Order Code RL33396
The Global Fund to Fight AIDS,
Tuberculosis, and Malaria:
Progress Report and Issues for Congress
Updated April 14, 2008
Tiaji Salaam-Blyther
Specialist in Foreign Affairs
Foreign Affairs, Defense, and Trade Division

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The Global Fund to Fight AIDS, Tuberculosis, and
Malaria: Progress Report and Issues for Congress
Summary
The Global Fund to Fight AIDS, Tuberculosis, and Malaria, headquartered in
Geneva, Switzerland, is an independent foundation that seeks to attract and rapidly
disburse new resources in developing countries aimed at countering the three
diseases. The Fund is a financing vehicle, not an implementing agency. The origins
of the Fund as an independent entity to fight the three diseases lie partly in a French
proposal made in 1998, in ideas developed in the 106th Congress, and in
recommendations made by United Nations Secretary-General Kofi Annan in April
2001. Though the Global Fund was established in January 2002, President Bush
pledged $200 million to such a fund in May 2001.
As of March 20, 2008, donors have pledged more than $19 billion to the Fund,
of which nearly $10 billion has been paid. The funds have been used to support more
than 500 grants totaling more than $10 billion for projects in 136 countries. Each
year, the Fund awards grants through Proposal Rounds. The Fund launched its eighth
Round on March 3, 2008. In 2005, the Fund approved Round 5 grants in two
tranches, because initially there were insufficient donor pledges to approve all the
recommended proposals. The Fund approved the first group of Round 5 proposals
in September 2005 and the second in December 2005, after donors pledged to make
additional contributions. The Global Fund only approves proposals if it has
sufficient resources on hand to support the first two years of a proposed project. This
policy is designed to avoid disruptions to projects due to funding shortages. Funding
lapses can cause interruptions in treatment regiments, which could lead to treatment-
resistant strains of the diseases or death.
The United States is the largest single contributor to the Global Fund. From
FY2001 through FY2008, Congress has appropriated $3.8 billion to the Fund,
providing $840.3 million in FY2008, the single largest U.S. contribution to date. Of
those funds, $545.5 million would come from the State Department, and $294.8
million from the Department of Health and Human Services (HHS). The President
requested $500 million for a FY2009 contribution to the Global Fund.
There has been some debate about the level of U.S. contributions to the Fund.
Some critics argue that the United States should temper its support to the Fund,
because the Fund has not demonstrated strong reporting and monitoring practices;
because contributions made to the Fund in excess of the President’s request are
provided at the expense of U.S. bilateral HIV/AIDS, TB, and malaria programs; and
because they maintain that the Fund needs to secure support from other sources,
particularly the private sector. Supporters of current funding levels counter that the
Fund has improved its reporting and monitoring practices, greater U.S. contributions
to the Fund parallel increases in U.S. bilateral HIV/AIDS, TB, and malaria programs,
and the Fund has attempted to raise participation of the private sector through the
launching of Product Red™. This report, which will be periodically updated,
discusses the Fund’s progress to date, describes U.S. contributions to the
organization, and presents some issues Congress might consider.

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Contents
Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Global Fund Progress to Date . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Funding Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Suspended, Discontinued, or Cancelled Grants . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Suspended Grants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Ukraine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Discontinued Grants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Nigeria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Pakistan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Senegal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
South Africa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Uganda . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Terminated Grants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Burma (Myanmar) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Projected Financial Needs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Meeting Millennium Development Goals . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Meeting Escalating Grant Requests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Congressional Actions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Issues for Congress . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Strengthen Reporting and Monitoring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Reauthorize Limits on U.S. Contributions to the Global Fund . . . . . . . . . . 14
Consider Proportion of Support for the Fund to Support for
Other Bilateral Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
List of Figures
Figure 1. U.S. Contributions to the Fund and All U.S. International HIV/AIDS,
TB, and Malaria Spending . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Figure 2. U.S. Contributions to the Fund as a Percentage of All U.S.
International HIV/AIDS, TB, and Malaria Spending . . . . . . . . . . . . . . . . . . 18
List of Tables
Table 1. Grant Agreement Totals to Date . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Table 2. Funding Requirements, 2008-2010 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Table 3. U.S. Appropriations to the Global Fund . . . . . . . . . . . . . . . . . . . . . . . . 11
Table 4. U.S. Pledges to the Fund as a Percentage of All Fund Pledges . . . . . . 15
Table 5. Total Global Fund Contributions and Pledges, 2001-2008 . . . . . . . . . 16
Table 6. Total U.S. Global HIV/AIDS, TB, and Malaria Appropriations . . . . . 17
Glossary of Abbreviations and Acronyms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

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The Global Fund to Fight AIDS,
Tuberculosis, and Malaria: Progress Report
and Issues for Congress
Background
In January 2002, the Global Fund to Fight AIDS, Tuberculosis, and Malaria
(Global Fund) was established as an independent foundation in Switzerland to
support country efforts to curb the number of illnesses and deaths caused by
HIV/AIDS, tuberculosis (TB), and malaria. Each year, the three diseases kill some
6 million people, mostly in Africa. The Fund’s Board meets at least twice annually
to discuss governance issues, such as grant approval. