Abstract

Global health initiatives (GHIs) have gained prominence as innovative and effective policy mechanisms to tackle global health priorities. More recent literature reveals governance-related challenges and their unintended health system effects. Much less attention is received by the relationship between these mechanisms, the ideas that underpin them and the country-level practices they generate. The Global Fund has leveraged significant funding and taken a lead in harmonizing disparate efforts to control HIV/AIDS. Its growing influence in recipient countries makes it a useful case to examine this relationship and evaluate the extent to which the dominant public discourse on Global Fund departs from the hidden resistances and conflicts in its operation. Drawing on insights from ethnographic fieldwork and 70 interviews with multiple stakeholders, this article aims to better understand and reveal the public and the hidden transcript of the Global Fund and its activities in India. We argue that while its public transcript abdicates its role in country-level operations, a critical ethnographic examination of the organization and governance of the Fund in India reveals a contrasting scenario. Its organizing principles prompt diverse actors with conflicting agendas to come together in response to the availability of funds. Multiple and discrete projects emerge, each leveraging control and resources and acting as conduits of power. We examine how management of HIV is punctuated with conflicts of power and interests in a competitive environment set off by the Fund protocol and discuss its system-wide effects. The findings also underscore the need for similar ethnographic research on the financing and policy-making architecture of GHIs.

KEY MESSAGES

  • National and sub-national evidence on global health initiatives must move beyond its present approach of examining programme-level outputs within the framework of intended and unintended effects. There is a need to examine processes and practices triggered in recipient countries and how these are shaped by the policy discourse and its governance structures and mechanisms.

  • A critical ethnography of the organization and governance of the Global Fund in India reveals how the emerging hidden transcript of the resistances and power conflicts in its operations runs counter to the public transcript of its commitment to partnership, local participation and strengthening of health systems.

  • The resulting environment, with multiple, discrete and often unsustainable projects, each leveraging control and resources, is detrimental to an effective response to the AIDS epidemic.

Introduction

Global health initiatives (GHIs) account for a significant proportion of the global health architecture and are the subject of growing interest in the global health governance debate. In parallel, there has been an increased volume of literature seeking to understand key issues affected by these initiatives. In the last decade, literature has evolved in its focus: from recipes of ‘successful’ partnerships (Buse and Walt 2001; Dowling et al. 2004; Druce and Harmer 2004) and donor-commissioned country assessments, which focused on recipients’ capacity to manage grants (GAO 2005; Caines et al. 2004), to more recent empirical research on their governance and system-wide effects. The latter includes both country-specific impact studies and ‘broad brush reviews’ (Hanefeld 2008; Biesma et al. 2009; WHO Maximizing Positive Synergies Collaborative Group 2009; Spicer et al. 2010) as well as quantitative evaluation of GHI-specific disease outcomes (Komatsu et al. 2007; Bendavid and Bhattacharya 2009; Duber et al. 2010).

Despite differences across GHIs and a rapidly changing global health landscape, there is consensus on their substantial contributions to global health, national systems and outcomes. GHIs are credited with mobilizing significant funding, thereby raising the global profiles of target diseases and widening stakeholder engagement at global and national levels (Caines et al. 2004; Buse and Harmer 2007; Oomman et al. 2008; Biesma et al. 2009; WHO Maximizing Positive Synergies Collaborative Group 2009). Beyond their anticipated and evaluated gains, concerns have, however, emerged around their potential to undermine health systems capacities as a result of often disjointed and parallel structures and processes (Bennett et al. 2006). Conversely, GHIs regard system-wide deficiencies and ineffective country-level governance as limiting their intervention capacity (Travis et al. 2004). Improving co-ordination across GHIs, integrating health and targeted interventions and overall alignment with national priorities are key strategic areas in the more recent literature (Atun et al. 2010; Grundy 2010). Although significant for global governance and the health systems strengthening agenda, the evidence is inadequate on three counts.

First, analysis has focused mostly on the institutional environment or national governance; for instance, studies on Global Fund have examined the constitution and decision-making processes within and outside the country co-ordinating mechanism (CCM) for its effects on programme co-ordination (Biesma et al. 2009; Cavalli et al. 2010; Oliveira-Cruz and McPake 2011). Much less attention is paid to the ‘micro-politics’ and processes of creation and implementation of partnerships, and even less at sub-national and provincial levels.

Second, studies that examine effects or impact of GHIs at sub-national levels frame findings as positive–negative (or even ‘unintended’) consequences and attribute partnership failures to weak national governance and ill-defined host arrangements (Buse and Harmer 2007; Hanefeld and Musheke 2009; Spicer and Walsh 2012). No systematic evaluation is carried out to examine the implicit assumptions in the ‘intended’ and how it departs from the ‘unintended’. In other words, an uncritical view of GHIs themselves is put forward and studies fail to critically appraise practice in the light of the ideas and discourse that underpin creation and operations of GHIs and continue to grant them legitimacy.

