Global health Initiatives (GHI) are a new form of partnership providing support to countries for development [1]. There are various definitions of GHIs most of which characterise GHIs by a set of common features, including their focus on an issue of international concern, operation in several countries, substantial funding, performance-based inputs, and direct investment in countries [2–4]. A number of GHIs were created to support low and middle income countries [1]. This new funding mechanism arose from the need to advocate for, mobilise and hasten funding for some key health problems facing the globe [5]. Over the past 20 years, approximately 100 or so GHIs have been created with the aim of assisting countries to achieve their health outcomes in line with the global goals [1, 5]. GHI support has been of different forms, ranging from monetary support for certain underfunded priority areas to technical support to improve health support systems for their better performance [4]. GHIs are also renowned for prompting the involvement of civil societies in planning and advocating for services [6], for being pro-poor and for supporting areas that affect the poorest of the poor. Furthermore, GHIs have been instrumental in promoting innovations meant to ease implementation of interventions [1].

GHIs have been a subject of contestation for several reasons [4, 5, 7–9]. At the pinnacle of these debates is the use of the tem term itself. For example, Nervi [2] claims that several initiatives that self-identify as global are in fact bilateral in nature, involving only one recipient country. Regarding their management, among the contentions surrounding GHI governance is that they are characterised as vertical, extremely demanding, and burdensome for the limited human resources in the low and middle income countries [4, 10]. Several studies point out that GHI management approach tends to duplicate efforts, is poorly coordinated and harmonised, and lacks country ownership [1, 3, 6, 11]. The nature of the support rendered by GHIs also has been a subject of debate [6, 10] particularly their level of funding, peculiar schedules and strict conditions and restrictions, which are perceived to water down the positive synergism of countries’ funding efforts [4]. Evidence further highlights the concerns over the implementation of GHIs in countries and how they impact the addressing of the countries’ priorities, long-term investments and sustainability of interventions [4].

The African Region has benefitted immensely from GHIs and continues to register an increase in their number. Their assistance has helped Africa to make tremendous progress towards the achievement of some key global health goals such as the Millennium Development Goals (MDGs) [4].

Countries with low levels of health expenditure have been able to advance interventions for priority health problems mostly through GHIs funding [8]. Some of the MDGs have been achieved through GHI support for key interventions such as immunisation, prevention of mother to child transmission of HIV, HIV related interventions, case detection of tuberculosis and provision of insecticide treated bed-nets [8, 12]. GHIs have been able to do this through their ability to mobilise huge levels of financial resources, linking inputs to performance and channelling resources directly to non-governmental civil society groups for greater accountability [7].

The mushrooming of GHIs has resulted in the complexity of the aid architecture [1], partly because of the limitations in the centralised information on all GHIs and their operations. Information on how they function and operate at the country level and their contribution to the harmonisation and alignment of partner programmes with country priorities and health systems strengthening is scarce and outdated. Most of the literature on GHIs focuses on their initiation phase; documentation on current developments is limited.

To fill the gaps in information, we conducted country case studies in Tanzania and Zambia. The main objectives were to understand the profile of the GHIs supporting health development in the two countries and assessing their governance structures, alignment with country priorities, harmonisation with other GHIs and donors, and contribution towards health systems strengthening.

In this article we adopt the definitions of the health system as provided by the World Health Organisation (WHO) defining a health system as consisting of “all organizations, people and actions whose primary intent is to promote, restore or maintain health”[12] organised around six building blocks namely service delivery; health workforce; information; medical products, vaccines and technologies; financing; and leadership and governance (stewardship) [13]. Health system strengthening is on the other hand defined as “improving these six health system building blocks and managing their interactions in ways that achieve more equitable and sustained improvements across health services and health outcomes”[14].

With this definition, the GHIs considered in this study include (1) those that are involved in research and development in product discovery, and development of new diagnostics, drugs and vaccines, e.g. the GAVI Alliance; (2) those that render technical or service support with the intention of improving service access, such as those that provide discounted or donated drugs; and (3) those that provide financing for specific disease programmes and health systems strengthening.

GHIs have been instrumental in supporting national strategic plans of both Tanzania and Zambia, where they have made a remarkable contribution towards the fight against major diseases such as HIV, tuberculosis and malaria. However, a number of challenges exist related to their governance, coordination and contribution to health systems strengthening.

There is no doubt that in both Tanzania and Zambia financial resources and technical assistance from GHIs have been remarkable [19]. The two two case studies show that several GHIs are supporting the countries’ health programmes. The positive aspects of their contribution relate to their alignment with country priorities, use of national health information systems and improved access of health interventions for the programmes that support.

