Aisling Walsh and Ruairi Brugha1

Global HIV/AIDS Initiatives Network (GHIN): Early lessons from a network

approach to global research

If global networks are ‘dynamic and flexible types of connections between individuals,

groups and organisations that criss-cross the world . . . (and) are a sign of ‘human

accomplishments’ and global openings, they also expose the costs of globalisation.

(Rogers et al, 2001, iii).

1. Background to GHIN and rationale for the network approach

1.1 What is GHIN?

Global funding for HIV/AIDS has increased dramatically during the past five years.

Three global HIV/AIDS initiatives (GHIs) are together contributing two thirds of the

direct external funding to scaling up HIV/AIDS prevention, treatment and care in

resource poor countries. Evidence is crucial in understanding the effects these initiatives

are having on country systems, at national and sub-national (district) levels. The three

GHIs are:

The World Bank’s Global HIV/AIDS Programme including the Multi-country AIDS

Programme (MAP)

The Global Fund to Fight AIDS, TB and Malaria (GFATM)

The United States President’s Emergency Plan for AIDS Relief (PEPFAR).

A network of researchers in 21 countries was established in March 2006 by researchers

based at the London School of Hygiene and Tropical Medicine (LSHTM) and the Royal

College of Surgeons in Ireland (RCSI), in collaboration with researchers in 15 countries

across sub-Saharan Africa, Eastern Europe, Asia and South America, supported by five

institutions in Europe and the US. Members of the Global HIV/AIDS Initiatives Network

(GHIN) are researching the country effects of these global HIV/AIDS initiatives at

1 Royal College of Surgeons in Ireland (RCSI)

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national and sub-national levels2 (www.ghin.lshtm.ac.uk3 – see annex A for membership).

Funding for coordination of the Network is from Irish Aid and DANIDA.

Objectives and plans for national and district level data collection across the GHIN

countries, 2007-08, depend on country contexts and the issues prioritised by the country

researchers as relevant to their countries. There are several common research themes

across the Network, some or all of which individual country studies are addressing. The

Network is facilitating comparative work and plans to synthesise findings around these

themes, which include the effects of global HIV/AIDS initiatives on: sub-national scale-

up of services; health systems capacity, including availability of human resources;

national and district level coordination; and equitable access to services (see Annex B for

further information on research themes).

The primary focus of GHIN country studies is on sub-national (district) level data

collection. However, most of the studies have a national component, primarily in the

form of national context mapping (desk reviews and qualitative stakeholder interviews).

District level data collection is being conducted in several districts in each country,

during 2007-08. District mapping of facilities and relevant initiatives is being followed

by quantitative and qualitative surveys of district stakeholders. Several country studies

will encompass district baseline and follow-up fieldwork (up to one year later).

1.2 Research Networks

The need for research partnerships at a global scale has been emphasised over the last 20

years, encompassing collaborations between the North and the South (KFPE, 2001).4

Participants at a KFPE conference concluded that “strong networks improve the situation

of many countries in the south. South to south partnerships, as well as national and

international networks, must be supported and new ones promoted” (KFPE, 2001, p39).

2 Some countries may also research the effects of other global health initiatives 3 A new website is being constructed www.ghinet.org which will be launched in at the Dublin international dissemination workshop, November 2007. Co-funding from UK DfID has enabled compilation of a database of research-based evidence, which will be accessible on the new GHIN website.4 We also use the terms ‘north’ and ‘south’, the former to denote the high income countries (and institutions) of Europe and North America. In many respects it is a misnomer. GHIN studies are being conducted in the Far East (Vietnam and China), in the Former Soviet Union and in Peru.

2

While the term network has entered global development discourse in the last decade,

there is no clear consensus about what is meant by adopting a ‘network approach’ in

health research, which limits our understanding of its strengths and weaknesses (Scott &

Hofmeyer, 2007). Many definitions of Networks exist, for example: Fricker & Lentin eds

2007; Global Networks Journal; Holton 2005; Rogers et al, 2001.

Examples of global research and development networks5

Acronym Full name GARNET Global Applied Research Network GHPRN Global Health Policy Research Network Géant(1)(2)(3) A collaboration between 26 National Research and Education Networks

(NRENs) across Europe, the European Commission, and DANTE.GDNET Global Development Network GRP Global Research Project on Explaining Growth INRUD International Network for Rational Use of DrugsINDEPTH International Network of Demographic Surveillance Sites HealthNet Health Netwoks SOMA-NET6 Social Science and Medicine Africa Network

1.3 GHIN’s approach

GHIN aims to embody a responsive model, which moves beyond the traditional model of

northern institutions channelling funds to and supervising research conducted in the

‘south’. GHIN is novel in some respects in that funding to country institutions is

independent of the network (see Annex A for relationships between funders and partners).