Third, in a multi-country review of GHIs, Spicer et al. (2010) draw attention to the paucity of data in some countries and some areas. Although their study fills this gap by examining the context of few middle- and low-income countries, the evidence is lacking from South Asia. India presents a unique context given its success in seven of the nine calls launched by the Global Fund, the plurality of actors and the challenge presented by the scale and scope of the country.

With the operations of the Global Fund to fight AIDS, TB and Malaria (GFATM), henceforth the ‘Fund’, in India as its locus of enquiry, this article attempts to highlight the micro-level dynamics that remain concealed in the global and official discourse on GHIs. To do so, we adopt the framework of public and hidden transcript, introduced in the seminal work of James Scott, ‘Domination and the arts of resistance: The hidden transcript of subordinate groups’ (1992). The term public transcript refers to the surface or public interactions present in the systems of governance (Scott 1992, p. 2), which remain unchallenged or unexamined. For the purpose of this article, the public script is generated from the Fund’s own statements and commissioned work which it appears to acknowledge or endorse. It also includes official narrative generated by the grantees in response to the Fund protocols (e.g. the country findings of the operations research and reporting requirements) which often gets cited as the evidence of the effectiveness of the Fund programme. In contrast, the term hidden transcript refers to the resistances and discourses that take place ‘offstage beyond direct observation by power holders’ (Scott 1992, p. 4), which is concealed from the official global and national narrative on the grant success.

This is done in two corresponding sections of the article. First, we develop the public transcript of the Fund by describing (1) key organizing principles of the Fund, which support its claim of innovation and (2) its country-level governance structures and the grant-making processes. Second, we examine its operations, focusing on Round 4 of the Fund grant awarded to India. We contrast the official narrative on its structures and operations with the study findings. Specifically, two case studies highlight the dynamics of implementation, shifting allegiances of partners, the routines they adopt to translate policy ideas around partnership, participation and innovation into programme outcomes and the structural factors underpinning these phenomena.

Methodology

This article draws on the findings from a larger qualitative enquiry that set out to understand the discourse and practice of public–private partnerships through an examination of the governance of the Global Fund in India1 (Kapilashrami 2010). Critical ethnography (Carspecken 1996) was regarded as appropriate methodology for its adeptness in capturing the real-life context in a dynamic environment with multiple actors, which is characteristic of the Fund organization in India. Ethnography is also useful in describing, analysing and revealing hidden agendas from public transcripts and power centres (Thomas 1993). An intensive period of field study was undertaken between 2007 and 2009 in five Indian states: Maharashtra, Tamil Nadu, Andhra Pradesh and Karnataka, categorized as high prevalence and characterized by concentrated presence of donors and Fund grants, and Delhi, epicentre of ministries, donors and Fund governance. The selection of states corresponded to the sites of interventions proposed under different funding rounds to ensure insights from different contexts of implementation. Collecting data across these rounds enabled an understanding of how partnerships emerged and evolved and how actors perceived and reconstructed their changing roles.

The findings represent a sub-set of data collected in relation to Fund governance and its AIDS component in India. Informed by Carspecken’s (1996) methodological theory (and empirical technique) of critical ethnography, both monological and dialogical data were generated by the primary author through observation of project meetings and implementation sites; a short-term consultancy with a grant recipient2; documentary analysis of co-ordination meetings, published and unpublished performance reports; and 70 ‘in-depth’ interviews carried out with 94 respondents at various levels of Fund governance: 28 decision makers and officials at national and sub-national agencies, 41 project managers and administrators and 25 implementers across sub-recipient organizations referred in Table 1. Interviews were conducted by the primary author in English and Hindi. All but one respondent at a health facility could speak either of the two languages. On this occasion, assistance was provided by other facility staff present. All interviews were recorded and transcribed verbatim by the primary author. Key ‘themes’ and ‘categories’ were generated from the interview transcripts and field notes. Using these, relevant data were coded, examined for additional links, commonalities and contrasting perspectives. This informed the development of a coherent interpretation of the processes which was then written up as narratives or ‘emerging stories’. The synthesis of multiple data sources—notes from consultancy, observation, site visits and interviews—allowed the author to reduce the effect of biases within one source.

Table 1

Details of GFATM grant rounds approved for India at the time of this research

Rounds Component PR agency Sub-recipient/partner agency Activities Grant start date Funds approved (in million $) 
Round 1 Tuberculosis (TB) Department of Economic Affairs (GOI)     
 
Round 2 HIV and AIDS Department of Economic Affairs, Government of India (GOI) State AIDS societies (treatment) and sub-contracted NGOs (prevention and care) Prevention of mother to child; public–private antiretroviral delivery May 2004 92.7 
 
Round 3 HIV/TB Department of Economic Affairs (GOI) State AIDS societies Reducing TB morbidity in PLHAs and preventing further spread of TB, HIV in high prevalence states January 2005 14.82 
 
Round 4 HIV and AIDS Department of Economic Affairs (GOI) National AIDS Control Organization and State AIDS Societies (treatment) Antiretroviral delivery in six high prevalence states and Delhi September 2005 122.67 
PFI (Civil society consortium 1) CIIs, Network of people living with HIV, freedom foundation, engender health society Access to care and treatment in high prevalence states April 2005 18.2 
 
Round 5 Not approved for funding 
 
Round 6 HIV and AIDS Department of Economic Affairs (GOI)  Expanding access to antiretrovirals, testing and counselling (all states), community care centres October 2007 214.17 
PFI (Civil Society Consortium 2) Catholic Bishops Conference of India, Constella Futures India, Network of people with HIV Promoting access to care and treatment (eight northern states) June 2007 30.6 
India HIV/AIDS Alliance (NGO Consortium 3) Five NGOs in Andhra Pradesh, Delhi and Tamil Nadu Scaling up care and support services for children June 2007 14.38 
 
Round 7 HIV and AIDS Department of Economic Affairs (GOI)  Strengthening systems (human and institutional) capacity June 2008 87.8 
Tata Institute of Social Sciences  Strengthening institutional capacity for counsellor training institutes  
Indian Nursing Council  Strengthening institutional capacity for nurses training  
 
Total funds approved for India  595.34 
Rounds Component PR agency Sub-recipient/partner agency Activities Grant start date Funds approved (in million $) 
Round 1 Tuberculosis (TB) Department of Economic Affairs (GOI)     
 
Round 2 HIV and AIDS Department of Economic Affairs, Government of India (GOI) State AIDS societies (treatment) and sub-contracted NGOs (prevention and care) Prevention of mother to child; public–private antiretroviral delivery May 2004 92.7 
 
Round 3 HIV/TB Department of Economic Affairs (GOI) State AIDS societies Reducing TB morbidity in PLHAs and preventing further spread of TB, HIV in high prevalence states January 2005 14.82 
 
Round 4 HIV and AIDS Department of Economic Affairs (GOI) National AIDS Control Organization and State AIDS Societies (treatment) Antiretroviral delivery in six high prevalence states and Delhi September 2005 122.67 
PFI (Civil society consortium 1) CIIs, Network of people living with HIV, freedom foundation, engender health society Access to care and treatment in high prevalence states April 2005 18.2 
 
Round 5 Not approved for funding 
 
Round 6 HIV and AIDS Department of Economic Affairs (GOI)  Expanding access to antiretrovirals, testing and counselling (all states), community care centres October 2007 214.17 
PFI (Civil Society Consortium 2) Catholic Bishops Conference of India, Constella Futures India, Network of people with HIV Promoting access to care and treatment (eight northern states) June 2007 30.6 
India HIV/AIDS Alliance (NGO Consortium 3) Five NGOs in Andhra Pradesh, Delhi and Tamil Nadu Scaling up care and support services for children June 2007 14.38 
 
Round 7 HIV and AIDS Department of Economic Affairs (GOI)  Strengthening systems (human and institutional) capacity June 2008 87.8 
Tata Institute of Social Sciences  Strengthening institutional capacity for counsellor training institutes  
Indian Nursing Council  Strengthening institutional capacity for nurses training  
 
Total funds approved for India  595.34 

HIV/AIDS in India and the Global Fund

Administered by the federal government, the national response to the epidemic in India is structured as a vertical programme, currently in its third phase. With a separate organizational structure, administration and budget provision, the programme enjoys functional independence from the wider health system. It is led by the national AIDS control organization (NACO), a project management organization under the Ministry of Health and Family Welfare (MoHFW) which is responsible for formulation of policy, technical guidance, evaluation research and procurement of test kits, drugs and equipment. NACO implements the national HIV policy through 35 state-specific divisions officiated by senior bureaucrats and non governmental organisations (NGOs) sub-contracted to deliver community support programmes. More recently, with the launch of the Fund, NACO has forged newer alliances with the corporate sector and NGOs as co-recipients of the Fund grant. The third phase of the national programme (2007–2012) lays emphasis on treatment to people living with HIV (PLHA) and prioritizes prevention efforts in high-risk groups while scaling-up efforts in the general population. The programme articulates ‘mainstreaming’ and ‘partnerships’ as key approaches to facilitate multi-sectoral response and leverage technical and financial resources of the development partners. The first grant agreement with the Fund was signed in January 2003. A landmark decision by the Government of India followed in 2004 on the phased introduction of free antiretroviral treatment at select public hospitals in India.

