MAXIMIZING POSITIVE SYNERGIES - World Health Organization

Objectives and Methodology
This study aimed to investigate the impact of the Global Fund on the provision of HIV/AIDS and TB
services in Tanzania, as well as on the wider health system. It sought to delineate how the national
disease control programs are organized with respect to the health system and to understand how
the Global Fund affects and, in turn, is affected by these organizational structures. Both intended
and unintended effects on the health system were considered.
The data collection for this case study included semi-structured interviews, field observations, and
examination of secondary data sources. Key informant interviews were conducted in a semistructured
fashion using a set of interview questions based on SYSRA and adapted to the analysis
of integration of health interventions [9,10]. Our analysis focused on the HIV/AIDS and TB
programs at the central, regional and district levels.
The sampling strategy for key informants targeted a diverse range of implementers, policymakers
and health leaders. The study used two sampling methods: purposive sampling and snowball
sampling. We conducted a total of 30 individual and group interviews. Our sample included 19
representatives from ministries or coordination and oversight bodies at the national level, three
from implementation partners in the NGO/FBO sector, two from the private health care sector, and
three from development partners. A total of 16 programme coordinators and managers from five
distinct districts were interviewed in a group format.
If informants consented, interviews were digitally recorded. The recordings were then used to
produce a set of detailed notes. Relevant sections of the interview were transcribed verbatim. A
framework approach was used to ‘rough code’ these notes and to chart data to the health system
functions described in the analytic framework developed by Atun and others [9]. Additional
information on the interaction between GHIs and the health system in Tanzania was gathered and
organized according to the WHO framework for health systems strengthening [11]. Secondary
data sources (e.g. national strategy papers, evaluation reports, Global Fund proposals) were
analysed in a similar thematic way. Primary and secondary data sources were compared for
internal validation of findings.
Results
Leadership and Governance
For effective and sustainable implementation of health activities, national governments need to be
able to exercise leadership: to set national level priorities and to oversee the development of a
strategic plan for the health sector and for the national responses to HIV/AIDS, TB and malaria.
There has been concern that global health initiatives (GHIs) like the Global Fund have undermined
this leadership capacity by imposing rigid conditionalities and guidelines. In Tanzania,
development partners provide a significant proportion of all health sector spending and, as such,
have considerable leverage over the national agenda. Interviews with stakeholders in Tanzania
suggest, however, that the activities supported by the Global Fund are considered to be largely in
line with the government’s own strategic objectives. Rather than influencing national priorities,
these funds are in effect helping to close the funding gap for existing priorities. The heavy
emphasis on HIV/AIDS, although possibly reinforced by the influx of large amounts of donor
money, is considered by stakeholders to be warranted by the severity of the disease burden.
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