Global Health Initiatives 2007 en

How have global health initiatives
impacted on health equity?

What strategies can be put in place to enhance their
positive impact and mitigate against negative
impacts?
A literature review commissioned by the Health

Systems Knowledge Network
January, 2007
Johanna Hanefeld, Neil Spicer, Ruairi Brugha, Gill Walt
Please send comments to Johanna.Hanefeld@lshtm.ac.uk and

Gill.Walt@lshtm.ac.uk .
1
Background to the Health Systems Knowledge Network
The Health Systems Knowledge Network was appointed by the WHO Commission on the
Social Determinants of Health from September 2005 to March 2007. It was made up of
14 policy-makers, academics and members of civil society from all around the world, each
with his or her own area of expertise. The network engaged with other components of
the Commission (see http://www.who.int/social_determinants/map/en) and also
commissioned a number of systematic reviews and case studies (see
www.wits.ac.za/chp/).
The Centre for Health Policy led the consortium appointed as the organisational hub of
the network. The other consortium partners were EQUINET, a Southern and Eastern
African network devoted to promoting health equity (www.equinetafrica.org), and the
Health Policy Unit of the London School of Hygiene in the United Kingdom
(www.lshtm.ac.uk/hpu). The Commission itself is a global strategic mechanism to
improve equity in health and health care through action on the social of determinants of
health at global, regional and country level.
2
Acknowledgments
This paper was reviewed by at least one reviewer from within the Health Systems Knowledge
Network and one external reviewer. Thanks are due to these reviewers for their advice on
additional sources of information, different analytical perspectives and assistance in clarifying
key messages.
This work was carried out on behalf of the Health Systems Knowledge Network established as
part of the WHO Commission on the Social Determinants of Health. The work of this network
was funded by a grant from the International Development Research Centre, Ottawa, Canada.
The views presented in this paper are those of the authors and do not necessarily represent the
decisions, policy or views of IRDC, WHO, Commissioners, the Health Systems Knowledge
Network or the reviewers.
3
How have global health initiatives impacted on health
equity?
Executive Summary
Global Health Initiatives (GHIs) have emerged as new models of development
assistance in the fight against diseases in low and middle- income countries over the
past decade. These structures are rapidly evolving and have succeeded in
leveraging significant new amounts of funding – an estimated US$ 8.9 billion was
spent on responses to HIV/AIDS alone in 2006.1 These expanded levels of funding
have the potential for making a major impact on health systems at country level, by
improving access to health services, prevention, treatment, care and support for
specific diseases.
This paper explores the impact of GHIs on health equity, looking specifically at those
involved in HIV/AIDS and focusing on gender equity. Three GHIs are examined in
detail: the US President’s Emergency Plan For AIDS Relief (PEPFAR); the World
Bank’s Multi-country AIDS Programme (MAP); and the Global Fund to Fight AIDS,
Tuberculosis and Malaria (GF). Together these GHIs provide significant levels of
funding for HIV/AIDS. All three GHIs focus primarily on alleviating the impact of
HIV/AIDS, but operate in very different ways.
Each of the GHIs is examined for policy, programme and funding references to
gender as a determinant of health equity and in relation to HIV/AIDS. We also
explore the policy-making process for each GHI, and highlight key recommendations
for further action. Since the three case study GHIs are relatively newly established,
empirical evidence relating to their impacts is limited.
The analysis suggests that PEPFAR’s overall approach to gender and women
appears to be characterised by attempts to counter women’s ‘vulnerability’, rather
than to promote women’s rights or entitlements, and that this may exacerbate
inequities rather than alleviate them in some areas. However, evaluations suggest
that the initiative has addressed some symptoms of inequity, by ensuring that access
to services and treatment reflects a gender balance: For example, 61% of those
receiving ARVs are women. While gender appears to have been neglected in past
MAP strategies, a new HIV/AIDS Programme revised in 2006 will specifically address
gender inequity. However, our report highlights continuing contradictions between
World Bank-supported macro-economic policies and MAP HIV/AIDS policies in many
countries – in relation to charges for education for example. The Global Fund
guidelines encourage countries to consider social and gender inequalities in their
funding applications, and the establishment of Country Coordinating Mechanisms
has the potential for more open participation in decision-making. Experience in
countries is however, highly context-specific. Analysis suggests all three GHIs may
have had some negative effects on human resources, potentially exacerbating
gender inequities, with, for example, the migration of health personnel from
comprehensive to disease-specific services.
1
This figure is the estimate for all funding for HIV/AIDS in 2006, not only funding leveraged
from GHIs. UNAIDS (2006) 2006 Report on the Global AIDS Epidemic; ch. 10 ‘Financing the
Response to AIDS’, p.224.However, two-thirds of funding for HIV/AIDS comes from the 3
GHIs covered in this paper GFATM (2006) Investing in Impact: mid-year results report 2006.
Geneva.
4
The analysis of the impact of these three GHIs on gender equity highlights the
importance of local knowledge to ensure that programmes are aware of, and
successfully address, gender inequities. The World Bank and Global Fund structures
appear more successful in drawing on stakeholders’ knowledge, or in highlighting
existing inequities. PEPFAR is the only GHI to set numerical targets globally and
nationally, and to monitor gender balances in reaching these targets.
The paper proposes nine key recommendations. GHIs should:
• Address explicitly the causes of gender inequities in access to health.
• Assess the impact of different interventions on social inequities.
• Include measures that are sensitive to gender and other equity priorities in
setting targets and monitor progress towards these.
• Enhance the collection of gender-disaggregated data.
• Use national policy processes for empowerment in order to facilitate greater

participation.
• Address GHIs’ impact on health systems and human resources.
• Harmonise activities and programmes across GHIs to build on comparative

advantage.
• Integrate social equity in access to health services within broader, macro-

economic and development policies.
• Monitor and evaluate GHIs impact on social equity.
5
How have global health initiatives impacted on health equity?
Introduction
This paper explores the impact of Global Health Initiatives (GHIs) on health equity,
looking specifically at GHIs involved in HIV/AIDS and focusing on gender equity.
Three GHIs are examined in detail, these are: the US President’s Emergency Fund
for AIDS Relief (PEPFAR), the World Bank’s Multi-country AIDS Programme (MAP)
and the Global Fund to Fight AIDS, TB and Malaria (GF). The paper concentrates on
low and middle - income countries as they overwhelmingly form the focus of GHI
expenditure on HIV/AIDS.
The paper further focuses on gender as HIV/AIDS disproportionately affects women

and the poor, and an estimated 70 percent of the world’s poor are women.2 Women
also carry the greatest burden of caring for others living with HIV/AIDS and orphans.
The volume of development assistance provided through GHIs means that their
impact on health systems especially in resource poor settings is significant. The ways
in which they engage or fail to engage with national health systems determine access
to health services for large parts or whole populations. The interventions they fund, if
they aim to address the causes of HIV/AIDS or any other focus disease, need to
address the wider social determinants of health, such as poverty, gender inequality
and discrimination. An assessment of Global Health Initiatives is imperative to
understand health systems and their development in many countries. It is equally
vital to develop appropriate and pragmatic strategies to successfully strengthen and
build health systems’ capacity to enable greater health equity.
Equity and health

Equity3 has emerged as a policy priority in global health assistance with the growing
realisation that aid and health sector reforms only benefit the poor and marginalised
sections of the population where issues of equity in access and outcomes of health
care are explicitly addressed.4
Equity of access to health services is not the same as equity in health outcomes.
Differences in outcomes arise through socio-economic circumstances external to the
health sector, or indeed to variations in quality of health services provided. Access to
health services is affected by many factors, including social and economic status
(including ‘race’ or ethnicity), demography (gender or age) and geography. For
example discrimination by staff against a particular section of the population might
result in less effective services for that particular group.
2
Sen, G., George, A., Oestlin, P. (2002) ‘Engendering health equity: a review of research and policy’, in
Engendering International Health, The Challenge of Equity, MIT Press, Cambridge.
3
For the purpose of this discussion equity or inequity needs to be differentiated from equality or
inequality in access to or attainment of health. Inequalities mean differences between different groups
without making judgements as to their fairness. Inequities refer to a subset of inequalities that are
deemed unfair. (Evans et. al. (2001) ‘Introduction’, p.4 in Challenging Inequities in Health, From Ethics
to Action; OUP). Indeed some inequalities in access, such as exemptions from user charges for the poor
or for high risk target groups, may be deemed equitable. Attaining optimal health should not to be
compromised by the social, political, ethnic or occupational group into which one happens to fall. To the
extent that disparities in health coincide with fault lines between such groups, these can be seen as
unfair and thus as constituting inequities. (Evans: 2001).
4
Gwatkin, D., Bhuiya, A., Victoria, C. (2004), ‘Making health systems more equitable’; The Lancet, Vol.
364.
JHanefeld, NSpicer, RBrugha, GWalt. LSHTM, London WC1E 7HT, UK 6

Equity and HIV/AIDS
While social equity has emerged as an overarching concern in development and

health, HIV/AIDS has particularly emphasised linkages between health and wider
socio-economic factors of inequity and inequality.5 Socio-economic inequalities
increase people’s risk of HIV infection, and once infected they act as barriers to
treatment, care and support for people living with and affected by HIV/AIDS.
HIV/AIDS also reinforces inequities and perpetuates underdevelopment and
poverty,6 including inequities linked to gender (see box 1).
Treatment and HIV/AIDS
Health systems play a key role in determining access to treatment and the care
people receive, including for HIV/AIDS.7 Gender, geographic location, income and
social status among others are factors determining equitable access to treatment,
and all are mediated through the health system. Costs associated with transport can
act as a barrier for people, particularly poor people in rural areas, and may act as a
deterrent to accessing health care, getting tested or even seeking treatment.
The linkages between treatment, morbidity and socio-economic status became more
starkly visible in the mid 1990s, when life-prolonging anti-retroviral drugs (ARVs)
were developed. Initially deemed too expensive and complex for public health care
systems in low and middle-income countries, by 2002 international political opinion
was shifting and treatment was increasingly an option in the South. However, the
availability of new and expensive treatments can exacerbate inequities, at least
temporarily, where access to treatment remains limited. In June 2006 WHO
estimated only twenty four percent of those requiring ARVs were receiving them
worldwide8, and while systematic evidence is scarce, many are concerned about
inequities in treatment access. In Zambia for example, one study on waiting lists for
ARVs noted that ‘…many … have the strong impression that people who are “better
off” are the ones getting access…’.9
The HIV/AIDS epidemic has increased pressures on already weakened health

systems. Problems are exacerbated by AIDS-related mortality among health care
staff in high prevalence countries, high burdens of care in health facilities: these
present major challenges for prescribing and treating people living with HIV/AIDS.10
An inherent feature of antiretroviral treatment (ART) scale-up in the poorest countries
is that ART centres are initially established in urban settings, where there is a health
infrastructure that can be augmented; and ART is rolled-out at a later point to rural
areas. Two of UNAIDS’ Three Scenarios for AIDS in Africa by 2025 envisage a slow
5
Parker, R. (2000) ‘Administering the Epidemic: HIV/AIDS Policy, Models of Development and
International Health’ in Whiteford, L., Manderson, L. Global Health Policy: The Fallacy of the Level
Playing Field; Boulder: London.
6
Sabatier R (1989) AIDS in the Third World; Panos Institute: London.
7
Jones’ study on Zambia cited below in the following also notes that ‘Discussions of scaling up ARVs in
Zambia must take place in the context of more general challenges of low coverage, poor quality and
insufficiently funded health care.’ Jones: 2005, p.85.
8
WHO (2006) Presentation by Kevin de Cock, HIV/AIDS WHO at the IAC Toronto August 2006. See
http://news.bbc.co.uk/2/hi/africa/4798343.stm. Accessed September 2006.
9
Jones, P.S. (2005), ‘On a Never-Ending Waiting List: Toward Equitable Access to Anti-Retroviral
Treatment? Experiences from Zambia’ p, 87. In Health and Human Rights; Vol.8, No. 2; Boston.
10
The G8 specifically recognised the debilitating impact of HIV/AIDS on the health care systems and the
aim of providing universal access by 2010. See Gleneagles Communiqué
http://www.fco.gov.uk/Files/kfile/PostG8_Gleneagles_Communique,0.pdf, accessed September 2006.