The India portfolio of Fund grants has an approximate value of US dollars (USD) 1057 million with USD 738 million approved for HIV/AIDS alone, making the Fund the single largest external donor for HIV. Funding disbursed for Rounds 2, 3, 4 and 6 alone amounted to 44% of the external aid component and 25% of the total funds earmarked for third phase of the national programme (a substantial increase from 6% in the second phase; NACO website). As of May 2012, the Fund’s India portfolio has 15 grants in progress, 6 of which are being implemented by the MoHFW through its three divisions on HIV/AIDS, tuberculosis and malaria. Ten of these grants target HIV/AIDS and are implemented by NACO [as the operating principal recipients (PRs) for four], a private company, an academic institution, an autonomous Nursing council under Government of India and three NGOs, namely, The Population Foundation of India (PFI), India HIV/AIDS Alliance and Emmanuel Hospital Association.

The public transcript of the Fund

Key organizing principles of the Fund

The Fund was launched in January 2002 with the purpose of dramatically increasing the resources to combat AIDS, tuberculosis and malaria and improving investments in drugs to enable treatment for all. Similar to other GHIs, the Fund is constantly evolving and expanding in terms of its outreach, in-country presence and influence. Its current contribution is estimated at USD 22 billion approved for >600 programmes in 150 countries (GFATM 2012).

The public transcript of the Fund sets it apart from traditional bilateral assistance and other approaches to health financing by claiming:

  • Country ownership: It operates ‘only’ as a ‘financial instrument and not as an implementing entity’ (GFATM 2012) with no presence in the countries it supports. It is widely credited for its timely and most ‘efficient’ disbursement. A funding round is held every 9–12 months and grants are disbursed based on proposals led by country governments, thus underscoring a commitment towards ‘country-driven’ programs that reflect national and local ownership.

  • Inclusiveness and partnership: The fund is credited for being one of the first international mechanisms to directly fund civil society (Hanefeld 2011), thereby enabling participation of actors who have hitherto been peripheral to national policy spaces. The CCM is regarded as the primary mechanism for ensuring local participation of all communities.

  • Conditions precedents and legal provisions: These are conditions exercised through grant evaluation/scorecards and application guidelines that must be achieved by the recipient before funds can be disbursed or grant awarded. Failure to meet a condition precedent by the terminal date given by the Fund can lead to termination of the grant agreement.

  • Evidence-based and ‘performance-based’ funding, with emphasis on achievement of clear and measurable results and timely implementation rather than inputs and processes. This is regarded as an incentive for improved accountability at the country level and productivity in service delivery (WHO Maximizing Positive Synergies Collaborative Group 2009).

Structures of the Fund governance

Through a secretariat and a board in Geneva, the Fund awards grants on a competitive basis to PRs in countries, who then sub-grant to others. It exerts its country presence in recipient countries by contracting a local fund agent (LFA), an independent organization that provides oversight and verifies programmatic and financial information submitted by the grantees on the basis of which a grant is awarded or renewed. In India, the United Nations Office for Project Services served as the LFA during the study period, succeeded by Price Waterhouse Coopers. Central to country-level Fund governance is the CCM for programme oversight and a secretariat to administer day-to-day functions. According to the Global Fund Framework Document, the CCM process is where various stakeholders collectively develop country proposals, design locally sensitive (and appropriate) programmes and implement strategies.

With each new round launched by the Fund board in Geneva, the India CCM invites expression of interest across three disease areas. Proposals submitted by organizations, independently or jointly as a consortium, are reviewed by technical committees comprising select CCM members. Once endorsed (or declined), the CCM amalgamates shortlisted proposals into a single-country proposal. This internally agreed upon grant proposal is submitted to the Global Fund secretariat in Geneva, reviewed for feasibility by a Technical Review Panel and submitted to the Global Fund board for a final decision. On approval, grants are received and disbursed by the PRs.

The India CCM claims wide ranging stakeholder participation across the sub-continent (India CCM 2011). Set up initially in 2002, it underwent several rounds of restructuring to expand representation of civil society in concurrence with the evolving Fund guidelines. A CCM evaluation commissioned by the Fund in early 2004 revealed under-representation of non-state actors (restricted to two NGOs engaged in HIV prevention with partial assistance from NACO). Informed by similar findings from other studies, which highlighted government domination in country CCMs (Brugha et al. 2004; Grace 2004), the Fund introduced tighter stipulation around inclusion of civil society as PRs and 40% representation in the CCM. This led to two developments. First, the president of a prominent network of people living with HIV was elected as the vice-chair. Second, the India CCM endorsed the PFI as the second PR for the grant alongside the government (with NACO as the operating PR), which until then was the sole recipient of the Fund grants. In the subsequent rounds, other NGOs, private sector and academic institutions have played a similar role.

