From Sept 19 to 22, the Global Fund to Fight AIDS, Tuberculosis and Malaria will gather international donors to replenish funding for its vital core mission towards Sustainable Development Goal (SDG) 3: ending AIDS, tuberculosis, and malaria and building resilient and sustainable health systems. But the global context of this replenishment is unlike any other. The COVID-19 pandemic has rendered vulnerable health systems even more fragile and derailed crucial programmes across the Global Fund's disease portfolio. A global cost-of-living crisis is sending domestic spending skyrocketing and is tightening donor budgets. These shocks will not be the last. The Global Fund's newest Strategy Framework 2023–2028 embraces the need to strengthen its crisis response capacity. Can the organisation meet its core objective while also strengthening the foundation for pandemic preparedness and response?
Since its inception, the Global Fund partnership has saved an estimated 44 million lives and cut the death toll from AIDS, tuberculosis, and malaria by 40%. In this replenishment round, the Global Fund is asking for at least US$18 billion to save 20 million lives, reduce the death toll across all three diseases by 64%, and avert 450 million infections. $6 billion will be used to strengthen health systems and pandemic preparedness. The Multilateral Organisation Performance Assessment Network (MOPAN) commends the Global Fund for its achievements towards disease-specific goals; however, the Global Fund has underperformed in building resilient and sustainable health systems. This underperformance is problematic for pandemic preparedness and response efforts, which, for the Global Fund, are a matter of scaling up health-systems strengthening but also continuing to silo disease-specific health responses at country level. But could facilities built for HIV surveillance accommodate a sudden demand for Ebola surveillance in an emergency? That would be true pandemic preparedness. Instead, the Global Fund's strategy for the next 5 years remains heavily tilted towards its original SDG3 mandate, rather than fully adopting a crisis-response objective. This approach might well be a result of pressure from donors—their governments are indeed more likely to get taxpayers buy-in for tangible results. But emergencies are never tangible.
Towards the end of 2021, critical discussions were held within the Global Fund on how to transition out money from COVID-19 emergency response mechanisms like the Access to COVID-19 Tools Accelerator. Despite its inclusive partnership model at an operational level, whereby governments, civil society, technical and development partners, the private sector, and affected communities all have a voice, concerns were raised about the lack of a democratic governance structure at executive level. Indeed, among the Board's 20 voting members, only two represent the whole of Africa, the region where the greatest investments are made in proportion to disease burden. Most Board seats are filled by donor countries. In this era of decolonising global health, the Board must reconsider this neocolonial imbalance in country representation. Democratisation of the governance structures, giving recipient countries an equal decision-making voice, is not just a basic ask but a necessary priority in pandemic preparedness.
Ultimately, a strong foundation for pandemic preparedness and response demands cohesive collaboration between all global health entities. But the global health landscape is growing ever more complex. This month the World Bank launches the Financial Intermediary Fund (FIF) for pandemic prevention, preparedness, and response. In collaboration with WHO, and operating within the International Health Regulations, the FIF will finance the global capacity to prepare and respond to pandemics and other global health security threats. To some, the FIF fills a glaring gap; to others, it sows confusion. Whether the Global Fund will be an implementer of FIF remains to be seen. What is certain is that uncoordinated competition for diminishing donor funds among a growing number of organisations risks diluting and delaying their work.
A perfect blueprint of global health architecture might not exist, but all relevant parties need to acknowledge the complexity and discuss coordination. Perhaps the only authoritative body that can bring everyone together is the UN Secretary General. Ban Ki-moon set precedent by prioritising women's and children's health during his second term. It is now time for António Guterres to prioritise global health in a (post-)COVID-19 world so that investments in health systems see maximum return in lives saved.
For the Seventh Replenishment see https://www.theglobalfund.org/en/fight-for-what-counts/
For the Global Fund Strategy Framework 2023–28 see https://www.theglobalfund.org/en/strategy/
For MOPAN's assessment report see https://www.mopanonline.org/assessments/globalfund2021/
For The Global Fund Board members see https://www.theglobalfund.org/en/board/members/
For the PPR FIF see https://www.worldbank.org/en/topic/pandemics/brief/factsheet-financial-intermediary-fund-for-pandemic-prevention-preparedness-and-response
For more on Ban Ki-moon women's and children's health agenda see https://news.un.org/en/story/2014/05/469652-toronto-ban-says-ensuring-health-women-children-best-investment-we-can-make
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