Global Fund Investments Research Articles

Leveraging Global Fund's investments to expand innovative public-private provider engagement in TB.

TB remains a significant global health threat, claiming 1.3 million lives annually. The COVID-19 pandemic disrupted progress in the global TB response. Most patients with TB initially seek care from private providers, whereas only a small proportion are engaged by national programmes. The Global Fund is the major international source of funding for TB responses and supports the scale-up of innovative private-public mix (PPM) models in TB. We collected programmatic and financial data on TB from 11 priority countries implementing PPM activities. Country examples and trends in the budget of Global Fund grants were analysed. These countries account for 60% of the global TB burden and Global Fund TB portfolio. PPM contributed 29% of national TB notifications in 2022 (range: 8% to 49%). During 2021-2023, US$1.4 billion was allocated for TB and US$155 million (11%) for PPM, while PPM contributed to 35% of national TB notification targets. PPM budgets increased over time from US$43 million (2002 to 2014) to US$129 million (2024 to 2026). The Global Fund's investments facilitated the expansion of innovative PPM models, improved access, and enhanced TB responses. Our indicative analysis underscores the need for evidence-based planning, collaboration, and increased domestic investment to accelerate the end of TB.

Ambitions and realities: Are Global Fund investments designed to achieve resilient and sustainable systems for health? Findings from the Global Fund Prospective Country Evaluation.

Strengthening resilient and sustainable systems for health (RSSH) is central to the Global Fund's strategy, however questions persist about the Global Fund's role in the health systems strengthening space, and the extent to which investments are designed to achieve strengthening objectives, or just fill in gaps in the system. This paper reports on findings from the Prospective Country Evaluations (PCE), a multi-country multi-year evaluation of Global Fund support. We adapted a framework from Chee et al. (2013) to assess whether Global Fund investments were designed to strengthen or support the health system. Per this framework, 'systems support' refers to improvements in health systems functioning primarily driven by increases in inputs, whereas 'systems strengthening' refers to activities that drive changes in how the health system operates (often related to policies, regulations, governance structures, behavior change, and resource optimization). In the 2017 and 2019 funding cycles, we found that despite calls from the Global Fund to invest more strategically to strengthen health systems, a high proportion of RSSH funding was directed toward activities that support the health system. Factors underlying this pattern include limitations imposed by the three-year grant cycle, a lack of clear guidance on how to design strengthening investments, a persistent need for funding to address input gaps, and minimal feedback during the funding request process related to RSSH design. For the Global Fund, and indeed other global health initiatives, to contribute to sustained strengthening of health systems, is likely to require enhanced guidance and technical assistance, as well as improved measurement of outputs and outcomes.

Performance-based technical support for drug-resistant TB responses: lessons from the Green Light Committee

Drug-resistant tuberculosis (DR-TB) constitutes a global threat and a major contributor to deaths related to antimicrobial resistance. Despite progress in DR-TB detection and treatment over the last decade, huge gaps remain in treatment coverage, access to quality care and treatment outcome. Global Fund investments have been critical to scaling up the existing and new diagnostic tools, treatment coverage and people-centred service delivery. The United Nations General Assembly (UNGA) high-level meeting represents unprecedented opportunities to accelerate towards addressing DR-TB. Established in 2000 and funded by the Global Fund since 2009, the Green Light Committee (GLC) mechanism has evolved from project approval to providing demand-based technical assistance to countries to scale up response to DR-TB based on their need and priorities. Lessons learnt from the GLC mechanism over 10 years demonstrate that a result-based, systematic and accountable technical assistance model to support scale-up of DR-TB response is critically important. Meeting the UNGA declaration targets requires major scale-up of current efforts and new tools, and hence the need for predictable, consistent and sustained technical support to countries, including through the regional GLC mechanism. The application of the principles and processes of this model could be adapted and replicated to design a similar performance-based and quality-assured technical support mechanism.

