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This paper reviews country-level evidence about the impact of global health initiatives (GHIs), which have had profound effects on recipient country health systems in middle and low income countries. We have selected three initiatives that account for an estimated two-thirds of external funding earmarked for HIV/AIDS control in resource-poor countries: the Global Fund to Fight AIDS, TB and Malaria, the World Bank Multi-country AIDS Program (MAP) and the US President's Emergency Plan for AIDS Relief (PEPFAR). This paper draws on 31 original country-specific and cross-country articles and reports, based on country-level fieldwork conducted between 2002 and 2007. Positive effects have included a rapid scale-up in HIV/AIDS service delivery, greater stakeholder participation, and channelling of funds to non-governmental stakeholders, mainly NGOs and faith-based bodies. Negative effects include distortion of recipient countries’ national policies, notably through distracting governments from coordinated efforts to strengthen health systems and re-verticalization of planning, management and monitoring and evaluation systems. Sub-national and district studies are needed to assess the degree to which GHIs are learning to align with and build the capacities of countries to respond to HIV/AIDS; whether marginalized populations access and benefit from GHI-funded programmes; and about the cost-effectiveness and long-term sustainability of the HIV and AIDS programmes funded by the GHIs. Three multi-country sets of evaluations, which will be reporting in 2009, will answer some of these questions.

The Global Financing Facility (GFF), launched in 2015, aims to catalyse funding for reproductive, maternal, newborn, child, and adolescent health, and nutrition. Few independent assessments have evaluated its processes and impact. We conducted a multi-layered policy analysis of GFF documents - the Investment Cases (ICs) and the GFF-linked World Bank Project Appraisal Documents (PADs) - examining the content of GFF documents for 28 countries, comparing four tracer themes (maternal and newborn health, adolescent health, community health, and quality), and analysing the policy processes in four country studies (Burkina Faso, Mozambique, Tanzania, and Uganda). From 2015 to 2022, GFF-linked PADs reported US$ 14.5 billion of funding across 26 countries through 30 PADs, with GFF contributing 4% to this value. GFF investments primarily focused on service delivery, governance, and performance-based financing. Countries received more targeted investments for maternal and newborn health and adolescent health linked to their burden of these tracer themes. Attention to community health and quality varied. ICs were broader than PADs and more inclusive in their development. Local contexts shaped policy processes. GFF supported priority-setting and learning; however, translating priorities into resourced actions proved challenging. Power dynamics influenced country ownership, donor coordination and resource mobilisation. The GFF is a significant opportunity to advance health for vulnerable populations. Progress in transparency and data use is evident, but accountability gaps, power imbalances, and limited engagement with civil society and private sector hinder national ownership. Further research is needed to determine GFF's attribution to catalytic resource mobilization.

In 2015, Uganda joined the Global Financing Facility (GFF), a Global Health Initiative for Reproductive, Maternal, Newborn, Child, and Adolescent Health (RMNCAH). Similar initiatives have been found to be powerful entities influencing national policy and priorities in Uganda, but few independent studies have assessed the GFF. To understand the policy process and contextual factors in Uganda that influenced the content of the GFF policy documents (Investment Case and Project Appraisal). We conducted a qualitative policy analysis. The data collection included a document review of national RMNCAH policy documents and key informant interviews with national stakeholders involved in the development process of GFF policy documents ( = 16). Data were analyzed thematically using the health policy triangle. The process of developing the GFF documents unfolded rapidly with a strong country-led approach by the government. Work commenced in late 2015; the Investment Case was published in April 2016 and the Project Appraisal Document was completed and presented two months later. The process was steered by technocrats from government agencies, donor agencies, academics and selected civil society organisations, along with the involvement of political figures. The Ministry of Health was at the center of coordinating the process and navigating the contestations between technical priorities and political motivations. Although civil society organisations took part in the process, there were concerns that some were excluded. The learnings from this study provide insights into the translation of globally conceived health initiatives at country level, highlighting enablers and challenges. The study shows the challenges of trying to have a 'country-led' initiative, as such initiatives can still be heavily influenced by 'elites'. Given the diversity of actors with varying interests, achieving representation of key actors, particularly those from underserved groups, can be difficult and may necessitate investing further time and resources in their engagement.

