The U.S. & The Global Fund to Fight AIDS, Tuberculosis and Malaria
The Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund) is an independent, multilateral, financing entity designed to raise significant new resources to combat HIV/AIDS, tuberculosis (TB), and malaria in low- and middle- income countries. First proposed in 2001, the Global Fund began operations in January 2002 and receives funding from both public and private donors to finance programs developed and implemented by recipient countries using a “country-defined” or “demand-driven” model (by contrast, bilateral support is provided from donors directly to recipient country governments, non-governmental organizations, and other entities and often reflects donor-defined priorities). To date, donor governments, which account for approximately 95% of total financial support, have pledged $41 billion, and the Global Fund has approved almost $38 billion in grants to over 150 countries.1,2
The U.S. has played an integral role in the Global Fund since its inception. During the administration of President George W. Bush, the U.S. provided the Global Fund with its founding contribution and was involved in the initial negotiations on the multilateral organization’s design. The U.S. maintains a permanent seat on the Global Fund Board, giving it a key role in governance and oversight, and has consistently been the Global Fund’s single largest donor (see Table 1).1,2,3 The Global Fund has been called the “multilateral component” of the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR),4 serving as an important part of the U.S. government’s global health response, expanding its reach to more countries, and leveraging additional donor resources.
During the Obama Administration the role of international cooperation and multilateral institutions, including the Global Fund, has been highlighted as necessary for meeting and sustaining the response to the world’s challenges.5,6 The administration has also pledged significant resources to the Fund. In October 2010, the administration announced a three-year (FY11-FY13), $4 billion pledge to the Global Fund – the first time the U.S. made a multi-year pledge to the Global Fund. The U.S. hosted the FY14-FY16 replenishment cycle and pledged an additional $4 billion.7,8 Most recently, the administration announced a pledge of $4.3 billion for the FY17-FY19 replenishment cycle.9
Still, there have been ongoing questions about the appropriate balance of U.S. funding between the Global Fund and U.S. bilateral programs, the role of multilateralism in U.S. global health policy, the Global Fund’s ability to prevent and address corruption, and the Global Fund’s sustainability given a shortfall in the availability of resources to meet country demand.10,11
|Table 1: Total Global Fund Pledges* and Contributions as of September 2016 (US$billions)1,2|
|Total Pledges||% of Total Pledges||Total Paid||% of Total Paid|
|All Other Countries||$7.5||18.2%||$6.9||18.2%|
|*Includes pledges made for the period 2001-2016 as well as those made with year of commitment yet to be confirmed. Pledge amounts are calculated in U.S. dollars and are, therefore, subject to exchange rate fluctuations. Amounts were converted to U.S. dollars using the Federal Reserve Foreign Exchange Rates tables.12 Totals may not sum up due to rounding.|
The Global Fund was established as an independent foundation under Swiss law and operates as a multilateral financing entity. Funding is currently provided to recipient countries using a performance-based funding system where a grant is regularly monitored and evaluated to determine if it should be extended or discontinued based on the effectiveness of the program. In addition, the Global Fund launched a new funding model in 2013 that, among other things, creates a more flexible timeline for eligible countries to apply and allows for a focus on high disease burden and low resource settings.15,16 The Global Fund’s organizational structure includes a broad set of stakeholders, and the U.S. government is involved in many of its core structures:
- Board. The Board guides policy and strategic decisions and approves all funding. There are 20 voting and 8 non-voting members as follows:
- Developing countries: 7 members, 1 from each of the six WHO regions and an additional member from Africa;
- Donors: 8 members, including the U.S. which has a permanent Board seat, and has served as Board Chair in the past. The U.S. is currently vice-chair of the Strategy Committee and sits on the Audit and Finance Committee as well as the Ethics and Governance Committee.17
- Civil Society/Private Sector: 5 members.
- Non-voting: 8 members, including the Global Fund Executive Director, the Board Chair and Vice-Chair, one representative from Global Fund partner organizations, one representative each from WHO, UNAIDS, the World Bank, and a Swiss citizen as required by Swiss law.
- Secretariat. Based in Geneva, the Secretariat manages day-to-day operations. Because the Global Fund finances but does not implement programs, it does not maintain any in-country staff.
- Technical Review Panel (TRP). An independent body of global health and development experts (which has included U.S. government experts) appointed by the Board to evaluate the merits of all proposals and make funding recommendations to the Board.