The emerging hidden transcript

Stakeholder participation and grant making through the CCM

A centralized mechanism to co-ordinate Fund activities across the diverse regional needs of the country was deemed inadequate, as reflected in a respondent’s view: ‘India being so large, people see this Delhi [CCM] sitting so remote from what is going on in states’.

Barriers to effective participation in the CCM were reported including:

  • Meetings were held around the launch of a new round either to finalize a country proposal or to submit the country progress report. As a result, the CCM’s ‘oversight’ role was reported as negligible.

  • Delays in notifying dates of meetings, prior to which significant volume of documentation had to be read, hindered participation of members particularly those from the southern states.

The processes of selecting CCM members and defining programme priorities were seen as arbitrary and non-transparent. NACO had a dominant presence in the general proceedings along with bilateral/multilateral agencies, who served as ‘technical experts’ in technical review committees, leaving little scope for participation of NGOs (interview transcripts and meeting notes). A respondent explained: ‘The Chair defers everything to NACO. Other two disease programmes don’t even get a look. Rest is very much about UNAIDS, WHO, NACO and that’s about it’. The vice-chair was regarded ‘voiceless’ in the proceedings. Inclusion in the CCM was seen as insufficient to guarantee equal treatment with other members. This observation corroborates the findings of the civil society consultation held by the AIDS Alliance in 2004.

The development and submission of the country proposal was described as ad hoc, rife with information lacunae and unsupportive to civil society. PRs recalled certain individuals, with the ability to work effectively in the context of extensive and complex application procedures, as key to successful bids and applications. These local, paid consultants were sought out by large organizations and much of the grant preparation process was transferred to them. The resulting proposal passed through several rounds of closed door negotiations that bypassed formal structures like the CCM. Describing the country proceedings for Round 7 proposal, a CCM member stated: ‘… a consortium from south [India] had put up a very unique proposal on workplace policy. It was selected by the technical committee but dropped from the final list [that was circulated for ratification]. I don’t know how.’

In contrast, an international NGO described its competitive edge in bidding for selection as a PR and in subsequent negotiations with NACO in securing the grant. ‘With a member of staff on the Geneva board, our profile within India increased substantially. We received support from our international colleagues else we would have made a mess … Few of us made regular trips to NACO office, behind closed doors … [and] succeeded in getting money back in the project again.’

The final country proposal is then ratified by the CCM, often within hours, and as reported by a senior officer within the Fund governance, submitted in person to meet the deadline: ‘Each time the person has to be flown to Geneva to make sure that 3 pm deadline is met. Time constraint has been such, for they [the Fund] require proposal to be sent online and 50 or so hard copies’.

Global Fund operations in India

The Fund’s annual grant-making cycle presents itself as an opportunity for diverse constituencies to forge new relationships, form new entities and participate in the national policy processes. Table 1 presents details on all grants approved for India until 2009 and highlights the constant spinning off of new projects. The rounds commence in sequence but run parallel, so much so that at any given time up to five rounds are running simultaneously, each with a distinct objective, partnership arrangement and funding. When the research was carried out, India awaited decision on the eighth round while funds from the first round remained unutilized.

Public transcript of the Round 4 activities

Round 4 marked a significant shift in Fund organization and governance in India, as the HIV component was led jointly by the NACO as one PR and PFI, leading a consortium of actors, as the second. This was seen as an ‘innovation’ catalysing widespread involvement of civil society to enable antiretroviral access through the public health delivery system (Country proposal Round 4). The proposal claimed a multi-stakeholder partnership between the government and the consortium, which included the corporate sector representative [Confederation of Indian Industries (CII)], two NGOs (Freedom Foundation and Engender Health) and the network of PLHA. NACO’s mandate was provision of testing and treatment services and included (1) antiretroviral therapy (ART) roll-out through selected public hospitals in selected states and (2) 10-bedded care centres sub-contracted to NGOs. The consortium on the other hand aimed at improving access and adherence to treatment in public facilities and providing care and support. Its project deliverables included a number of service delivery sites around different models of palliative care, support and adherence education: (1) positive living centres, (2) treatment counselling centres (TCCs), (3) care and support centres, (4) district networks of PLHA and (5) corporate ART centres.

Partnership dynamics and disruption: revealing the hidden transcript of Round 4

In practice, the partnership emerged as weak and activities developed across multiple service delivery sites with little demarcation of roles and increasing conflict among interests. ‘There is no link between the partners or projects. Everybody works in isolation. Engender Health has a good training curriculum but we attend NACO trainings for accreditation … It’s a lot of duplication.’ Conflicting views on the programme, its rationale and significance, implied increasing disagreements on competency of partners and the value they added to the programme. These, as highlighted in the cases below, became constant sources of distrust and tension between government and non-government partners.

Case study: a tale of two centres

An observable locus of this tension was the interface between the civil society consortium-run TCCs and government-run ART centres. The TCC was proposed to strengthen treatment adherence by offering counselling at the centres and outreach and follow-up (for retrieval of the missed and defaulter ART cases) in communities through the district-level PLHA networks. In the grant period, a total of 44 TCCs were established at the ART centres. However, when extending the Round 4 programme to other states, the TCC model was withdrawn and the following explanation was offered ‘… As the ART program scaled up and matured in the high prevalence states, the number of counsellors at the ART centres was increased on the basis of the volume of patients at the ART centres. The national program therefore perceived the need for increased outreach. The TCC strategy was therefore revised in June 2009 and the TCC counsellors placed at the district networks to address this gap’ [Rolling Continuation Channel (RCC) proposal, p. 44]. The account does not clarify the basis for recruiting new counsellors instead of integrating the TCC counsellors with the ART centres.

Conversely, our study findings suggest that the TCC, from the outset, was strongly resisted by senior officers at NACO, its state divisions and providers at the public facility. These respondents viewed the consortium members (in this case, the PLHA network) as driven solely by demonstrating results to the Fund. A senior medical officer and ART centre in-charge claimed: ‘… they are not doing anything worthwhile but are forced upon us. They got funding, started networks and are only interested in numbers’. Drawing attention to the abundance of counsellors at public facilities, they argued that TCC added little value to the programme. A senior bureaucrat at the state division of NACO said, ‘Rather than using VCTC3 counsellors who are more in number, you want to depend on these new entities and expect them to do outreach, which they hardly do. Some places you have their counsellors, other places you don’t. It is leading to confusion’. The duplication overburdened patients, mandating them to visit multiple counsellors in a single hospital visit, which a project officer argued, ‘results in additional costs [since] these patients are often poor, come from distant villages and are unable to complete such time consuming procedures’.

The consortium members, on the other hand, presented the resistance from the public health facility employees as a barrier to meeting programme objectives. Medical officers and counsellors were reported as unco-operative and unwilling to share patient information with the TCC staff on grounds of confidentiality. Lacking the necessary information, the project staff reported their inability to enrol patients into district networks. Fearing non-performance, they devised various strategies to increase enrolments and ‘maintain targets’. These included providing a free nutrition package, poaching patients queuing outside the ART centre and developing a new cadre of outreach workers to follow up people on treatment. The network staff was reportedly resented for having better salaries and working environment (with access to computers, separate offices and counselling space) despite lower qualifications and training. A network member shared: ‘They started saying, “We don’t want the TCC. They are making our lives miserable. Whose computer is it? Is it the doctor’s or the counsellor’s? If I don’t have one, how can the counsellor?” ’.

The friction could also be attributed to the failure to foresee and address accountability issues arising from the burden of procedures and technical reporting. The Fund’s reporting protocol demands quarterly consolidated reports developed by project officers on the basis of a large quantum of information and statistics generated at the implementation site using computerized information systems and documentation, such as patient forms, cards and registers. Visits to public hospitals revealed that on an average, 250–300 patients visited treatment centres daily. Most counsellors and other support staff (social worker, pharmacists and data entry operators) were expected to complete documentation alongside their primary duty of administering drugs and counselling clients. Given the burden of reporting, much of the patient–provider interaction observed at the centres was limited to the information sought in the forms (notes from site visits).

The internal conflict added chaos at the treatment roll-out site affecting the quality of counselling, follow-up and consequently adherence rates. It became clear that the low levels of support from the health facility staff and state divisions of NACO (and not the need for more outreach workers) explained the termination of the TCC model.

Case study: the business sector and HIV

An ambitious component of the Round 4 proposal was the involvement of the business sector in establishing and running ART centres for the general population. Heralded as ‘a true innovation’ and genuine public–private partnership where ‘corporate sector resources are leveraged for benefit of communities’ (Mohanty 2008), this initiative raised the profile of the consortium considerably with the Fund. CII, the corporate representative on the consortium, had the mandate of facilitating companies to establish 10 ART centres in the grant period, with four in the first 2 years. Yet, only two were set up by the third year of the programme.

The official narrative—generated from reports, publications (Mohanty 2008) and interviews with a few consortium members—attributed this delay to several factors, namely:

  • delay in assessment and accreditation of ART centres by NACO,

  • interference by NACO in identification of sites, and communication gaps between NACO and its state divisions, and,

  • irregular supply of antiretroviral, opportunistic infection drugs and test kits to the corporate ART centre.

