What's Next for the Global Fund?

January 15, 2010

Access the full Working Group report: Challenges and Opportunities for the New Executive Director of the Global Fund: Seven Essential Tasks (pdf)

Steve RadeletIn its first four years, the Global Fund to Fight AIDS, Tuberculosis and Malaria has quickly become one of the most important aid agencies in the world. It has approved over 360 grant programs in 132 countries valued at $5.6 billion, and it has disbursed over $2.7 billion. Next week the Fund will select a new Executive Director (ED). CGD senior fellow Steve Radelet chaired a working group to identify key challenges for the Fund ahead of the selection. He explains the purpose and scope of the forthcoming report, which will be released on October 26th.

Q: What is the purpose of the Global Fund?

A: The Fund was created to substantially increase funding for programs aimed at fighting HIV/AIDS, TB and malaria in countries around the world. These diseases needlessly kill more than 16,000 people every day. Until the founding of the Global Fund and the launch of other programs in recent years -- like the U.S. President's Emergency Plan for AIDS Relief (PEPFAR) -- the international community had done shockingly little to respond to the crisis. The Fund is a foundation -- not a U.N. agency or a broader development agency -- and as such it acts primarily as a financing mechanism, rather than an implementing agency or a clearinghouse for technical assistance. It works in cooperation with other groups -- multilateral organizations, bilateral agencies, NGOS, civil society and faith based groups -- that help design programs, provide technical assistance, and otherwise provide support for country programs.

Q: The Global Fund seems to operate differently from many other organizations. How is it structured?

A: The Fund is really quite an unusual organization. It is governed by a 24 member Board of Directors consisting of donor governments, recipient governments, people living with the diseases, NGO representatives from both donor and recipient governments, the Bill & Melinda Gates Foundation (its largest non-government donor), and private sector representatives. The ED manages a very small Secretariat: just 240 staff, all based in Geneva, overseeing 360 grants, making it one of the leanest of all major international organizations. In recipient countries, overall responsibility falls with a Country Coordinating Mechanism (CCM), a group whose composition in some ways mirrors the Board: government officials, NGOs, civil society and faith based groups, and multilateral and bilateral representatives. The CCM is responsible for designing programs, submitting grant proposals to the Global Fund, and picking one or more organizations to implement programs. The Fund takes very seriously -- much more seriously than most organizations -- the ideas of country ownership, broad participation in key decisions, and transparency. Its focus on these principles, along with striving for accountability in results and low administrative costs, sets the Fund apart, but also leads to some of the key challenges and tensions we describe in our report.

Q: What impact has it had so far?

A: As of June 2006, its grants were supporting antiretroviral (ARV) treatment for 544,000 people living with HIV; testing and counselling for HIV for 5.7 million people; directly observed treatment short course (DOTS) for 1.4 million people with TB; and 11.3 million insecticide-treated bed nets for malaria prevention. These are the numbers of people already being reached -- the targets for current programs are even higher.

People associate the Global Fund mostly with HIV/AIDS, but it is crucial to remember that it funds programs in all three diseases, and proportionally on a global scale it makes even bigger contributions to TB and malaria. Currently the Fund provides two-thirds of global donor funding for malaria, 45 percent for TB programs, and about 20 percent for HIV/AIDS, numbers I find impressive for a four-year-old organization.

With grants disbursing in 128 countries, the Fund's global reach is broader than any organization outside of the United Nations. This is a very tall order, and while the Fund has made commendable progress, it faces some significant challenges as well.

Q: What are some of the biggest challenges?

A: Well, with 360 grant programs in 128 countries, you're bound to get some programs that work well and others where there are concerns. In some countries the CCM process works fine, but in others there are concerns about who is included and who is excluded, government domination over NGOs, and the quality of CCM oversight. The ideals of broad participation and country ownership -- which many donors don't even attempt -- are very hard to put into practice in many countries. And as with any broadly participatory process -- like democracy -- the process is sometimes slow and not as decisive as it could be. But the process helps build legitimacy, create some buy-in, and build capacity over time.