growth and stagnation around 20-25 % in the proportion of countries’ populations on

ART over the next 20 years.11
BOX 1: Gender, equity and HIV/AIDS
Gender is particularly relevant and important to assess in this context, as

HIV/AIDS disproportionately affects women. Women represent half of all
people in the world living with HIV/AIDS, and in sub-Saharan Africa they
constitute nearly 60% of all infections.12 An estimated 70% of the world’s
poor are women.13 These gender inequities are reflected in women’s
greater vulnerability to HIV/AIDS.
While gender is a determining factor in equity, it does not operate in

isolation, and must be considered alongside other socio-economic factors
that might determine a person’s access to health. 14 15
Women and girls are biologically more vulnerable to HIV infection than
men. They carry the main reproductive burden, and are more likely to be
affected by inadequate health services and treatment. They are also
affected by gender-based violence, increasingly recognised as a deeply
embedded and world-wide problem which has deleterious effects on
women’s health and wellbeing. The UN Political Declaration on HIV/AIDS
acknowledged in 2006 that ‘Gender inequalities and all forms of violence
against women and girls increase their vulnerability to HIV/AIDS’.16
Gender also determines socio and economic status, which increases

possible vulnerability to HIV infection. Women often have less access to
economic resources and are financially dependent on a husband or
partner. Where women find it difficult to gain formal or informal
employment they may be more likely to resort to transactional or
commercial sex, to ensure their survival and that of their children.17
Some cultural practices and norms may also make it harder for women to
protect themselves against HIV infection. For example enforcing condom-
use in a relationship may be difficult if the woman depends on her partner
for survival or income. A recent study of injecting drug users in Ukraine
found a higher incidence of HIV in female users than in male. Women
interviewed said that as the stigma facing female injecting drug users was
greater than that facing men, they were less likely to access prevention
services, which would identify them as IDUs.18 In some countries it is
11
UNAIDS. AIDS in Africa: Three scenarios to 2025. Geneva: UNAIDS.
12
UNAIDS website; http://www.unaids.org/en/GetStarted/Women.asp. Accessed October 5th 2006.
13
Sen, G., George, A., Oestlin, P. (2002) ‘Engendering health equity: a review of research and policy’,
in Engendering International Health, The Challenge of Equity, MIT Press, Cambridge.
14
Evans et al (2001), p.9.
15
Sen, G., George, A., Oestlin, P. (2002) ‘Engendering health equity: a review of research and policy’,
in Engendering International Health, The Challenge of Equity, MIT Press, Cambridge.
16 th
United Nations General Assembly. 60/262 Political Declaration on HIV/AIDS. 87 Plenary Meeting,
A/RES/60/262, June 2006. Sourced at http://data.unaids.org/pub/Reprot/2006/20060615
17
The Global Coalition on Women and AIDS (2006) Economic Security For Women Fights AIDS;
Briefing Note No 3.
18
International HIV/AIDS Alliance (2006), Recommendations from HIV/AIDS Alliance Study from
Alliance Ukraine gender study help improve the effectiveness of HIV prevention services;
http://www.aidsalliance.org/sw35159.asp. Accessed September 2006.

considered inappropriate for a woman to travel on her own to access care.

For example, in the Indian state of Uttar Pradesh, 80 percent of women
require their husbands’ permission to visit a health centre.19
Global Health Initiatives (GHIs) and gender equity – methods

Three global health initiatives are examined here: the US President’s Emergency
Plan For AIDS Relief (PEPFAR), the World Bank’s Multi-country AIDS Programme
(MAP) and the Global Fund to Fight AIDS, Tuberculosis and Malaria (GF). Together
these GHIs provide almost two thirds of external funding going to HIV/AIDS:
PEPFAR (21%), World Bank/UNAIDS (22%), Global Fund (21%).20 In 2003 US
President Bush pledged USD 15 billion over five years for addressing the epidemic.21
The World Bank MAP has provided USD 1.1 billion22 since 2000. The Global Fund
has committed USD 6.8 billion (2002-2006).23 All three GHIs focus primarily on
alleviating the impact of HIV/AIDS, but operate in very different ways.
For each of the GHIs discussed here references or acknowledgements to gender as

a determinant of health equity are examined, and where possible, the extent to which
this is translated into policies and funding guidelines. We also explore the policy-
making process for each GHI, and highlight key recommendations for further action.
Since all these GHIs are relatively newly established, empirical evidence is limited.
The report draws on a few studies which have been, or are being undertaken; some
relatively independent ‘grey’ literature, which may or may not be in the public domain;
and information provided by the GHIs themselves, UN bodies and aid agencies.
Materials used
A wide range of documents including academic and grey literature were

analysed as part of this study. Extensive use was made of the
evaluation reports, strategy papers and guidelines published by Global
Fund to Fight AIDS, TB and Malaria, by the US Office of the Global AIDS
Administrator and by the World Bank, including the consultation
documents about the World Bank’s new HIV/AIDS programme for sub-
Saharan Africa, which was revised throughout 2006. All of these
documents are available on the respective institute’s web sites and
where possible a web address has been provided.
Despite a lack of detailed information, especially about the longer-term

impact of many GHIs at the country level, at the time of writing there
was more information available about the Global Fund than about
PEPFAR, and while there is a body of literature that has examined the
19
World Bank (2005) World Development Report 2006, Equity and Development; OUP: New York; p.52.
20
Global Fund to Fight AIDS TB and Malaria. Investing in impact, mid-year results report 2006. Geneva:
GFATM.
21 th
http://www.pepfar.gov/ accessed January 11 2007.
22
World Bank
http://web.worldbank.org/WBSITE/EXTERNAL/COUNTRIES/AFRICAEXT/EXTAFRHEANUTPOP/EXTA
FRREGTOPHIVAIDS/0,,contentMDK:20415735~menuPK:1001234~pagePK:34004173~piPK:34003707
~theSitePK:717148,00.html. Accessed September 2006.
23
Global Fund to Fight AIDS TB and Malaria (2006) http://www.theglobalfund.org/EN/. Accessed
th
January 11 2007.

impact of wider World Bank policies throughout the 1980s and 90s on
health, very little independent analysis has focused on their Multi-
country AIDS Programme. The paper also draws on independent
evaluations of these global health initiatives, as well as the academic
literature that analyses and studies their impact. Sources also include
unpublished NGO reports, MSc and PhD theses. Most of this literature is
very recent and varies in rigor, objectivity and generalisability.
For the introductory definitions of equity, gender and their interactions

with HIV/AIDS writings on gender and health were consulted. Where
evidence, especially on country-level impact has been scarce, the
authors have drawn on their own on-going research and field work,
including materials presented at the XV International AIDS Conference
in Toronto in 2006.
The emergence of Global Health Initiatives

There have been two major, noteworthy changes in global health over the past
decade. First, development assistance for health has increased hugely: it is
estimated to have risen by 26% from USD 6.4billion in 1997 to USD 8.1billion in
2002.24 A significant new funder in health is the Bill and Melinda Gates Foundation,
providing some US$ 6billion for health alone between 1999 and 2006.25 The
mechanisms through which aid is being delivered have also expanded, from grants
and loans provided through bilaterals, multilaterals and the World Bank between the
1950s and 1990s, to include general budget support to governments and
performance-based funding in the 2000s, the former provided by bilaterals, the latter
initiated by the Global Alliance on Vaccines and Immunizations (GAVI) and the
Global Fund. Increasing interest is being shown in such funding.26
Second, the traditional donors in health (UN organisations such as WHO or bilateral
agencies) no longer dominate international health policy as they did until the 1980s.
The entry of the World Bank into health in 1984 heralded an opening of the health
policy environment.27 This was in part a response to disillusion with perceived
stagnation and bureaucracy in the UN agencies, and the growth of civil society
organisation activity, among other things.28 Some of these new entrants, such as the
Bill and Melinda Gates Foundation have had significant influence in global health
policy, both as a Foundation in its own right, but more as a partner with others.
Furthermore, the number of partnerships at the global level has proliferated
enormously. These are extremely diverse in nature, scope and size29 but they often
24
WHO 2006. Engaging for Health. Eleventh General Programme of Work 2006 – 2015. WHO: Geneva.
P5
25
http://www.gatesfoundation.org/GlobalHealth/Grants/default.htm?showYear=2006. Accessed October
2006
26
Barder and Birdsall (2006); ‘Payments for Progress – A Hands-Off Approach to Foreign
Aid’ Center for Global Development Working Paper 102.
27
Walt G Health care in the developing world, 1974 – 2001 in: Webster C (ed) Caring for Health: History
and Diversity, Open University Press: Milton Keynes (2001)
28
Buse K & Walt G Global public-private partnerships: Part 1 – a new development in health? WHO
Bulletin 78; 4; 549 - 561 (2000)
29
The Initiative on Public Private Partnership for Health, undertook a review of more than one hundred
global health partnerships and classified these into seven different categories: product development,
improvement in of access to health products, global coordination mechanisms, health service
strengthening, public advocacy, education and research, regulation and quality assurances and other.

