The Global Fund at a Crossroads: Recommendations for the Next Five Years

“Failure of the Global Fund would be a global health catastrophe,” wrote a panel that evaluated the Fund’s risk management systems in a report released on Monday. I agree. I have been closely involved with the Global Fund to Fight AIDS, Tuberculosis and Malaria for the past five years, working both at the Board level and with partners on the ground to make sure that its resources reach communities, support the right things, and are used in a way that is transparent and accountable. In that time, I have seen the Global Fund transform countries’ responses to HIV, TB, and malaria. And above all, I have seen the Global Fund save lives.

One of the Global Fund’s hallmarks has been its willingness to take risks and to invest in the most marginalized communities. Through its bold statements on gender inequalities and the health and rights of sexual minorities, I have witnessed the Global Fund prompt countries like Uganda to move away from demonizing sex workers and men who have sex with men to establishing strategies that address the HIV needs of these vulnerable communities.

In countries like Ukraine and Zambia, I have seen the Global Fund empower civil society and people living with and affected by the diseases to hold governments accountable when they fail to appropriately manage Global Fund grants.

Through its use of an independent, non-political technical review panel to judge whether the programs it supports are the ones likely to have the greatest impact, I have also seen the Global Fund prompt countries like Thailand and Swaziland to take a hard look at their HIV programs and refocus on addressing the most critical gaps in their responses.

For these reasons, the Global Fund is one of the most innovative, transparent, and effective aid organizations currently in operation. It has contributed to stronger civil society organizations, stronger community-based responses, and stronger health systems. But now, the Global Fund is at a crossroads. The decisions the Board and Secretariat make over the next few months will determine whether it continues to be a high-impact aid organization that is responsive to the needs of communities, or whether it becomes irrelevant.

The past few years have not been easy for the Global Fund. Its October 2010 replenishment failed to bring in the money necessary to continue to scale up programs, leading to delays in the launch of new funding opportunities and increased pressure to prove that its investments are achieving value for money. The ongoing global financial crisis continues to put downward pressure on aid dollars, while donor fatigue with the AIDS response and a shift by donors to prioritize funding for broader health systems have made fundraising even more difficult. To make matters worse, the misuse of funds by recipients in a limited number of countries has put pressure on the Global Fund to prove that its risk mitigation systems are adequate to the task of moving billions of dollars to scale up health programs and save lives, while safeguarding against fraud and corruption. Over the past few months, increasing risk aversion from the Secretariat and local partners has resulted in a level of micromanagement that has paralyzed programs and the ability to adapt to changing circumstances on the ground.

Fortunately, the Global Fund has several opportunities to change course and refocus. The Board and Secretariat will meet on September 26 to review recommendations made by the “High Level Independent Review Panel on Fiduciary Controls and Oversight Mechanisms.” If adopted, the panel’s broad and far-reaching recommendations could fundamentally change the way the Global Fund does business. The recommendations range from changing the job description and authority of Fund Portfolio Managers, to reorganizing the board, to creating a more iterative process for proposal development and review. In addition, the Board and Secretariat are developing a new five-year strategic plan that has the potential to refocus the Fund on achieving its mission: preventing new infections and saving lives.

The Global Fund’s Board and Secretariat have a real opportunity at this point to take this organization to the next level, increase its effectiveness, and ensure that its funding is really being used to save lives.  As it does this, the Global Fund should strive to:

• Fight fraud while continuing to support risk-taking and innovation (which are often the things that make aid programs effective);
• Build in more consistent feedback loops with countries and allow greater flexibility to adjust programs according to changing needs;
• Ensure greater predictability and more transparency of funding in order to increase accountability;
• Strengthen “country ownership” by supporting the real and meaningful participation of all stakeholders in decision-making about the use of Global Fund resources, particularly most-affected and marginalized communities;
• Give more attention to improving program quality and building real capacity in countries;
• Empower civil society to monitor transparency in the procurement, supply, and quality of medicines, and ensure technical assistance for the effective use of flexibilities within intellectual property agreements; and
• Put human rights front and center to make sure that it is funding appropriate interventions and addressing real barriers to care.

It would be unfortunate if the Global Fund emerges from this process with a focus only on strengthening its financial safeguards without also committing to address some of the other factors that can just as easily undermine the effectiveness of its programs, such as a weak civil society or inadequate protections for human rights. Strengthening civil society, increasing transparency, and challenging the unjust legal and policy environments that allow HIV, tuberculosis, and malaria to flourish should be just as much a priority.