Global Fund Fights AIDS, TB and Malaria

A pregnant Sudanese woman being treated for Malaria in a health center in Nyala. (Photo: Raul Touzon, National Geographic Society, Corbis)

The long-awaited shake-up in the Geneva-based Global Fund to Fight AIDS, Tuberculosis and Malaria (the Fund) finally became operational this month with the assumption of office of Gabriel Jaramillo, a former leading banker, as the new general manager. The change followed various unflattering audit reports of the Fund operations in some recipient countries that suggested money lost to corrupt practices and lax oversight. In addition, a high-level panel recommended a far-reaching restructuring of the Fund to ensure tighter oversight of technical and ground operations as well as portfolio risk management.

Perhaps the last straw was the Fund's decision to temporarily suspend funding activities in recipient countries from 2014 due to flagging donor support and pledges. For supporters of the Fund, this remains an ominous sign. The Fund was established 10 years ago as a model global financing mechanism to prove, in part, that a lean, nimble, transparent, results-oriented international organization can deliver care to target populations in all corners of the globe. The current predicament of the Fund is unfortunate since donors in this difficult economic climate are unlikely to favor organizations that appear unable to manage resources prudently.

It is important to note that, despite ongoing problems, the Fund today remains an indispensable vehicle in the fight against AIDS, tuberculosis and malaria. In the last decade, it committed $22.6 billion to more than 1,000 projects in 150 countries. At least 3.3 million people are on antiretroviral therapy due to the Fund, and 8.6 million people have received treatment for tuberculosis.

Reforms going forward

The first question is whether the Fund intends to be directly involved in country-level efforts to reach at-risk populations to ensure funded programs are verifiably making a positive difference in the health status of program recipients. If the answer is affirmative, this will drive the roadmap for all other reform decisions within the Fund. In addition, a positive response automatically elevates logistics of care delivery to the highest operational priority area of the Fund, with commensurate investments. HIV/AIDS, tuberculosis and malaria predominantly kill people who are poor, have problems with timely access to quality care and are most likely to be living with other dangerous comorbidities. No organization can reach these individuals and make a difference on their health status without investments on the ground in target countries and communities.

It is critical that at-risk populations and recipient countries have a real, not just perceived, say in decisions. Despite the best efforts of the board and the secretariat of the Fund, the organization remains fundamentally a top-down entity. A strong mechanism needs to be created that can channel the goals, priorities and aspirations of at-risk populations and recipient countries in the decision-making processes.

The second reform-related question relates to the Fund's identity. Should it become an investment agency supporting other organizations that finance or manage the delivery of treatment? Should it be a strict financing entity that provides targeted financial support for programs already on the ground? Should it participate in the entire project cycle of healthcare delivery—including design, implementation, monitoring and evaluation—at country and community levels for its funded programs? A clear direction will drive any serious, sustainable reform effort. If done right, such an effort could tighten internal operational controls, reorganize operating structures, refine risk assessment and project portfolio management mechanisms, and adopt indicators for monitoring efficiency and effectiveness.

Assessment and accountability

The Fund should have valid measurement indicators that document how funded programs are preventing the transmission of disease among at-risk populations, measuring how well people actually responded to treatment protocols within specific populations. Population-based knowledge, attitude and perception (KAP) surveys can provide important clues as to whether funded programs are making a difference. Process indicators, especially program input and output indicators that dominated the global fund matrix in the last decade, while good for management reviews, are not adequate for measuring the impact of funded programs against communicable diseases. Process indicators are also unreliable in showing evidence of impact within at-risk target populations.

Applying to get financial support from the Fund is an onerous, time-consuming process. Country-level verification mechanisms and protocols can be simplified. The technical review process can also be simplified. Reports from the Fund look like lengthy academic review papers, reinforcing the perception of an agency that needs shoring up on operational issues. The Fund needs to become not only a lean operational entity but also transform itself into a financing mechanism that makes quick, clear technical decisions on funding support. Perhaps to accelerate this, the Fund can invest more on technical field visits, independent expert reviews, identification of projects ripe for scaling up, and an information-dissemination mechanism for various audiences and constituencies. In addition, the Fund should promote itself more aggressively in donor countries, showcasing its successes through simplified reporting mechanisms.

The next few years of the global fund against AIDS, tuberculosis and malaria will be critical as its leadership seeks to reposition the organization. The next year will be important as the new general manager realigns operations, corrects deficiencies, simplifies processes and procedures, and reassures nervous donors and supporters. The future of the global fund remains bright. However, a lot of work remains ahead.

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