Key debates

The literature argues that in some cases, especially in Africa, the establishment of NACs as stand alone institutions has created political tensions with the MOH and undermined the ability of the MOH to deliver the health sector response to HIV. For example, in some countries, such as Malawi, the establishment of the NAC led to the transfer of many MOH staff into the new institution. The World Bank reviews (2001, 2004 and OED 2005) of the MAP in Africa noted that in many MAP countries the establishment of a NAC outside of the MOH has caused resentment and confusion among health officials. MOHs are reported to have felt disempowered and there is concern the health sector is not getting the support it needs.

While the Three Ones Principles were not presented to countries as one size- fits-all global blueprints, some authors (eg Putzel 2004) have argued that the NAC “organisational template” was imposed on developing countries, especially in Africa through the conditionality associated with the WB MAP programme in the early 2000s. Indeed the model of organisation promoted by the Africa MAP seems to have been based on experience in a limited number of countries, including Uganda. The examples used to support the model are said to have been misinterpreted, with there being no example of a Commission having played such a role successfully (Putzel 2004)

The Ethiopia case study prepared by the OED evaluation in 2005 concludes that the creation of a multi-sectoral institution does not necessarily foster a multisectoral approach. Ethiopia’s institutional framework was created in response to World Bank eligibility criteria and without institutional and political analysis. The World Bank’s 2004 review of the MAP noted that, although there was early recognition of the complexity of creating new institutions, the Bank could have analysed more systematically the institutional environment and requirements for effective implementation.

Debates are ongoing about the best mechanism to enhance multisectoralism and achieve coordination. IDASA (2003) has critically examined whether NACs are the best mechanism to enhance cross-sectoral partnerships and participation. Advantages of the MOH leading the HIV response have been cited, while questions have been raised whether an implementing ministry can also effectively engage other sectors (eg see Pacific Regional HIV/AIDS Project 2006 review). Others have argued that NACs would be more effective to be re-framed into national fund managers with autonomy and control over resources, responsible for contracting service providers (England 2006).

The OED 2005 evaluation “could find no evidence to suggest that any one institutional arrangement is more effective or efficient in producing results on the ground than the alternatives, if the political commitment is present” and concludes that “evidence to support the effectiveness of institutions to manage the AIDS response outside of the Ministry of Health from the Bank’s experience is scant.”