A counter explanation attributed the holdup to companies’ reluctance to commit resources and management delays. Following the grant approval, dialogue with companies proved resource intensive and unproductive as they were unwilling to bear all costs of establishing and running the centres, as originally proposed to the Fund. A CII respondent reported, ‘having a positive person on antiretroviral implied … a long term investment, which the companies were not willing to commit to’. Companies were also reported as cutting costs, as noted by a company officer: ‘When we started with our own drugs, only those with less than 6 CD4 count, were put on anti retroviral’. Hence, once the grant was received, CII entered into negotiations with NACO to provide free drugs to companies. Terms were eventually re-negotiated such that the government will provide all drugs and laboratory reagents for the general population while companies bear infrastructure and antiretroviral costs for their workforce. The new alliance with NACO resulted in a reported increase in the number of patients receiving treatment and also enabled companies to bypass some of the bureaucratic hurdles of accreditation.

The location of the centre was also disputed, contributing to the delay. The two corporate ART centres that were launched at the time of the research were stand alone, that is not attached to company hospitals thus failing to provide inpatient facilities. This decision was reportedly taken by the companies’ management to protect themselves from risks such as demands for compensation arising from an AIDS-related death in the company hospital.

Notwithstanding the different accounts for the delay, the failure to meet targets resulted in friction among the consortium members. A consortium member reported ‘… since it [the corporate ART centres] is a component of our programme, the non-performance reflects on the entire consortium’. Members expressed dissatisfaction with the shift in the onus of financing the centres (from companies to the government) and for bypassing PFI’s authority while renegotiating the terms with NACO.

A high degree of competition was observed between the two projects—public and corporate ART centres. A corporate ART centre in-charge noted: ‘The government is due to start an ART centre in the neighbouring district. So numbers will definitely be a challenge. But once we get the reagents from NACO, the patients could be tested here and motivated to come here for ART … after all that is a government hospital’. As the corporate component stood at the time of the study, it failed to deliver on one of the main rationales behind partnering with for-profit private sector as it failed to shift the cost burden from the government programme. Although companies invested in infrastructural costs, this investment was small in comparison to the recurrent costs of drugs and reagents that government bore. Moreover, the corporate ART model was not aligned with the model of ART roll-out in public hospitals, which enabled access to inpatient services. This implied that patients who were at an advanced stage of the disease and required immediate treatment or admission were referred to a private clinic or public health facility despite the barriers to access. The corporate ART roll-out was not included in the next round of funding and consortium activities. However, CII was successful in securing an extension of the project through the RCC of the Fund with objectives of advocacy and quality assurance.

Discussion

Points of departure and disciplinary regime of the Fund protocol

There are several points on which the emerging hidden transcript of Fund activities in India departs from the public narrative adopted by the Fund.

First, commentaries on the grant application process (and CCM proceedings) described earlier depart from the Fund’s claims around the organic nature of proposals and enhanced participation of the affected communities. On the contrary, organizations’ success in securing grants was determined by their access to social, economic and political capital in the form of national visibility and international links, information (on grant rounds, priorities and requirements) and technical ‘expertise’ (in the form of consultants). These enabled ‘international’ NGOs or ‘transnational’ networks and large national or state-funded NGOs to serve as principal and sub-recipients or penetrate national policy networks and Fund governance structures such as the CCM. In contrast, local organizations, with insufficient clout and connections, had low rates of success in getting their proposals approved. Processes of decision making are increasingly situated within this complex hierarchical setting with token participation of local NGOs. Literature on GHIs highlights barriers to effective CCM functioning (Brown 2009; WHO Maximizing Positive Synergies Collaborative Group 2009). Although state dominance is widely reported, literature is less telling of the role of bilateral and international agencies in steering partnership arrangements and country proposals along with the elite national agencies.

Second, contrary to the CCM serving as a ‘multi-stakeholder partnership to oversee progress’, the CCM membership and proceedings are strictly confined to implementing the Fund protocol. Actors are brought together, without an explicit logic, in response to the yearly launch of the Fund rounds and in the earlier described rush to submit the country proposal. These arrangements are imposed on sub-national levels without clarifying the intent of partnership, resource allocation among partners and defining lines of authority and arbitration in case of failures. As a result partnership arrangements become instruments for exerting policy influence, advancing interests of national and transnational elites, and shifting, if not contradicting the purpose with which they were initially set up, as seen in the case of corporate involvement. At the implementation level, this vertical approach has led to differential access to capital generated through the grants and power conflicts among various actors attempting to manage the epidemic.

Third, the Fund’s emphasis on performance and evidence is regarded as an incentive for increased accountability and improved productivity at the country level (WHO Maximizing Positive Synergies Collaborative Group 2009). However, our findings suggest that not only do the increased demands of extensive, timely and structured reporting strain already weak health systems (previously widely reported in literature), they also impact the organic nature of partnership building, result in competition and affect the continuity (sustainability) of programmes in the funding cycle. Partnership ruptures in both case studies can be attributable to the competitive environment triggered by Fund governance, where demonstrating results and efficiency in absorbing funds became primary in shaping the relationship between partner agencies. Transition from one to the next round of funding, therefore, marked a shift in allegiance of ‘partners’, with organizations collaborating in one seen as adversaries competing for funds in another. Commenting on the impact of these multiple interventions and providers within a national programme, a senior bureaucrat in the state division of NACO expressed, ‘all these separate rounds and overlaps between them lead to confusion and chaos at the implementation level’.

