Opinion: The Global Fund needs to broaden its mandate

A scene from the Sixth Replenishment Conference of the Global Fund to Fight AIDS, Tuberculosis and Malaria in Lyon, France. Photo by: Sandrine Thesillat

The past couple of decades has seen the world wake up from a consciousness crisis on sky-high mortality from completely preventable diseases and coalesce around several initiatives designed to cut down the unacceptably high global death toll from three major infectious killers.

It has paid off. The number of deaths from malaria in Africa was reduced by nearly half from 839,000 deaths in 2000 to less than 438,000 in 2015. Global HIV mortality peaked in 2006 with nearly 2 million deaths worldwide and has since come down dramatically with less than 1 million recorded deaths in 2017, just as the number of people living with HIV has kept increasing, thanks to vastly greater access to antiretrovirals in sub-Saharan Africa.

Increased access to effective diagnosis and treatment of TB has saved an estimated 43 million lives from the disease between 2000 and 2015, and the mortality rates from TB have decreased by 42% over that period.

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Reducing the global burden of three of the top infectious killers by this magnitude and speed is arguably one of the greatest ever achievements of the international community. The Global Fund has been at the forefront of this battle and has contributed massively to this extraordinary endeavor.

More importantly, it has done so by transferring ownership of the monies and the decision making regarding their use to the beneficiary countries, through the famous country coordinating mechanisms, thus introducing unprecedented levels of accountability in the sector and powerful incentives for delivering results.

The fund, along with other vertical health initiatives, was borne out of mistrust in the more traditional institutions, including World Health Organization and the World Bank, whose perceived ineffectiveness in dealing with the AIDS epidemic in the 80s and 90s prompted the emergence of highly focused, results-driven organisations to channel massive chunks of the world’s aid for health. The model has been effective, to an extent.

The problem is this: such an enormous shift toward issue-based funding has almost certainly happened at the expense of strengthening health systems’ ability to provide comprehensive care, respond to disease outbreaks, and produce a large and competent health workforce for all.

We can’t know what would have happened in the fund’s absence, but it is reasonable to assume that part of this huge pool of resources has displaced or crowded out other financing mechanisms for low-income countries’ health systems.

To be clear, some of the fund’s resources were directed towards strengthening health systems more broadly. Indeed, one study from 2013 estimated that 38% of the fund’s round 8 budget was dedicated to system building. However, it also showed that only one-third of this was truly horizontal — i.e. not targeting any disease in particular and that just seven out of 139 grants were dedicated to health system strengthening.

A great many of us believe this effort now needs rebalancing, at a time of rapidly changing global health needs: the rise of noncommunicable diseases, the increasing frequency of major outbreaks, the risks of a global pandemic, climate change, antimicrobial resistance and the resurgence of old and newer infectious diseases.

None of these major challenges can be met without much stronger, better funded, and more resilient health systems for all. The Ebola outbreak that the Democratic Republic of Congo has been battling with for over a year must lead to the realization that the entire humanity’s safety depends upon improving health systems much more holistically in neglected parts of the world. The fact that pneumonia, the largest cause of child deaths globally and responsible for twice as many deaths as malaria, is at best a peripheral issue to the fund's mission defies logic.

The Global Fund is the single largest funding mechanism in global health, and channels more money than WHO and GAVI combined. The time has come to broaden its scope and mandate beyond HIV, malaria, and TB and make health system strengthening not a means to an end, but the end that justifies all means.

About the author

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    Samy Ahmar

    Samy Ahmar is head of health programs at Save the Children UK, where his team oversees a global portfolio of over 40 health projects in 15 countries. An experienced manager, economist, and thinker in international development with 12 years of experience in the private and charity sectors, Samy is passionate about universal health coverage, reducing poverty and inequalities, and driven by evidence and sustainability.