This paper examines the institutional management of the Global Fund to Fight AIDS, Tuberculosis and Malaria(GFATM) in Botswana. We analyse the often contested roles of the state and non-governmental organisations(NGOs) as recipients of GFATM and partners in extending public health service provision to communities.Of importance is that Botswana’s first GFATM grant had to be administratively closed, and the country was notawarded any other grant (especially for HIV/AIDS) until over a decade later. Following this, it is of interest tounderstand the ways in which institutions manage grant programmes. This article concludes that the “big brother”relationship of the state in relation to NGOs is crippling the critical and constructive effects of these organisationsto deliver needed community-based health services in Botswana. GFTAM represents a window of opportunity forcreating an effective civil society whose local activities will not be seen as being led covertly by the state. Thisarticle contributes to both theory and practice within the scholarship of development aid in Africa. Qualitativeresearch methods were used, including in-depth interviews with public sector policy makers, all GFATM principaland sub-recipients, members of the Country Coordinating Mechanism (CCM) and NGOs.

Keywords: aid effectiveness, health services, country coordinating mechanism, power and accountability, principal recipient

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