Birungi Charles, Colbourn Timothy
Institute for Global Health, University College London, London, United Kingdom.
UNAIDS, Harare, Zimbabwe.
Afr J AIDS Res. 2019 Dec;18(4):370-381. doi: 10.2989/16085906.2019.1689148.
The role of trust funds in the practice of and the policy discourse on the sustainable financing for health and HIV is growing. However, there is a paucity of political analyses on implementing trust fund arrangements. Drawing on a novel meta-framework - connecting multiple streams and advocacy coalition frameworks to policy cycle models of analysis - to politically analyse HIV financing policy design, adoption and implementation as well as insights from public finance literature, this article critically analyses the politics of the AIDS Trust Fund (ATF) in Uganda. We find that politics was the most fundamental driver for the establishment of the ATF. Whereas HIV financing is inherently both technical and political, enacting the ATF was largely a geopolitical positioning policy instrument that entailed navigating political economy challenges in managing multiple stakeholder groups' politics. With the mandated tax revenues earmarked to capitalise the ATF covering only 0.5% of the annual resource needs, we find a very insignificant potential to contribute to financial sustainability of the national HIV response per se. As good ideas and evidence alone often do not necessarily produce desired results, we conclude that systematic and continuous political analysis can bring meaningful insights to our understanding of political economy dimensions of the ATF as an innovative financing policy instrument, thereby helping drive technically sound health financing policy proposals into practice more effectively. For Uganda, while proponents have invested a considerable amount of hope in the ATF as a source of sustainable domestic funding for the HIV response, substantial work remains to be done to address a number of questions that continue to beguile the current ATF architecture. Regarding global health financing policy, the findings suggest the need to pay attention to the position, power and interests of stakeholders as a powerful lever in health financing policy reforms.
信托基金在卫生与艾滋病可持续融资的实践及政策讨论中的作用日益增强。然而，关于实施信托基金安排的政治分析却很匮乏。本文借鉴一个新颖的元框架——将多源流和倡导联盟框架与政策周期分析模型相联系——对艾滋病融资政策的设计、采纳和实施进行政治分析，并结合公共财政文献中的见解，对乌干达艾滋病信托基金（ATF）的政治情况进行批判性分析。我们发现，政治因素是设立ATF的最根本驱动因素。虽然艾滋病融资本质上兼具技术性和政治性，但设立ATF在很大程度上是一项地缘政治定位政策工具，在管理多个利益相关者群体的政治问题时需要应对政治经济挑战。由于指定用于为ATF注资的法定税收收入仅占年度资源需求的0.5%，我们发现其对国家艾滋病应对措施本身的财务可持续性贡献潜力非常小。由于仅有好的想法和证据往往不一定能产生预期结果，我们得出结论，系统且持续的政治分析能够为我们理解ATF作为一种创新融资政策工具的政治经济层面带来有意义的见解，从而有助于更有效地将技术上合理的卫生融资政策建议付诸实践。对于乌干达而言，尽管支持者对ATF作为艾滋病应对措施可持续国内资金来源寄予了厚望，但仍有大量工作要做，以解决一些继续困扰当前ATF架构的问题。关于全球卫生融资政策，研究结果表明需要关注利益相关者的地位、权力和利益，将其作为卫生融资政策改革的有力杠杆。