A Quarter for Prevention? Global Fund Investments in HIV Prevention Interventions in Generalized African Epidemics

A Quarter for Prevention? Global Fund Investments in HIV Prevention Interventions in Generalized African Epidemics

The Global Fund to Fight AIDS, Tuberculosis and Malaria's investments in harm reduction through the rounds-based funding model (2002–2014)

BackgroundHarm reduction is an evidence-based, effective response to HIV transmission and other harms faced by people who inject drugs, and is explicitly supported by the Global Fund to Fight AIDS, Tuberculosis and Malaria. In spite of this, people who inject drugs continue to have poor and inequitable access to these services and face widespread stigma and discrimination. In 2013, the Global Fund launched a new funding model-signalling the end of the previous rounds-based model that had operated since its founding in 2002. This study updates previous analyses to assess Global Fund investments in harm reduction interventions for the duration of the rounds-based model, from 2002 to 2014. MethodsGlobal Fund HIV and TB/HIV grant documents from 2002 to 2014 were reviewed to identify grants that contained activities for people who inject drugs. Data were collected from detailed grant budgets, and relevant budget lines were recorded and analysed to determine the resources allocated to different interventions that were specifically targeted at people who inject drugs. Results151 grants for 58 countries, plus one regional proposal, contained activities targeting people who inject drugs–for a total investment of US$ 620million. Two-thirds of this budgeted amount was for interventions in the “comprehensive package” defined by the United Nations. 91% of the identified amount was for Eastern Europe and Asia. ConclusionThis study represents an updated, comprehensive assessment of Global Fund investments in harm reduction from its founding (2002) until the start of the new funding model (2014). It also highlights the overall shortfall of harm reduction funding, with the estimated global need being US$ 2.3billion for harm reduction in 2015 alone. Using this baseline, the Global Fund must carefully monitor its new funding model and ensure that investments in harm reduction are maintained or scaled-up. There are widespread concerns regarding the withdrawal from middle-income countries where harm reduction remains essential and unfunded through other sources: for example, 15% of the identified investments were for countries which are now ineligible for Global Fund support.

Global Fund investments in human resources for health: innovation and missed opportunities for health systems strengthening

Since the early 2000s, there have been large increases in donor financing of human resources for health (HRH), yet few studies have examined their effects on health systems. To determine the scope and impact of investments in HRH by the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund), the largest investor in HRH outside national governments. We used mixed research methodology to analyse budget allocations and expenditures for HRH, including training, for 138 countries receiving money from the Global Fund during funding rounds 1-7. From these aggregate figures, we then identified 27 countries with the largest funding for human resources and training and examined all HRH-related performance indicators tracked in Global Fund grant reports. We used the results of these quantitative analyses to select six countries with substantial funding and varied characteristics-representing different regions and income levels for further in-depth study: Bangladesh (South and West Asia, low income), Ethiopia (Eastern Africa, low income), Honduras (Latin America, lower-middle income), Indonesia (South and West Asia, lower-middle income), Malawi (Southern Africa, low income) and Ukraine (Eastern Europe and Central Asia, upper-middle income). We used qualitative methods to gather information in each of the six countries through 159 interviews with key informants from 83 organizations. Using comparative case-study analysis, we examined Global Fund's interactions with other donors, as well as its HRH support and co-ordination within national health systems. Around US$1.4 billion (23% of total US$5.1 billion) of grant funding was allocated to HRH by the 138 Global Fund recipient countries. In funding rounds 1-7, the six countries we studied in detail were awarded a total of 47 grants amounting to US$1.2 billion and HRH budgets of US$276 million, of which approximately half were invested in disease-focused in-service and short-term training activities. Countries employed a variety of mechanisms including salary top-ups, performance incentives, extra compensation and contracting of workers for part-time work, to pay health workers using Global Fund financing. Global Fund support for training and salary support was not co-ordinated with national strategic plans and there were major deficiencies in the data collected by the Global Fund to track HRH financing and to provide meaningful assessments of health system performance. The narrow disease focus and lack of co-ordination with national governments call into question the efficiency of funding and sustainability of Global Fund investments in HRH and their effectiveness in strengthening recipient countries' health systems. The lessons that emerge from this analysis can be used by both the Global Fund and other donors to improve co-ordination of investments and the effectiveness of programmes in recipient countries.

Global health initiative investments and health systems strengthening: a content analysis of global fund investments.