involve a partnership between the more traditional development actors, such as

multilateral agencies, and new actors, such as private sector corporations, or
philanthropic entities such as the Clinton or Rockefeller Foundations.30 The
International AIDS Vaccine Initiative (IAVI) for example, combines the Gates
Foundation, private businesses, UN agencies and non-governmental organisations,
with the purpose of developing a new product (in this case an AIDS vaccine).31 The
Global Alliance on Vaccines and Immunization (GAVI) has some of the same
partners, but a wider remit, which includes the introduction of new vaccines,
strengthening existing childhood vaccinations as well as making inputs to the health
system. Others, such as the Stop TB Partnership, Roll Back Malaria or Global Polio
Eradication are more closely associated with WHO, and focus on fighting a particular
disease.
Some of these partnerships are called Global Health Initiatives, but nomenclature is
problematic. Initially called global public-private partnerships32, they have been
variously referred to as global health programmes or global public policy networks
among other names. Many organisations use the term to describe particular projects
– often around specific diseases. For example, the World Economic Forum has a
global health initiative which their website claims as the largest public-private sector
network tackling HIV/AIDS, TB and malaria.33 However, in general, most would agree
that GHIs include state and non-state partners, involve new funding or leveraging of
funds, and are shaped around a particular disease addressed through a strategy, or
set of interventions.34 While this definition covers most global health initiatives, it
would preclude PEPFAR, which is a bilateral initiative, between the US government
and recipient country partners. Brugha has summarised the various descriptions of
different GHIs and defined them as ‘a blueprint for financing, resourcing,
coordinating, and/or implementing disease control across at least several countries in
more than one region of the world’35. This definition includes PEPFAR.
The three GHIs examined in this paper differ from each other:
PEPFAR (the US President’s Emergency Plan for AIDS Relief), initiated in 2003,
is referred to as a GHI largely because of its disease focus (on HIV/AIDS) and as it
was initially designated to cover 15 countries addressing a global dimension to
disease control. As a government initiative its budget is dependent on approval by
the US Congress every year36, and it has a global strategy for HIV/AIDS treatment,
prevention and care, which follows a specific set of guidelines.37 There is little policy
www.ippph.org 2006. While this categorisation is useful, GHI’s often fit more than one of these
categories. Caines et. al in their study used four categories, research and development, technical
assistance/service support, advocacy and financing. (Caines et.al.: 2004)
30
Buse, K. et. al. (2000)
31
Some of the earliest examples of GHIs, such as the Mectizan Donation Program where partnerships
with the private sector involving donations of medicines or product development. Brugha, R.
(forthcoming), Buse, K. et. al. (2000).
32
Buse K & Walt G Global public-private partnerships: Part 1 – a new development in health? WHO
Bulletin 78; 4; 549 - 561 (2000)
33
See http://www.weforum.org/en/initiatives/globalhealth/index.htm. Accessed 5 October 2006
34
Caines study found that most GHI’s or GHPs, focus on communicable diseases and that 60% focus
on the ‘big diseases’ – HIV/AIDS, TB and Malaria. Caines, K. (2004) Addressing the impact of Global
Health Partnerships; DFID Health Resource Centre: London.
http://www.dfidhealthrc.org/shared/publications/GHP/GHP%20Synthesis%20Report.pdf. Accessed
September 2006.
35
Brugha, R. (forthcoming), p.4.
36
Brugha, R. (forthcoming), p.3.
37
It has also been included as a GHI in recent reviews of these structures, such as the McKinsey study
in 2005. McKinsey and Company (2005) Global Health Partnership: Assessing Country Consequences.

discussion on strategy at the country level, and the approach is largely top-down,
from Washington D.C. to the country level.
PEPFAR is coordinated by the Office of the US Global AIDS Coordinator in

Washington D.C., but most of its funding is channelled through existing US agencies
in the 15 countries (largely in Africa) where it is active. ‘Primary Partners’ implement
PEPFAR’s strategy at a country level. These include national and international non-
governmental organisations. They may include recipient countries’ governments. In
Guyana for example, the government’s Prevention of Mother To Child Transmission
(PMTCT) programme and the second-line anti-retroviral treatment is funded by
PEPFAR.38 Other ‘primary partners’ include private contractors or universities that
win contracts to implement aspects of PEPFAR’s country strategy.
Some primary partners provide grants to local ‘sub-partners’ who receive funding on
a competitive basis. In Zambia for example, PEPFAR works through 43 primary
partners who provide funding for 97 sub-partners. Thirty-four of the primary partners
in Zambia are not local.39
The World Bank, on the other hand, is a multilateral organisation, which introduced
its Multi-country AIDS Programme (MAP) in 2000 in 29 countries in Africa. It is
distinguished as a special initiative, and follows different structures and funding
mechanisms within the Bank. The World Bank has been revising its HIV/AIDS
strategy for Africa throughout 2006 and is expected to present an updated version in
early 2007.40 The aim of the World Bank MAP is to scale up the provision of HIV
related treatment, care and prevention services. It does this through the provision of
funds to government and civil society.41 The processes guiding MAP are relatively
participatory, and include funding of civil society organisations.42 The World Bank’s
Global AIDS Programme coordinates the overall mainstreaming of HIV/AIDS
activities across the Bank’s programmes and is responsible for the coordination with
other donors.43 Country-level activities funded by the MAP have to be aligned to the
respective country’s government’s strategy. A national HIV/AIDS coordinating
authority (e.g. National AIDS Councils) and a strategic plan or framework are
preconditions for countries to receive MAP funding. Since the nature of the
interventions funded is decided by the recipient countries, and fits into the national
38
Amnesty International (2006) ‘I am not ashamed’ - HIV/AIDS and Human Rights in the Dominican
Republic and Guyana;
39
PEPFAR (2006) Zambia – Partner and Sub-Partner Counts by Local Status, Organization Type and
Program Area (FY 2005) http://www.state.gov/s/gac/progress/other/data/partners/60461.htm. Accessed
September 2006.
40
Following an evaluation of the MAP in 2004, the World Bank presented a new Global HIV/AIDS
Program of Action in December 2005, and throughout 2006 has undertaken a consultation of its Africa-
wide HIV/AIDS programming, which will result in a new Agenda for Action on HIV/AIDS in Africa,
preliminary concepts, methodology and outline of the Agenda were presented in August 2006. These
different framework documents guide the World Bank’s overall HIV/AIDS work, and draw heavily on
MAP experiences. For part of the consultation documents, see
FRREGTOPHIVAIDS/0,,contentMDK:20411613~menuPK:717155~pagePK:34004173~piPK:34003707~
th
theSitePK:717148,00.html. Accessed January 12 2007.
41
World Bank brochure (2006) Multi-country AIDS Program for Africa.
42
49,000 NGOs have directly received funds through the MAP; World Bank MAP website
FRREGTOPHIVAIDS/0,,contentMDK:20415735~menuPK:1001234~pagePK:34004173~piPK:34003707
~theSitePK:717148,00.html. Accessed September 2006
43
Nandini Oomman, (2006) An Overview of the World Bank’s Response to the HIV/AIDs Epidemic in
Africa, with a Focus on the Multi-Country HIV/AIDS Program (MAP); HIV/AIDS Monitor; Tracking AID
Effectiveness; Centre for Global Development.
http://www.cgdev.org/section/initiatives/_active/hivmonitor/worldbankaids. Accessed September 2006.

HIV/AIDS plan, MAP funding effectiveness depends on strong national frameworks

and adequate implementation.
The Global Fund to Fight AIDS, Tuberculosis and Malaria is a funding

mechanism rather than an operational agency. It has no country presence, and
operates through a small secretariat in Geneva. Countries apply for funds, through a
Country Coordinating Mechanism (CCM), an independent, multi-partner body
operating at the national level. The introduction of CCMs has opened the policy
environment, allowing different stakeholders to take part in decision-making around
strategies to combat HIV/AIDS, TB and malaria. Applications for funding are judged
through a technical review process, by a set of Technical Review Panels, that make
recommendations to the GF Board. Funds are awarded to one or more principal
recipients (who may be government departments, national AIDS councils or civil
society organisations) at the country level, and are overseen by a local fund agent,
an independent auditor of expenditure and activities.44 Funds are released on the
basis of performance. One hundred and thirty six countries around the world receive
funding from the GF.45
Global Health Initiatives and equity
Given that most GHIs have only been in existence for a few years – the Global Fund
was launched in 2002, the MAP in 2000 and PEPFAR in 2003 – it is too early to
assess their longer-term impact on equity. Observers have noted both positive and
negative potential influences. There is little doubt that the large amounts of funds
flowing into HIV/AIDS programmes have increased considerably the numbers of
people living with HIV/AIDS who have received treatment, and that expenditure on
preventive activities and education has increased. How equal access is to these
services is not clear, and many suggest there is likely to be an urban bias in relation
to ARV treatment. Concerns have also been raised about diversion of attention and
resources from core problems such childhood diarrhoea or chronic alcohol related
diseases, disadvantaging already marginalised groups. On the other hand, other
usually stigmatized groups have gained from particular AIDS policies which have
focused on vulnerable groups such as sex workers and injecting drug users.46
There are a number of examples where GHIs have had some influence on national
policies. One study suggests that the Global Fund was able to affect HIV/AIDS
policies in China by making funding conditional on the revision of proposals regarding
harm reduction methods. Through this insistence, groups working with injecting drug
users, which had been excluded from policy fora, were invited to participate to revise
China’s HIV/AIDS policy.47 Others have suggested that the Global Fund, by insisting
on the formation of CCMs and the active participation of civil society organisations,
44
Global Fund Framework Document (2003)
http://www.theglobalfund.org/en/files/publicdoc/Framework_uk.pdf. Accessed October 5th 2006.
45
Global Fund website http://www.theglobalfund.org/EN/, Accessed January12th 2007.
46
International HIV/AIDS Alliance (2006), Recommendations from HIV/AIDS Alliance Study from
Alliance Ukraine gender study help improve the effectiveness of HIV prevention services;
http://www.aidsalliance.org/sw35159.asp. Accessed September 2006.
47
Van Kerkhoff,L et al (2006) ‘Linking global knowledge with local action: examining the Global Fund to
fight AIDS, Tuberculosis and Malaria through a knowledge systems lens’. Bulletin of the World Health
Organisation 84; 629 – 635.

has opened up policy processes to a wider community of people, information,

resources and facilitated rapid programme implementation.48
A systematic review of the effects of GHIs on health and equity has not yet been
undertaken. Because of the diversity of players at the country level, continuing
difficulties in harmonizing practices between donors, including GHIs, and problems in
measuring impact, there are continuing problems of attribution, with all GHIs (and
donors) wishing to claim impact around activities which are inherently co-funded
achievements. This is particular true with GHI-specific evaluations.49
The next section explores the extent to which GHIs have affected gender equity.
48
Pawinski & Lalloo 2006 Multi-sectoral responses to HIV/AIDS: applying research to policy and
practice. American Journal of Public Health; Vol 96, No 7; 1189 -91.
49
Bennet S, Boerma J, Brugha R (2006) Scaling up HIV/AIDS evaluation. The Lancet, 367;

