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

7 months ago

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 2023 regular Congressional appropriations to the Global Fund totaled almost $25 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 2023, the Global Fund had approved more than $66 billion in funding to almost 130 countries for its core HIV, TB, and malaria programs; the Global Fund estimates these investments have helped to save 59 million lives. In addition to its core programmatic activities, the Global Fund played a major role in COVID-19 response efforts, awarding nearly $5 billion to respond to COVID-19 as of June 2023, and continues to support countries as they shift from emergency pandemic response to longer-term health systems strengthening and pandemic preparedness efforts.

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, nearly $89 billion¹ has been pledged by all donors (governments, the private sector, and private foundations) to the Global Fund, including $15.7 billion at the most recent replenishment conference for the 2023-2025 funding cycle. ² Using these resources, the Global Fund has approved more than $66 billion in grants to almost 130 countries³ for its core HIV, TB, and malaria programs, and awarded nearly $5 billion in funding to respond to the COVID-19 pandemic’s impact on these three epidemics.⁴

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.⁵ The Trump administration had proposed funding cuts to the Global Fund and a reduced pledge amount, although Congress rejected these proposals.⁶ Currently, 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 pledged $6 billion over a three-year period⁷ at the most recent replenishment conference in September 2022.⁸ The U.S. has also 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.⁹ The Global Fund has been called the “multilateral component” of the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR),¹⁰ serving as a significant 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.¹¹ Further, while the Global Fund continues to respond to the impacts of the COVID-19 pandemic, there are ongoing discussions about its future role in pandemic preparedness and response more broadly and its latest strategy includes a new pandemic preparedness and response objective.¹²

Table 1: Global Fund Pledges and Contributions, as of September 2023 (in U.S. $ billions)
Donor	Total Pledges to the Global Fund	% of Total Pledges	Total Paid to the Global Fund	% of Total Paid
TOTAL	$88.9	100.0%	$70.4	100.0%
United States	$31.7	35.7%	$23.2	32.9%
France	$9.5	10.7%	$7.8	11.1%
United Kingdom	$8.3	9.3%	$6.7	9.5%
Germany	$6.7	7.5%	$5.6	8.0%
Japan	$5.4	6.1%	$4.6	6.5%
Canada	$4.4	4.9%	$3.5	4.9%
European Commission	$4.2	4.7%	$3.9	5.6%
All Other Countries/Public Sector	$12.9	14.5%	$10.5	14.9%
Gates Foundation	$3.9	4.4%	$3.0	4.3%
All Others	$2.0	2.2%	$1.7	2.4%
NOTES: Includes pledges made for the period 2001-2025 as well as those made with year of commitment yet to be confirmed. “All Other Countries/Public Sector” includes commitments to be personally secured by Bill Gates and Bono with the support of France for the period 2020-2022.  “All Others” includes contributions made by the private sector and nongovernmental organizations, Debt2Health, and the Affordable Medicines Facility – malaria (AMFm). Some donor countries included in this table contribute funding to the Debt2Health and AMFm finance mechanisms; these amounts are not included in individual donor country totals. 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). Totals may not sum due to rounding. SOURCES: KFF analysis of The Global Fund: https://data-service.theglobalfund.org/downloads; accessed September 7, 2023.

Funding Model & Organizational Structure¹³

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 an updated 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.¹⁴ 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.¹⁵

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 Audit & Finance and Ethics & Governance Committees.¹⁶
    • 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.
• 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.
• 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.
• Independent Evaluation & Learning. An independent body consisting of an Evaluation & Learning Office and Independent Evaluation Panel (IEP) that provides advisory services and oversight on the Fund’s evaluation efforts, including progress toward achieving the goals laid out in its strategy.¹⁷
• 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 2023, the Global Fund had approved more than $66 billion in funding for its core HIV, TB, and malaria activities, and as of June 2023, awarded nearly $5 billion in funding to respond to COVID-19 (see the Global Fund & COVID-19 section below).¹⁸ This funding has reached almost 130 countries¹⁹, 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).²⁰ 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%).²¹ 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 2021 (the U.S. was the largest),²² estimates that, since 2002, its grants have helped save the lives of 59 million people who would have otherwise died due to complications from AIDS, TB, or malaria.²³

Table 2: Global Fund Portfolio Status, as of September 2023
Portfolio Status	HIV	TB	Malaria	HIV/TB	Other
Approved Grant Funding (in U.S. $ billions)	$27.0	$9.9	$19.1	$7.6	$2.5
% of Approved Grants	40.8%	15.0%	28.8%	11.6%	3.7%
# of Countries Receiving Grants	120	109	85	60	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: KFF analysis of The Global Fund Data Explorer: https://data.theglobalfund.org/; accessed September 7, 2023.

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).²⁴ The U.S. first contributed to the Global Fund in FY 2001 through annual appropriations bills.²⁵ All U.S. support for the Global Fund was then incorporated into PEPFAR when it was created in 2003.²⁶ 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.”²⁷ 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.”²⁸ 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.²⁹ Discussions are currently underway to reauthorize PEPFAR again. See the KFF policy watch on PEPFAR reauthorization key issues as well as the KFF brief on PEPFAR legislation over time .

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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 2023, regular Congressional appropriations to the Global Fund totaled almost $25 billion. In FY 2021, an additional $3.5 billion was provided as emergency funding to respond to the COVID-19 pandemic.³⁰ Congress has historically matched or provided more to the Global Fund each year than the President has requested. (See the KFF budget tracker and the KFF fact sheet on the U.S. Global Health Budget: Global Fund 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: ³¹

• 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 2023 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)³² 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. Now, as countries shift from emergency pandemic response to longer-term efforts, the Global Fund has allowed countries to reprogram their C19RM funds for health systems strengthening and pandemic preparedness activities.³³ As of June 2023, the Global Fund had awarded almost $5 billion in funding to more than 100 countries to support countries’ responses to COVID-19.³⁴ 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.³⁵ The ACT-Accelerator is organized into pillars of work: Diagnostics, Therapeutics, Vaccines, Health Systems & Response Connector, and Access & Allocation.³⁶ The Global Fund co-leads three of these pillars — the Diagnostics Pillar, Health Systems & Response Connector, and the Therapeutics Pillar.³⁷

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 malaria³⁸ and been described as “complementing PEPFAR objectives.”³⁹ 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 and long-term 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 the U.S. and the Global Fund can 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.