BackgroundMillions of dollars are invested annually under the umbrella of national health systems strengthening. Global health initiatives provide funding for low- and middle-income countries through disease-oriented programmes while maintaining that the interventions simultaneously strengthen systems. However, it is as yet unclear which, and to what extent, system-level interventions are being funded by these initiatives, nor is it clear how much funding they allocate to disease-specific activities – through conventional ‘vertical-programming’ approach. Such funding can be channelled to one or more of the health system building blocks while targeting disease(s) or explicitly to system-wide activities.MethodsWe operationalized the World Health Organization health system framework of the six building blocks to conduct a detailed assessment of Global Fund health system investments. Our application of this framework framework provides a comprehensive quantification of system-level interventions. We applied this systematically to a random subset of 52 of the 139 grants funded in Round 8 of the Global Fund to Fight AIDS, Tuberculosis and Malaria (totalling approximately US$1 billion).ResultsAccording to the analysis, 37% (US$ 362 million) of the Global Fund Round 8 funding was allocated to health systems strengthening. Of that, 38% (US$ 139 million) was for generic system-level interventions, rather than disease-specific system support. Around 82% of health systems strengthening funding (US$ 296 million) was allocated to service delivery, human resources, and medicines & technology, and within each of these to two to three interventions. Governance, financing, and information building blocks received relatively low funding.ConclusionsThis study shows that a substantial portion of Global Fund’s Round 8 funds was devoted to health systems strengthening. Dramatic skewing among the health system building blocks suggests opportunities for more balanced investments with regard to governance, financing, and information system related interventions. There is also a need for agreement, by researchers, recipients, and donors, on keystone interventions that have the greatest system-level impacts for the cost-effective use of funds. Effective health system strengthening depends on inter-agency collaboration and country commitment along with concerted partnership among all the stakeholders working in the health system.

Negative health system effects of Global Fund's investments in AIDS, tuberculosis and malaria from 2002 to 2009: systematic review

ObjectivesBy using the Global Fund as a case example, we aim to critically evaluate the evidence generated from 2002 to 2009 for potential negative health system effects of Global Health Initiatives (GHI).DesignSystematic review of research literature.SettingDeveloping Countries.ParticipantsAll interventions potentially affecting health systems that were funded by the Global Fund.Main outcome measuresNegative health system effects of Global Fund investments as reported by study authors.ResultsWe identified 24 studies commenting on adverse effects on health systems arising from Global Fund investments. Sixteen were quantitative studies, six were qualitative and two used both quantitative and qualitative methods, but none explicitly stated that the studies were originally designed to capture or to assess health system effects (positive or negative). Only seemingly anecdotal evidence or authors’ perceptions/interpretations of circumstances could be extracted from the included studies.ConclusionsThis study shows that much of the currently available evidence generated between 2002 and 2009 on GHIs potential negative health system effects is not of the quality expected or needed to best serve the academic or broader community. The majority of the reviewed research did not fulfil the requirements of rigorous scientific evidence.

Implementing the Global Plan to Stop TB, 2011–2015 – Optimizing Allocations and the Global Fund’s Contribution: A Scenario Projections Study

BackgroundThe Global Plan to Stop TB estimates funding required in low- and middle-income countries to achieve TB control targets set by the Stop TB Partnership within the context of the Millennium Development Goals. We estimate the contribution and impact of Global Fund investments under various scenarios of allocations across interventions and regions.Methodology/Principal FindingsUsing Global Plan assumptions on expected cases and mortality, we estimate treatment costs and mortality impact for diagnosis and treatment for drug-sensitive and multidrug-resistant TB (MDR-TB), including antiretroviral treatment (ART) during DOTS for HIV-co-infected patients, for four country groups, overall and for the Global Fund investments. In 2015, China and India account for 24% of funding need, Eastern Europe and Central Asia (EECA) for 33%, sub-Saharan Africa (SSA) for 20%, and other low- and middle-income countries for 24%. Scale-up of MDR-TB treatment, especially in EECA, drives an increasing global TB funding need – an essential investment to contain the mortality burden associated with MDR-TB and future disease costs. Funding needs rise fastest in SSA, reflecting increasing coverage need of improved TB/HIV management, which saves most lives per dollar spent in the short term. The Global Fund is expected to finance 8–12% of Global Plan implementation costs annually. Lives saved through Global Fund TB support within the available funding envelope could increase 37% if allocations shifted from current regional demand patterns to a prioritized scale-up of improved TB/HIV treatment and secondly DOTS, both mainly in Africa − with EECA region, which has disproportionately high per-patient costs, funded from alternative resources.Conclusions/SignificanceThese findings, alongside country funding gaps, domestic funding and implementation capacity and equity considerations, should inform strategies and policies for international donors, national governments and disease control programs to implement a more optimal investment approach focusing on highest-impact populations and interventions.