Global Health Initiatives and gender equity

PEPFAR’s strategy on equity and gender
PEPFAR has acknowledged gender equity in its fight against HIV/AIDS and its
publications state that it is working to ensure that activities it supports ‘provide
equitable access to services for both men and women’.50 Monitoring data collected to
evaluate and report on PEPFAR’s implementation are gender disaggregated for all
interventions; however it does not establish gender-sensitive implementation targets.
Therefore, while PEPFAR can report that up to 2006, 61 % of all people receiving
ART through its funding were women, it does not specify how or who should be
reached to fulfil its target to provide treatment to two million people. Nevertheless, the
gender data it collects, reporting numbers and percentages of men and women
receiving services, provide a tangible way of measuring PEPFAR’s gender equity
effects.
As part of its focus on gender equity PEPFAR highlights its work to address
imbalances and gender discrimination within legal codes. Examples are community
level legal protection and female education in Zambia and Uganda, and support
around inheritance rights in Kenya.51 However, the longer-term interventions aimed
at addressing gender imbalances and changing causes for gender inequity are
harder to evaluate than the distribution of ART to target populations. Evidence on
the extent to which PEPFAR programmes have an impact on gender equity is mainly
anecdotal in its own monitoring reports, and limited to certain successful case
studies. PEPFAR’s strategy focuses on treatment, prevention and care, as the three
main areas of intervention. Within ‘care’ the specific burden of women as primary
care givers in many country contexts is recognised.52 Strategies aimed at providing
care for people living with HIV/AIDS and for orphans and vulnerable children (OVCs),
including the training of new staff, are seen as implicitly addressing gender inequity.
Treatment programmes funded by PEPFAR focus on the provision of anti-retroviral

medication, often building on existing government treatment programmes, but also
introducing its own clinical guidelines and conditions for ART programmes it supports
(see box 2). In 2005, 46 % of all PEPFAR funding was used for treatment. By March
2006, PEPFAR reported that of the 561,000 people that had received ART through
its support, sixty-one percent were women, which PEPFAR has viewed as an
indicator of its success in promoting gender equity.53
50
US Office of the Global AIDS Coordinator (2006), Action Today, A Foundation For Tomorrow: Second
Annual Report to Congress on PEPFAR; Available on http://www.state.gov/s/gac/rl/c16742.htm.
Accessed September 2006.
51
Annual Report to Congress on PEPFAR; Available on http://www.state.gov/s/gac/rl/c16742.htm., p. 67.
52
Office of the Global AIDS Coordinator (2003), The Presidents Emergency Plan for AIDS Relief, US
Five Year Global Strategy, p.43. See http://www.state.gov/documents/organization/29831.pdf. Accessed
September 2006.
53
US Department of State (2006), Factsheet: Making a Difference: Supporting Antiretroviral Treatment;
US State Department website http://www.state.gov/s/gac/rl/fs/2006/67451.htm. Accessed September
2006.

BOX 2 - PEPFAR and anti-retroviral therapy
PEPFAR funding can only be used to purchase medication approved by the

US Food and Drugs Administration (FDA). This excludes most generic,
cheaper versions of ARVs, even if these are WHO approved. This means
that the funding made available under PEPFAR regulations purchases
medication at a higher cost than monies available through the World Bank
MAP or the Global Fund. In other words, fewer medicines can be bought
with PEPFAR funding.
This policy means that governments need to adopt flexible and sometimes
complex strategies to ensure funds are used equitably and to greatest
effect.54 In Guyana for example, the government is using Global Fund
money to buy all first-line ART generically for patients, while PEPFAR
funding is only used in its PMTCT programme and for second-line
treatment, where fewer generic medicines are available. Such pragmatic
responses illustrate how countries are successfully adapting and
incorporating the conditional support of GHIs into their national
programmes. However, in other countries, like Zambia, where the
combined funds from the Global Fund, PEPFAR and the government are
insufficient to provide treatment for all people who require it, PEPFAR’s
policy may mean fewer people access medication.
Prevention
PEPFAR’s approach to prevention is called the ABC approach: Abstinence until

marriage, Be Faithful, and Condom-use55. PEPFAR prevention strategies focus on
abstinence approaches in young people, specifically on the delay in onset of sexual
activity, and faithfulness in marriage. Condom distribution is recognised as a
prevention strategy for people engaging in ‘high risk’ behaviour.56 However women
are not normally perceived by PEPFAR as high risk, unless they are sex workers,
substance abusers or sexually active in discordant couples. This effectively means
that the majority of women are not targeted by prevention campaigns or interventions
that involve condoms.
UNAIDS estimates that 80 percent of new infections in sub-Saharan Africa occur

through heterosexual intercourse, and that 60 percent of new infections are in
women.57 While precise proportions are not available, many HIV transmissions occur
within marriage.58 In this light the prevention approach championed by PEPFAR,
54
PEPFAR’s clinical guidelines recommend commencing ART when a patient’s CD4 count is 300 or
below; whereas WHO’s guidelines, which have been adopted by most HIV/AIDS endemic and aid
recipient countries, recommend ART be initiated at the lower CD4 count of 250. The consequence is
that, under PEPFAR guidelines, more patients will be placed on ART using more expensive ARVs than
those sourced with support from other donors.
55
Five Year Global Strategy, p.24. See http://www.state.gov/documents/organization/29831.pdf. Accessed
September 2006.
56
‘High risk populations or behaviour’ are described as including, people engaging in casual sexual
encounters, sex work, injecting drug use, migrant workers, men who have sex with men, or discordant
couples.
57
UNAIDS, UNFPA, UNIFEM. Women and HIV/AIDS: Confronting the Crisis. 2004;
http://genderandaids.org/downloads/conference/308_filename_women_aids1.pdf . Accessed September
2006
58
CHANGE has analysed data according to marriage onset of sexual activity and PEPFAR funding for
many of the focus countries. Centre for Health and Gender (CHANGE) (2005) Risk and Reality: US

which appears to assume that ‘be faithful’ is an appropriate preventive measure

within marriage is insufficient.59 In some countries heavily affected by HIV/AIDS,
including in Southern Africa, couples often live apart for long periods of time due to
labour migration or for other economic reasons; this tends to increase the likelihood
of multiple sexual partners even when married. In such a context, a policy stressing
‘fidelity in marriage’ over condom-use may lead to HIV infection of women, who are
consistently ‘faithful’ to their partners. It may also reinforce social norms or
perceptions that make it difficult for women to enforce condom use.
HIV testing
PEPFAR’s prevention strategy includes a focus on prevention of mother to child

transmission (PMTCT), through short course ART prophylaxis and a routine offer of
HIV testing to pregnant mothers.60 As a result, in 2006, 69 percent of all people
tested by PEPFAR-supported counselling and testing were women.61 Routine
provision of testing for HIV has been subject to intense debate during the past years,
partly because of its potentially negative side-effects on women (see box 3). Routine
provision of HIV testing in ante-natal clinics may also create inequities in access, by
neglecting for example, non-pregnant or childless women, or men. The issue is not
confined to PEPFAR, but of the three GHI’s examined here, PEPFAR is the only one
to have actively encouraged adoption of a routine test for all pregnant women
receiving PMTCT services through its funding.
BOX 3 - To test or not to test
The fact that most people living with HIV are unaware of their status, has
emerged as a key policy concern. In addition to the stigma and fear that
might deter people from seeking an HIV test, many people do not have
access to an HIV test. In 2004 WHO and UNAIDS estimated that only ten
percent of people exposed to the virus and who needed a test had access
to voluntary counselling and testing services.62
Funding of HIV Prevention Programmes. See

http://www.pepfarwatch.org/pubs/9CountryCollectionAtAGlance.pdf. Accessed September 2006.
59
PEPFAR does acknowledge in its prevention approach that even women faithful to one partner can
be at risk either through sexual violence or the behaviour of their partner, but it is unclear how this is
informing prevention work with women, as fidelity appears favoured prevention approach. So for
example, PEPFAR’s fact sheet on gender, acknowledges male behaviour as a risk factor for women but
omits a mention of condoms use as a prevention strategy for women, and instead exclusively highlights
the need to target male behaviour. http://www.pepfar.gov/pepfar/press/76365.htm. Accessed January
12th 2007.
60
Five Year Global Strategy, p.23 and 25. See http://www.state.gov/documents/organization/29831.pdf.
61
US Office of the Global AIDS Coordinator (2006), Action Today, A Foundation For Tomorrowthis does
not appear to inform their prevention policy.
61
Five Year Global Strategy, p.23 and 25. See http://www.state.gov/documents/organization/29831.pdf.
61
62
WHO/UNAIDS (2004), Policy Statement on HIV Testing; http://data.unaids.org/una-
docs/hivtestingpolicy_en.pdf. Accessed January 15th 2006.

The issue of how to progressively scale up testing for HIV, while

respecting and protecting the human rights of all patients has caused
intense debate during the past years.63 At the time of writing WHO and
UNAIDS were consulting on a revised testing protocol that proposed a
provider–initiated approach to testing, marking a change from previous
approaches focusing more on patient-initiated testing.64
Much of the debate on testing centres on the gender dimension. The policy
of a routine offer of an HIV test to all pregnant women, instead of only to
those who request a test, may have unintended consequences. As
disproportionately more women than men are tested and aware of their HIV
positive status, women are more likely to face the negative consequences
of a positive test result. In contexts where stigma and discrimination
prevail, this may result in loss of housing or shelter, violence from a
husband or partner on disclosure, or loss of employment.65 66 Clearly,
population-wide coverage with PMTCT is beneficial, in terms of prevention
of vertical HIV transmission and should be beneficial to the mother, if her
current and future needs for ART are factored in. However, the risk
inherent in a target-driven GHI, which has attribution needs, is that the
longer term needs of women may fall by the wayside.
Sex work
PEPFAR recognises sex work (described in PEPFAR documents as ‘prostitution’), as

increasing people’s - mainly women’s - vulnerability to HIV/AIDS. The focus of its
work with sex workers is to develop alternative income-generating activities, and
create greater equality in the access to economic resources. However, a criterion for
eligibility to PEPFAR (and all other US) funding includes a requirement that recipients
pledge that they oppose sex work, including its legalisation. This part of PEPFAR’s
strategy has been criticised as working counter to best practice in engaging sex
workers.67
Organisations such as the Sangram Cooperative in western India have rejected US

funding, as it would make it impossible for them to continue their fourteen years of
working with sex workers.68 The opposition to sex workers and the strict conditions
that are imposed on work with them, might limit access to services for sex workers,
as well as access to information and tools to prevent HIV/AIDS infections, or legal or
63
For a summary of the debate, see ‘Special Focus on Emerging Issues in HIV/AIDS’, Health and
Human Rights; Vol. 8.2.; Cambridge, MA, 2005.
64
WHO (2006) Invitation for public comment on draft WHO/UNAIDS guidance on provider-initiated HIV
testing; http://www.who.int/hiv/topics/vct/publicreview/en/index.html. Accessed January 15th 2006.
65
Amnesty International, (2006), Report ‘I am not ashamed’ – HIV/AIDS and Human Rights in the
Dominican Republic and Guyana
66
The International Community of Women Living with HIV/AIDS (2005), ‘The International Community of
Women Living with HIV/AIDS: Point of View’, Health and Human Rights,Vol.8, No. 2.
67
Recognised best practice by UNAIDS includes the Sonagachi Project in Calcutta, which has centred
its engagement of sex workers around the need legal protection of their rights to enable them to be safe,
to fight stigma and discrimination and integrate sex workers into public life. Center for Health and
Gender Equity CHANGE, (2005) Policy Brief: Implications of US Policy Restrictions for Programs Aimed
at Commercial Sex Workers and Victims of Trafficking Worldwide.
http://www.genderhealth.org/pubs/ProstitutionOathImplications.pdf. Accessed September 2006.
68
Discussed in AlertNet; Kaplan, E. (2006) Pledges and Punishment,
http://www.alternet.org/audits/33284/?comments=view&cID=96620&pID=96270. Accessed September
2006.

