Your deepest, darkest questions on the Global Fund: ANSWERED!

Sep 3rd, 2010 12:38 PM UTC
By Todd Summers

This month, we’ll be featuring blog posts that help illustrate the Global Fund’s effect on programs that fight AIDS, tuberculosis and malaria around the world — and the people suffering from these diseases.

Last month, we asked our friends on Facebook and Twitter to send in their most burning questions about the Global Fund — or more broadly, international health aid and development. Here’s a roundup of some of those questions, answered by Todd Summers, ONE’s resident global health policy expert:

How does the Global Fund prioritize spending, programming, and allocation of resources?
- Catherine Kustanczy and @lylinaguas, via Facebook and Twitter

One of the great features of the Global Fund is that it responds to the needs of eligible countries rather than making them fit in with Global Fund priorities.

So there are no specific allocations of its resources, just a general policy that it should work to support comprehensive strategies for the three diseases. Going forward, there’s a shift from funding discrete projects to supporting comprehensive national strategies to improve global health, and this will allow the Global Fund to have more of a role in ensuring that countries are spending money on the right things and doing so efficiently.

What indicators does the Global Fund ask countries to track? Are they different from those set out in PEPFAR? Is money tied to those specific indicators?
- Keri McDaniel Miller, via Facebook

Indicators for success are key to tracking progress, both for the countries (to ensure that they’re achieving what they need to save lives) and for the Global Fund (to ensure that its funding is being used effectively).

The specific indicators come from a set recommended by the Global Fund in its Monitoring and Evaluation Toolkit, and are memorialized in the proposals and grant agreements.

Countries must demonstrate progress against those indicators in order to get payments, with results independently verified by outside reviewers called Local Fund Agents. A key challenge is to make the indicators reflect real improvements in health. For example, it’s better to measure people newly diagnosed with HIV or tuberculosis than just to measure people tested.

In light of escalating executive compensation/salaries and other benefits globally, how is compensation provided for Global Fund staff?
- Eugene Ingram Jr., via Facebook

Salaries are approved by the executive director as part of a budget package ultimately approved by the board of directors, with most of the review done by the board’s Finance and Audit Committee.

When the Global Fund first started, it had an agreement with the World Health Organization (WHO) such that all of the Global Fund employees were actually WHO staff –- and therefore had WHO salaries and benefits. A few years ago, the Global Fund concluded that agreement and now directly employs all of its staff. In that process, the board agreed to try its best to maintain the same salary and benefit levels in order to be fair to employees and to be competitive within Geneva.

It’s fair to say that Geneva salaries are quite high in comparison to what we’re used to seeing in the US and elsewhere in Europe, partly because the cost of living there is very, very high. Fortunately, the Fund covers most of its operational costs through interest earnings, so contributions are use for services rather than overhead.

How much of this fund is going towards education?
- Stephan Yurkowski, via Facebook

If you mean education strictly defined, such as funding schools and teachers, then that isn’t the focus of the Global Fund -– it finances programs for HIV, tuberculosis and malaria.

If you mean education around the diseases as part of prevention and treatment work, then quite a bit. For HIV and TB, for example, the Global Fund supports numerous programs that help people understand and avoid infection, recognize when they might need to be tested and respond if indeed they are.

For malaria, there’s work to help mothers and health care workers identify and respond to malaria, and ensure that they don’t assume malaria when it could be something else like pneumonia.

How does the Global Fund ensure accountability and transparency for its funding and programs? Are there instances of corruption, and if so, how does the Global Fund address these issues?
- Aidan Twineomujuni and Birdie Gurley, via Facebook

Around accountability and transparency, grantees are held to high levels of accountability for their funding through independent reviews and audits to ensure that progress is made before further funding is provided.

As for corruption, there have been a number of cases that have been identified. It’s pretty sad to think that people steal money intended to save lives, but it happens. Fortunately, there are robust systems to identify instances when money is diverted or contracting is rigged. The first line of defense is at the country level, with many of the cases of corruption caught by auditing systems used by the grantees.

The second line of defense are the Local Fund Agents mentioned earlier –- they’re hired by the Global Fund to watch over things.

And the third line of defense is the Global Fund, with its grant management procedures -– similar to those used by other foundations.

Finally, the Global Fund has a robust Office of Inspector General that operates independently and engages when corruption is alleged. You’ll find documentation and reports on many of the instances of corruption that have been identified right on the Global Fund’s website -– and you’ll see that grants have been suspended or terminated when funds are misused.

What do all these [global health] funding streams look like on the other end for recipients? Do they ever have trouble reconciling priorities if, say, the Netherlands wants a country to spend on DOTS treatment for tuberculosis, but Japan wants its money to go toward vaccines?
- Porter McConnell, via Facebook

To be honest, it can be a big mess at the country level, with multiple donors with multiple reporting systems and priorities. Unfortunately, this has gotten worse as the volume of funding has gone up. This has been a big concern at the Global Fund, and there are many different efforts underway to reduce the transaction costs for countries and to harmonize with their own systems and priorities.

It’s a work in progress, but the Global Fund is ahead of many other donors in its efforts here. In fact, no government donors to the Global Fund are allowed to restrict or “earmark” their funds for specific diseases, interventions or countries.

We’ve witnessed a global recession in which many health organizations lost money and cannot fully implement their programs. Is the Global Fund structured to adjust to the recession and ensure that funds are adequate? How quickly and flexibly can the Global Fund adjust and react to the economic crisis in a positive way?
- Benedit Emmanuel, via Facebook

The economic challenge has certainly made an impact on the Global Fund, constraining resources of both donor and implementing countries. Many donors have indicated that it’s a particularly tough time to come up with the additional funding needed to maintain the Global Fund’s ability to meet country demand.

There’s a fund raising process underway right now, with donors being asked to commit funds for the next three years. ONE is working hard to push them to meet the Global Fund’s needs (why being a ONE member is so important!!). Some countries like Italy have failed to fulfill their pledges, and have got to be pushed and pulled back.

Without a good replenishment of $17-20 billion globally, it will be very difficult for the Global Fund to support countries as they continue to scale up their programs. That means districts don’t get funding to spray for mosquitoes or distribute insecticide-treated bed nets. It means that people may be denied treatment, even when their lives are at stake.

So this isn’t abstract – it’s real, and lives will depend on the willingness of donors to stretch even in tougher times.

It’s also a good time to focus on efficiency. There’s lots of evidence that Global Fund grantees aren’t getting the best value for the money; they’re either paying too much for commodities or services, or simply funding things that aren’t effective.

ONE and other advocates and donors are rightly pushing for increased efforts to measure and improve spending efficiency. Some important steps have already been taken.

The last funding round, for example, required that proposals show whether they were meeting certain cost benchmarks -– and if not, to explain why. There are also more stringently applied requirements that grantees report on their commodity purchases so that they and others can see what the market is getting for things like drugs and bed nets.

At a minimum, the Global Fund has a very conservative policy regarding its funding commitments: the Secretariat can only sign grant agreements when the money needed is “in the bank” (in this case, in its accounts at the World Bank) and has to keep that money protected until those agreements are finished.

So there won’t ever be a case where the Global Fund defaults on an agreement, though that doesn’t mean that the Fund will have enough to provide follow-on funding if needed.

Todd Summers is ONE’s senior adviser for global health. Before joining ONE, he was a senior program officer at the Bill & Melinda Gates Foundation, where he lead a multilateral relations team responsible for working with major partners like the Global Fund.

TAGS: Global Fund, ONE, Spotlight