The volume of literature examining the effects of GHIs has grown substantially in the recent years. There is wide consensus that there are few ‘unintended’ effects. For example, competition for scarce resources is a finding not unique to our study. Spicer et al. (2010) report it as a significant barrier to effective co-ordination causing distrust among organizations at national and sub-national levels. However, such competition coupled with weak secretariat and civil society’s capacity, limited transparency and communication is regarded as ‘residual national and sub-national obstacle’ to co-ordination. In other words, weak governance and ill-defined hosting arrangements, which introduce inefficiencies in decision making and result in poor accountability, are seen as driving the unintended effects (Caines et al. 2004; WHO Maximizing Positive Synergies Collaborative Group 2009; Nishtar 2004). GHIs are further credited for exposing these weaknesses at the organizational, managerial and operational level (WHO Maximizing Positive Synergies Collaborative Group 2009). The starting point of such framework of analysis is that the GHI model (and the implicit public–private partnership mechanism) is per se desirable. Such perspective, we argue, grants spurious legitimacy to these initiatives and overlooks the extent to which actors’ interests and practices (and the ‘unintended’ outcomes) are shaped by the stringent protocols and their underlying ideas of participation, innovation and performance efficiency. This article, therefore, adds to the scholarly work on GHIs by proposing an alternative framework which evaluates the practices set off by these initiatives against the ideas they promote and derive legitimacy from (the rhetoric).

Conclusion

The Fund’s entry into India has resulted in an environment characterized by a mixed form of governance exercised by transnational networks and organizations, identity-based networks and organized corporate interests across state boundaries. Elsewhere, the primary author describes how this enables the movement of leading international organizations into India and large national organizations from other sectors into the AIDS industry (Kapilashrami and O’Brien 2012). This article illustrates how this mixed form of governance has instilled an environment where principles of partnership, enshrined in the public transcript of the Fund, are subsumed by competition for resources and exacerbated tensions between different actors over individual roles, control of funds and legitimacy.

We conclude that while the official transcript of the Fund as only a ‘financial mechanism’ abdicates its responsibility for country-level operations, the hidden transcript reveals the salience and authority of the Fund protocol (implicit and explicit rules and conditionalities) in regulating the environment in which the programme is ‘steered’, thus conditioning its operation and effects. The disjuncture between the ‘public’ and the ‘hidden’, we argue, emerges from the interaction between externally imposed structures and agendas and the strategic interactions and interpretations of local and transnational actors acting locally. Although proposals are developed in country, the various condition precedents and other process related strictures on proving programme effectiveness affect the way in which programmes are implemented.

The Fund’s emphasis on rapid and efficient disbursement of funds mandates extensive and rigid reporting formats and requirements. Meeting this demand has over-stretched already weak health systems’ capacity and led partners to focus on demonstrating their effectiveness over being effective, resulting in counter claims on quality and ‘passing the buck’ in case of failures. At the service delivery sites, which are characterized by high patient load, poor infrastructure and lack of human resources, the competition for numbers compromises quality of services, adding to patient costs.

Widening ‘civil-society’ participation restructures the state’s role with regard to implementation and regulation and shifts subsidies to encourage the business sector’s involvement, even though minimal, in national disease control programmes. Despite the multi-provider environment instilled by the Fund and the increasing role of the private sector in decision making, the administrative burden and patient load is disproportionately high for the public sector. Multiple service delivery points result in a substantial increase in the number of people testing and undergoing treatment leading to congestion at the secondary and tertiary levels of the public sector. Furthermore, as the private sector response falls short of a comprehensive response to the community needs, a mismatch between the demand and supply can be observed. Creation of unsustainable structures through forging newer alliances at the cost of strengthening local systems and consolidating existing efforts will hinder an equitable and effective response to the AIDS epidemic.

Endnotes

1. The research was undertaken by the primary author as part of her doctoral research (2006–2010). It was funded by bursary support from Queen Margaret University.
2. A consultancy was undertaken by the primary author with a PR to develop an operation research under the Fund grant. The consultancy entailed two field visits in two of the five states included in the study and interaction with state- and district-level implementers. The visits enabled a preliminary assessment of the scale and scope of the Fund programme in India and better familiarity with the regional context. Field notes from this visit were also used as data source.
3. VCTC or voluntary counselling and testing centres are units which provide pre-test and post-test counselling services under the national programme at public health set ups, also attached to antiretroviral treatment centres.

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Endnotes