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Non-state actors, including humanitarian agencies, play a prominent role in providing health care in low- and middle-income countries. Between 2007 and 2009, Musina, a South African municipality bordering Zimbabwe, became the site of several interventions by non-state organisations as an unprecedented number of Zimbabweans crossed the border, putting strain on already burdened local systems. After the initial need for humanitarian relief dissipated, organisations started to implement projects that were more developmental in nature. For example, Médecins sans Frontières developed a mobile clinic programme to improve health care access for migrant farm workers, a programme that was subsequently integrated into the Department of Health. Since the handover of the programme, it has faced multiple challenges. Using qualitative methodology and a case study approach, this paper traces the development of the programme, exploring the changing relationship between MSF and the state during this time. This research raises questions about the implications of short-term ‘innovative’ interventions targeting the access that migrants have to care, within a context in which policy and programmatic responses to health are not migration aware. Furthermore, it highlights the ways in which the energies and resources of local DoH employees were redirected by MSF's involvement in the area.

The past decade has witnessed a tremendous growth in the scale and policy influence of civil society in global health governance. The AIDS 'industry' in particular opens up spaces for active mobilisation and participation of non-state actors, which further crystallise with an ever-increasing dominance of global health initiatives. While country evaluations of global initiatives call for a greater participation of 'civil society', the evidence base examining the organisation, nature and operation of 'civil society' and its claims to legitimacy is very thin. Drawing on the case of one of the most visible players in the global response to HIV epidemic, the Global Fund to Fight AIDS, Tuberculosis and Malaria, this article seeks to highlight the complex micropolitics of its interactions with civil society. It examines the nature of civil society actors involved in the Fund projects and the processes through which they gain credibility. We argue that the imposition of global structures and principles facilitates a reconfiguration of actors around newer forms of expertise and power centres. In this context, the notion of 'civil society' underplays differences and power dynamics between various institutions and conceals the agency of outsiders under the guise of autonomy of the state and people.

In Namibia, support through the Global Fund and President's Emergency Plan for AIDS Relief has facilitated an increase in access to HIV and AIDS services over the past 10 years. In collaboration with the Namibian government, these institutions have enabled the rapid scale-up of prevention, treatment and care services. Inadequate human resources capacity in the public sector was cited as a key challenge to initial scale-up; and a substantial portion of donor funding has gone towards the recruitment of new health workers. However, a recent scale-down of donor funding to the Namibian health sector has taken place, despite the country's high HIV and AIDS burden. With a specific focus on human resources, this paper examines the extent to which management processes that were adopted at scale-up have proven sustainable in the context of scale-down. Drawing on data from 43 semi-structured interviews, we argue that human resources planning and management decisions made at the onset of the country's relationship with the two institutions appear to be primarily driven by the demands of rapid scale-up and counter-productive to the sustainability of interventions.

As we enter the fourth decade of HIV and AIDS, sustainability of treatment and prevention programmes is a growing concern in an environment of shrinking resources. The Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) will be critical to maintaining current trajectories of scale-up and ultimately, ensuring access to HIV treatment and prevention for people in low/middle-income countries. The authors' prior research in India, Zambia and South Africa contributed evidence on the politics and impact of new institutional and funding arrangements, revealing a 'rhetoric-reality gap' in their impact on health systems, civil society participation, and achievement of population health. With its new funding strategy and disbursement model, the Fund proposes dramatic changes to its approach, emphasising value for money, greater fund predictability and flexibility and more proactive engagement in recipient countries, while foregrounding a human rights approach. This paper reviews the Fund's new strategy and examines its potential to respond to key criticisms concerning health systems impact, particularly the elite nature of this funding mechanism that generates competition between public and private sectors and marginalises local voices. The authors analyse strategy documents against their own research and published literature and reflect on whether the changes are likely to address challenges faced in bringing HIV programmes to scale and their likely effect on AIDS politics.