Global Fund Financing of Tuberculosis Services Delivery in Prisons

Despite concerted efforts to scale up tuberculosis control with large amounts of international financing in the last 2 decades, tuberculosis continues to be a social issue affecting the world's most marginalized and disadvantaged communities. This includes prisoners, estimated at about 10 million globally, for whom tuberculosis is a leading cause of mortality and morbidity. The Global Fund to Fight AIDS, Tuberculosis and Malaria has emerged as the single largest international donor for tuberculosis control, including funding support in delivering tuberculosis treatment for the confined population. The Global Fund grants database, with an aggregate approved investment of $21.7 billion in 150 countries by the end of 2010, was reviewed to identify tuberculosis and human immunodeficiency virus/tuberculosis grants and activities that monitored the delivery of tuberculosis treatment and support activities in penitentiary settings. The distribution and trend of number of countries with tuberculosis prison support was mapped by year, geographic region, tuberculosis or multidrug-resistant tuberculosis burden, and prison population rate. We examined the types of grant recipients managing program delivery, their performance, and the nature and range of services provided. Fifty-three of the 105 countries (50%) with Global Fund-supported tuberculosis programs delivered services within prison settings. Thirty-two percent (73 of 228) of tuberculosis grants, representing $558 million of all disbursements of Global Fund tuberculosis support by the end of 2010, included output indicators related to tuberculosis services delivered in prisons. Nearly two-thirds (64%) of these grants were implemented by governments, with the remaining by civil society and other partners. In terms of services, half (36 of 73) of grants provided diagnosis and treatment and an additional 27% provided screening and monitoring of tuberculosis for prisoners. The range of services tracked was limited in scope and scale, with 69% offering only 1 type of service and less than one-fifth offering 2 types of service. This study is a preliminary attempt to examine Global Fund investments in the fight against tuberculosis in prison settings. Tuberculosis services delivered in prisons have increased in the last decade, but systematic information on funding levels and gaps, services provided, and cost-effective delivery models for delivering tuberculosis services in prisons are lacking.

Global Fund investments in harm reduction from 2002 to 2009

BackgroundInjecting drug use has been documented in 158 countries and is a major contributor to HIV epidemics. People who inject drugs have poor and inequitable access to HIV services. The Global Fund to Fight AIDS, Tuberculosis and Malaria is the leading multilateral donor for HIV programmes and encourages applicants to include harm reduction interventions in their proposals. This study is the first detailed analysis of Global Fund investments in harm reduction interventions. MethodsThe full list of more than 1000 Global Fund grants was analysed to identify HIV grants that contain activities for people who inject drugs. Data were collected from the detailed budgets agreed between the Global Fund and grant recipients. Relevant budget lines were recorded and analysed in terms of the resources allocated to different interventions. Results120 grants from 55 countries and territories contained activities for people who inject drugs worth a total of US$ 361million, increasing to US$ 430million after projections were made for grants that had yet to enter their final phase of funding. Two-thirds of the budgeted US$ 361million was allocated to core harm reduction activities as defined by the United Nations. Thirty-nine of the 55 countries were in Eastern Europe and Asia. Only three countries with generalised HIV epidemics had grants that included harm reduction activities. ConclusionThis study represents the most comprehensive assessment of Global Fund investments in harm reduction. This funding, while substantial, falls short of the estimated needs. Investments in harm reduction must increase if HIV transmission among people who inject drugs is to be halved by 2015.

An analysis of GAVI, the Global Fund and World Bank support for human resources for health in developing countries

Shortages, geographic imbalances and poor performance of health workers pose major challenges for improving health service delivery in developing countries. In response, multilateral agencies have increasingly recognized the need to invest in human resources for health (HRH) to assist countries in achieving their health system goals. In this paper we analyse the HRH-related activities of three agencies: the Global Alliance for Vaccines and Immunisation (GAVI); the Global Fund for Aids, Tuberculosis, and Malaria (the Global Fund); and the World Bank. First, we reviewed the type of HRH-related activities that are eligible for financing within each agency. Second, we reviewed the HRH-related activities that each agency is actually financing. Third, we reviewed the literature to understand the impact that GAVI, Global Fund and World Bank investments in HRH have had on the health workforce in developing countries. Our analysis found that by far the most common activity supported across all agencies is short-term, in-service training. There is relatively little investment in expanding pre-service training capacity, despite large health worker shortages in developing countries. We also found that the majority of GAVI and the Global Fund grants finance health worker remuneration, largely through supplemental allowances, with little information available on how payment rates are determined, how the potential negative consequences are mitigated, and how payments are to be sustained at the end of the grant period. Based on the analysis, we argue there is an opportunity for improved co-ordination between the three agencies at the country level in supporting HRH-related activities. Existing initiatives, such as the International Health Partnership and the Health Systems Funding Platform, could present viable and timely vehicles for the three agencies to implement this improved co-ordination.