care services they require. The condemnation and opposition to sex work and
prostitution adds to the stigma and discrimination.69
The ‘Gag Rule’
All US government funding, including PEPFAR, is subject to restrictions relating to

abortion services and information about abortion and family planning services. These
restrictions are referred to as the Global Gag Rule or the Mexico City Policy. 70 They
stipulate that no US funding can go to health services that provide abortion, or
organisations that provide information which includes the termination of a pregnancy
as a choice, or to those which conduct advocacy around such services. This means
that PEPFAR-funded programmes, including treatment and testing, cannot take
place in the same facility or be delivered by a provider who offers comprehensive
sexual and reproductive health services.
This also makes it difficult to use PEPFAR funding to strengthen overall health
systems. Where they are so used, it is to the exclusion of comprehensive sexual and
reproductive health services. One study in South Africa quoted a health department
official saying ‘PEPFAR won’t fund anyone that does abortions. We have given
women this right for twenty years. We have data to show our programs have
prevented septic death. It would not be acceptable for our province to apply for
PEPFAR funding because of the PEPFAR prescripts, which are not in line with our
government policies’.71
PEPFAR’s overall approach to gender and women appears to stress women’s

‘vulnerability’. It is not framed in terms of women’s rights or entitlements, a concept
which underlies many gender and health equity discussions.72 The approach to sex
workers (the majority of whom are women), and the restrictions on full information,
tools of prevention and comprehensive sexual and reproductive health services
reinforce gender inequities and are ‘paternalistic’ in approach. The routine offer of an
HIV test to all pregnant women, as part of PEPFAR funding policies, may be seen as
offering them a greater likelihood of giving birth to a HIV-negative baby. It also
reinforces women’s role and importance as carers and mothers, and may undermine
them as individuals whose human rights need to be protected and guaranteed.
On the other hand, such a view needs to be tempered in the light of the dramatic
scale-up in treatment access since the launch of PEPFAR, as well as the evolution
and perhaps an increasing flexibility in PEPFAR’s contribution to this scale-up. Its
own evaluation suggests that PEPFAR has gone at least part of the way to
69
Loff, B. et al (2003), ‘Can health programmes lead to mistreatment of sex workers?’, The Lancet, Vol.
361, Issue 9373, pp. 1982-1983.
70
The White House (2001) Restoration of the Mexico City Policy, Memorandum for the Administrator of
the United States Agency for International Development.
http://www.whitehouse.gov/news/releases/20010123-5.html. Accessed September 2006.
71
Ghanotakis, E 2006. Are Global Health Initiatives Responding to Evidence of a Link between Gender
Based Violence and HIV/AIDS? Unpublished MSc report, LSHTM, p22
72
Sen, A (2001), ‘Health Equity: Perspectives, Measures” in Evans, T. et. al. Challenging Inequities in
health: from ethics to action. OUP,

addressing some of the gender inequities, by ensuring that access to services and
ARVs reflects a gender balance.73
The World Bank MAP and gender equity
The World Bank MAP has received less attention than the Global Fund or PEPFAR,
or even the impact of wider Bank policies and lending on health equity in developing
countries. Given the unique position of the World Bank at the country level, especially
its impact on health systems, an analysis of MAP’s impact on equity, or that of other,
future World Bank HIV/AIDS initiatives, needs to have an awareness of these
broader linkages.
The World Bank as an organisation is committed to equity. ‘Equity, defined primarily

as equality of opportunities among people, should be an integral part of a successful
poverty reduction strategy anywhere in the developing world.’ 74, it states in its 2006
World Development Report – the World Bank’s flagship publication – which focuses
specifically on equity and development. However equity is not explicitly defined as an
objective in the available MAP documentation. The World Bank’s Global HIV/AIDS
Program for Action, which was reviewed in 2006, does recognise some of the
previous structural limitations of MAP programming, which have impacted on equity
of access to services. It also explicitly acknowledges that with the increased provision
of ART, equity is a concern.75
The World Bank does not set specific targets for numbers of people to be reached by
interventions; nor does it offer specific operational guidelines. A key feature of the
MAP approach is that programmes should be needs-driven and locally designed. In
addition to this reliance on country plans and systems for their implementation, MAP
has limited incentives for performance, and does not remedy underperformance in
specific ways.76 Furthermore, as MAP evaluations have reported, a lack of adequate
support and funding to Ministries of Health has meant that they have not been coping
with the demands imposed by the escalating HIV/AIDS epidemic, including the
demands imposed by MAP processes.77 In part these problems arose from the
‘learning -by –doing’ way in which the MAP has rolled out; and the late realisation by
the Bank of the importance of health systems in the response to HIV/AIDS. The MAP
review noted that it is vitally important for the Bank to revisit its support for health
systems.78 In its revised Global HIV/AIDS Program for Action the World Bank has
emphasised the need to ensure better national planning and frameworks, and better
monitoring & evaluation (M&E) systems.79
73
Five Year Global Strategy See http://www.state.gov/documents/organization/29831.pdf. Accessed
September 2006.
74
World Bank (2006) Equity Enhances the Power of Growth to Reduce Poverty: The World
Development Report 2006.
http://web.worldbank.org/WBSITE/EXTERNAL/NEWS/0,,contentMDK:20653001~pagePK:64257043~pi
th
PK:437376~theSitePK:4607,00.html. Accessed January 15 2006.
75
World Bank (2005), Global HIV/AIDS Program for Action; Briefing Note/Summary;
76
World Bank (2004)
77
World Bank (2004)
78
Nandini (2004), p.11
79
World Bank (2005), Global HIV/AIDS Program for Action; Briefing Note/Summary;

Gender
The 2004 Interim MAP report specifically noted that, despite its importance, the need
to ensure gender equity was completely absent from proposals and national
frameworks in all but one of the six countries reviewed.80 This meant that
programmes funded through MAP had not considered either the impact of gender
inequities in the design of services, nor the contribution MAP-supported programmes
might have towards promoting gender equity. In response, the World Bank
developed an Operational Guide on Integrating Gender into HIV/AIDS Programming,
in November 2004, recognising that its funding and programmes were failing to
address these issues.81
The Bank’s Global HIV/AIDS Program for Action outlines how it will expand its
gender related activities and operations, focusing mainly on legal frameworks,
including women’s inheritance and property rights, and gender- based violence.82 If
implemented, these interventions will help address some of the underlying factors of
gender inequity and could promote greater equity in HIV/AIDS prevention, treatment,
care and support. However, the consultation documents for the Agenda for Action in
Sub-Saharan Africa list gender concerns only under impact, rather than as one of the
underlying determinants that needs addressing.
World Bank policy beyond the MAP
Given other World Bank and International Monetary Fund (IMF) lending and funding
policies, and the Bank’s unique position as a development agency, Bank evaluations
have commented on the lack of integration of gender analyses into its wider
development planning processes83. The World Bank’s own 1997 health strategy,
outlining its support for health systems, did not include an HIV/AIDS component,
which probably reflects its lack of engagement with the epidemic at that time.84 World
Bank macro-economic policies, during the 1980s and 90s, militated against attempts
address inequities, and were seen as likely to increase gender inequities, in access
to health services, as well as in the prevention of diseases85 (see Box 4.). During the
later 1990s the World Bank changed its policies to address some of these
shortcomings and both the World Bank MAP, as well as its Poverty Reductions
Strategy Papers are policy instruments aimed at addressing these.
Despite these changes the World Bank’s own evaluations of MAP and its
consultation documents acknowledge the lack of integrated planning as a
80
World Bank (2004), MAP Interim Review, p.9,
http://www.cgdev.org/section/initiatives/_active/hivmonitor/worldbankaids. Accessed September 2006.
81
The World Bank (2004), Operational Guide: Integrating Gender Issues into HIV/AIDS Programs.
http://www-
wds.worldbank.org/external/default/WDSContentServer/IW3P/IB/2005/10/11/000090341_20051011143
115/Rendered/PDF/337410Gender1and1HIV1AIDS1Guide1Nov104.pdf. Accessed September 2006.
82
World Bank (2005), Global HIV/AIDS Program for Action.
http://siteresources.worldbank.org/INTHIVAIDS/Resources/375798-1127498796401/GHAPAFinal.pdf.
83
Shakow, A. (2006) Global Fund – World Bank HIV/AIDS Programs; A Comparative Advantage Study;
84
HIV/AIDS Agenda for Action in Sub-Saharan Africa; Concept Note for Consultation;
theSitePK:717148,00.html.
85
Wagstaff, A. (2002), ‘Health sector inequalities and public policy’, Bulletin of the World Health
Organisation, 80: 97-105. de Vogli, R., Birkbeck, G. (2005) ‘Potential Impact of Adjustment Policies on
Vulnerability of Women and Children to HIV/AIDS in Sub-Saharan Africa’ in Journal of Population and
Nutrition; Vol. 23., No. 2.

shortcoming and aim to ensure that future HIV/AIDS related programming is

mainstreamed in other Bank development policies and instruments.86 The
consultation document for its ‘HIV/AIDS Agenda for Action in Sub-Saharan Africa’
specifically mentions the past failure to include HIV/AIDS concerns in Poverty
Reduction Strategies.
BOX 4 Zambia – HIV/AIDS and education
Female education is recognised as a key factor in HIV prevention.87 The

World Bank describes education in its own publications as a ‘social
vaccine’.88 Zambia is one of the poorest countries in the world89, ranked
166th on the Human Development Index and has a generalised HIV
epidemic.90 Women and girls are particularly affected by HIV/AIDS -
prevalence rates among 15-24 year olds are around 18 %,91 significantly
higher than in men (13%).92 While overall rates are only somewhat higher in
women (54%) and partly reflect their greater biological vulnerability, the six
times higher rate of HIV in 14-19 year old girls dramatically illustrates their
much greater vulnerability and the lack of effective measures and social
norms to protect them.
The Zambian government implemented many structural reforms during the