Only three of the country studies are directly funded through the GHIN Coordinators in

Dublin and London. Participation in GHIN is voluntary and open to research groups that

can subscribe to the principles and purpose of the Network. The intention from the start

was to move beyond the traditional ‘hub-and-spoke’ model, to a more organic

knowledge-driven approach, where different types of linkages – including ‘south-to-

south’ ones – can evolve. Relationships and roles within GHIN aim to be dynamic,

responsive and flexible.

5 This list is not exhaustive 6 This is a regional network

3

The aim of this paper is to describe early lessons learned from this network approach to

researching global HIV/AIDS initiatives. Specific objectives are to describe the role of

the Global HIV/AIDS Initiatives Network (GHIN) in:

a. promoting and enabling research capacity building and research ownership

b. research governance

c. generating multi-country comparisons and generalisable lessons, and supporting

advocacy and dissemination to global and country stakeholders

This paper focuses on the practical lessons learned from GHIN and does not contain a

theoretical analysis of the applications of network theory to health research networks and

GHIN. As GHIN was established in March 2006, lesson learning is ongoing. This paper

is written from the Network Coordinators’ perspectives. Perspectives of country

teams/network members and other stakeholders will be obtained over the coming months

and on an ongoing basis over the next two years.

2. The genesis and birth of GHIN

2.1 Global Fund Tracking Study and SWEF studies

GHIN has its origins in two sets of multi-country studies on the Global Fund that were

conducted between 2003 and 2006, and in the relationships established between global

and country researchers, and between the researchers and funding agencies. The Global

Fund 4-country Tracking Study was conducted in 2003-04 by Brugha and Walt, based at

the London School of Hygiene and Tropical Medicine (LSHTM), working with

researchers based in Mozambique, Tanzania, Uganda and Zambia (Brugha et al 2004,

Brugha 2005). Irish Aid and DANIDA were the first two of four European bilateral donor

agencies who funded the study.

In 2003, Bennett and Stillman, based at Abt Associates in the US, developed a research

protocol and framework for studying the ‘System-wide effects’ of the Global Fund

(SWEF) on countries (SWEF 2003). They organised a workshop in Oxford, UK, in late

2003, attended by researchers from Ethiopia, Benin, Malawi, Georgia, Nicaragua and the

UK (LSHTM). At this consultative meeting, a network approach was agreed and a

common research protocol developed. During 2004, Bennett obtained funding from

USAID and the EU to support studies in these countries (Stillman and Bennett 2005).

4

SWEF, unlike the Tracking Study, constituted a Network approach in that ‘southern’ and

‘northern’ researchers participated in its genesis; and in many ways SWEF was the

precursor to GHIN. See annex A for a background to funding for the country studies.

Communication with global stakeholders also took place from late 2003-2005.7

2.2 The launch of GHIN

Maselli et al (2006) have outlined the importance of a broadly-based consultative

process, which should precede any research collaboration. An international workshop was

held by the LSHTM in London in March 2006 to which the different country research

teams were invited. Participants expressed the need for and committed themselves to

forming a network for tracking global HIV/AIDS initiatives. Eleven country teams were

represented at this workshop, including three from the Former Soviet Union (FSU) and

five groups from sub-Saharan Africa (sSA). During the workshop, researchers worked in

groups that reflected the types of HIV epidemics they would be studying – generalised

(sSA) and concentrated (FSU).

Lessons learned from other networks (Maselli et al, 2006) show that coordination is

crucial. Participants at the London workshop agreed that the Network should have the

following aims:

Promote comparability through common research protocols and tools

Share expertise across country study teams and build research capacity

Generate multi-country comparisons and context-specific policy lessons

Coordinate dissemination of findings and recommendations and streamlining

communication with global stakeholders

A half day was set aside at the London workshop to inform global stakeholders

(representatives of the GHIs and bilateral donors) and to get their inputs about the

7 After initial difficulties in communication between LSHTM and the Global Fund Secretariat, relationships improved following the

appointment of Schwartlander to head up the Fund’s Evaluation division in December 2003. Bennett, with the support of other stakeholders in WHO, organised a meeting in Geneva in June 2003 to present and discuss the SWEF approach. Bennett and Brugha participated in a meeting of the Global Fund’s Technical Evaluation Reference Group (TERG) in Glion in April 2004, which was planning the Global Fund’s Five Year Evaluation. Both kept in close touch with the Global Fund during 2004 and 2005, regularly briefing the Fund on the genesis and birth of GHIN.

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proposed GHIN network and studies. Representatives present were from the Global Fund

and four bilateral donors: Irish Aid, DANIDA, USAID and UK DfID.

