Table 3.

Summary of policy transfer in both settings utilizing Dolowitz and Marsh (1996) policy transfer framework

	(A) What is transferred & what is the evidence of transfer?	(B) To what degree has the policy been transferred?	(C) What are the constraints on transfer?	(D) From where are lessons drawn?	(E) Who are key actors involved in the transfer process?	(F) Why do actors engage in transfer?
Summary findings(presented as common to both settings or specific to either country)	Both: The 90–90–90 treatment targets (also the policy goal of eliminating the AIDS epidemic, and much of the associated policy content) and concepts for more targeted programming that is cognizant of geography and population groups. In addition the need to increase programme efficiency and mobilize resources domestically. This was evidenced in rhetoric with all key informants in both settings and in policy, programme and budgetary documents (but to a lesser extent for the latter). Ghana: Latest NSP oriented entirely around 90–90–90 targets, meeting the targets is a core aim, is mentioned upfront in chairman's letter indicating high level commitment, and has separate sections are devoted to each 90 target stating which interventions will be implemented to meet that target. However, indication from informants that less is ready for implementation other than roll out of test and treat as supported by PEPFAR and The Global Fund. Uganda: More limited mention of 90–90–90 in national strategic and operational documents, but very clear, targeted approach in PEPFAR Country Operational Plans.	Both: Whilst many documents demonstrate a direct copy of the target, upon further investigation across operational and implementation documents, a more modest set of targets appear to have been adopted or are to be aimed for. Ghana: The focus is predominantly on the first two 90s as access to viral load machines is limited. For the third 90 there is an emphasis more on health systems strengthening and adherence initiatives. Uganda: National strategic plan and PEPFAR Country Operational Plans contain targets for second 90 of 80% opposed to 81%. It is not clear why this slightly lower target has been adopted—one informant said it was as a consequence of a modelling analysis of what programme coverage levels could realistically be achieved with anticipated available resources.	Both: Inadequate financial resources available for commodities for the response: HIV test kits, antiretroviral treatment for treating all PLHIV, and viral load testing. Health system capacity constraints, such as human resources to support higher patient loads. Complex policy targets that may require application of mathematical modelling to guide programme decisions, but capacity at the local level for such approaches is relatively limited. Large-scale programmatic shift required from approach of broad nationwide scale up to targeted approach, including shift in the manner in which resources are allocated for the response. Ghana: Uncertainty in epidemiological information at lower administrative levels results in difficulty in prioritizing resources lower than the regional level. Resources are being allocated to improve data quality and for monitoring of progress toward 90–90–90. Previously lack of political support for targeted approaches as did not want to appear not equitable in service provision. Uganda: Appears to be greater flexibility in reallocation of resources to more targeted approach as PEPFAR are the major funder of the HIV programme and thus have more autonomy with which to decide how to reallocate compared with government resources. Therefore, fewer constraints on transfer in Uganda.	Both: From international organizations and implementing agencies. Notably directly from UNAIDS’ 90–90–90 strategy document, derived from mathematical modelling study. Decision-makers in both countries reported using in-country experience about effective interventions. Lessons learned from new modelling studies in both countries in addition to the application of epidemiological information to consider which geographies and populations to prioritize in the response.	Both: Well-coordinated health network present in both settings, clearly defined roles, comprised of actors at local and global levels: National/local: NAC, MOH, major local implementers Global: WHO, UNAIDS, and US Government entities (CDC, PEPFAR, USAID), The Global Fund (but to a lesser extent in both countries in the first two years after 90–90–90 was released as both countries were in the middle of an existing funding period) Ghana: Private companies (in particular, oil industry) through corporate social responsibility agreements, resource mobilization officer (UNDP funded) EQUIP providing technical assistance in implementation for responding to 90–90–90 Health Policy Plus providing modelling for scenarios for the National Strategic Plan Uganda: Civil society organizations, e.g. NAFOPHANU (hosted the 90–90–90 country launch) Futures Institute—modelled and costed scenarios for 90–90–90 for consideration Irish Aid To a lesser extent than in Ghana—private sector, groups such as the Uganda Olympics Committee	Both: Whilst the reasons for adoption of the targets are many there are substantial constraints operating the may limit the rationality of implementing these targets, in particular when considering the cost required in terms of overall benefit to population health as a decision maker. There is a clear amount of international pressure to respond to the targets – in many cases countries may have signed on to respond to the targets before even conducting studies into the feasibility of implementation. Respondents in both settings cited the feeling of international pressure to adopt the targets regardless of available funding. Summary: Transfer of 90–90–90 is voluntary as was not a pre-requisite for receipt of funding, driven by perceived necessity as a mandate to the UN and for international acceptance/conforming to global norms to respond. However, to receive funding from PEPFAR for ‘test and treat’ both countries needed to revise their treatment guidelines—for this specific policy this could therefore be argued as more a direct imposition. Ghana: 90–90–90 transfer utilized as an advocacy tool to secure additional funds due to counterpart funding needs.