concept « Une seule santé ¼ sont particulièrement adaptés aux systèmes pastoraux. L'intérêt que suscite le pastoralisme pour l'OIE se justifie pleinement par l'importance économique et environnementale du pastoralisme et par sa valeur en tant que moyen de subsistance. La mise en place d'améliorations durables passe par une connaissance et un examen approfondis des nombreuses interactions sociales et écologiques à l'oeuvre dans le pastoralisme ; c'est à cet examen que les auteurs et coordinateurs de ce numéro de la Revue se sont attachés à contribuer.

Las regiones pastorales están viviendo difíciles transformaciones sociales y ecológicas. Aun así, hay pruebas cada vez más concluyentes de que el pastoreo constituye un medio de sustento viable y sostenible y de que las sociedades que viven de él contribuyen al cumplimiento de los Objetivos de Desarrollo Sostenible (ODS) fijados por las Naciones Unidas. En este número de la Revista científica y técnica de la Organización Mundial de Sanidad Animal (OIE) los autores ofrecen una vasta panorámica del pastoreo y de la producción ganadera que le es propia, abordando el tema desde múltiples ángulos y teniendo en cuenta tanto aspectos ligados a la sociedad y la ecología como las cuestiones zoosanitarias y sanitarias. El tratamiento temático se complementa con estudios de ámbito regional, dedicados a Asia Central, China, Europa, África Oriental, Central y Occidental y América Latina. Las cuestiones más generales ligadas a la producción ganadera por pastoreo y a las posibilidades que esta ofrece para mejorar y preservar la sanidad animal revisten gran interés para la OIE. Las diversas contribuciones aquí reunidas evidencian, en resumen, que los sistemas socioecológicos pastorales encierran una enorme diversidad cultural y biológica. Revisten además carácter polivalente, en el sentido de que generan fuentes diversificadas de ingresos y contribuyen a una gestión duradera de los recursos naturales. Las poblaciones dedicadas al pastoreo necesitan regímenes institucionales y jurídicos favorables, para lo cual es indispensable mejorar y reformar las estructuras de gobierno instrumentando una participación efectiva de esas poblaciones y fórmulas que las doten de poder de decisión y actuación. Los ingredientes básicos para mantener duraderamente y en buen funcionamiento los sistemas de producción propios del pastoreo son: una gestión descentralizada de los recursos naturales; servicios sociales más eficaces y adaptados a las condiciones locales; y un elevado grado de flexibilidad para mantener la movilidad. Es preciso alentar activamente a los jóvenes a que abracen los modos y medios de vida del pastoreo, lo que debe acompañarse de mejores ordenamientos jurídicos sobre el uso de las tierras por todas las partes interesadas. Todavía queda margen para optimizar la producción ganadera extensiva mediante mejoras genéticas adaptadas y técnicas más eficaces de transformación, almacenamiento y comercialización de los alimentos de origen animal. Los conceptos modernos de la vigilancia y la respuesta sanitarias, que combinan la salud humana y la sanidad animal con arreglo a los principios de «Una sola salud¼, casan especialmente con los sistemas de pastoreo. El interés de la OIE por el pastoreo está sobradamente justificado por la importancia económica y ambiental de esta actividad y por la repercusión que tiene en los medios de sustento. Toda mejora duradera en este ámbito pasa por entender un conjunto de interacciones sociales y ecológicas y por debatir al respecto, proceso este de reflexión al que se han propuesto contribuir los autores y compiladores del presente número de la Revista.

Comparing the cost effectiveness of harm reduction strategies: a case study of the Ukraine.

BACKGROUND: Harm reduction strategies commonly include needle and syringe programmes (NSP), opioid substitution therapy (OST) and interventions combining these two strategies. Despite the proven effectiveness of harm-reduction strategies in reducing human immunodeficiency virus (HIV) infection among injecting drug users (IDUs), no study has compared the cost-effectiveness of these interventions, nor the incremental cost effectiveness of combined therapy. Using data from the Global Fund, this study compares the cost-effectiveness of harm reduction strategies in Eastern Europe and Central Asia, using the Ukraine as a case study. METHODS: A Markov Monte Carlo simulation is carried out using parameters from the literature and cost data from the Global Fund. Effectiveness is presented as both QALYs and infections averted. Costs are measured in 2011 US dollars. RESULTS: The Markov Monte Carlo simulation estimates the cost-effectiveness ratio per infection averted as $487.4 [95% CI: 488.47-486.35] in NSP and $1145.9 [95% CI: 1143.39-1148.43] in OST. Combined intervention is more costly but more effective than the alternative strategies with a cost effectiveness ratio of $851.6[95% CI: 849.82-853.55]. The ICER of the combined strategy is $1086.9/QALY [95% CI: 1077.76:1096.24] compared with NSP, and $461.0/infection averted [95% CI: 452.98:469.04] compared with OST. These results are consistent with previous studies. CONCLUSIONS: Despite the inherent limitations of retrospective data, this study provides evidence that harm-reduction interventions are a cost-effective way to reduce HIV prevalence. More research on into cost effectiveness in different settings, and the availability of fiscal space for government uptake of programmes, is required.