Devex CheckUp: Why the US commitment to the Global Fund has cratered

Funding for the Global Fund to Fight AIDS, Tuberculosis and Malaria took a significant hit in U.S. President Joe Biden’s 2025 budget request, falling from $2 billion in 2024 to $1.2 billion. But the cut has little to do with all the dysfunction around government spending in Washington over the past few years.

Instead, it’s the result of the Global Fund falling short in its own fundraising efforts.

The U.S. had pledged to donate $6 billion over the fund’s three-year cycle from 2023-2025. At the same time, a law prevents the U.S. from contributing more than a third of the total funding from all Global Fund donors. But the fund fell short of raising the $18 billion it would need to claim the full U.S. pledge, hitting only $15.7 billion for the 2023-2025 replenishment round.

At the same time, the Biden administration didn’t make any effort to reallocate the excess funds to similar areas, and money for USAID global health programs also fell by about $175 million. That adds up to a lot less than the global health sector was hoping for from the president’s budget. Other global health institutions, such as UNICEF and Gavi, the Vaccine Alliance, have received a slightly higher allocation, but most are earmarked to receive amounts similar to what they got in 2023. The administration did set aside $134.5 million for WHO, a 23.9% increase from 2023 levels.

The global health community will now be pressing the U.S. Congress, which ultimately controls government spending, to make up for what they see as the administration’s shortfall.

Chris Collins, president and CEO of the Friends of the Global Fight Against AIDS, Tuberculosis and Malaria, tells my colleague Jenny Lei Ravelo that he believes additional matching funds are available from past replenishment cycles to increase U.S. appropriation to the Global Fund, and that the friends will ask Congress — which at times allocated more to the fund than was requested — to appropriate $1.65 billion in 2025.

What’s the basis for this? Collins explains that when considering all donations to the Global Fund since 2004, the U.S. has not always given up to the limit, or 33%, as the law says.

If money doesn’t come through, the fund could lose a potential $1.2 billion, leaving it with only $14.5 billion for its seventh replenishment period, just slightly higher than the $14.02 billion it received from its sixth replenishment in 2019. But given inflation, that translates to 10% less purchasing power for the fund, says Pete Baker, deputy director of the global health policy program at the Center for Global Development.
“[This] gives you an idea of how bad global health funding is right now that even the Global Fund, which is kind of one of the stars, I guess, is really struggling to get government commitments at the level they used to,” he says.

This poses serious questions for the fund’s upcoming replenishment in 2025. If donors are not putting forward the money now, “it’s hard to imagine why in the next couple of years they would reverse these decisions,” Baker adds.

Read: Budget constraints limit foreign affairs funding in Biden proposal (Pro)

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Up for debate

The Pandemic Fund says another competing pandemic fund is unnecessary. Specifically, Priya Basu, the head of the World Bank-housed Pandemic Fund, says that creating a new financing mechanism as part of the pandemic treaty negotiations would just duplicate the work her organization is already doing.

The existing fund is designed to help countries strengthen their pandemic prevention, preparedness, and response capabilities. But there is concern that it isn’t meeting its ambitious targets: It has raised only $2 billion of the $10.5 billion needed annually to meet global PPPR needs.

There is also concern that its structure is not inclusive enough. Though donors and recipients share the same number of seats on the board, some charge that decision-making is weighted toward the donors. That has led some African countries to push for a new fund not just to cover any obligations that might come out of the forthcoming pandemic treaty, but also to include more member-state oversight.

Speaking of that pandemic treaty, it inched closer to becoming a reality with the release of a revised draft from last week following a marathon negotiating session within the Intergovernmental Negotiating Body.

As with all previous treaty versions, few are really happy with the text. NGOs are disappointed that the text doesn’t include legal guarantees that low- and middle-income countries would be compensated for sharing information on pathogens.

The Africa group, for instance, is looking for guarantees that pathogen sharing will result in manufacturers sharing information about how to produce vaccines, therapeutics, and diagnostics in the event of a future pandemic or, at least, a commitment to sell any products that used their information at affordable prices.

The pharmaceutical industry is lined up against any deal that would link pathogen sharing with access to medical countermeasures.

Meanwhile, the self-imposed deadline of resolving all of these issues and finalizing the treaty by late May looms ever closer.

Read: Not another pandemic fund, says Pandemic Fund

Read more: Latest pandemic treaty draft still has ‘many weaknesses’

Show me the money

Global health has always been one of the top priorities of the Bill & Melinda Gates Foundation. But which organizations have benefited the most from the $24.2 billion the foundation has channeled into global health grants between 1998 and 2022?

My colleague Miguel Antonio Tamonan crunched the numbers and came up with some less-than-surprising results.

Topping the list was PATH. The Seattle nonprofit, which shares its hometown with the Gates Foundation, has been a longtime Gates partner to the tune of $1.8 billion in grants.

That sets the tone for the rest of the list, which includes eight organizations based in the United States — and two more in Switzerland. Devex Pro members can click through to see the whole top 10.

Read: Gates Foundation’s top 10 health grant winners (Pro)

Happy together

Are cooperatives the answer to the many problems that plague access to health care in low- and middle-income countries? In an opinion article for Devex, Dr. Nicholas Okumu, an orthopedic surgeon in Kenya, argues that the model could go a long way toward addressing some key challenges, including a lack of public investment and private health care that is unresponsive to patient needs.

Because they are built in consultation between health providers and the communities they are helping, health cooperatives are designed to be responsive to patient needs. And because they are small and agile, they can harness new technology — such as solar power — without waiting for sign-off from a board or shareholders.

Ultimately, Okumu writes that embracing health cooperatives would allow “communities to build sustainable and equitable health care systems that prioritize the well-being of all.”

Opinion: How a cooperative model can transform global health care

Step right up

To boost eligibility for chronic hepatitis B treatment, officials are taking a page from the global HIV treatment response playbook.

The 2015 guidelines for hepatitis B treatment eligibility set barriers around age and also often required patients to exceed certain thresholds on tests that determine how advanced the virus is.

But — as the HIV community began to do decades ago — officials are now trying to expand eligibility and simplify the guidelines so that people with chronic hepatitis B are identified sooner and started on treatment before the disease causes irreparable damage. With the changes, officials expect the number of people living with hepatitis B who are eligible for treatment to jump from 15% to 50%.

Read: New hepatitis B guidelines could boost response in sub-Saharan Africa

What we’re reading

A new, locally produced HPV vaccine promises wider access for Indian women, potentially saving lives from cervical cancer. [The Guardian]

New research finds that offering people a range of options for how to prevent an HIV infection, including oral and injectable choices, dramatically increases the uptake of services. [Aidsmap]

One to three of every 100 COVID-19 infections could last a month or longer — a much higher rate than researchers had previously suspected — which gives the virus more opportunities to mutate than previously thought. [Health Policy Watch]

Jenny Lei Ravelo contributed reporting to this edition of Devex CheckUp.