1980s and 1990s, including the liberalisation of its education and health
sectors.93 It has also implemented a budget reform programme, in repeated
efforts to achieve debt relief.94 Its reforms have often included adding an
HIV/AIDS component to other policy areas. Zambia’s Poverty Reduction
Strategy Paper (PRSP) has an HIV/AIDS component and conditions for
reaching Highly Indebted Poor Country (HIPC) completion point in 2005
included a national HIV/AIDS framework and the removal of fees in
education for primary school children.
Despite these many programmes aimed at integrating HIV/AIDS prevention

in all areas of policy, including the education sector, education from grade
86
World Bank (2004), MAP Interim Review; World Bank (2006), HIV/AIDS Agenda for Action in Sub-
Saharan Africa; Concept Note for Consultation;
theSitePK:717148,00.html Accessed September 2006. The World Bank (2005) Global HIV/AIDS
Program for Action; December 2005.
87
Brent, R. J. (2006), ‘Does Female Education Prevent the Spread of HIV/AIDS in Sub-Saharan Africa,’
Applied Economics, Vol. 38, Issue. 5. UNAIDS, UNFPA, UNIFEM (2004) Women and AIDS: Confronting
the Crisis, ch. 5. http://www.unfpa.org/hiv/women/report/chapter5.html. Accessed October 5th 2006.
88
World Bank website.
http://web.worldbank.org/WBSITE/EXTERNAL/TOPICS/EXTEDUCATION/0,,contentMDK:20298959~m
th
enuPK:613702~pagePK:148956~piPK:216618~theSitePK:282386,00.html. Accessed 5 October 2006.
89
Zambia also has a PRSP, received MAP funding and undertook a series of social reforms to achieve
HIPC completion point.
90
UNDP (2006) Human Development Index: Zambia;
http://hdr.undp.org/statistics/data/hdi_rank_map.cfm. Accessed September 2006.
91
2002 prevalence rates quoted in http://www.pepfarwatch.org/pubs/9CountryCollectionAtAGlance.pdf
92
WHO (2005), Summary Country Profile for Treatment Scale-up: Zambia;
http://www.who.int/3by5/support/june2005_zmb.pdf. Accessed September 2006.
93
Gilson, L. et al. (2003), ‘The SAZA study: implementing health financing reform in South Africa and
Zambia’, Health Policy and Planning, Vol. 18 (1); Zambia National Ministry of Education (2000), The
Development of Education, National Report of Zambia; International Bureau of Education.
http://www.ibe.unesco.org/international/ICE/natrap/Zambia.pdf . Accessed September 2006.
94
Times of Zambia (2005) HIPC Completion: How Zambia Achieved it

seven onwards is not free.95 Evidence also suggests that costs associated
with education, such as books and school uniforms impose a burden on
families that might prevent them being able to send their children to
school.96 The lack of free education for all appears paradoxical given
evidence that female education helps prevent HIV/AIDS, the particular
vulnerability of girls and young women in Zambia, and the Bank’s attempts
to address the impact of HIV/AIDS through MAP funding.
While the Bank has made attempts to integrate HIV/AIDS components into
policy instruments, it stopped short of using development policies to
address the inequities that drive the HIV/AIDS epidemic.
The Global Fund to Fight AIDS, TB and Malaria and equity
The Global Fund does not have a country presence. It enters into contracts and
disburses funds through national Principal Recipients (both governmental and non-
governmental) to address HIV/AIDS, tuberculosis and malaria. It does not set targets
but relies on countries to develop these as part of their national proposals, developed
by Country Coordination Mechanisms (CCMs). Its reliance on national recipients and
Local Fund Agents (LFAs) for programme monitoring and reporting also means that
the Fund has not collected data uniformly that are disaggregated by gender. The
Fund’s primary instrument to foster greater equity is through its founding policy and
implemented through funding guidelines. Its Framework states that the Fund ‘aims to
eliminate stigmatisation and discrimination against those infected and affected by
HIV/AIDS, especially women, children and vulnerable groups.’97 and to provide
funding for ‘public health interventions that address social and gender
inequalities…’.98
In addition to the national monitoring and evaluation framework that forms part of
country proposals, the Fund invites external evaluations and reviews, providing some
qualitative information about the different structures, processes and their impact. The
International Centre for Research on Women (ICRW) reviewed the Global Fund,
including its impact and approach on gender. The findings criticised the lack of
gender disaggregated data, and expressed a concern that its gender focus was
restricted to women’s representation on CCMs. This translated into a relative
absence of programmes addressing underlying factors contributing to women’s
vulnerability to HIV/AIDS infection and gender inequity. For example the review found
no specific reference to gender in relation to access to ARVs or to testing. ICRW
highlighted that until 2004 the main emphasis in targeting women had been on
PMTCT programmes. The authors also specifically noted the lack of programmes
targeting gender violence.99
95
Jesuit Centre for Theological Reflection (2006), How Free is Free Education: The Cost of Education in
Lusaka. July 2006. http://www.jctr.org.zm/downloads/Cost%20of%20Education%202006.pdf. Accessed
September 2006.
96 th
The Post Zambia ‘How free is Education in Zambia’, The Post Newspaper, Zambia: August 29
2006.
97
The Global Fund Framework, Section III, H10.
98
Ibid. Section IV, H.
99
ICRW (2004), Civil Society Participation in Global Fund Governance: What difference does it make?
Preliminary research findings June 2004.
http://www.theglobalfund.org/en/files/links_resources/library/studies/PP_PS2_full.pdf. Accessed
September 2006.

By mid 2006, when the Global Fund was designing a five year evaluation, it was
becoming increasingly apparent that the country level data available to it were
inadequate for its evaluation needs. The Fund was able to demonstrate the
allocation of its resources in relation to regional distributions of burden for the three
diseases, including allocations to regions with the highest proportion of the burden
(Africa) and to countries with the greatest numbers of infection. However, it did not
have data on how resources were actually spent for the purpose of assessing the
gender and other equity effects of scale-up in country programmes the Fund was
supporting.100 Lack of such data was an inherent feature of the Fund as a financing
instrument where data collected by LFAs was mainly for the purpose of accounting
for inputs to disease control. The availability of data on equity and gender effects in
scale-up was dependent on the capacity of country monitoring and evaluation and
reporting systems.
Country Coordination Mechanisms – an inclusive political space
The CCMs were a new body at the country level, opening a new political space for
participation by civil society, including previously marginalised groups. Differences in
the success of CCMs as participatory bodies that ensure country ownership have
highlighted how these structures can potentially promote equitable participation.101
Criticism of CCMs during the first rounds of Global Fund proposals was partly
attributed to a lack of clear guidelines from the Fund on CCM structure, function and
processes, with some observers describing CCM processes as a rubber stamping
exercises.102 Despite nominal involvement of NGOs on CCMs, in some countries
their processes displayed low levels of meaningful participation.103
The criticism of CCMs highlighted the need for clear communication and guidelines,
capacity-building and empowerment,104 which would help to promote equity and
empowerment of groups previously marginalised in the political spectrum. The Global
Fund responded by issuing a set of guidelines in 2003105, which were revised in 2004
to include detailed criteria for composition of the CCMs. These guidelines specify
sectors of representation and a minimum membership requirement of 40 percent
from non-government, non-donor (multilateral and bilateral) agencies. However, the
addition of a gender focus was somewhat vague and open to different interpretations:
‘the Global Fund encourages CCMs to aim at a gender balanced composition’.106 An
evaluation by the Global Fund of female participation in the CCMs found a global
average of 30 percent with regional variations from 45 percent in Latin America to
100
Personal communication from Brugha in providing technical support to the Global Fund Secretariat,
April to August 2006, in assessing the available evidence for answering the question: ‘Is theits report:
Review of the Global Fund fundingPortfolio. Funding the right things?’. Final draft, October 2006.
http://www.theglobalfund.org/en/files/terg/23_portfolio_rev.pdf
101
This section draws in particular on the evaluations of CCMs in Brugha, R. et al. (2005) The Global
Fund Tracking Study: a cross-country comparative analysis
102
Brugha, R. et al (2005).
103
Brugha, R. et.al. (2005), p.11. Common recommendations included the need for capacity – building
to enable participation, including funding, guidelines and communication.
104
These concerns are reiterated in Brugha, R. et al (2005), McKinsey (2005) and Shakov, A. (2006)
Global Fund-World Bank HIV/AIDS Programes; Comparative Advantage Study.
http://www.theglobalfund.org/en/links_resources/library/position_papers/gen2/. Accessed September
2006.
105
Global Fund to Fight AIDS, TB and Malaria. Guidelines on the Purpose, Structure and Composition
of Country Coordinating Mechanisms. June 4, 2003
106
Global Fund to Fight AIDS, TB and Malaria (2004) Revised Guidelines on the Purpose, Structure and
Composition of Country Coordinating Mechanisms and R Requirements for Grant Eligibility;
http://www.theglobalfund.org/pdf/5_pp_guidelines_ccm_4_en.pdf. Accessed September 2006.

only 18 percent in East Africa (see table 1 below for regional figures).107 The data
show that despite women’s equal, or in the case of HIV/AIDS, larger disease burden,
they have been under-represented on CCMs. In regions where women are
particularly disproportionately affected by HIV, such as in Sub-Saharan Africa, 32%
or fewer of the CCM’s members are women.
Table 1:
Region Percentage of women
CCM members
East Asia and the Pacific 31 %
Eastern and Central 37%
Europe
Latin America and the 45%
Caribbean
North Africa and the 28%
Middle East
Eastern Africa 18%
Southern Africa 32%
West and Central Africa 25%
South Asia 23%
Average and North 30%
A more recent study of CCM proposal development processes, which was

commissioned by the Global Fund and involved data collection in seven countries in
late 2005, sought information on how gender equity was being managed.108 The
perceptions among country stakeholders, most of whom were in the process of
drafting Round 5 proposals, were that it was difficult to get CCMs to focus on gender
mainstreaming and multi-sectoral responses, especially in Cambodia, Sri Lanka and
Cameroon where the proposal was health and ART-focused. Where gender equity
was given attention, e.g. Namibia and Nigeria, this was because countries had
already prioritised the issue. Even in these countries, several respondents did not
believe that this concern had been translated into equitable treatment of minorities
more broadly. These country findings highlight the limited capacity of a top-down
global initiative to drive what would be fundamental changes in country attitudes and
practices.
National health services – the risk of a vertical approach
For the implementation of all activities funded, the Global Fund relies on national
recipients, many of which are wholly or partly dominated by public sector bodies
Ministries of Health, National AIDS Councils). Its framework specifically highlights the
need to link with sectorwide approaches (SWAPs) and Poverty Reduction
107
The Global Fund to Fight AIDS, TB and Malaria; Technical Evaluation Reference Group, (2005),
Assessments of Country Coordinating Mechanisms: Performance Baseline Result Tables; ‘Table 1.2
Representation of women and non-governmental sectors on Country Coordinating Mechanisms’.
http://www.theglobalfund.org/en/files/about/terg/announcements/161205_CCM_Assessment_Results.pd
f. Accessed September 2006.
108
Wilkinson D, Brugha R, Hewitt S, Trap B, Eriksen J, Nielsen L, Weber W. Assessment of the
Proposal Development and Review Process of the Global Fund to Fight AIDS, Tuberculosis and
Malaria. Assessment Report. Global Fund No.: HQ-GVA-05-010. Euro Health Group.
http://www.theglobalfund.org/en/files/links_resources/library/studies/integrated_evaluations/GFTAM_Ass
essment_Report_7_March_2006_Final.pdf

