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Global Fund Fights AIDS, TB and Malaria

The long-awaited shake-up in the Geneva-based Global Fund to Fight AIDS, Tuberculosisand Malaria (the Fund) finally became operational this month with the assumption of officeof Gabriel Jaramillo, a former leading banker, as the new general manager. The change

followed various unflattering audit reports of the Fund operations in some recipientcountries that suggested money lost to corrupt practices and lax oversight. In addition, ahigh-level panel recommended a far-reaching restructuring of the Fund to ensure tighteroversight 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 inrecipient countries from 2014 due to flagging donor support and pledges. For supporters ofthe Fund, this remains an ominous sign. The Fund was established 10 years ago as a modelglobal financing mechanism to prove, in part, that a lean, nimble, transparent, results-oriented international organization can deliver care to target populations in all corners ofthe 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 manageresources prudently.

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

Reforms going forward

The first question is whether the Fund intends to be directly involved in country-levelefforts to reach at-risk populations to ensure funded programs are verifiably making apositive 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, apositive response automatically elevates logistics of care delivery to the highest operationalpriority area of the Fund, with commensurate investments. HIV/AIDS, tuberculosis andmalaria predominantly kill people who are poor, have problems with timely access toquality care and are most likely to be living with other dangerous comorbidities. Noorganization can reach these individuals and make a difference on their health statuswithout 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, theorganization remains fundamentally a top-down entity. A strong mechanism needs to becreated that can channel the goals, priorities and aspirations of at-risk populations andrecipient countries in the decision-making processes.

The second reform-related question relates to the Fund's identity. Should it become aninvestment agency supporting other organizations that finance or manage the delivery of

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treatment? Should it be a strict financing entity that provides targeted financial support forprograms already on the ground? Should it participate in the entire project cycle ofhealthcare deliveryincluding design, implementation, monitoring and evaluationatcountry and community levels for its funded programs? A clear direction will drive anyserious, sustainable reform effort. If done right, such an effort could tighten internal

operational controls, reorganize operating structures, refine risk assessment and projectportfolio management mechanisms, and adopt indicators for monitoring efficiency andeffectiveness.

Assessment and accountability

The Fund should have valid measurement indicators that document how funded programsare preventing the transmission of disease among at-risk populations, measuring how wellpeople actually responded to treatment protocols within specific populations. Population-based knowledge, attitude and perception (KAP) surveys can provide important clues as towhether funded programs are making a difference. Process indicators, especially programinput and output indicators that dominated the global fund matrix in the last decade, whilegood for management reviews, are not adequate for measuring the impact of fundedprograms against communicable diseases. Process indicators are also unreliable in showingevidence 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 technicalreview process can also be simplified. Reports from the Fund look like lengthy academicreview papers, reinforcing the perception of an agency that needs shoring up on operationalissues. The Fund needs to become not only a lean operational entity but also transformitself into a financing mechanism that makes quick, clear technical decisions on fundingsupport. Perhaps to accelerate this, the Fund can invest more on technical field visits,independent expert reviews, identification of projects ripe for scaling up, and aninformation-dissemination mechanism for various audiences and constituencies. Inaddition, the Fund should promote itself more aggressively in donor countries, showcasingits successes through simplified reporting mechanisms.

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