The negative elements include weaknesses in their coordination as evidenced by their use of their own structures as opposed to SWAp mechanisms. Although GHIs have contributed to the strengthening of health systems, this has not been comprehensive, and in some cases they have caused distortions in the systems. The challenges to the planning of their activities have been related to the lack of comprehensive information and concerns about unpredictability of funding.

GHIs have been the subject of criticism [5, 6, 20, 21]. Literature from their early years cites discrepancies between their objectives and country priorities [6]. In particular, there was concern about the alignment of GHI objectives with those of the strategic plans of various countries across the African Region [6, 22]. From these two case studies, it is unmistakable that GHIs have improved their alignment with national health priorities. Now most of the GHIs in Tanzania and Zambia are guided by either the national development plans or the health strategic plans. The implementation of GHI interventions also uses existing health systems.

This study and other literature show, however, that GHI processes such as selective and restrictive funding for specific areas compromise their alignment with national priorities [4, 20, 23]. Also, as noted in our study, harmonisation between GHIs and other health development partners in both countries is weak. Most of the GHIs do not have a permanent representative or office in the countries to attend coordination meetings on health policy issues or to participate in other processes such as strategic planning and technical discussions. This has led to duplication of efforts and has been the source of an additional burden for the countries [4, 23]. Previous studies also have alluded to the poor harmonisation between GHIs and donors [8, 23]. One such example from the literature was the failure of the World Bank to use the Three Ones’ principles with other partners, which was a prerequisite for the Multi-country HIV/AIDS Program review [24]. Instead of using one strategic framework, one national authority and one monitoring and evaluation framework, the countries are often been burdened with extensive and complex procedural and reporting requirements [8, 20, 23]. This was observed in our study too.

GHIs have a tendency to set up their own coordination mechanisms and a committee that may overrule national level authorities. Our study noted this. Other authors have made similar observations, such as Lancet [20] who claims that GHIs have at times overridden the policy-making authority of UN systems through bypassing them and working directly with countries. Additionally, the involvement of government officials in GHI activities removes them from actively participating in planned government activities and might negatively affect the leadership and stewardship of those activities. Similarly, the high transaction costs for countries with scarce health technical staffing associated with the increased reporting modalities, separate accountability systems and the multitude of meetings hamper implementation of other priority activities [4, 23, 25].

In Tanzania and Zambia several GHIs give priority to health system strengthening explicitly referencing the WHO health systems building blocks. However, there are gaps with that approach [2, 4, 23]. Our study found that none of the GHIs adopted a holistic approach to health systems strengthening, but most of them focused on the main health systems bottlenecks that hampered the attainment of their specific objectives. Some GHIs have addressed the HRH challenges such as those relating to pre- and post-training and staff motivation but little attention has been given to the production side [4, 10, 25–27]. The selective approach to interventions by either area or disease was seen also with health information systems, monitoring and evaluation processes and data quality assurance. Renewed attention and support from GHIs have helped improve procurement and supply management systems, as evidenced in our study and other literature [4]. This support was perceived as creating parallel and unsustainable systems with a tendency to bring in new and foreign staff rather than strengthening the existing country capacity. Further, our study and available evidence indicate that the service delivery activities focused on some specific areas such as HIV/AIDS with interventions such as introduction of standards for treatment and prevention, renovation or building of health infrastructure for specific areas, improvement of laboratory equipment and provision of medicines [4]. This was perceived by respondents in our study as exacerbating inequity in service delivery. Such interventions are not sustainable and could even threaten efforts already made by the countries to improve their health services coverage.

GHIs are important funders for health in low and middle income countries. To optimise the return on investment by GHIs, there is need to improve their governance at the country level. Coordination of GHIs by a single mechanism under the leadership of a national authority could help the countries to tackle existing fragmentation and duplications. Institutional reforms in this regard should be prioritised, building on lessons from the countries using SWAp mechanisms. To reduce transaction costs, there is need for coordination and integration of GHI procedures. A unified procedure under a government authority is recommended. Each country’s health authorities need to be in a position to negotiate on each project aiming at comprehensively strengthening their health systems to achieve universal coverage.

CSOs, civil society organisations; GFTAM, Global Fund to Fight AIDS, Tuberculosis and Malaria; GHIs, global health initiatives; HHA, Harmonization for Health in Africa; HRH, human resources for health; HSS, health systems strengthening; MDGs, Millennium Development Goals; MoH, Ministry of Health; PEPFAR, US President’s Emergency Plan for AIDS Relief; PMI, US President’s Malaria Initiative; SWAp, Sector-wide Approach; WHO, World Health Organization