The U.S. & The Global Fund to Fight AIDS, Tuberculosis and Malaria

Key Facts

  • The Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund), founded in 2002, is an independent, multilateral financing entity designed to raise significant resources and accelerate efforts to end the AIDS, tuberculosis (TB), and malaria epidemics.
  • The U.S. government (U.S.), which provided the Global Fund with its founding contribution, is its largest single donor; between FY 2001 and FY 2021 Congressional appropriations to the Global Fund totaled $21 billion. In FY 2021, an additional $3.5 billion was provided by Congress as emergency funding to respond to the COVID-19 pandemic.
  • The U.S. also plays a key role in the organization’s governance and oversight, having its own Board seat and sitting on two of the Board’s committees.
  • As of September 2021, the Global Fund had approved more than $62 billion in funding to over 120 countries for its core HIV, TB, and malaria programs; the Global Fund estimates these investments have helped to save 44 million lives. In addition to its core programmatic activities, the Global Fund had awarded over $4 billion to respond to COVID-19.
  • The Global Fund has played a major role in COVID-19 response efforts in countries that receive its support, creating a “COVID-19 Response Mechanism (C19RM)” and allowing for grant flexibilities. Still, the Global Fund reports that some key programmatic results, including for prevention, testing, and treatment services, declined for the first time in its history, highlighting the devastating toll the COVID-19 pandemic has taken.

What is the Global Fund?

Overview

The 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. The Global Fund uses a “country-defined” and “results-based financing” model that focuses on country ownership and is supported by investments from both donors and implementing countries (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, almost $73 billion has been pledged by all donors (governments, the private sector, and private foundations) to the Global Fund, including for the Global Fund’s COVID-19 response.1 Using these resources, the Global Fund has approved more than $62 billion in grants to over 120 countries2 for its core HIV, TB, and malaria programs, and awarded more than $4 billion in funding to respond to the COVID-19 pandemic’s impact on these three epidemics.3

The U.S. has played an integral role in the Global Fund since its inception. Under the George W. Bush administration, the U.S. provided the Global Fund with its founding contribution and was involved in the initial negotiations on the multilateral organization’s design. Under the Obama administration, the U.S. pledged $12.3 billion to the Global Fund over three replenishment periods.4 The Trump administration had proposed funding cuts to the Global Fund and a reduced pledge amount, although Congress rejected these proposals.5 Most recently, the Biden administration has signaled increased support for the Global Fund, particularly given its direct role in responding to the COVID-19 pandemic (see the Global Fund & COVID-19 section below), and the U.S. has provided an additional $3.5 billion in FY 2021 emergency funding to the Global Fund to address the impact of COVID-19 on HIV, TB, and malaria programs.

In addition to being the Global Fund’s single largest donor (see Table 1), the U.S. maintains a permanent seat on the Global Fund Board, giving it a key role in governance and oversight.6 The Global Fund has been called the “multilateral component” of the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR),7 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.

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, and the Global Fund’s sustainability given a shortfall in the availability of resources to meet country demand.8 Further, the ongoing COVID-19 pandemic continues to complicate HIV, TB, and malaria efforts globally, with the Global Fund reporting that some key programmatic results, including for HIV prevention and testing services and TB testing and treatment services, have declined for the first time since its inception.9 Questions remain on the role being played by the Global Fund in global COVID-19 response efforts and the role it might play more generally in pandemic preparedness and global health security.

Table 1: Global Fund Pledges and Contributions, as of September 2021
(in U.S. $ billions)
Donor Total Pledges to the
Global Fund
% of
Total Pledges
Total Paid
to the
Global Fund
% of
Total Paid
TOTAL $72.7 100.0% $58.1 100.0%
United States $25.7 35.4% $17.6 30.3%
France $7.9 10.9% $6.7 11.6%
United Kingdom $7.0 9.6% $5.8 10.0%
Germany $5.2 7.2% $4.8 8.2%
Japan $4.3 5.9% $4.1 7.0%
Canada $3.4 4.6% $2.9 4.9%
European Commission $3.3 4.5% $2.7 4.6%
All Other Countries $11.1 15.3% $9.5 16.4%
Gates Foundation $3.0 4.1% $2.5 4.3%
All Other Donors* $1.7 2.3% $1.5 2.6%
NOTES: Includes pledges made for the period 2001-2022 as well as those made with year of commitment yet to be confirmed. * “Other Donors” includes contributions made by the private sector and nongovernmental organizations, Debt2Health, and the Affordable Medicines Facility – malaria (AMFm). Pledge and Paid amounts, if listed by the Global Fund in the currency of origin, were converted to U.S. dollars by the Global Fund using fixed replenishment exchange rates (for the years 2014 and onward) and spot exchange rates (for years earlier than 2014).
SOURCES: The Global Fund: https://www.theglobalfund.org/en/updates/data/2019-11-12-donor-pledges-and-contributions/; accessed September 24, 2021; KFF analysis.

