By Guido Schmidt-Traub, Executive Director, Sustainable Development Solutions Network
Since its inception in 2001, the Global Fund to Fight AIDS, Tuberculosis and Malaria has become a highly respected pooled financing institution that scores top marks in independent reviews.1, 2
It has disbursed some USD 40 billion in grants for complex disease control and treatment programmes in fragile and non-fragile countries alike.
Success was far from assured in 2001, as developing countries, particularly in sub-Saharan Africa, faced a perfect storm of surging HIV/AIDS, multi-drug-resistant tuberculosis and surging malaria deaths. Control and treatment interventions were available in high-income countries, but no one knew how to tackle the diseases in resource-poor settings. In particular, HIV/AIDS treatment was deemed impossible in Africa and was outside recommended approaches for tackling the disease.3
The Global Fund was designed precisely to tackle the lack of quality programmes and implementation mechanisms in developing countries. All too often, however, it is seen as just another funding mechanism. Many reviews lump it together with other multilateral mechanisms and trust funds.4
This is a mistake. The Global Fund has unique design principles that set it apart from bi- and multilateral financing mechanisms with the notable exception of Gavi.5
These design principles have been at the heart of the health sector’s success in innovating new technologies, treatment models and management systems for controlling the three diseases, and in propagating the lessons to all countries. So we should think of the Global Fund as an enabler of innovation and rapid learning in four ways.
First, countries were invited to submit large-scale funding proposals for review by the Global Fund’s Technical Review Panel (TRP) comprising independent experts. The TRP only judged the technical soundness of proposals and their compliance with medical best practice. It did not consider the politics of the requesting countries or the volume of funding requested. The Board of the Global Fund could only approve or reject all TRP recommendations in toto. This removed the politics of considering proposals from individual countries and ensured the technical integrity of the independent review process.
Remarkably, the TRP rejected China’s two initial applications for HIV/AIDS funding because the proposals did not include harm reduction, as recommended in the technical literature. China protested, but then changed its approach to managing the disease, before receiving large-scale funding from the Global Fund, which helped reverse the course of the disease.6, 7
It is highly unlikely that other funders without independent technical reviews would have outright rejected a technically deficient proposal from such a large country.
After each Global Fund round, countries whose proposals had been rejected would study successful proposals and incorporate lessons. Since there was no limit on how much funding a country could request, finance ministers took note and worked with health ministries to address governance or operational challenges. After each round, the TRP briefed technical partners of the Global Fund, such as WHO, UNAIDS and Roll-Back Malaria, on lessons from the proposals. These technical partners then supported countries in addressing weaknesses and incorporating innovations from other countries.
The second way in which the Global Fund has fostered innovation is through its ability and willingness to disburse funds directly to government departments, local and international civil society organisations, international organisations, or the private sector. In countries where governments are weak, civil society organisations may operate national-scale programmes, such as the multi-drug-resistant tuberculosis programme in Somalia. Civil society organisations also run outreach programmes targeting marginalised populations that might be difficult or impossible for government institutions to undertake. This competition between different disbursement channels lowers costs and fosters innovation in programme design and implementation.
Third, the Global Fund has been working closely with businesses to harness innovation and ensure well-functioning markets. Its demand forecasts for malaria bednets and other commodities, for instance, reduce uncertainty and enabled businesses to invest in product development and production. This, in turn, generated rapid cost reductions for major commodities.8, 9
Fourth, the Global Fund supports systematic implementation research and independent evaluations of its operations and programmes. The independent Office of the Inspector General can initiate reviews and inspections of any aspect of the Fund’s work. These reports are made public and have uncovered weaknesses in programmes supported by the Fund. They have also documented best practice and helped inform WHO treatment guidelines. In this way, Global Fund programmes helped reach a consensus on the free or highly subsidised distribution of malaria bednets10 or improvements in AIDS treatment guidelines.11
Thanks to these four drivers of innovation resulting from the Global Fund’s unique design principles, virtually every country, including low-income and fragile states, now has functioning control and treatment programmes for the three diseases. This is a complete reversal from the situation in 2001 when no developing country had such programmes in place. Some of the mainstream tools for fighting the diseases were not known or widely available in 2001, and their development and widespread adoption were enabled by the Global Fund’s grant model, which continuously pushed the boundaries of clinical and public health best practices.
The design principles of the Global Fund can be applied to other investment challenges under the Sustainable Development Goals, such as education, access to basic infrastructure or smallholder farming. Yet, in my experience, they are largely unknown outside the health community, and no multilateral pooled financing mechanisms apply the four drivers of innovation that have fueled rapid progress under the Millennium Development Goals. In view of the large funding needs for Agenda 2030 and the pressure on aid budgets, it’s high time to accelerate innovation and learning outside health. This should start with studying and applying lessons from the Global Fund and Gavi.
1.↩ DFID. Raising the standard: the Multilateral Development Review 2016. (Department for International Development, 2016).
2. PublishWhatYouFund. Aid Transparency Index 2016. (PublishWhatYouFund, 2016).
3.↩ Binswanger, H. P. Scaling up HIV/AIDS programs to national coverage. Science 288, 2173–2176 (2000).
4.↩ OECD. Multilateral Aid 2015. Better Partnerships for a Post-2015 World. (Organisation for Economic Co-operation and Development, 2015).
5.↩ Sachs, J. D. & Schmidt-Traub, G. Global Fund lessons for Sustainable Development Goals. Science 356, 32–33 (2017).
6.↩ Wang, R.-B. et al. Transition from control to elimination: impact of the 10-year global fund project on malaria control and elimination in China. Adv. Parasitol. 86, 289–318 (2014).
7. Minghui, R., Scano, F., Sozi, C. & Schwartländer, B. The Global Fund in China: success beyond the numbers. Lancet Glob. Health 3, e75–e77 (2015).
8.↩ Zelman, B., Kiszewski, A., Cotter, C. & Liu, J. Costs of eliminating malaria and the impact of the Global Fund in 34 countries. PloS One 9, e115714 (2014).
9. Stover, J. et al. Long-term costs and health impact of continued Global Fund support for antiretroviral therapy. PLoS One 6, e21048 (2011).
10.↩ WHO. Guidelines for the Treatment of Malaria. (World Health Organization, 2010).
11.↩ WHO. Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection: recommendations for a public health approach. (World Health Organization, 2016).