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Daniele Dionisio: Overhauling the Global Fund

4 Sep, 12 | by BMJ

The Global Fund (GF) is a partnership between governments, civil society, the private sector, and relevant communities as an international financing institution for HIV, tuberculosis (TB), and malaria prevention, and treatment programmes. The GF supports national programmes by distributing funds, provided verifiable results are pledged.

Since its inception in 2002, the GF has become the main funder of initiatives to fight HIV, TB, and malaria. US$ 23 billion of funding has been given out for more than 1,000 programmes in 151 countries, as of mid 2012.

To date, the programmes backed by the GF secure HIV and TB treatment for 3.6 million and 9.3 million people respectively (a 21 per cent increase since the end of 2010), and 270 million insecticide treated nets for the prevention of malaria. Under programmes endorsed by the GF, the number of cases of malaria that have been treated has risen by more than half in the same period to 260 million. At the same time, with GF support, TB and HIV services have more than doubled, HIV testing and counselling sessions have risen by 43 per cent to 210 million, and the number of HIV infected pregnant women enjoying full course antiretroviral treatment has increased to 1.5 million.

Overall, while 8.7 million lives have been saved to date thanks to programmes supported by the GF, the institution wishes to earmark up to US$8 billion in grants to fight HIV, TB, and malaria over the coming 20 months, with US$5 billion of earmarked for Africa.

Drastic redesign
These prospects, however, could be mired in uncertainty now that the GF is experiencing a deep  financial shortfall as the global economic crisis has slowed down or frozen some donor governments’ commitments.

Donors are increasing pressure for better management and greater returns on their investments, and new measures are needed to ensure the GF keeps working effectively for years to come.

On 23 November 2011, the GF’s board decided to reject new grant requests until at least 2014. They also decided to make savings in the grant portfolio and only finance services for working programmes coming to an end before 2014, and to further curb funding to some upper middle income countries. The board also appointed a general manager to work alongside the executive director and ferry the GF through a drastic shake-up and get a better performance.

As such, since general manager Gabriel Jaramillo‘s appointment in February this year, the GF has been rolling out a process to effectively manage grants, raise donations, and strengthen the fund’s forecasting.

While changing the way the GF does business and disburses money, the redesign includes an improved approach to risk management from country to country, which takes into account recent allegations of fraud among fund recipients and the results of audits and investigations by the Office of the Inspector General between 2005 and 2012.

These revealed that at least 3 per cent of funding had been misspent, misappropriated, or inadequately accounted for.

Tough changes stand out in the overall GF overhauling:

  • A 40 per cent cut from bureaucracy so that 75 per cent of GF staff will work in grant management.
  • A “windows” financing model to replace the rounds based system and secure (without waiving the high standard of technical review) more flexibility and predictability, a high focus on interventions, countries, and people most in need, and a simplification of the grant process to shake things up and get disbursements unlocked.
  • Implementation of recommendations from a high level, and an independent panel to review the GF’s financial controls and the way grant money is spent.
  • Three strong impact teams will be established, which will oversee 20 countries that account for more than 70 per cent of HIV, TB, and malaria global burden. Two teams focus on Africa and one on Asia.
  • A country-team approach to grant management by putting together staff from different departments.
  • Opening up to partners in the GF’s committees to share the decision making on the appropriateness of investments. Partners include implementing countries, civil society, the private sector, and relevant institutions like PEPFAR (President’s Emergency Plan to Fund AIDS Relief), PMI (President’s Malaria Initiative), and agencies such as RBM (Rollback Malaria), and Stop TB.
  • Reform of HIV, TB, and malaria committees to assess the progress of operations once a month and mend the course.
  • Strengthening of preventive measures.

The GF will continue to focus on lower income and lower middle income countries, and to implement about 40 per cent of grants through civil society for the greatest effect in isolated areas and people most at risk.

The GF will also continue to encourage grant recipients to apply the flexibilities laid down in national laws and in the World Trade Organisation’s Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS) in a way that allows the cheapest prices for  assured quality products.

And it will enhance working with health ministries to strengthen national systems, improve  transparency and accountability, boost local drug procurement and supply chains, and help train health workers and professionals.

Back in business?

So, after all has been done and planned, is the GF ready to win back business?

It seems likely according to the GF’s May financial forecast of US$1.6 billion for the 2012-14 period, which is thanks to new donations, accelerated disbursements, and decisions by some implementing governments to forgo some funds to the advantage of low income nations.

Indeed, countries like India, Russia, and China now play substantive roles as donors and as recipients of grants.

Yet, the current progress rate is not enough to achieve the health related Millennium Development Goals (MDGs) by 2015. And barely 41 per cent of countries backed by the GF are expected to meet the fourth MDG on cutting down child mortality and the sixth on fighting HIV/ AIDS, malaria, and other infections.

That’s why the GF is trying to get fast growth countries including China, India, Brazil, Indonesia, Mexico, South Korea, Saudi Arabia, and Turkey (besides leading donors such as France, Japan, the United States, UK, Germany, and the Gates Foundation) to donate and substantially increase their contributions.

But, are the advanced countries ready today to embrace the GF’s calls as an opportunity for national security and profitable return on their disbursements, rather than just a heavy burden in times of economic slump? This would make a great difference.

Daniele Dionisio is a member of the European Parliament Working Group on Innovation, Access to Medicines and Poverty-Related Diseases. He is reference advisor for “Medicines for the Developing Countries” for the Italian Society for Infectious and Tropical Diseases (SIMIT), and former director of the Infectious Disease Division at the Pistoia City Hospital (Italy). Starting February 2012, Dionisio is head of the research project Geopolitics, Public Health, and Access to Medicines (GESPAM).

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