title: Transforming governance or reinforcing hierarchies and competition: examining the public and hidden transcripts of the Global Fund and HIV in India.
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.
authors.affiliation: Global Public Health Unit, University of Edinburgh, Edinburgh, UK. anuj.kapilashrami@gmail.com
authors.forename: Anuj
authors.initials: A
authors.lastname: Kapilashrami
authors.forename: Barbara
authors.initials: B
authors.lastname: McPake
mesh_terms: D003163:Competitive Behavior; D003695:Delivery of Health Care / Q000458:organization & administration*; D015658:HIV Infections / Q000517:prevention & control*; D006289:Health Planning Support; D006291:Health Policy; D006801:Humans; D007194:India; D007391:International Cooperation; D019982:Organizational Case Studies; D011050:Policy Making; D036301:Qualitative Research
keywords: GFATM; HIV/AIDS; Public-hidden transcript; global health initiatives; health policy