INTRODUCTION Apolipoprotein E4 (APOE4) carriers’ tendency toward hypercholesterolemia may contribute to Alzheimer's disease (AD) risk through oxysterols, which traverse the blood‐brain barrier. METHODS Relationships between baseline plasma oxysterols, APOE status, serum lipids, and cognitive impairment risk were examined in 328 postmenopausal women from the Women's Health Initiative Memory Study. Women were followed for 25 years or until incident dementia or cognitive impairment. RESULTS Levels of 24(S)‐hydroxycholesterol (24‐OHC), 27‐hydroxycholesterol (27‐OHC), and 24‐OHC/27‐OHC ratio did not differ by APOE status (p’s > 0.05). Higher 24‐OHC and 27‐OHC were associated with higher total, low density lipoprotein (LDL), non‐high density lipoprotein (HDL), remnant, LDL/HDL, and total/HDL cholesterol and triglycerides (p’s < 0.05). Higher 24‐OHC/27‐OHC was associated with greater dementia risk (hazard ratio = 1.51, 95% confidence interval:1.02‐2.22), which interaction analyses revealed as significant for APOE3 and APOE4+, but not APOE2+ carriers. DISCUSSION Less favorable lipid profiles were associated with higher oxysterol levels. A higher ratio of 24‐OHC/27‐OHC may contribute to dementia risk in APOE3 and APOE4+ carriers.

The aftermath of Hurricane Katrina has placed a national spotlight on the shameful state of healthcare for America's poor. In the face of this highly publicized disaster, public health experts are more concerned than ever about persistent disparities that result from income and race.This book tells the story of one groundbreaking approach to medicine that attacks the problem by focusing on the wellness of whole neighborhoods. Since their creation during the 1960s, community health centers have served the needs of the poor in the tenements of New York, the colonias of Texas, the working class neighborhoods of Boston, and the dirt farms of the South. As products of the civil rights movement, the early centers provided not only primary and preventive care, but also social and environmental services, economic development, and empowerment.Bonnie Lefkowitz-herself a veteran of community health administration-explores the program's unlikely transformation from a small and beleaguered demonstration effort to a network of close to a thousand modern health care organizations serving nearly 15 million people. In a series of personal accounts and interviews with national leaders and dozens of health care workers, patients, and activists in five communities across the United States, she shows how health centers have endured despite cynicism and inertia, the vagaries of politics, and ongoing discrimination.

In 2015, Tanzania joined the Global Financing Facility (GFF), a global health initiative for Reproductive, Maternal, Newborn, Child, and Adolescent Health and Nutrition (RMNCAH-N). Despite its resource mobilization goals, little is known about power dynamics in GFF policy processes. This paper presents the first power analysis of Tanzania's GFF engagement. To examine policy processes in developing GFF documents during its first two phases in Tanzania. An exploratory qualitative case study using document reviews (*n* = 22) and key informant interviews (*n* = 21) conducted in 2022-2023. Data were thematically analyzed and interpreted using Gaventa's power cube (levels, spaces, and forms of power). Stakeholders praised the GFF's country-led, evidence-based approach and local autonomy. However, closed-door decision-making in phase one excluded civil society and the private sector. Invisible power imbalances in funding allocations left stillbirths and adolescent health without dedicated budgets, while vulnerable groups (e.g. people with disabilities) were overlooked. Disbursement-linked indicators emphasized measurable outcomes, reflecting visible power. Phase two showed adaptive learning, with improved inclusivity. While government-led, global actors (e.g. World Bank, donors) heavily influenced decisions. Greater civil society engagement is needed for accountability. Future efforts must address power imbalances through meaningful citizen participation to strengthen RMNCAH-N services.