- Technical Evaluation Reference Group (TERG). An independent body of global health and development experts appointed by the Board to provide oversight on the Fund’s evaluation efforts, including evaluation of the Global Fund business model, investments, and impact.
- Office of the Inspector General. An independent body of the Global Fund that reports directly to the Board through its Audits and Ethics Committee, the Office of the Inspector General provides the Board with audits and investigations of the Funds’ activities, in an effort to promote good practices, reduce funding risks, and report on potential abuse.
- Country Coordinating Mechanisms (CCMs). The country-level entity comprised of public and private sector representatives, such as governments, businesses, and non-governmental organizations (NGOs), that submits proposals to the Global Fund and oversees funded grants within a country. U.S. representatives sit on CCMs in almost all PEPFAR focus countries and often help with proposal development. The U.S. has also entered into MOUs in several countries to bring together PEPFAR with Ministries of Health and the Global Fund to clarify collaboration and partnership activities, particularly in the area of antiretroviral drug procurement.
- Principal Recipients (PR). The legal entity chosen by the CCM to receive Global Fund disbursements, implement programs or contract with sub-recipients, and provide regular reports and progress updates to the Secretariat.
- Local Funding Agents (LFA). Since it does not have an in-country presence, the Global Fund contracts with a local entity (usually an accounting firm) to monitor program implementation, ensure financial accountability, and provide funding recommendations to the Secretariat.
As of September 2016, the Global Fund had approved more than $37 billion in funding and disbursed approximately $31 billion to over 120 countries, including countries that also receive U.S. bilateral support for HIV, tuberculosis, and/or malaria, but also many others that do not (see Table 2).1,2 Funding supports a wide range of care, treatment, and prevention activities and health systems development and strengthening. The Sub-Saharan African region has received the largest share of approved funding (65%), followed by the Asia and the Pacific region (19%).18 Most approved funding has supported HIV programs, followed by malaria and TB (see Table 2). The Global Fund, which was the second largest donor to health programs in 2014 (the U.S. was the largest),19 estimates that, since 2002, its grants have helped avert the deaths of 20 million people who would have otherwise died due to complications from AIDS, tuberculosis, or malaria.20
|Table 2: Global Fund Portfolio Status|
|Approved Grant Funding (billions)||$18.8||$5.8||$10.5||$0.72|
|% of Approved Grants||50.8%||15.8%||28.2%||1.9%|
|# Countries Receiving Grants*||120||107||80||14|
|Note: Joint HIV/TB grants, which accounted for $1.2 billion (3.2%) in approved grant funding, are not included.
*Represents countries that received approved grant funding; Kosovo and Zanzibar are not counted and are considered part of Serbia and Tanzania, respectively.
** Other refers to what was previously classified as Health Systems Strengthening.
U.S. Funding & Requirements
In addition to U.S. governance and oversight of the Global Fund, U.S. financial support has been significant and a key component of U.S. involvement (see Figure 1).2 The U.S. first contributed to the Global Fund in FY 2001 through annual appropriations bills.21 All U.S. support for the Global Fund was then incorporated into PEPFAR when it was created in 2003.22 At that time, Congress authorized up to $1 billion for the Global Fund for FY 2004 and “such sums as may be necessary for FY 2005-2008.”23 In the 2008 reauthorization of PEPFAR, Congress authorized up to $2 billion in FY 2009, and “such sums as may be necessary for FY 2010-2013”.4 In 2013, Congress again reauthorized PEPFAR including “such sums as may be necessary” for the Global Fund through 2018.
Congress earmarks support for the Global Fund each year as part of PEPFAR appropriations, and funding is typically provided through the State Department, although funding has also been provided through USAID and NIH. Between FY 2001 and FY 2016, Congressional appropriations to the Global Fund have totaled $14.0 billion, including $1.35 billion in FY 2016. President Obama requested $1.35 billion for FY 2017.2
Congress has historically matched or provided more to the Global Fund each year than the President has requested, but it has also placed restrictions on U.S. contributions and raised concerns about monitoring and evaluation:2,4,10,24
- Requiring that total U.S. contributions do not exceed 33% of total contributions from all donors, a provision that was part of the original PEPFAR authorization and maintained in the reauthorization. Designed to leverage U.S. contributions to increase support from other donors and to limit the U.S. from becoming the predominant donor to the Global Fund, it was invoked only once, in FY 2004 when appropriated funds were held back until the following fiscal year when the 33% cap would not be exceeded.
