Q&A: Key issues at the Global Fund replenishment

LYON, France — Bono, Bill Gates, and heads of state convened in eastern France Thursday for the Sixth Replenishment of the Global Fund to Fight AIDS, Tuberculosis and Malaria, which slightly exceeded its aim of raising $14 billion from donors for the next three years.

It says the 15% increase on its last replenishment will allow it to save 16 million lives between 2021 and 2023.

Last year, 770,000 people died from HIV-related illnesses. In 2017, 1.6 million died from TB (including 300,000 among those with HIV) and 435,000 died from malaria. Médecins Sans Frontières warned this week that donor and domestic funding for HIV programs dropped in 2018 for the first time in more than a decade, while the funding gap for TB widened to $3.5 billion per year.

“After years of remarkable progress in the fight against HIV, TB and malaria, new threats have pushed us off track,” the Global Fund argued in its investment case for the replenishment. At present, the fund said, “wavering political commitment, shortfalls in funding and increasing insecticide and drug resistance have slowed progress and enabled the diseases to gain ground.”

On Thursday, President Emmanuel Macron announced that France, as well as the Bill & Melinda Gates Foundation, would increase their contributions by 15%. They joined others, such as the European Union, Germany, and Canada, that had already announced increases.

U.S. President Donald Trump has proposed around $400 million less than the fund hoped, as well as proposing an end to the U.S. commitment to provide one-third of its overall funding. Congress, which controls the money, rejected that however, with the Senate and House of Representatives putting forward bills, not yet passed, with $1.56 billion per year for the fund — a more than 15% increase on the current cycle.

As delegates began filing into the many side events Wednesday morning in Lyon, Devex spoke with Marijke Wijnroks, the Global Fund’s chief of staff, to ask what she is watching for this week.

This conversation has been edited for length and clarity.

What is the status of the United States’ pledge?

It’s Congress that does the appropriations, and they have already decided on the 2020 budget of $1.56 billion ... The Senate added a sentence to it, because they always appropriate on a yearly basis, that they would consider this the amount that would be contributed on an annual basis for the next three-year cycle.

So, you are treating the U.S. position as settled?

We absolutely have full confidence that the U.S. will live up to its commitment.

What happens after the pledge amount is known?

Our audit and finance committee will meet next week and they will decide, on the basis of the money that has been raised, the funding that’s necessary to keep the secretariat running. They make a calculation and decide what is the amount that will be available for allocations.

The board has agreed on an approach to allocation, which is based on a combination of economic indicators, disease burden ... And then we have factors that, for example, can compensate for countries that have a high multidrug-resistant tuberculosis burden so that they get higher rates. For HIV, we have a compensating factor for countries that have low overall rates but higher rates among key populations, because we know that is often under-reported.

Then we will have a process that we call qualitative adjustment, where we say, “ok, what is the formula spitting out?” And on that basis, we allocate the money for highest impact.

Whether it’s slightly over or slightly under the target, it will all be included in the allocation formula and countries will by December receive a letter with the funding that will be available for them for the next three years.

Other than the numbers, what issues you are watching this week?

The messages sent during the pledging session are always incredibly important. A number of heads of state and ministers from implementing countries will speak. Some will announce contributions to the Global Fund, but also I would hope that some of them will commit to increase domestic resources for health.

There will be announcements from private sector partners for funding but also in-kind contributions where companies make their capacity and expertise available to support implementation on the ground.

It’s going to be really interesting what donors will focus on, what they expect the Global Fund to do: Looking at some of the messages that came with the pledges that have been made so far we can expect ... a very strong focus on health systems, also in relation to global health security and tackling human rights and gender-related barriers to access.

What about some of the other donors? Nando’s, the chicken restaurant, was mentioned at a side-event...

Nando’s provide funding for regional malaria elimination. In southern Africa, there are a couple of countries that have done really well at malaria elimination, but as long as there is still a lot of malaria in Mozambique it’s going to be really difficult for countries like Swaziland and South Africa to eliminate malaria. So we have some regional activities and coordination, and Nando’s has contributed.

Are there any donors you won’t work with?

We have a policy on private sector engagement, which was approved by the board. We follow basically what the World Health Organization is doing, so we would not work with the arms industry and the tobacco industry. Those are no-go areas in global health.

What about big oil, are they involved in the Global Fund?

No, but Chevron has been. It was the first company that committed a long-term pledge to the Global Fund. We do quite intense due diligence with new partners from the private sector on corporate social responsibility. If we considered that the risk of being associated with an organization ... was too high we would not accept it.

We are really careful with dealing with real and perceived conflict of interest. So, if people could perceive that companies were buying influence on the Global Fund board we could not accept donations.

The due diligence that we are doing looks at all of those things: Could people think that they accept donations from a certain company thinking that would increase the market for that company in terms of Global Fund’s procurement? If we feel that there is risk, even if it’s perceptions of risk, then we would be super careful.

Update, Oct. 10: This story was updated to include the latest pledging figures from the conference.