Funding Model & Organizational Structure10

The Global Fund was established as an independent foundation under Swiss law and operates as a multilateral financing entity. Funding is pooled from multiple sources, including from donor governments, the private sector, and private foundations. Countries submit proposals to the Global Fund, and if approved, funding is provided using a performance-based 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. The Global Fund launched a new funding model in 2013 that, among other things, created a more flexible timeline for eligible countries to apply and allowed for a focus on high disease burden and low resource settings.11 In order to incentivize recipient countries to increase their domestic investments and increase country ownership, the Global Fund also requires a minimum of 15% co-financing for each approved grant.12

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 members (10 implementers and 10 donors) and 8 non-voting members as follows:
    • Implementers:
      • Developing countries: seven members, one from each of the six WHO regions and an additional member from Africa.
      • Civil Society: three members, one from a developing country non-governmental organization (NGO), one from a developed country NGO, and one representative from an NGO who is a person living with HIV/AIDS or from a community living with TB or malaria.
    • Donors:
      • Government: eight members, including the U.S., which has a permanent Board seat. The U.S. also sits on the Ethics & Governance and Strategy Committees.13
      • Private Sector: one member.
      • Private Foundation: one member.
    • Non-voting: eight 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, and the World Bank, and one representative from certain public donors that are not part of a voting donor constituency.
  • 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 Audit and Finance Committee, the Office of the Inspector General provides the Board with audits and investigations of the Fund’s 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 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 a memorandum of understanding (MOU) 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.

Results

As of September 2021, the Global Fund had approved more than $62 billion in funding for its core HIV, TB, and malaria activities, and as of October 2021, awarded more than $4 billion in funding to respond to COVID-19 (see the Global Fund & COVID-19 section below).14 This funding has reached over 120 countries15, including not only countries that also receive U.S. bilateral support for HIV, TB, and/or malaria but also many others that do not (see Table 2).16 Funding supports a wide range of prevention, treatment, and care activities and health systems development and strengthening. The African region has received the largest share of approved funding (66%), followed by South-East Asia (12%).17 Most approved funding has supported HIV programs, followed by malaria and TB. The Global Fund, which was the second largest donor to global health programs in 2019 (the U.S. was the largest),18 estimates that, since 2002, its grants have helped save the lives of 44 million people who would have otherwise died due to complications from AIDS, TB, or malaria.19

Table 2: Global Fund Portfolio Status, as of September 2021
Portfolio Status HIV TB Malaria HIV/TB Other
Approved Grant Funding
(in U.S. $ billions)
$26.4 $9.5 $18.4 $6.2 $1.7
% of Approved Grants 42.5% 15.3% 29.5% 10% 2.8%
# of Countries Receiving Grants 120 109 85 52 43
NOTES: Does not include approved funding for COVID-specific amounts, as they cannot be attributed to a specific area, such as HIV, TB, or malaria. See the Global Fund & COVID-19 section below to learn more about COVID-specific funding. Approved (or “signed”) grant funding totals include funding for multi-country grants. Kosovo and Zanzibar are not counted separately under number of countries receiving grants and are considered part of Serbia and Tanzania, respectively. Additional countries may be reached through multi-country or regional programs. “HIV/TB” includes grant funding for joint HIV/TB services. “Other” includes grant funding for Resilient & Sustainable Systems for Health (RSSH) and multicomponent funding.
SOURCES: The Global Fund Data Explorer: https://data.theglobalfund.org/; accessed September 2021; KFF analysis.

U.S. Engagement with the Global Fund

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).20 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.”24 In 2013 and 2018, Congress again reauthorized PEPFAR, and while it included provisions on U.S. support for the Global Fund (see below), it did not include specific funding amounts.25 See the KFF brief of PEPFAR reauthorization.

Congress specifies support for the Global Fund each year as part of PEPFAR appropriations, and funding is typically provided through the Department of State, although funding has also been provided through USAID and NIH in past years. Between FY 2001 and FY 2021, regular Congressional appropriations to the Global Fund totaled $21 billion. In FY 2021, an additional $3.5 billion was provided as emergency funding to respond to the COVID-19 pandemic.26 Congress has historically matched or provided more to the Global Fund each year than the President has requested. (See the KFF budget tracker for details on historical appropriations for the Global Fund.)

While Congress has provided strong funding support for the Global Fund, it has also placed restrictions on U.S. contributions:27

  • 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 reauthorizations. 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 a percentage of the U.S. contribution until the Global Fund could demonstrate improved oversight and accountability in grant disbursement.
  • Requiring, as part of the FY 2012 through FY 2021 appropriations bills, that the administration consult with Congress prior to making multi-year funding pledges.