- Setting aside 5% of U.S. contributions to cover the cost of technical assistance to Global Fund grantees, a provision first included in foreign operations appropriations bill language in 2005 and in subsequent years.
- Authorizing the Secretary of State to withhold 20% of the U.S. contribution until the Global Fund could demonstrate improved oversight and accountability in grant disbursement; first required as part of foreign operations appropriations in 2006 and again in 2008, this provision was reduced to 10% in the 2009 appropriations, was not included in the 2010 and 2011 appropriations, and was reinstated at 10% in the 2012 appropriations, and has remained at that amount since then.
- Requiring, as part of the FY 2012 through FY2016 appropriations bills, that the Administration consult with Congress prior to making multi-year funding pledges.
While the Global Fund has contributed to significant global scale-up of resources, service delivery, and coverage to combat HIV, TB, and malaria,25 and been described as “complementing PEPFAR objectives,”26 the extent of U.S. involvement in the Global Fund is an ongoing discussion, one that takes on new importance as the Administration, Congress, and the Global Fund make decisions in a resource constrained setting. These issues include:
- The future of U.S. financial commitments to the Global Fund, including questions about the U.S. “fair share” relative to other donors, particularly in light of demand from recipient countries;
- The appropriate balance between U.S. support for multilateral efforts, such as the Global Fund, which allow for the leveraging of available resources, greater reach, and enhanced coordination, and bilateral programs, which allow for increased control and oversight;
- The ability of the U.S. and the Global Fund to coordinate and complement efforts to address the impacts of HIV, TB, and malaria when the availability of resources has become constrained.
The Global Fund: http://www.theglobalfund.org/; as of September 2016.
Kaiser Family Foundation Analysis.
White House. President Announces Proposal for Global Fund to Fight HIV/AIDS, Malaria and Tuberculosis; May 11, 2001.
U.S. Congress. Public Law No: 110-293; July 30, 2008.
White House. Statement by the President on Global Health Initiative; May 5, 2009.
White House. Fact Sheet: U.S. Global Development Policy, September 22, 2010.
U.S. State Department. Obama Administration’s Pledge to Global Fund to Fight HIV/AIDS, Malaria and Tuberculosis. October 5, 2010.
The Global Fund. Fourth Voluntary Global Fund Replenishment Pledges. December 2013.
The U.S. pledge to the Global Fund for the FY17-FY19 period is "to match one dollar for every two dollars in pledges made by other donors" up to $4.3 billion (see White House, Office of the Press Secretary. Statement by National Advisor Susan E. Rice on the United States' Global Fund Pledge; August 31, 2016). Final funding amounts are dependent on Congressional approval.
U.S. Senate Committee on Foreign Relations (Minority Staff Report). Fraud and Abuse of Global Fund Investments at Risk without Greater Transparency; April 5, 2011.
The Global Fund. The Global Fund Strategy 2012-2016. November 2012.
Federal Reserve. Foreign Exchange Rates. Accessed August 2016 from https://www.federalreserve.gov/releases/h10/hist/.
The Global Fund. The Global Fund to Fight AIDS, Tuberculosis & Malaria: By-laws, As Amended; November 21, 2014.
Center for Global Development, Overview of the Global Fund to Fight AIDS, Tuberculosis and Malaria.
The Global Fund. Global Fund Launches New Funding Model; February 28, 2013.
The Global Fund. Funding Model Overview; Accessed February 3, 2016.
The Global Fund. Electronic Report to the Board: Appointment of the Vice-Chair of the Finance and Operational Performance Committee. May 2015.
The Global Fund. Global Fund Results Report 2016; September 2016.
Kaiser Family Foundation Analysis of OECD DAC CRS database; September 2016.
The Global Fund. Global Fund Report Shows 20 Million Lives Saved; September 1, 2016.
Congressional Research Service. The Global Fund to Fight AIDS, Tuberculosis, and Malaria: Issues for Congress and U.S. Contributions from FY2001 to the FY2012 Request; July 1, 2011.
U.S. Congress. Public Law No: 108-25; May 27, 2003.
The Global Fund. Strategic Investments for Impact: Global Fund Results Report 2012; September 2012.
U.S. Congress. Public Law No: 112-74; December 23, 2011.
Kaiser Family Foundation, Donor Funding for Health in Low- & Middle-Income Countries, 2002-2013; November 2015.
Congressional Research Service. The Global Fund and PEPFAR in U.S. International AIDS Policy; November 3, 2005.