title: Impact of global health governance on country health systems: the case of HIV initiatives in Nigeria.
abstract: BACKGROUND
  Three global health initiatives (GHIs) - the US President's Emergency Plan for AIDS Relief, the Global Fund to Fight AIDS, Tuberculosis and Malaria, and the World Bank Multi-Country HIV/AIDS Program - finance most HIV services in Nigeria. Critics assert that GHIs burden fragile health systems in resource-poor countries and that health system limitations in these countries constrain the achievement of the objectives of GHIs. This study analyzed interactions between HIV GHIs and the Nigerian Health System and explored how the impact of the GHIs could be optimized.
  
  
  METHODS
  A country case study was conducted using qualitative methods, including: semi-structured interviews, direct observation, and archival review. Semi-structured interviews were held with key informants selected to reach a broad range of stakeholders including policymakers, program managers, service providers, representatives of donor agencies and their implementing partners; the WHO country office in Nigeria; independent consultants; and civil society organizations involved in HIV work. The fieldwork was conducted between June and August 2013.
  
  
  RESULTS
  HIV GHIs have had a mixed impact on the health system. They have enhanced availability of and access to HIV services, improved quality of services, and strengthened health information systems and the role of non-state actors in health care. On the negative end, HIV donor funding has increased dependency on foreign aid, widened disparities in access to HIV services, done little to address the sustainability of the services, crowded out non-HIV health services, and led to the development of a parallel supply management system. They have also not invested significantly in the production of new health workers and have not addressed maldistribution problems, but have rather contributed to internal brain drain by luring health workers from the public sector to non-governmental organizations and have increased workload for existing health workers. There is poor policy direction, strategic planning and coordination, and regulation of externally-financed HIV programs by the government and this poses a great limitation to the optimal use of HIV-specific foreign aid in Nigeria.
  
  
  CONCLUSIONS
  A few reforms are necessary to improve the strengthening effect of GHIs and to minimize their negative and unintended consequences. This will require stronger leadership from the Nigerian government with regards to better coordination of externally-financed health programs. Also, donors need to play a greater role in addressing the negative consequences of foreign aid. The findings highlight important unintended consequences and system-wide impacts that get little attention in traditional program evaluation.
authors.affiliation: The University of Texas Health Science Center at Houston, School of Public Health, Houston, Texas, USA.
authors.forename: Charles Chikodili
authors.initials: CC
authors.lastname: Chima
authors.affiliation: The University of Texas Health Science Center at Houston, School of Public Health, Houston, Texas, USA.
authors.forename: Nuria
authors.initials: N
authors.lastname: Homedes