By guest contributors Johanna Hanefeld and Anuj Kapilashrami
The Global Fund to Fight AIDS Malaria and TB is a leading funder in global health. In just over a decade since its inception in 2002, the organization has committed over USD 20 billion in funding for the three focal diseases. The organization has been at the forefront of the scale up of treatment for HIV, TB, and Malaria, and is credited for innovative financing mechanisms such as the affordable malaria facility.1
Despite these immense successes, the organization has just emerged from a difficult period of restructuring, which saw changes in senior staff, including its executive director.2 This had been precipitated by evidence uncovered in 2010 of misuse of funds by grantees in four countries.3 Moreover, research focused on national and subnational impact of Global Fund funding during the 2000s revealed that the Fund—while opening up new spaces for civil society participation—has favored certain types of civil society engagement over others.4 Evidence also demonstrated how non- governmental organizations funded by the Fund created competition to the public sector for health workers as these were able to provide higher salaries and greater incentives.5,6 Further documented impact related to additional administrative burden resulting from monitoring and evaluation.7,8
The Global Fund is recognized for being highly responsive to criticism. Acknowledging the above country-level challenges, the Global Fund published a revised strategy in November 2011, which committed the organization to more strategic investment that supports national systems, prioritizing high impact countries and most affected populations. It committed the organization to evolving its funding model, a more active involvement in implementation and included an explicit commitment to human rights.
The Fund recently introduced a new funding model. It translates some aspects of the strategy: emphasis is on aligning resources more closely with the burden of disease faced by countries, to create a more iterative process for proposal development and to ensure that funding is more predictable. A more flexible model of grantmaking that allows for development of proposals in response to country needs, not the call for funding is particularly welcome. It aims to strengthen national health systems through making funding conditional on national health strategies or countries, demonstrating how proposals will support national systems, and increases sustainability with a possible cost sharing of programs over time.
The new financial model is not without limits. While the process of grant making highlights ‘country dialogue’ extending beyond established mechanisms it does not explicitly set out how this will avoid reinforcement of the complex power hierarchies at country level, evident in some of the qualitative national and sub-national research conducted.4 Also notable is the lack of explicit translation of the commitment on human rights.
Many, not least the over 4 million people depending on the Global Fund for their anti-retroviral treatment, will welcome the Fund’s recent announcements and actions. Yet, skepticism remains in countries that are witnessing the phasing out or flatlining of funding by global health actors including the Global Fund and US PEPFAR post financial crisis.9 Health gains and rights of the affected population in countries are under threat as they face the challenge of sustaining HIV prevention and treatment programs. The Global Fund’s prioritization of countries, which are in a position to achieve rapid impact may compound this effect. Use of national income, absorptive capacity, and national burden as the criteria for funding will bypass inefficiencies in fund utilization, but runs the risk of excluding more marginalized populations in countries characterized by weak governance.
The model announced will be tested for one year before becoming fully operational. The Global Fund should not waste this opportunity to address challenges that became apparent in its first decade, even where these may require dealing with the more ‘messy’ and softer issues such as power dynamics within and between groups facing marginalization, or making a genuinely country led, rights-based process a reality.
1. S. Tougher, Y. Ye, J. H. Amuasi, et al., “Effect of the Affordable Medicines Facility–malaria (AMFm) on the availability, price, and market share of quality-assured artemisinin-based combination therapies in seven countries: A before-and-after analysis of outlet survey data,” Lancet 380/9857 (2012), pp. 1916-1926.
2. A. D. Usher, “Mark Dybul appointed to lead the Global Fund,” Lancet 380/9856, pp. 1803-1804.
3. The Lancet, “Supporting the Global Fund to fight fraud,” Lancet 377/9764 (2011), pp. 440.
4. A. Kapilashrami and O. O’Brien, “The Global Fund and the re-configuration and re-emergence of ‘civil society’: Widening or closing the democratic deficit?” Global Public Health 7/5 (2012), pp. 437-451.
5. A. Kapilashrami and B. McPake, “Transforming governance or reinforcing hierarchies and competition: Examining the public and hidden transcripts of the Global Fund and HIV in India,” Health Policy and Planning (2012).
6. J. Hanefeld and M. Musheke, “What impact do global health initiatives have on human resources for antiretroviral treatment roll-out? A qualitative policy analysis of implementation processes in Zambia,” Human Resources for Health 7/8 (2009).
7. B. Samb, T. Evans, M. Dybul , et al., “An assessment of interactions between global health initiatives and country health systems,” Lancet 373/9681 (2009), pp. 2137-2169.
8. R. Atun, S. K. Pothapregada, J. Kwansah, et al., “Critical interactions between the Global Fund-supported HIV programs and the health system in Ghana,” Journal of Acquired Immune Deficiency Syndromes 57 Suppl 2 (1999), S72-S76.
9. C. Omenka and C. Zarowsky, “‘No one knows what will happen after these five years’: Narratives of ART, access and agency in Nigeria,” Global Health Promotion 20 (2013), pp. 45-50.
Dr. Johanna Hanefeld is a Lecturer in Health Systems Economics in the Department of Global Health and Development at the London School of Hygiene and Tropical Medicine.
Dr. Anuj Kapilashrami is a Lecturer in Global Health at Queen Margaret University, Edinburgh.