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.

Global health initiatives (GHIs) are implemented across a variety of geographies and cultures. Those targeting maternal health often prioritise increasing facility delivery rates. Pressure on local implementers to meet GHI goals may lead to unintended programme features that could negatively impact women. This study investigates penalties for home births imposed by traditional leaders on women during the implementation of Saving Mothers, Giving Life (SMGL) in Zambia. Forty focus group discussions (FGDs) were conducted across four rural districts to assess community experiences of SMGL at the conclusion of its first year. Participants included women who recently delivered at home (3 FGDs/district), women who recently delivered in a health facility (3 FGDs/district), community health workers (2 FGDs/district) and local leaders (2 FGDs/district). Findings indicate that community leaders in some districts—independently of formal programme directive —used fines to penalise women who delivered at home rather than in a facility. Participants in nearly all focus groups reported hearing about the imposition of penalties following programme implementation. Some women reported experiencing penalties firsthand, including cash and livestock fines, or fees for child health cards that are typically free. Many women who delivered at home reported their intention to deliver in a facility in the future to avoid penalties. While communities largely supported the use of penalties to promote facility delivery, the penalties effectively introduced a new tax on poor rural women and may have deterred their utilization of postnatal and child health care services. The imposition of penalties is thus a punitive adaptation that can impose new financial burdens on vulnerable women and contribute to widening health, economic and gender inequities in communities. Health initiatives that aim to increase demand for health services should monitor local efforts to achieve programme targets in order to better understand their impact on communities and on overall programme goals. Des initiatives mondiales de santé (GHIs) sont mises en œuvre à travers une variété de régions géographiques et de cultures. Celles relatives à la santé maternelle accordent souvent la priorité à l’augmentation des taux d’accouchements dans les formations sanitaires. La pression sur les responsables locaux pour atteindre les objectifs GHI peut induire des caractéristiques imprévues du programme qui peuvent avoir un impact négatif sur les femmes. La présente étude examine les sanctions imposées par les chefs traditionnels aux femmes ayant accouché à domicile, lors de la mise en œuvre du programme Saving Mothers, Giving life (SMGL) en Zambie. Quarante discussions de groupes (FGDs) ont été menées dans quatre districts ruraux afin d’évaluer les expériences vécues par les communautés à l’issue de la première année du programme SMGL. Les participants comprenaient des femmes ayant accouché récemment à la maison (3 FGDs/district), des femmes ayant accouché récemment dans un centre de santé (3 FGDs/district), des agents de santé communautaires (2 FGDs/district) et des dirigeants locaux (2 FGDs/district). Les résultats indiquent qu’indépendamment des directives du programme formel, les leaders communautaires de certains districts ont recours aux amendes pour pénaliser les femmes ayant accouché à la maison plutôt que dans un centre de santé. Dans presque tous les groupes de discussion, les participants ont déclaré avoir entendu parler des sanctions imposées dans le cadre de la mise en œuvre du programme. Certaines femmes ont déclaré avoir été sanctionnées directement, notamment des amendes en espèces et en bétail, ou des frais pour les carnets de santé des enfants, alors qu’ils sont généralement gratuits. Beaucoup de femmes ayant accouché à la maison ont déclaré vouloir accoucher dans un centre de santé à l’avenir, pour éviter les amendes. Alors que les communautés sont largement favorables à l’utilisation