3. Principles of GHIN

The philosophy under-pinning GHIN is that its principles and processes should not be

predetermined by Network Coordinators from the ‘north’, and that shared responsibility

and transparency should be promoted from the outset. This is in keeping with other

global guidelines for promoting successful research partnerships (KFPE 1998). At the

London March 2006 workshop, Network members discussed and agreed a core set of

principles for the GHIN Network, which were subsequently written down by the

Coordinators, disseminated to members and approved by them:

Participation: Network members are encouraged and will be facilitated to

participate in major Network events, including the international workshops

planned for November 2007 (Dublin) and end of 2008 (Geneva). Members will

have the opportunity and will be supported to take on other roles such as

participating in Network coordination activities, technical assistance and peer

review, communication with global stakeholders and global dissemination of

research findings.

Fairness: ‘Southern’ and ‘northern’ Network members will have the opportunity

to contribute to decision-making and guiding the overall direction of the Network.

‘southern’ and ‘northern’ Network members will have access to Network

resources. Opportunities for authorship, including journal articles, will be

allocated among Network members.

Accountability: There are complex layers of accountability. Network members,

including the Coordinators, are accountable to the Network; each is accountable

to its funder (Irish Aid and DANIDA, in the case of the Coordinators); and

country researchers and the Coordinators have a responsibility to disseminate

findings to their respective stakeholders who are in a position to utilise and act on

study findings, at the global and country levels.

Transparency: Network members, including the Coordinators, will inform each

other of developments relevant to the aims of the Network, at global and country

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levels. The Coordinators will report regularly to Network members regarding

forthcoming decisions and those taken; and will enable members to take part in

decision-making. Country teams are encouraged to share research methods, tools,

lessons learned and findings with Network members. The Network will also

communicate with stakeholders beyond the Network; and about activities and

outputs from country studies, thereby making the Network more transparent.

4. Network governance: beyond the ‘hub and spoke’ approach

GHIN aims to promote collaboration and partnership by giving an equal say to ‘southern’

and ‘northern’ partners in governance of the network. At the March 2007 London

workshop, Network members agreed that there was a need for an institution or

institutions to take on the role of Network Coordinator. They agreed that LSHTM and

RCSI should adopt this role.

Strong central coordination needs to be balanced with responsiveness to the views and

needs of Network members in accordance with the Network principles. Hence, the role

needs to be facilitative and enabling rather than managerial in orientation. From the

outset, there was an attempt to distribute coordination responsibilities amongst Network

member institutions. For example, Network members were given the opportunity to take

on a particular role such as leading on or coordinating agreed Network activities at the

regional level, participating in regular coordination teleconferences, or participating in a

proposed Steering Group.

Initially it was proposed that coordination of GHIN activities would take place through a

number of working groups, including a) a generalised epidemic group and a concentrated

epidemic group, b) a coordination group and c) an advisory group. It was proposed that

the concentrated and generalised HIV epidemic groups would each nominate a country

team as Regional Coordinator, and that this role would rotate annually. Country teams

were to be given the opportunity to put themselves forward and the final choice would be

made by network members.

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This was discussed at the two regional workshops in Lilongwe and Kyiv, September and

October 2007, where country teams were invited to become regional Coordinators or

members of a GHIN Steering Group. Country research teams indicated that they were

happy for the full-time Coordinators from RCSI and LSHTM to take on all the

coordination activities, allowing country research teams to focus their efforts on their

studies. Most country researchers were fully occupied with several other studies and had

limited capacity to take on other roles.

Does this mean that unequal participation and unequal power relations exist within

GHIN? According to Scott & Hofmeyer, the perspective that Networks are member-

controlled “…. is intriguing as it implies a formal structure somewhat akin to the notion

of networks as organisations. This level of formality is not always the case.” (Scott &

Hofmeyer, 2007, p13). It is known that Networks make heavy demands on partners. It

appears that competing demands for their time have constrained southern researchers

from participating more actively in GHIN (the GHIN Coordinators indicated that they

would make financial resources available to southern research to take on additional roles,

but discussions did not proceed in this direction).

Each team has been represented at international and regional workshops. The Malawi and

Ukraine country teams were funded to coordinate the regional workshops in Lilongwe

and Kyiv. All teams participated in the programme development and chairing of sessions

at these workshops; and almost all are attending the November 2007 Dublin workshop.

5. Research capacity building and the role of GHIN

The importance of research capacity strengthening in global health research has been well

documented over the last 20 years, as evidenced by an abundance of literature, training

tools, programmes, grants, task forces, conferences and guidelines (Maselli et al, 2006;

Nchinda, 2002; Nurse & Wight, 2006; KFPE, 1998; Paraje, Sadana & Karam, 2005;

Nuyens, 2007). However, recent evidence (Paraje, Sadana & Karam 2005) suggests that

the knowledge gap between the North and the South, particularly low-income developing

countries, is growing ever wider. There are challenges in using the network approach

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when it comes to capacity building. Capacity issues and needs vary from country to

country, requiring different strategies and levels of support.