Effect of investment in malaria control on child mortality in sub-Saharan Africa in 2002-2008.

BackgroundAround 8.8 million children under-five die each year, mostly due to infectious diseases, including malaria that accounts for 16% of deaths in Africa, but the impact of international financing of malaria control on under-five mortality in sub-Saharan Africa has not been examined.Methods and FindingsWe combined multiple data sources and used panel data regression analysis to study the relationship among investment, service delivery/intervention coverage, and impact on child health by observing changes in 34 sub-Saharan African countries over 2002–2008. We used Lives Saved Tool to estimate the number of lives saved from coverage increase of insecticide-treated nets (ITNs)/indoor residual spraying (IRS). As an indicator of outcome, we also used under-five mortality rate. Global Fund investments comprised more than 70% of the Official Development Assistance (ODA) for malaria control in 34 countries. Each $1 million ODA for malaria enabled distribution of 50,478 ITNs [95%CI: 37,774–63,182] in the disbursement year. 1,000 additional ITNs distributed saved 0.625 lives [95%CI: 0.369–0.881]. Cumulatively Global Fund investments that increased ITN/IRS coverage in 2002–2008 prevented an estimated 240,000 deaths. Countries with higher malaria burden received less ODA disbursement per person-at-risk compared to lower-burden countries ($3.90 vs. $7.05). Increased ITN/IRS coverage in high-burden countries led to 3,575 lives saved per 1 million children, as compared with 914 lives in lower-burden countries. Impact of ITN/IRS coverage on under-five mortality was significant among major child health interventions such as immunisation showing that 10% increase in households with ITN/IRS would reduce 1.5 [95%CI: 0.3–2.8] child deaths per 1000 live births.ConclusionsAlong with other key child survival interventions, increased ITNs/IRS coverage has significantly contributed to child mortality reduction since 2002. ITN/IRS scale-up can be more efficiently prioritized to countries where malaria is a major cause of child deaths to save greater number of lives with available resources.

Long-term costs and health impact of continued global fund support for antiretroviral therapy.

BackgroundBy the end of 2011 Global Fund investments will be supporting 3.5 million people on antiretroviral therapy (ART) in 104 low- and middle-income countries. We estimated the cost and health impact of continuing treatment for these patients through 2020.Methods and FindingsSurvival on first-line and second-line ART regimens is estimated based on annual retention rates reported by national AIDS programs. Costs per patient-year were calculated from country-reported ARV procurement prices, and expenditures on laboratory tests, health care utilization and end-of-life care from in-depth costing studies. Of the 3.5 million ART patients in 2011, 2.3 million will still need treatment in 2020. The annual cost of maintaining ART falls from $1.9 billion in 2011 to $1.7 billion in 2020, as a result of a declining number of surviving patients partially offset by increasing costs as more patients migrate to second-line therapy. The Global Fund is expected to continue being a major contributor to meeting this financial need, alongside other international funders and domestic resources. Costs would be $150 million less in 2020 with an annual 5% decline in first-line ARV prices and $150–370 million less with a 5%–12% annual decline in second-line prices, but $200 million higher in 2020 with phase out of stavudine (d4T), or $200 million higher with increased migration to second-line regimens expected if all countries routinely adopted viral load monitoring. Deaths postponed by ART correspond to 830,000 life-years saved in 2011, increasing to around 2.3 million life-years every year between 2015 and 2020.ConclusionsAnnual patient-level direct costs of supporting a patient cohort remain fairly stable over 2011–2020, if current antiretroviral prices and delivery costs are maintained. Second-line antiretroviral prices are a major cost driver, underscoring the importance of investing in treatment quality to improve retention on first-line regimens.

The Global Fund's resource allocation decisions for HIV programmes: addressing those in need.