des sanctions pour promouvoir l’accouchement dans les centres de santé, ces sanctions ont effectivement introduit une nouvelle taxe sur les pauvres femmes des zones rurales, et les ont peut-être dissuadé de recourir aux services postnataux et de soins de santé infantile. L’imposition de sanctions est donc une adaptation punitive qui peut imposer de nouvelles charges financières aux femmes vulnérables et contribuer au renforcement des inégalités sanitaires, économiques et entre les genres au sein des communautés. Les initiatives de santé qui visent à accroître la demande de services de santé doivent contrôler les efforts locaux visant à l’atteinte des objectifs du programme, afin de mieux comprendre leur impact sur les communautés et sur les objectifs généraux du programme. Las iniciativas globales de salud (IGSs) se implementan a través de una variedad de geografías y culturas. Aquellas que se enfocan en la salud materna a veces priorizan el aumento de las tasas de parto en las instalaciones de salud. La presión sobre los ejecutores locales para cumplir los objetivos de las IGSs puede conducir a funciones involuntarias del programa que podrían impactar negativamente a las mujeres. Este estudio investiga las penalizaciones por los partos en casa impuestas por los líderes tradicionales a las mujeres durante la aplicación de Salvando Madres, Dando Vida (SMDV) en Zambia. Cuarenta grupos de discusión de enfoque (GDEs) se llevaron a cabo en cuatro distritos rurales para evaluar las experiencias comunitarias de SMDV al terminar su primer año. Entre los participantes se incluyeron mujeres que recientemente habían tenido un parto en casa (3 GDEs/distrito), mujeres que recientemente tuvieron un parto en una instalación de salud (3 GDEs/ distrito), trabajadores comunitarios de salud (2 GDEs/ distrito) y líderes locales (2 GDEs/distrito). Los resultados indican que los líderes de la comunidad en algunos distritos -independientemente de la directiva formal del programausaron multas para penalizar a las mujeres que tuvieron un parto en casa en vez de en una instalación. Los participantes en casi todos los grupos de discusión dijeron haber escuchado acerca de la imposición de penalizaciones tras la ejecución del programa. Algunas mujeres reportaron haber recibido las penalizaciones de primera mano, incluyendo multas en dinero en efectivo o en ganado, o en pagos para las tarjetas de salud del niño que son típicamente gratis. Muchas mujeres que tuvieron el parto en la casa reportaron su intención de tener un parto en una instalación en el futuro para evitar sanciones. Mientras que las comunidades apoyaron en gran parte el uso de penalizaciones para promover el parto en las instalaciones, las penalizaciones introdujeron de manera efectiva un nuevo impuesto a las mujeres pobres rurales y pueden haberlas disuadido de la utilización de los servicios de cuidado de la salud postnatales y de los niños. La imposición de penalizaciones es así una adaptación de castigo que puede imponer nuevas cargas financieras a las mujeres vulnerables y contribuir a la ampliación de las desigualdades de salud, económicas y de género en las comunidades. Las iniciativas de salud que tienen como objetivo aumentar la demanda de los servicios de salud deberían monitorear los esfuerzos locales para alcanzar los objetivos del programa con el fin de comprender mejor su impacto en las comunidades y sobre todos los objetivos del programa. 全球医疗倡议 （GHIs） 在很多地区和文化中实施。这些针对 产妇医疗的机制主要着眼于提高机构分娩率。在地方上执行 GHI的压力可能会导致意料之外的后果并对妇女产生负面影 响。本文研究在赞比亚实施拯救母亲, 赋予生命 （SMGL） 项 目中实行的对在家分娩的惩罚。我们在四个乡村地区进行了 40个焦点小组访问 （FGDs）, 用来评估SMGL实施第一年的 社区经验。参与者包括最近在家分娩的妇女 （每个地区3个焦 点小组访问）, 最近在机构分娩的妇女 （每个地区3个焦点小 组访问）, 社区医疗工作者（每个地区2个焦点小组访问）以 及当地领袖 （每个地区3个焦点小组访问） 。研究结果显示一 些地区的领袖对那些在家分娩的妇女进行罚款。几乎所有参 与焦点小组访问的人表示听说过在项目实施后进行罚款的事 情。一些妇女本身自己就经历了罚款, 罚款形式包括现金和牲 口, 或者是对原本免费的儿童医疗卡进行收费。一些在家分娩 的妇女表示以后会尝试机构分娩以避免这些麻烦。尽管总的 来说社区支持这种为了附近机构分娩的罚款, 这种罚款对贫困 乡村的妇女相当于是一种新的税, 这有可能负面影响她们的产 后检查和儿童医疗服务。因为罚款给脆弱妇女增加了一项新 的经济负担, 并加剧了社区中医疗、经济和性别的不平等。旨 在增加对医疗服务需求的医疗机制应该监测当地为了达到目 标的一些行为以更好的理解对社区的影响和总的项目目标。