Strategies.109 Studies have suggested that the funding and programmes

implemented by the Global Fund were seen as having exposed rather than having
caused weaknesses in national health and HIV control systems. 110 Initially the Global
Fund did not place a particular emphasis on support to health systems in its call for
proposals. However, by Round Five the Fund had invited specific proposals for
strengthening health systems and human resources to promote greater access to the
products and health services it was funding. Despite these efforts, some
commentators still see the Fund as inherently vertical, because of its disease-
focused funding. Verticalisation can create inequities in the health system and
weaken more generic health service components and distract attention from non-
focal diseases.111 The examples of human resources (see box 5) highlight the
potentially negative impact on health equity. However, it should be noted that the
Global Fund is ‘a learning organisation’ and later round proposals that sought support
for health workers were more likely to be successful than those submitted in Rounds
One and Two.
BOX 5: The internal brain drain – GHI’s and human resources
A study assessing the system-wide effect of the Global Fund in Ethiopia

showed how because of the insecurity about funding, the government has
been reluctant to increase salaries of staff in the health services.112 Human
resources are a major constraint in Ethiopia’s health system. To address
the human resource need created by the implementation of the Global
Fund proposal, medical staff were hired on consultancy contracts at triple
the salary available in the public sector. This has led to a verticalisation of
the health sector with staff moving from one section of the sector to the
next.113 It raises considerable concerns about the equitable access to
overall health services. In Ethiopia the study found that a lack of
integration of Global Fund projects with sexual and reproductive health
services led to staff moving away from sexual and reproductive health
services, and as a result a worsening human resources crisis in a part of
the health sector that is disproportionately accessed by women and girls.
Studies suggest that PEPFAR-funded health service providers are also

often paid higher salaries than those available in the public sector,
potentially creating an internal brain drain. In some settings PEPFAR’s
ability to pay higher salaries has led to health managers and programme
makers moving from government positions to local PEPFAR partners.114
In Guyana PEPFAR financed nine United Nations Volunteers doctors to

help alleviate the impact of HIV/AIDS. These UNV doctors however were
109
The Global Fund to Fight AIDS, TB and Malaria (2002) The Framework Document of the Global
Fund to Fight AIDS, Tuberculosis and Malaria; http://www.theglobalfund.org/en/about/how/. Accessed
September 2006.
110
Brugha, R. et al. (2005) The Global Fund Tracking Study: a cross-country comparative analysis
111
SWEF. Common Research Protocol. Monitoring and Evaluating the Health System-Wide Effects of
the Global Fund to Fight AIDS, Tuberculosis and Malaria. November 2003
112
Partners for Health Reform plus (PHRplus) Banteyerga, H.; Kidano, A., Bennet, S., Stillman, K.
(2005), System- Wide Effects of the Global Fund in Ethiopia: Baseline Study Report; p. 31
http://www.phrplus.org/swef.php?_number=5&PHPSESSID=e27d88460505fae66a22ef557cde7dfd.
113
Ibid, p. 34.
114
Personal Communication February 2006.

from India, Kenya, Nicaragua, Nigeria, Pakistan, Sierra Leone, Sudan,

Uganda, and Zambia - all low-income countries. Zambia, Uganda and
Kenya are also PEPFAR focus-countries.115 While this intervention
addresses the human resource crisis in Guyana, it is potentially worsening
the crisis in the countries of the physicians’ origins. The staff packages
that UNV doctors receive, including housing and schooling for their
dependents, are better than those a Guyanese doctor might receive, or
what is available to physicians in their own public health care sectors.
In the case described in Box 5, women’s access to quality sexual and reproductive
health services has potentially been undermined by Global Fund funding. Again,
these issues are not peculiar to the Global Fund and the problems related to the
migration of health workers between public and private services, as well as the
neglect of other, focal, diseases, are equity concerns for all GHI funding.
115 th
UNV (2005) News release, November 6 2005 ‘UN Volunteer doctors mobilised to combat HIV/AIDS
in Guyana’, http://www.unvolunteers.org/Infobase/news_releases/2005/05_10_05GUY_aids_doc.htm.

Global Health Initiatives – conclusions
Global Health Initiatives have emerged as a new model of development assistance in

the fight against diseases in low and middle- income countries during the past
decade. These structures are rapidly evolving and have succeeded in leveraging
significant new amounts of funding. At a country-level this funding has a potentially
major positive impact on poor people’s access to health services; and to prevention,
treatment, care and support for specific diseases. This new level of funding – US$
8.9 billion for HIV/AIDS alone in 2006116 - has the potential for making an immense
impact on health systems, and on wider issues of social equity that may affect
access to health care, including gender equity and women’s empowerment.
General characteristics
Despite the differences in the structures through which PEPFAR, the MAP and the
Global Fund operate, and the policies and programmes they fund or implement,
certain general characteristics about their effects can be observed.
By focusing on their strategies with regard to gender equity, this report suggests that
GHIs have an impact through their policies and programmes, and through the
processes that govern their policy design and implementation. PEPFAR’s policy to
ensure equitable access to ART for women serves as an example. It has directly
resulted in gender equitable access to such treatment. The Global Fund’s Country
Coordination Mechanisms have shown the potential of this process to empower
women, by providing new political spaces and by acknowledging their importance in
the political process.
However, GHIs also have unintended impacts on gender inequities. PEPFAR’s policy
of making an HIV test a condition for women to receive PMTCT, may further
exaggerate gender inequities, and a change in WHO guidance on the issue of testing
means that this will affect all GHI funding. Through the absence of guidelines that
require a gender focus, or specific targets relating to gender the World Bank MAP
has neglected the opportunity to include gender equity concerns as part of MAP-
funded national frameworks and programmes. All three GHIs are vertically shaped
around one or more specific diseases. This has impacted on other parts of the health
system, including human resources, and on the kinds of services available. The
evidence from Ethiopia suggests that due to a neglect of sexual and reproductive
health services, these may have worsened.
GHIs need to consider social inequities, including gender inequities, in designing

context-specific programmes, to ensure that these are equally accessible to women
and men. For example ensuring opening hours of a health facility that provides ART,
that take into account their circumstances, will allow female farmers to access these
services; and similarly the provision of health services that enable mobile male
workers, such as truckers, to receive treatment. Ensuring equity of access to health
services is, however, merely addressing the symptoms of underlying social inequities
116
This figure includes all funding for responses to HIV/AIDS, as estimated by UNAIDS, not
just those leveraged by GHIs. UNAIDS (2006) 2006 Report on the Global AIDS Epidemic; ch.
10 ‘Financing the Response to AIDS’, p.224. UNAIDS at the same time observes that funding
levels are actually slowing down for HIV/AIDS. Over two-thirds of the funding for HIV/AIDS is
provided by the three GHIs covered in this paper. GFATM (2006) Investing in Impact: mid-
year results report 2006. Geneva.

that determine access to health. These include poor access by women to economic
resources and their experiences of sexual violence. While all three GHIs examined
here have acknowledged the need to address the underlying causes of inequity, their
policies and funding so far fall short of fully addressing these.
GHI’s also need to ensure that they do not directly impact negatively on gender
equity. For example, despite a focus on the issue, PEPFAR funding requirements are
potentially resulting in inequities. The focus on faithfulness in marriage, the policy on
HIV testing, its condemnation of sex work and not approving the integration of
services with comprehensive sexual and reproductive health services for all women,
may increase inequities. PEPFAR may thus undermine the efforts of its own
programmes to be more gender equitable, and to successfully fight HIV/AIDS.
The World Bank, while having HIV/AIDS components in its other policy instruments,
has not integrated an analysis of its causes into broader development policy, as the
impact of its economic reform programmes on education shows. While increasing
efforts are being made to alleviate the impact of the epidemic, it is still not addressing
the root causes of inequities of access to health in its planning. The Global Fund
was designed as a purely financing mechanism for what would be a country-driven
process. Consequently, it is limited to issuing guidelines and norms and does not
collect or request data to determine if women or marginalised groups have equitable
access to services that it supports.
Comparative advantages
Each of the three GHIs examined has a very distinct structure and set of policies or
operational guidelines that impact on equity in a variety of different ways. These
different structures interact at the country level and one of the main challenges is to
ensure that this interaction is ‘harmonised’ and maximises the positive impact of
resources. However, in practice, the ‘harmonisation and alignment’ agenda117,118 has
paid little attention to ensure gender and marginalised population equity is not
sacrificed in pursuit of numbers-driven treatment targets.119 Competing claims to
satisfy initiative-specific attribution characterised the relationship between the GHIs in
2005,120 but by the 2006 International AIDS Conference, a consensus was being
reached that country specific scale-up targets were needed, which could facilitate the
future monitoring of gender -specific targets.
The most obvious difference between these three initiatives is that PEPFAR, as a
bilateral initiative, is more top-down, directive and proscriptive; and opportunities for
influencing and cooperating with it are limited. The World Bank and Global Fund rely
on countries to define strategies that are then funded or supported. This has an
impact on the ways in which they can foster or address inequities through their
funding. The dilemma for them is that their more bottom-up approach, supporting
countries to develop policy frameworks and strategic plans which they then fund, has
been an impediment to ensuring funds are targeted to addressing gender and other
equity concerns. Where PEPFAR might have an active strategy, designed and
defined internationally to address gender inequity, the Global Fund and World Bank
117
Global Task Team, Final Report 14 June 2005. Geneva: UNAIDS.
118
Paris Declaration on AIDS Effectiveness 2005;
http://www1.worldbank.org/harmonization/Paris/FINALPARISDECLARATION.pdf. Accessed January
15th 2007.
119
Bennett, S., Boerma, J., Brugha, R. (2006) ‘Scaling up HIV/AIDS evaluation’, The Lancet Vol. 367.
120
ibid