BackgroundBetween 2002 and 2010, the Global Fund to Fight AIDS, Tuberculosis and Malaria's investment in HIV increased substantially to reach US$12 billion. We assessed how the Global Fund's investments in HIV programmes were targeted to key populations in relation to disease burden and national income.MethodsWe conducted an assessment of the funding approved by the Global Fund Board for HIV programmes in Rounds 1-10 (2002-2010) in 145 countries. We used the UNAIDS National AIDS Spending Assessment framework to analyze the Global Fund investments in HIV programmes by HIV spending category and type of epidemic. We examined funding per capita and its likely predictors (HIV adult prevalence, HIV prevalence in most-at-risk populations and gross national income per capita) using stepwise backward regression analysis.ResultsAbout 52% ($6.1 billion) of the cumulative Global Fund HIV funding was targeted to low- and low-middle-income countries. Around 56% of the total ($6.6 billion) was channelled to countries in sub-Saharan Africa. The majority of funds were for HIV treatment (36%; $4.3 billion) and prevention (29%; $3.5 billion), followed by health systems and community systems strengthening and programme management (22%; $2.6 billion), enabling environment (7%; $0.9 billion) and other activities. The Global Fund investment by country was positively correlated with national adult HIV prevalence. About 10% ($0.4 billion) of the cumulative HIV resources for prevention targeted most-at-risk populations.ConclusionsThere has been a sustained scale up of the Global Fund's HIV support. Funding has targeted the countries and populations with higher HIV burden and lower income. Prevention in most-at-risk populations is not adequately prioritized in most of the recipient countries. The Global Fund Board has recently modified eligibility and prioritization criteria to better target most-at-risk populations in Round 10 and beyond. More guidance is being provided for Round 11 to strategically focus demand for Global Fund financing in the present resource-constrained environment.

Critical interactions between Global Fund-supported programmes and health systems: a case study in Lao People's Democratic Republic

In Lao PDR, investment by the Global Fund to Fight AIDS, Tuberculosis and Malaria has played an important role in scaling up the response to HIV and tuberculosis (TB). As part of a series of case studies on how Global Fund-supported programmes interact with national health systems, we assessed the nature and extent of integration of the Global Fund portfolios within the national HIV and TB programmes, the integration of the HIV and TB programmes within the general health system, and system-wide effects of Global Fund support in Lao PDR. The study relied on a literature review and 35 interviews with key stakeholders using the Systemic Rapid Assessment Toolkit and thematic analysis. In Lao PDR, the HIV and TB programmes remain vertical and mostly weakly integrated with the general health system. However, Global Fund investments have extended the network of facilities delivering care at local level, resulting in greater integration with primary care and improved access for patients, particularly for TB. For HIV, as the prevalence remains low, services primarily target high-risk groups in urban areas. Less integrated functions include procurement and drug supply, and monitoring and evaluation. HIV and TB programmes are only starting to coordinate with each other. Global Fund-supported activities are generally integrated within the national disease programmes, except for monitoring and evaluation. Synergies of Global Fund support with the health system include improved access to services, institutional strengthening and capacity building, improved family planning (with wider condom distribution through HIV/AIDS social marketing programmes), and the delivery of add-on interventions, such as vaccinations and health education, alongside Global Fund-supported interventions at community level. Unintended consequences concern the lack of alignment between national stated priorities (maternal and child health) and the strong focus of external partners, such as the Global Fund, on financing communicable disease programmes.

System-wide effects of Global Fund investments in Nepal

Nepal, with a concentrated HIV epidemic and high burden of tuberculosis (TB) and malaria, was perceived to have immensely benefited from grants by the Global Fund to Fight AIDS, Tuberculosis and Malaria in addressing the three diseases, amounting to total approved funding of US$80 million. This paper looks at the interaction and integration of Global Fund-supported programmes and national health systems. A mixed method 'case study' approach based on the Systemic Rapid Assessment Toolkit (SYSRA) was used to systematically analyse across the main health systems functional domains. The Country Coordinating Mechanism has been credited with providing the stewardship in attracting additional resources and providing oversight. The involvement of civil society for delivering key HIV and malaria interventions targeting high-risk groups was perceived to be highly beneficial. TB and malaria services were found to be well integrated into the public health care delivery system, while HIV services targeting at-risk groups were often delivered using parallel structures. Political instability, absence of continuity in leadership and sub-optimal investments in health were together perceived to have led to fragmentation of financing and planning activities, especially in HIV the programme. The demand for timely programmatic and financial reporting for donor-supported programmes has contributed to the creation of parallel monitoring and evaluation structures, with missed opportunities for strengthening and utilizing the national health management information systems.