A huge challenge is that when the international community designed the Global Fund to be primarily a financing mechanism, they assumed that others would be able to step up and provide countries with other support needed to make programs work, such as technical assistance, on-the-ground monitoring, and other inputs. But this hasn't always happened, and country capacity to absorb funds and implement programs was more of a constraint that many foresaw. Building strong capacity in countries that will allow them to implement effective programs over the long term is an enormous challenge. Going forward there will need to be much greater cooperation across agencies, and stronger support for other organizations to allow them to ramp up technical assistance and other support to countries facing major capacity constraints.

The Fund also faces the big challenge of how to ensure results. From the outset, the Fund has tried to emphasize performance-based funding, but as other organizations have found out, this is not easy. Just determining what to actually measure and collecting the data is far from easy, and figuring out how to independently monitor progress on the ground is a major challenge. And once problems are detected, it is not straightforward to determine when the best course of action is to try to reprogram or refocus the grant, or to cut off funding and redirect it another country where it might be more effective. Some of the biggest debates around the Fund in the last year have been whether or not to cut off funding to a small number of poorly performing grants, and these debates are unlikely to be any easier in the future.

Q: What about funding?

A: This is a big concern, and not just for the Global Fund. Although world-wide funding has increased significantly in recent years, the diseases are continuing to spread, and all estimates for global needs show a sharp escalation in coming years. According to estimates from UNAIDS, Roll Back Malaria, and the Stop TB Partnership, global needs to effectively fight the three diseases already top $20 billion annually and are increasing steadily. Obviously the Global Fund doesn't have to fund all of that, or even necessarily be the largest funder. But to effectively address the three diseases, the Fund faces two major challenges. First, it must significantly ramp up its contributions from traditional and non-traditional donors and the private sector to meet these growing needs. Second, since even with increased funding its resources will always be less than needs, it must determine how best to allocate its funds and manage it grants across countries to ensure maximum impact and have the greatest possible impact on the diseases.

Q: How is the new ED being chosen?

A: The Global Fund Board created a Nomination Committee in April 2006, which, among other steps, hired an Executive Search firm to help in the process. In all, 334 people applied for the position. The Nomination Committee, through several rounds of consideration, has narrowed the list to five finalists: Hilde Johnson (Norway), Michel Kazatchkine (France), Congressman Jim Kolbe (U.S.), Bill Roedy (U.S.), and Michel Sidibe (Mali). The Board is now interviewing the five candidates via teleconference. At its next Board meeting on October 31st in Guatemala City, the Board will make its decision and choose the new ED. Assuming all the arrangements can be put in place, the new ED will start very early in 2007.

Q: The working group you chaired offered several recommendations for the new director. Can you tell us, in advance of the release of the report on Thursday, some of the most important issues it examines?

A: We identified seven key tasks for the new ED to focus attention, ranging from strengthening in-country operations, ramping up efforts for more effective technical assistance, strengthening procurement and supply chain management systems, and improving relationships between the Board and the ED, which have not always been smooth. For each task, we make several specific recommendations. Some recommendations are very specific and seem small, but can have big impacts, such as the Secretariat quickly distributing information it picks up in its Early Warning System to a wide range of interested parties -- multilateral organizations, bilateral agencies, NGO groups, as well as host governments -- so that steps can be taken rapidly to address weak programs.

Some recommendations will require much greater cooperation with other organizations, since the Global Fund by design must work together with other agencies to support country programs. Thus we recommend establishing a "Heads of Agencies Group" in which the heads of the Global Fund, UNAIDS, WHO and the World Bank (and perhaps a very small number of others) would meet regularly to work out at the highest levels key strategies for jointly addressing technical assistance, global procurement, program monitoring and other issues.

In terms of the Secretariat, we recommend the new ED commission a management audit of the Secretariat to help determine its optimal size and staffing patterns, and focus particularly on steps to strengthen the work of the Fund Portfolio Mangers that support each grant. We also recommend that the Secretariat add to its staff a full-time, professional, fundraising team. And although our focus in on the ED, we make a few recommendations to the Board in how it can help the ED succeed. In particular, we recommend that Board make the ED a non-voting member of the Board to help strengthen communications and improve Board decisions.

The new ED joins the Global Fund at a critical time as it shifts from an innovative start-up to a mature organization. The next two years will have a tremendous impact on defining the future role and sustainability of the Fund and its long-term impact in fighting the three diseases. It is our hope that this report helps the new ED to better understand the key issues facing the Fund and some of the most important steps that can be taken to make the Fund even more effective in fighting HIV/AIDS, TB and malaria.