1. How can global funders support and strengthen local community responses to HIV? Reflections from a recent three-country study on “Aid for AIDS” Jerker Edström and Hayley MacGregor Institute of Development Studies

2. The study in a nutshell Much theorising about global health and HIV governance has taken a view from above and we aimed to complement this with perspectives from grassroots organisations and service providers. Based on a qualitative field study conducted in 2009, we asked “What are the implications of multiple major international financing structures for HIV on local and district-level responses in Kenya, Malawi and Zambia?” 130 interviews were conducted at national level and in six districts, triangulated across public and private sectors. Finding positive as well as negative experiences of engagement with Global Health Initiatives We suggest that these initiatives should engage with each other, with governments and with local stakeholders to develop a joint Code of Practice for more coherent systems down to community levels.

3. Conceptual framework Support? GF ATM PEPFAR WB MAP CBOsFBOsNGOsOther Response? Access/voice? Influence/direction? Intermediaries?Processes? NATIONAL LEVEL LOCAL LEVEL

4. Some key findings Major international donors strongly influence national agendas and priorities. Sufficient amounts of money are not seen to be getting through to local levels, due to low capacity, ill-adapted systems, corruption, politics etc. Most government representatives do not favour using NGO intermediary organisations and want more donor money flowing through government. – However, governments are often not seen as effective at funding local groups. Funding driven by donor-targets makes it difficult for groups to develop and sustain programmes meeting community needs In most countries formal mechanisms exist for civil society engagement (esp. CCMs); and some civil society networks do influence government, if not always in highly visible ways.

5. “We actually are still colonised. White people are the ones who know how long we will live and how far they can go in helping us. All the nurses and doctors are now working for NGO’s because there is no money in the government. How can the government lead the fight when they can’t pay the health workers?” (local level intermediary, Zambia) “This is influenced by donors and these don’t reflect what the community would have preferred to be done. They should involve the locals in decisions making.” (FGD peer educators Nairobi/Kayole, Kenya) “There is also a lot of bureaucracy. NACC has five agencies implementing TOWA. It is hard and cumbersome to bombard communities with all these different agencies…” (CBO, Kenya) “CBOs are unable to access these money. The problem is the system used. The CBO writes a proposal to NAC, NAC responds and conditions have to be fulfilled. Formats, forms used are quite complex.” (NCA, Malawi)

6. Questions relating to ‘community systems strengthening’ ‘Community systems strengthening’ may provide an avenue for more recognition of some of the capacity and sustainability issues raised – But, there remains a need for critical analysis of this concept: A reactive INGO response to the recent push for ‘health systems strengthening’, or a co-option of civil society into top-down systems? Are highly diverse community responses amenable to categorisation as “systems” in any truly useful way? A reduction and ‘down-streaming’ of the role of civil society to one of service provision as an extension to government? – Does it let governments off the hook and what are the implications for independent civil society functions of advocacy etc.? Amore sustainable and enabling route might be for GF and other big players to harmonise/simplify standards and procedures for local level access, monitoring and accountability?

7. Research partners: African Population and Health Research Centre (APHRC), Kenya Institute of Development Studies (IDS), United Kingdom Institute of Economic and Social Research (INESOR), Zambia Research for Equity and Community Health Trust (REACH), Malawi Whilst conceptualised and designed independently by the authors, this research was funded through a grant by the Swedish International Development Agency (Sida) and supported through the Swedish/Norwegian Regional HIV/AIDS Team, in Lusaka. Research for Equity and Community Health Trust (Malawi)

8. Sources Edström J. and MacGregor, H. (2011) Aid for AIDS: How do Community Groups and Other Stakeholders Negotiate the New Financial Architecture in Kenya, Malawi and Zambia, IDS Research Report 66, April 2011, IDS: Brighton Available free at ttp://www.ids.ac.uk/go/bookshop/ Edström, J. and MacGregor, H. (2010) ‘The Pipers Call the Tunes in Global Aid for AIDS: The global financial architecture for HIV funding as seen by local stakeholders in Kenya, Malawi and Zambia’, Global Health Governance Journal, Volume IV, No. 1 (fall 2010) Available free at http://www.ghgj.org