One of the primary roles of GHIN is to provide support to country studies, where country

research groups have identifiable capacity gaps. “Promoting focused collaborative

networks for sharing information and experience at the national, regional and global

levels is a pre-requisite of approaches to building research capacity” (KPFE, 2001, p.37).

The consensus among participants at the London workshop in March 2006 was that the

most appropriate means of harnessing the collective technical experience of southern and

northern research teams was to hold regional workshops at key stages of development of

country studies, which GHIN did in September – October 2006. Workshop objectives

were to discuss and agree research methods and plans for national and district data

collection, identify and promote cross-country comparability, review and standardise data

collection tools and prepare analysis plans.

Technical assistance to developing countries has been experienced as “heavily

overpriced, under evaluated and stubborn to change” because “too much of it continues to

be identified, designed and managed by donors themselves, tied to donor countries’ own

firms, poorly coordinated and based on a set of often untested assumptions about

expatriate expertise and recipient ignorance” (ActionAid International, 2006, p3). Nurse

& Wight (2006) have postulated a paradigm for research capacity strengthening, which

involves the north and the south working towards a framework of engagement built on

principles such as Southern-driven priorities and ownership, demand-led research, a focus

on development relevance, and mutually beneficial working relationships (Nurse &

Wight, 2006).

One of the central tenets of GHIN is that country teams’ technical support needs are

demand- rather than supply-driven. At the Lilongwe and Kyiv regional workshops in

2006, country teams identified areas where they felt they needed research capacity

strengthening. Members led various methods sessions, utilising their particular strengths;

and the Network Coordinators mainly played facilitating and technical resource roles.

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The different time-sequences of country studies8 has benefited not only the ‘late starters’.

For example, the INCO (EU) consortium is the most recent addition to the network, but

other teams are expected to benefit from their guidelines and tools for national level data

collection in 2008. The longitudinal nature of the research means there are multiple

opportunities for lesson-learning as the research progresses from baseline to follow-up.

Lessons learned from the Global Research Project (GRN) on Explaining Growth (Maselli

et al, 2006) showed that researchers from industrialised countries who were less familiar

with certain regions or countries benefited by learning about institutional and historical

aspects of growth in the countries concerned. Nchinda (2002) has documented the

importance of partners from the North spending periods of time with their colleagues in

the South to gain a better idea of the context in which the research is taking place

including the constraints of southern institutions in accessing field work sites. Traditional

‘north-to-south’ capacity building has been an important component of GHIN in that

GHIN Coordinators have travelled to Southern institutions to support country study field-

work. This has enhanced the capacity of the GHIN Coordinators to understand the

complexities of generalising the effects of HIV/AIDS initiatives within the specific

country contexts. It has also enabled ‘south- to-south’ lessons learned to be passed on to

others country teams within the sSA and other regions. The Coordinators have also

played a role in terms of follow-up visits to countries, as well as remote support such as

feedback on written materials, whether research design or analysis or findings.

South-to-south capacity building is reckoned to be important for promoting research

capacity strengthening. KFPE (2001, pp.36-37) has recognised that “exposure to different

knowledge systems and mutual learning in collaborative structures are a highly effective

means of building research capacity….Such collaboration is most profitable in

international terms, relying on North-South and South-South partnerships and working in

a problem oriented and transdisciplinary way. Promoting collaboration in such terms

implies a programme approach that combines sustainability with flexibility.” GHIN has

supported research exchange between country teams within Ukraine, Georgia and

8 Some country teams have already completed both baseline and follow-up district level field work, whereas others have not yet begun national level fieldwork.

10

Kyrgyzstan. This proved to be particularly educative for the researchers, and provided a

comparative view as well as field work experience on a number of aspects of the

research.

The Health Research System Analysis Perspective (WHO/RPC, 1998) has outlined

characteristics of an enabling environment for researchers, one of which is to establish

teams of researchers including a variety of health research disciplines ranging from basic

science and health systems to social science and epidemiology. GHIN aims to

demonstrate such characteristics. The benefits of this were demonstrated in the regional

workshops, where for example social scientists were able to benefit from the medical

doctors in understanding terminology and the application of HIV/AIDS services within

the clinical setting. Medical doctors have been able to benefit from the qualitative skills

of some of the social researchers.

6. Promoting cross-country comparability and generalisability

One of the primary aims of GHIN is to maximise comparability; and to facilitate

comparisons, analyses and the production of cross-country syntheses of findings and

lessons learned across countries, regions, epidemics and health systems contexts. All of

the studies have incorporated elements of the original SWEF protocol, which has

facilitated this. Hence, a key activity of the Network is to generate comparative outputs

on key themes and to synthesise findings from multiple country studies, so as to inform

policy across countries as well at the global level.

It is expected that cross country syntheses will primarily focus within regions and

epidemics – generalised and concentrated. Wider lesson-learning will be considered at a

later stage. GHIN workshops in Malawi and Ukraine in 2006 have helped to focus this

comparability, where teams developed common detailed research questions relevant to

their HIV epidemics, while also adapting these to specific country contexts. GHIN

Coordinators have developed generic tools for generalised and concentrated epidemics,

which have been built on and improved by various countries, leaving scope for them to

be adapted to suit country contexts.

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In lessons learned from a case study, ‘SPP-E, Module 7 Environment and Development’,

it was reported that much progress was made in methodological approaches, but most of

these were never put down on paper and never communicated and therefore never made

accessible to others (Masseli et al, 2006). The November 2007 GHIN International

Workshop will dedicate significant time to allow country teams to discuss lessons learned

from baseline fieldwork. Similarly, country field visits (‘north-to-south’ and south-to-

south’) have resulted in methodological problems being shared. For example, tools which

were developed by GHIN Coordinators (adapted from the Tracking and SWEF studies)

were further adapted and developed by Malawi, Zambia and Tanzania. Apart from

obvious lessons learned from one country to another, this will also lead to enhanced

ability to compare results across countries.

Grouping the transition countries of Eastern Europe with sub-Saharan African countries,

Peru and China is an over-simplification that can cause difficulties. “The differences

between the least developed and the ‘newly industrialised’ and ‘threshold’ countries are

often larger than the differences between the latter and the industrialised countries”

(KFPE, 1998, p.2). This is the challenge for GHIN going forward, but has partly been

addressed by adopting a regional approach. There have been challenges in coordinating

GHIN studies with other GHI studies, for example the Global Fund Five Year Evaluation,

which is currently underway. The team undertaking the evaluation will be represented at

the November 2007 Dublin workshop.

7. Role of GHIN in advocacy and dissemination with key stakeholders

The devastating nature of the HIV/AIDS epidemic and the large amounts of funds

flowing into countries make this research highly sensitive. Countries are under pressure

to be accountable to GHIs for funds received and performance, and hence have a

significant interest in whether studies produce positive or negative accounts. They are

also accountable to the intended beneficiaries. Early and ongoing dialogue and

engagement with key stakeholders has been critical in promoting their buy-in. Presenting

results at the end of the studies alone will not effectively influence policy; therefore

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GHIN has aimed to put advocacy and dissemination on its agenda, since its inception, at

both the global and country level.

7.1 Global level

An important role of the Network is to coordinate and streamline communication with

global stakeholders at the outset, in order to achieve greater impact on policy change. The

transaction costs for global research users in engaging with a single Network of studies

are lower than with multiple uncoordinated studies. Indeed, the collective power of the

messages emerging from many complementary studies is likely to be much greater than

any one individually, thereby increasing the prospects of influencing global policies.

Lessons learned from the Global Research Project on Explaining Growth showed that a

weakness was that it postponed the adoption of a dissemination strategy aimed at the

broader policy and development community until research activities were completed

(Maselli et al, 2006). The strategies employed by the global HIV/AIDS initiatives are

constantly evolving, and the questions that the researchers within the Network are

addressing are live ones. GHIN members recognise that findings from the studies need to

be channelled into policy debates at the country and global levels on an ongoing basis.

Discussions were held with senior staff at the Global Fund from January 2006 who were

kept informed about network developments. They expressed support for the network

approach to supporting country studies. Contact was also made with senior staff of the

World Bank MAP and PEPFAR. The GHIN Coordinators are taking steps to ensure that

communication is established and coordination is promoted with other large, multi-

country evaluations of the major global HIV/AIDS initiatives, including the Global Fund

Five Year Evaluation (5YE) and studies by the Centre for Global Development (CGD).

All of these stakeholders will be represented at the Dublin November 2007 workshop.

Regular ongoing interactions will inform decision makers, continue to shape research

questions, enable lesson-learning and sharing of tools; and, ultimately, the generation of

larger cross-country comparisons. Findings from the individual GHIN studies will be

synthesised across countries and packaged into short policy briefs that focus upon

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ongoing country and global debates of particular relevance to policy makers,

representatives of multilateral (including UNAIDS) and donor agencies, and of global

HIV/AIDS initiatives.

GHIN has opened global dissemination opportunities to country teams by notifying

members of upcoming relevant conferences and have supported one of the country teams

to attend the Global Forum for Health Research Conference in Beijing (Oct/Nov 2007).

The second GHIN international workshop will be the first opportunity to disseminate

country level results to global stakeholders. The new GHIN website, www.ghinet.org will

prove useful in disseminating research outputs. Linkages with country research institution

websites will promote these institutions, both within countries and globally.

7.2 Country level

As Nchinda (2002) and others have documented: “There has often been complete rupture

between the scientist in the South with the policy makers in the Ministries. Results of

research are hardly ever passed on for implementation. Even when this is done, policy

makers complain that they are submitted in highly technical language with no clear

recommendations that would facilitate implementation” (Nchinda, 2002, p.1701).