The Global Fund & COVID-19

Since the beginning of the pandemic, the Global Fund has acted to support countries in their efforts to address COVID-19’s impact on HIV, TB, and malaria programs. The Global Fund established a “COVID-19 Response Mechanism” (C19RM)28 in April 2020, and also has allowed for grant flexibilities that give countries the ability to use a certain percentage of their current grants for COVID-19 response activities. As of October 2021, the Global Fund had awarded over $4 billion in funding to more than 100 countries to support countries’ responses to COVID-19.29 Support from the Global Fund to countries has been used to:

  1. support national COVID-19 response efforts, including purchasing tests, treatments, and medical supplies;
  2. mitigate COVID-19’s impact on Global Fund-supported programs; and
  3. improve health and community-led response systems.

The Global Fund is also a founding partner of the Access to COVID-19 Tools Accelerator (ACT-Accelerator), a global partnership working to accelerate the development, production, and equitable distribution of COVID-19 tests, treatments, and vaccines. The ACT-Accelerator is organized into pillars of work: Diagnostics, Therapeutics, Vaccines, Health Systems Connector, and Access & Allocation.30 The Global Fund co-leads two of these pillars — the Diagnostics Pillar and Health Systems Connector – and supports procurement and distribution for the Therapeutics Pillar.31

Key Issues for the U.S.

The Global Fund has contributed to significant global scale-up of resources, service delivery, and coverage to combat HIV, TB, and malaria32 and been described as “complementing PEPFAR objectives.”33 Still, the extent of U.S. involvement in the Global Fund is an ongoing discussion, especially as the current administration, Congress, and the Global Fund make decisions in a resource-constrained setting. The key issues include:

  • The future of U.S. financial commitments to the Global Fund for HIV, TB, and malaria programs as well as to address the ongoing impacts of COVID-19;
  • The appropriate balance between U.S. support for multilateral efforts, such as the Global Fund, which allows for the leveraging of other donor and implementing country resources, greater reach, and enhanced coordination, and bilateral programs, which allows for increased control and oversight;
  • How can the U.S. and the Global Fund best coordinate and complement their respective efforts to address the impacts of HIV, TB, and malaria;
  • The role of the U.S. government in middle-income countries’ responses to HIV, TB, and malaria as the Global Fund phases-down and ends its support for certain countries over time, and whether COVID-19 will impact these considerations; and
  • The role played by the Global Fund’s ongoing COVID-19 response efforts and in pandemic preparedness and global health security more generally, going forward, and how its efforts may complement ongoing U.S. efforts in these areas.
Endnotes
  1. Includes pledges through 2022. Includes COVID-specific emergency contributions.

    ← Return to text

  2. Does not include countries that may have received funding through multi-country or regional programs. Additional countries may be reached through multi-country or regional programs.

    ← Return to text

  3. Core activities represent HIV, TB, HIV/TB, malaria, multi-purpose, and Resilient & Sustainable Systems for Health (RSSH) funding only; the more than $62 million in approved funding does not include COVID-specific amounts as they cannot be attributed to a specific area, such as HIV, TB, or malaria. The Global Fund Data Explorer: https://data.theglobalfund.org; accessed September 2021. KFF analysis. The Global Fund, Press release: Global Fund Crosses US$4 billion Mark in Funding to Support Countries in the Fight Against COVID-19, October 8, 2021.

    ← Return to text

  4. The U.S. pledged $4 billion in both the FY11-FY13 and FY14-16 replenishment cycles and $4.3 billion in the FY17-FY19 replenishment cycle. 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. White House, Office of the Press Secretary. Statement by National Security Advisor Susan E. Rice on the United States' Global Fund Pledge; August 31, 2016.

    ← Return to text

  5. The Trump administration proposed reducing U.S. contributions to the Global Fund in each of its annual budget requests to Congress. In addition, the Trump administration proposed a pledge of $3.3 billion, matching $1 for every $3 contributed by other donors for the next replenishment period, a decline of more than $1.0 billion compared to the U.S. pledge during the prior replenishment period under the Obama administration (up to $4.3 billion, matching $1 for every $2 provided by other donors). See U.S. Department of State, FY2021 Congressional Budget Justification – Department of State, Foreign Operations, and Related Programs, February 2020.

    ← Return to text

  6. Global Fund: http://www.theglobalfund.org/; as of March 2021. KFF analysis. White House, President Announces Proposal for Global Fund to Fight HIV/AIDS, Malaria and Tuberculosis; May 11, 2001.

    ← Return to text

  7. U.S. Congress, Public Law No: 110-293; July 30, 2008.

    ← Return to text

  8. 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. Global Fund, The Global Fund Strategy 2017-2022, November 2017.