Background Global Health Initiatives (GHIs) have been instrumental in the rapid acceleration of HIV prevention, treatment access, and availability of care and support services for people living with HIV (PLH) in low and middle income countries (LMIC). These efforts have increasingly used combination prevention approaches that include biomedical, behavioral, social and structural interventions to reduce HIV incidence. However, little research has evaluated their implementation. We report results of qualitative research to examine the implementation of a national HIV combination prevention strategy in El Salvador funded by the Global Fund to Fight AIDS, Tuberculosis and Malaria. Methods We conducted in-depth interviews with principal recipients of the funding, members of the Country Coordinating Mechanism (CCM) and front line peer outreach workers and their clients. We analyzed the data using a dynamic systems framework. Results El Salvador’s national HIV combination prevention strategy had three main goals: 1) to decrease the sexual risk behaviors of men who have sex with men (MSM), commercial sex workers (CSW) and transgender women (TW); 2) to increase HIV testing rates among members of these populations and the proportion of PLH who know their status; and 3) to improve linkage to HIV treatment and adherence to antiretroviral therapy (ART). Intervention components to achieve these goals included peer outreach, community prevention centers and specialized STI/HIV clinics, and new adherence and retention protocols for PLH. In each intervention component, we identified several factors which reinforced or diminished intervention efforts. Factors that negatively affected all intervention activities were an increase in violence in El Salvador during implementation of the strategy, resistance to decentralization, and budget constraints. Factors that affected peer outreach and sexual risk reduction were the human resource capacity of grassroots organizations and conflicts of the national HIV strategy with other organizational missions. Conclusions Overall, the national strategy improved access to HIV prevention and care through efforts to improve capacity building of grass roots organizations, reduced stigma, and improved coordination among organizations. However, failure to respond to environmental and organizational factors limited the intervention’s potential impact.

Childhood tumors in the central nervous system (CNS) have longer diagnostic delays than other pediatric tumors. Vague presenting symptoms pose a challenge in the diagnostic process; it has been indicated that patients and parents may be hesitant to seek help, and health care professionals (HCPs) may lack awareness and knowledge about clinical presentation. To raise awareness among HCPs, the Danish CNS tumor awareness initiative hjernetegn.dk was launched. This study aims to present the learnings from designing and implementing a decision support tool for HCPs to reduce diagnostic delay in childhood CNS tumors. The aims also include decisions regarding strategies for dissemination and use of social media, and an evaluation of the digital impact 6 months after launch. The phases of developing and implementing the tool include participatory co-creation workshops, designing the website and digital platforms, and implementing a press and media strategy. The digital impact of hjernetegn.dk was evaluated through website analytics and social media engagement. hjernetegn.dk was launched in August 2023. The results after 6 months exceeded key performance indicators. The analysis showed a high number of website visitors and engagement, with a plateau reached 3 months after the initial launch. The LinkedIn campaign and Google Search strategy also generated a high number of impressions and clicks. The findings suggest that the initiative has been successfully integrated, raising awareness and providing a valuable tool for HCPs in diagnosing childhood CNS tumors. The study highlights the importance of interdisciplinary collaboration, co-creation, and ongoing community management, as well as broad dissemination strategies when introducing a digital support tool.