Country dissemination is the responsibility of country researchers within GHIN. Country

teams have been encouraged to take the lead in establishing within-country links and

communication channels for dissemination of updates and findings at regular intervals to

policy makers and other key research users, in order to maximise opportunities for

country policy influence. In many countries, the National AIDS Councils have been a key

initial contact. Country groups have also contacted bilateral donor country offices and

who have acted as a conduit to other relevant country partnerships on HIV/AIDS. A

number of country teams have developed advocacy and dissemination strategies. A

central element of these strategies is to disseminate results as research progresses and

importantly at the sub-national level.

There may be considerable sensitivities about the research process within countries since

GHI resources represent a large proportion of country budgets for health. Country

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stakeholders such as policy makers are likely to see the research as more beneficial and

less threatening if their country study is part of a network of coordinated studies.

Researchers have emphasised to country stakeholders that studies will raise common

issues and problems experienced across multiple countries relating to GHIs, as well as

country specific issues. This should help alleviate sensitivities about the impact the study

findings may have on GHI funding within countries. Teams are giving national

stakeholders the opportunity to comment on written drafts of country reports before they

are circulated to global stakeholders.

There is also a role for the country researchers to work with other networks at country

level, for example the Health and Development Network (HDNet), who can assist with

advocacy and dissemination strategies. Not all network members have the same

experience in publishing results. Care must be taken to ensure that all partners can take

part to the proper extent in the dissemination of results, particularly publications in

journals. The forthcoming international workshop will involve teaching and interaction

sessions on how to advocate, writing policy briefs etc. There has also been two-way

communications between the GHIN Coordinators and country teams to promote within

country coordination with other evaluations. Several of the country teams are members of

AIDS Platforms established by the Global Fund to support in-country ownership and

design of the 5YE and interpretation of outputs.

Conclusion

Lesson learning from GHIN is in the early stages and will continue to evolve over the

next two years. GHIN has aimed to embody an alternative model to the traditional

research partnership model by country and global stakeholder ownership of the research,

cross-country comparability, research capacity-building and sharing of expertise amongst

groups; and coordination of dissemination of findings. This is a working paper, written

from the perspective of the Coordinators of the Network. The Coordinators plan, over the

next two years, to systematically collect and record perspectives from network members,

including country research teams and funders, and other stakeholders.

Questions and challenges for GHIN in 2008-09 include:

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- Country teams expressed the need for a strong regional dimension to the Network.

What is the added value of having one global network over two or more regional

networks?

- How to assess research capacity and how to address capacity-weaknesses,

particularly using south to south capacity building?

- How equitable is GHIN’s research governance model and what lessons can GHIN

learn from other (earlier and current) Networks, particularly around governance

and coordination?

- What is the appropriate balance between maintaining independence and engaging

more intensively and seeking to meet the needs and concerns of global and

country stakeholders?

- What communication and dissemination strategies will best enable research-into-

policy at the country level?

To address these questions would enable us to consider GHIN not only as a

straightforward “global opening” (Rogers et al, 2001), but also to look at the costs of

running a Network to assess to what extent GHIN “exposes the costs of globalisation.”

(Rogers et al, 2001)

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Stillman, K. & Bennett, S. (2005). Systemwide effects of the Global Fund: interim findings from three country studies. Abt Associates.

Stone, D (2002) Introduction: global knowledge and advocacy networks. Global Networks: A Journal of Transnational Affairs, Vol. 2 (1)1-12(12)

SWEF. Common Research Protocol. Monitoring and Evaluating the Health System-Wide Effects of the Global Fund to Fight AIDS, Tuberculosis and Malaria. November 2003

UNESCO (1996) World Science Report, 1996. Paris

Global Forum for Health Research (2004) 10/90 Report on Health Research 2003-2004, Geneva

Author Information

Aisling Walsh is researcher and one of the coordinators of the Global HIV/AIDS Initiatives Network (GHIN), which is a network of researchers in 15 countries across sub-Saharan Africa, Eastern Europe, Asia and South America, supported by five institutions in Europe and the US that are researching the country effects of global HIV/AIDS initiatives at national and sub-national levels. The Network is facilitating comparative work and plans to synthesise findings around these themes, which include the effects of global HIV/AIDS initiatives on: sub-national scale-up of services; health systems capacity, including availability of human resources; national and district level coordination; and equitable access to services.

