Table 3.

Analysis framework and summary of key findings

Health system building block	Themes	Major findings
Leadership and governance	System design, policy guidance and regulation, health sector accountability, civil society participation, dependency	• The country has not done a good job at coordinating donor funded programs for HIV • The coordinating infrastructure for HIV foreign aid is chaotic and not integrated with the health system • Because of the absence of strong policy direction, strategic planning, and regulation by the government, GHIs take a self–directed approach and do things as they deem fit • HIV GHIs have strengthened the role of non–state actors in health care • Donor funding has deepened a culture of dependency on foreign aid
Health information systems	Data availability, data demand and use	• HIV donor funding has strengthened information systems in the health sector • The culture of proper records keeping and data gathering has rubbed off positively on the system • HIV donor funding has improved the availability of good quality health information through population health surveys • Because of political constraints, improvements in availability of health data have not necessarily translated to increased utilization of data in program planning and implementation in the public sector
Human Resources for Health	Training; retention, distribution, and brain drain; workload, motivation and incentives	• GHIs have generally not invested significantly in the production of new health workers • PEPFAR is increasingly investing in pre–service training to improve the quality of health workers • The system is experiencing a training overload • The trainings are rarely evaluated for impact • Per diems have created disincentives for learning in the system: people go to trainings with the hope of ‘getting paid’ rather than to build their capacity • Activities of HIV GHIs have not positively affected the shortage of human resources for health in rural areas in tangible ways • A new trend in medical brain drain is emerging whereby health workers are lured away from the public sector to non–governmental or private sector organizations or projects funded by GHIs • HIV donor funded programs have increased workload for existing health workers by failing to invest in manpower recruitment • Though there are no salary differentials between health workers of the same cadre working on HIV programs and those working elsewhere, however those working on HIV programs typically have more opportunities for professional development and other benefits
Financing	Domestic allocations and sustainable financing	• Domestic allocations for HIV program delivery have generally been abysmal, as the government has practically handed over financing of HIV services to donors • Recently though, the President committed in July 2013 to scale up government’s financial commitment by launching the president’s comprehensive response plan (PCRP) for HIV/AIDS in Nigeria • The achievements made in HIV service delivery over the past decade is not sustainable as the current system cannot afford to continue deliver the services free of charge when donor funding ceases
Service delivery	Physical infrastructure, quality, equity and coverage, access and uptake, spillover effect	• HIV programs generally deliver services of higher quality than the rest of the system • An HIV donor funded initiative – The National Alliance for Health Systems Strengthening (NAHSS) – is working with the Federal Ministry of Health to develop a National Quality Improvement program (NigeriaQual) • Aid implementing agencies trade equity for efficiency when making service delivery decisions • Access to HIV services has increased but uptake has not been optimal • Best practices in patient care and follow–up in HIV program settings have impacted on other health services positively • HIV program scale–up crowded out delivery of non–HIV health service in the emergency phase of the AIDS response, however by strengthening health infrastructure HIV donor funds have also positively affected the delivery of other health services
Supply management systems	Procurement and distribution	• HIV GHIs have led to the development of a parallel procurement and supply management system • The elimination of fragmentation in the supply management system for HIV has reduced stock outs • The supply management system is not sustainable as it is run by a consortium of foreign technical organizations supported by donor grants

GHI – Global Health Initiative, PEPFAR – US President’s Emergency Plan for AIDS Relief