MAP have relied on fostering context-specific policies or structures. The World Bank
MAP, at least in the past, has missed some opportunities to foster the development
of programme proposals and national frameworks that address gender inequities.
PEPFAR and the World Bank have their own country-level oversight for
implementing structures, whereas the Global Fund is a funding mechanism, working
exclusively through local partners. This impacts on the kind of support and funding
each agency is best able to provide. The World Bank for example is well placed to
support and strengthen health systems, as well as to ensure that the impact on
equity in access to health is considered in other areas of development planning,
including poverty reduction strategies.
The World Bank and Global Fund structures appear more successful in drawing on
stakeholders’ knowledge in programme development, by requiring proposals and
strategies to be developed at the national level according to their respective
guidelines. Both the World Bank MAP and the Global Fund have introduced
guidelines to foster the inclusion of gender specific programming in proposal
development. The Global Fund, despite shortcomings, has been most successful in
using its policy-making process as a potential tool for empowerment and enabling
country-led programming.
PEPFAR is the only GHI examined here that sets numerical targets globally and
nationally, and monitors gender balances in people reached. Its approach has been,
in-effect, to set up parallel monitoring and evaluation (M&E) systems. The dilemma –
again for the World Bank and Global Fund – is that, where they have monitored
outputs, they have relied on national M&E systems. The weakness of these systems
and countries’ failure or inability to collect data that are disaggregated by gender and
other important stratifying factors (socioeconomic status and access to services) has
resulted in a failure to monitor the impact of the GHIs, and disease control scale-up
more generally, by equity criteria.
Overcoming this obstacle and strengthening countries’ systems capacity to monitor

outcomes and impact will require more joined-up action by the WHO (as the
normative UN agency) and the World Bank (as the agency with a particular remit for
country systems strengthening). This needs to be supported by more effective
conditionalities from the major funding agencies (including the Global Fund) to
ensure that strategies target inequities and that systems monitor their effectiveness.
It will also require a willingness among donors, especially PEPFAR, to sacrifice the
rewards of attribution that parallel monitoring provides. However, ultimately, it is
countries that need to take the initiative in establishing (and if necessary demanding
support for) programmes that address the underlying determinants of
marginalisation, including that of women; and then monitor their effectiveness. This
has been the case in Haiti, which has conducted empowerment programmes with
People Living with HIV/AIDS, Men who have Sex with Men (MSM) and Street
Girls.121
The level of funding and profile of GHI’s has meant that these have attracted
considerable attention during the past two years and a number of in-depth
121
Kunin-Goldsmith J, Laurenceau B. Protection, empowerment, and meaningful involvement of
PLWAs and vulnerable populations. Poster E7, XV1 International AIDS Conference, Toronto Canada,
13-18 August 2006.

evaluations, and comparative studies have been undertaken.122 These past

evaluations acknowledge the need for a greater focus on health systems, and
systemic impacts of GHIs, and the need for harmonisation. They do not fully address
GHI’s potential impact on social inequities, or on the strategies or structural changes
that are required to address the inequities that determine access to health. In
implementing the recommendations from these evaluations, GHI’s impact on social
equity needs to be addressed explicitly. At the same time, this discussion has
concentrated on the impact GHI have on gender equity, and a number of
recommendations are made here on how to address this issue more effectively.
These do equally depend on the overall effectiveness of individual health
partnerships or initiatives. They therefore need to be addressed together with other
recommendation for greater overall effectiveness of GHI’s.
Ultimately, none of the GHI’s examined will achieve their aims of successfully
responding to diseases like HIV/AIDS, TB and Malaria, unless wider issues of social
inequity are addressed. It is therefore imperative that social equity concerns are
reflected throughout all GHI policies, funding and processes.
Strategies for action – key recommendations

These recommendations refer in some instances to gender inequities specifically, but
they can and should be applied to all other socio-economic factors that might
determine access to health. They form an initial step for an advocacy strategy to
ensure equity in access to health services and ultimately in health outcomes.
1. Address explicitly the causes of gender inequities in access to health. GHIs

need to ensure that all interventions funded and implemented address the gender
inequities that might determine access health services, and ensure that programmes
and processes are equitably accessible to women and men. Programmes and
funding also need to address the causes of social inequity, such as gender inequity.
This includes gender violence, a lack of women’s access to economic resources, and
the full guarantee and protection of their rights.
2. Assess interventions’ impacts on social inequities. All policies and

programmes should be checked for their potential longer-term impact on social
inequities before being implemented. This will help avoid long-term negative
consequences, which might perpetuate existing social inequities or create new ones
(for example the PEPFAR policies on sex work). Such assessments need to be
country-driven and participatory, including all sections of a population.
3. Include measurements that are sensitive to gender and other inequities

when deciding targets. This includes targets of numbers of people to be reached by
Global Health Initiatives. Existing targets set such as the Millennium Development
Goals and the national and global targets set for universal access need to be
adjusted to reflect this. Where GHIs do not have a global target, an equitable global
target, to be reached through cumulative programmes funded, can be a strategy to
122
These include the McKinsey study (2005), Shakov, A. (2006), Caines, K. et. al. (2004) Assessing the
Impact of Global Health Partnerships; DFID Health Resource Centre
http://www.dfidhealthrc.org/shared/publications/GHP/GHP%20Synthesis%20Report.pdf#search=%22DF
ID%20impact%20of%20Global%20health%20partnerships%22. Accessed September 2006. And
Brugha, R. et. al. (2004) the Global Fund Tracking studies, country and comparative studies. See
http://www.ghin.lshtm.ac.uk

ensure greater health equity. Targets should measure health outcomes as well as
services provided. This will monitor the quality of services, and safe-guard against
discrimination.
4. Enhance the uniform collection of gender-disaggregated data. To enable

monitoring of equity in access to services and participation in political processes,
disaggregated data needs to be collected, and should be specifically gender
disaggregated, including for the provision of health care services, prevention services
and political process.
5. Use policy-making processes for empowerment. The policy design and

implementation processes can address gender inequities by creating new political
spaces for public debate, participation and empowerment. GHIs need to ensure their
policy processes are open, and that they can capitalise on opportunities for
redressing inequities. This includes equitable representation in policy processes and
funding for capacity-building that will enable meaningful participation.
6. Address GHI impacts on health systems and human resources. Global Health
Initiatives need to address the system-wide impact of their programmes and funding
to avoid verticalisation and distortion of health systems and human resources. This
is essential to ensure that access to health services does not become less equitable
as a result of GHI’s interventions. This includes ensuring that incentives between
services are not subject to major imbalance. Particular attention needs to be paid to
their impact on sexual and reproductive health services.
7. Harmonize to build on comparative advantage. To ensure equitable access to

health services, programmes and interventions, to provide services to as many
people as possible, and to ensure that programmes do not create inequities that
hinder access to health for specific parts of the population, such as women and girls,
GHI’s need to coordinate their activities at the national level and draw on each
other’s comparative advantage. Clear communication flows to all groups and
stakeholders is a vital first step in this.
8. Integrate social equity in access to health in other development policies.

Strategies that address gender and other inequities that might determine people’s
access to health need to be cross-referenced throughout all development assistance
and Poverty Reduction Strategies to ensure programmes funded and implemented
by Global Health Initiatives are not undermined by the effects of other development
assistance. This needs to go beyond having a disease specific component or
focusing on the impact of a health crisis on development, and ensure that the causes
of social inequities that determine access to health are considered and addressed.
9. Monitor and evaluate GHIs impact on social equity All M+E frameworks should
have an indicator assessing intervention successes and failures in addressing social
inequities. They should also have a set of indicators measuring wider socio-economic
inequities e.g. income distribution, access to education etc, to assess how GHIs
impact on these over time.

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How have global health initiatives

impacted on health equity?

A literature review commissioned by the Health

Johanna Hanefeld, Neil Spicer, Ruairi Brugha, Gill Walt

Please send comments to Johanna.Hanefeld@lshtm.ac.uk and

The paper proposes nine key recommendations. GHIs should:

• Address explicitly the causes of gender inequities in access to health.

• Assess the impact of different interventions on social inequities.

• Enhance the collection of gender-disaggregated data.

• Use national policy processes for empowerment in order to facilitate greater

• Address GHIs’ impact on health systems and human resources.

• Harmonise activities and programmes across GHIs to build on comparative

• Integrate social equity in access to health services within broader, macro-

• Monitor and evaluate GHIs impact on social equity.

The paper further focuses on gender as HIV/AIDS disproportionately affects women

Equity and health

JHanefeld, NSpicer, RBrugha, GWalt. LSHTM, London WC1E 7HT, UK 6

Equity and HIV/AIDS

While social equity has emerged as an overarching concern in development and

Treatment and HIV/AIDS

The HIV/AIDS epidemic has increased pressures on already weakened health

JHanefeld, NSpicer, RBrugha, GWalt. LSHTM, London WC1E 7HT, UK 7

growth and stagnation around 20-25 % in the proportion of countries’ populations on

BOX 1: Gender, equity and HIV/AIDS

Gender is particularly relevant and important to assess in this context, as

While gender is a determining factor in equity, it does not operate in

Gender also determines socio and economic status, which increases

JHanefeld, NSpicer, RBrugha, GWalt. LSHTM, London WC1E 7HT, UK 8

considered inappropriate for a woman to travel on her own to access care.

Global Health Initiatives (GHIs) and gender equity – methods

For each of the GHIs discussed here references or acknowledgements to gender as

A wide range of documents including academic and grey literature were

Despite a lack of detailed information, especially about the longer-term

JHanefeld, NSpicer, RBrugha, GWalt. LSHTM, London WC1E 7HT, UK 9

For the introductory definitions of equity, gender and their interactions

The emergence of Global Health Initiatives

JHanefeld, NSpicer, RBrugha, GWalt. LSHTM, London WC1E 7HT, UK 10

involve a partnership between the more traditional development actors, such as

JHanefeld, NSpicer, RBrugha, GWalt. LSHTM, London WC1E 7HT, UK 11

PEPFAR is coordinated by the Office of the US Global AIDS Coordinator in

JHanefeld, NSpicer, RBrugha, GWalt. LSHTM, London WC1E 7HT, UK 12

HIV/AIDS plan, MAP funding effectiveness depends on strong national frameworks

The Global Fund to Fight AIDS, Tuberculosis and Malaria is a funding

Global Health Initiatives and equity

JHanefeld, NSpicer, RBrugha, GWalt. LSHTM, London WC1E 7HT, UK 13

has opened up policy processes to a wider community of people, information,

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Global Health Initiatives and gender equity

Treatment programmes funded by PEPFAR focus on the provision of anti-retroviral

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BOX 2 - PEPFAR and anti-retroviral therapy

PEPFAR funding can only be used to purchase medication approved by the

PEPFAR’s approach to prevention is called the ABC approach: Abstinence until

UNAIDS estimates that 80 percent of new infections in sub-Saharan Africa occur

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which appears to assume that ‘be faithful’ is an appropriate preventive measure

PEPFAR’s prevention strategy includes a focus on prevention of mother to child

BOX 3 - To test or not to test