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ANNEX A: The GHIN Network – Funders and Researchers

GHI Network Funders

Research

Partners

Country StudiesResearch Funders

Tanzania

Uganda

Peru

China

Georgia

Malawi

Ethiopia

Benin

Malawi

Alliance (AHPSR)

Karolinska

(Sweden)

Vietnam

RCSI (Irel)

Belgium

Portugal

Mozambique

Angola

South AfricaINCODEV

LSHTM (UK)

Kyrgyzistan

Ukraine

Zambia

OSI

Irish Aid DANIDA SIDA

USAIDSWEF / Health Systems 20/20

Funding for country studies

The process of obtaining funding for the GHIN studies started with six months of

negotiations between Walt and Brugha of LSHTM and the Open Society Institute (OSI)

from November 2004, which resulted in OSI funding a three-country study. An approach

to Irish Aid and DANIDA in March 2005 resulted one year later in a three year grant,

which funded coordination costs of the GHIN Network. In April 2004, Brugha met in

Geneva with Van Damme of the Institute of Tropical Medicine Antwerp and Ferrinho of

the Institute of Hygiene and Tropical Medicine Lisbon to discuss a proposal to the EU for

a three country study in Southern Africa, which was eventually funded in late 2005.

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Of crucial importance to the direction GHIN has taken was a call to country researchers

for proposals, based on the SWEF framework (SWEF 2003), issued by the Alliance for

Health Policy and Systems Research (AHSPR) in late 2005. Six country research groups’

proposals were funded. Bennett moved from Abt Associates to become the manager of

the AHSPR) in early 2006 and since then has been overseeing funding and contributing to

coordination of these studies. In early 2007, Stillman of Abt Associates who was

overseeing and supporting the SWEF studies received confirmation that Abt Associates

would receive funding from USAID for the new Health Systems 20/20 Project, which

might support further country studies.

Five of the country research groups who had been previously funded under the Tracking

Study (Mozambique, Uganda, Zambia) and the SWEF Network (Malawi and Georgia),

all of which had existing links with northern researchers, were now in receipt of funds for

new studies on the global HIV/AIDS initiatives.

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Network members

COUNTRY RESEARCH TEAMS are headed by:

Mário Fresta, Centros de Estudos Avançados em Educação e Formação Médica, Angola: mariofresta@netcabo.co.ao

Sourou Gbangbade, Independent Researcher, Benin: sgbangba@yahoo.com

Xiulan Zhang, Beijing Normal University, China: zhang99@bnu.edu.cn

Aklilu Kidanu, Miz-Hasab Research Centre, Ethiopia: miz_hasab@telecom.net.et

Ketevan Chkhatarashvili, Curatio International Foundation, Georgia: k.chkhatarashvili@curatio.com

Gulgun Murzalieva, Centre for Health System Development, Kyrgyzstan: gulgun@manas.elcat.kg

Brian Mtonya, The Alliance Group, Malawi: alliancegroup@malawi.net

Victor Mwapasa, College of Medicine, Malawi: vmwapasa@medcol.mw

Baltazar Chilundo, Universidade Eduardo Mondlane, Maputo, Mozambique: chilubal@yahoo.com

Carlos Caceres, Cayetano Heredia University, Peru: ccaceres@upch.edu.pe

David Sanders, University of the Western Cape, Cape Town, South Africa: dsanders@uwc.ac.za

Eric Buch, University of Pretoria, South Africa: eric.buch@up.ac.za

Innocent Semali, Muhimbili University College of Health Sciences, Tanzania: innosemali@yahoo.com

William Bazeyo, Makerere University, Uganda: HREF="mailto:n.rukhadze@curatio.com" MACROBUTTON HtmlResAnchorsengooba@iph.ac.ugHREF="mailto:n.rukhadze@curatio.com" MACROBUTTONHtmlResAnchor wbazeyo@iph.ac.ug

Tetyana Semigina, National University of Kyiv-Mohyla Academy, Ukraine: tv_sem@ukma.kiev.ua

Nguyen Thi Kim Chuc, Hanoi Medical University, Vietnam: ntkchuc@yahoo.com

Phillimon Ndubani, University of Zambia, Zambia: pndubani@yahoo.co.uk

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NORTHERN RESEARCH TEAMS are represented by:Sara Bennett, Alliance for Health Policy and Systems Research: bennetts@who.int

Ruairi Brugha, Aisling Walsh, Sam McConkey and Regien Biesma Royal College of Surgeons, Ireland: HREF="mailto:rbrugha@rcsi.ie" MACROBUTTON HtmlResAnchorrbrugha@rcsi.ie, aislingwalsh@rcsi.ie, HREF="mailto:smcconkey@rcsi.ie"MACROBUTTON HtmlResAnchor smcconkey@rcsi.ie and rbiesma@rcsi.ie

Anna Thorson and Anastasia Pharris Karolinska Institutet, Sweden: Anna.Thorson@ki.se and Anastasia.Pharris@ki.se

Kate Stillman and David Hotchkiss, Health Systems 20/20: kate_stillman@abtassoc . com and hotchkis@tulane.edu

Wim van Damme, Institute of Tropical Medicine, Antwerp, Belgium: wvdamme@itg.be

Gilles Dussault, Instituto de Higiene e Medicina Tropical, Universidade Nova de Lisboa, Portugal: gillesdussault @ihmt.unl.pt

Gill Walt and Neil Spicer, London School of Hygiene and Tropical Medicine: gill.walt@lshtm.ac.uk and neil.spicer@lshtm.ac.uk

Irish Aid, DANIDA and DfID provide support for Network activities. Support for the country studies is provided by the Open Society Institute, the Alliance for Health Policy and Systems Research, USAID and the EU (INCO). Funding for all of the studies and the GHIN Network is independent of the initiatives being studied.