    ← Return to text

  9. The Global Fund, Results Report 2021, September 2021.

    ← Return to text

  10. Global Fund, The Global Fund to Fight AIDS, Tuberculosis & Malaria: By-laws, As Amended, November 14, 2017. Center for Global Development, Overview of the Global Fund to Fight AIDS, Tuberculosis and Malaria.

    ← Return to text

  11. Global Fund, Global Fund Launches New Funding Model, February 28, 2013. Global Fund, Funding Model Overview, accessed December 2020.

    ← Return to text

  12. The Global Fund funding model includes a co-financing requirement that at least 15% of each approved grant is withheld until the country has committed to additional investments over and above previous levels of spending. Global Fund, Website: Funding Model: Co-financing, available at: https://www.theglobalfund.org/en/funding-model/funding-process-steps/co-financing/.

    ← Return to text

  13. Global Fund, Website: Board Committees, available at: https://www.theglobalfund.org/en/board/committees/#members; accessed September 2021.

    ← Return to text

  14. Global Fund Data Explorer: https://data.theglobalfund.org/home; accessed September 2021. KFF analysis. The Global Fund, Press release: Global Fund Crosses US$4 billion Mark in Funding to Support Countries in the Fight Against COVID-19, October 8, 2021.

    ← Return to text

  15. Does not include countries that may have received funding through multi-country or regional programs. Additional countries may be reached through multi-country or regional programs.

    ← Return to text

  16. Global Fund Data Explorer: https://data.theglobalfund.org/home; accessed September 2021. KFF analysis.

    ← Return to text

  17.  Global Fund Data Explorer: https://data.theglobalfund.org/home; accessed September 2021. KFF analysis. Regions based on WHO regional classifications.

    ← Return to text

  18. KFF analysis of OECD DAC CRS database, September 2021.

    ← Return to text

  19. Global Fund, Global Fund Results Report 2021, September 2021.

    ← Return to text

  20. KFF analysis.

    ← Return to text

  21. Congressional Research Service, The Global Fund to Fight AIDS, Tuberculosis, and Malaria: Issues for Congress and U.S. Contributions from FY 2001 to the FY 2012 Request, July 1, 2011.

    ← Return to text

  22. U.S. Congress, Public Law No: 108-25; May 27, 2003.

    ← Return to text

  23. U.S. Congress, Public Law No: 108-25; May 27, 2003.

    ← Return to text

  24. U.S. Congress, Public Law No: 110-293; July 30, 2008.

    ← Return to text

  25. U.S. Congress, Public Law No: 113-56; December 2, 2013. U.S. Congress, Public Law No: 115-305; December 11, 2018.

    ← Return to text

  26. KFF analysis. The American Rescue Plan Act of 2021 included $3.75 billion “to support programs for the prevention, treatment, and control of HIV/AIDS in order to prevent, prepare for, and respond to coronavirus, including to mitigate the impact on such programs from coronavirus and support recovery from the impacts of the coronavirus,” of which not less than $3.5 billion was for the Global Fund. U.S. Congress, Public Law No: 117-2; March 11, 2021. KFF, Global Funding Across U.S. COVID-19 Supplemental Funding Bills, March 2021.

    ← Return to text

  27. KFF analysis. U.S. Congress, Public Law No: 110-293; July 30, 2008. 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. U.S. Congress, Public Law No: 112-74; December 23, 2011.

    ← Return to text

  28. The Global Fund, Website: COVID-19 Response Mechanism, available at: https://www.theglobalfund.org/en/covid-19/response-mechanism/.

    ← Return to text

  29. The Global Fund, Press release: Global Fund Crosses US$4 billion Mark in Funding to Support Countries in the Fight Against COVID-19, October 8, 2021.

    ← Return to text

  30. WHO, What is the Access to COVID-19 Tools (ACT) Accelerator, how is it structured and how does it work?; April 2021.

    ← Return to text

  31. The Global Fund, Results Report 2021, September 2021.

    ← Return to text

  32. KFF, Donor Funding for Health in Low- & Middle-Income Countries, 2002-2013; November 2015.

    ← Return to text

  33. Congressional Research Service, The Global Fund and PEPFAR in U.S. International AIDS Policy; November 3, 2005.

    ← Return to text

The Henry J. Kaiser Family Foundation Headquarters: 185 Berry St., Suite 2000, San Francisco, CA 94107 | Phone 650-854-9400
Washington Offices and Barbara Jordan Conference Center: 1330 G Street, NW, Washington, DC 20005 | Phone 202-347-5270

www.kff.org | Email Alerts: kff.org/email | facebook.com/KaiserFamilyFoundation | twitter.com/kff

Filling the need for trusted information on national health issues, the Kaiser Family Foundation is a nonprofit organization based in San Francisco, California.