For further information, please visit our website: www.ghin.lshtm.ac.ukAlternatively please contact: Neil Spicer, neil.spicer@lshtm.ac.uk or Aisling Walsh, aislingwalsh@rcsi.ie, or any of the individual country researchers.

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Annex B: GHIN Briefing Sheet

Global HIV/AIDS Initiatives Network:

Researching the national and sub-national effects of global HIV/AIDS initiatives at

the country level

Global funding for HIV/AIDS has increased dramatically during the past five years.

Three global HIV/AIDS initiatives are together contributing most of the direct external

funding to scaling up HIV/AIDS prevention, treatment and care:

The World Bank’s Global HIV/AIDS Programme including the Multi-country AIDS

Programme (MAP)

The Global Fund to Fight AIDS, TB and Malaria (GFATM)

The United States President’s Emergency Plan for AIDS Relief (PEPFAR).

In the high HIV prevalence, low-income countries of southern and eastern Africa, the

combined commitments from these initiatives can amount to over half of countries’ total

health budgets. In the context of the concentrated epidemics of middle-income countries

the scale of funding is less, but the potential impacts on containment of the HIV epidemic

are still significant.

A network of researchers was established in 2006 to track the effects of this scale-up.

Members of the Global HIV/AIDS Initiatives Network (GHIN) are researching the

country effects of these initiatives at national and sub-national levels9. This network

builds on two earlier studies: the Tracking Study, led by the London School of Hygiene

and Tropical Medicine (2003-2004) and the System-Wide Effects of the Fund (SWEF)

Research Network (since 2003) coordinated by the Partners for Health Reformplus

project.

9Some countries may also research the effects of other global health initiatives

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Unlike earlier studies, which focused primarily on the Global Fund, the new Network is

examining the effects and the inter-relationships of these three major global HIV/AIDS

initiatives. National and sub-national data collection is taking place in 2006 and 2007;

and in most cases follow-up studies are planned for 2008.

GHIN countries undertaking 2-4 year studies include: Angola, Benin, China, Ethiopia,

Georgia, Kyrgyzstan, Malawi, Mozambique, Peru, South Africa, Tanzania, Uganda,

Ukraine, Vietnam and Zambia.

GHIN will provide added value to individual country studies by:

Promoting comparability through common research protocols and tools

Sharing expertise across country study teams and building research capacity

Generating multi-country comparisons and context-specific policy lessons

Coordinating dissemination of findings and recommendations and streamlining

communication with global stakeholders

Research Themes

While the research protocols developed for individual country studies reflect the needs

and contexts of these countries, there are several common themes across the Network,

some or all of which individual country studies are addressing. The Network is

facilitating comparative work and plans to synthesise findings around these themes,

which include the effects of global HIV/AIDS initiatives on:-

Sub-national scale-up

The levels and types of HIV/AIDS services delivered – including prevention,

treatment and support services – demonstrating trends over time

Quality of HIV/AIDS services

Non-focal (non-HIV/AIDS) priority services

Health systems capacity

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Human resources for health, including effects on the public-private mix

National and sub-national coordination, harmonisation and alignment

Supply of commodities and equipment

Equitable access

Accessibility and patterns of utilisation of HIV/AIDS services

Institutional/programmatic factors and household/community factors that determine

service accessibility

Communicating Findings, Influencing Policy

The strategies employed by the global HIV/AIDS initiatives are constantly evolving, and

the questions that the researchers within the Network are addressing are live ones. GHIN

members recognise that findings from the studies need to be channelled into policy

debates at the country and global levels on an ongoing basis.

Country research teams have been interacting with country stakeholders, including

policymakers and civil society organisations, from an early stage to help ensure the

policy-relevance of their studies. The GHIN Coordinators have been interacting in the

same way with global stakeholders, also taking steps to ensure that communication is

established and coordination is promoted with other large, multi-country evaluations of

the major global HIV/AIDS initiatives.

Regular ongoing interactions will both inform decision makers and continue to shape

research questions. Findings from the individual studies will be synthesised across

countries and packaged into short policy briefs that focus upon ongoing country and

global debates of particular relevance to policy makers, representatives of multilateral

(including UNAIDS) and donor agencies, and of global HIV/AIDS initiatives.

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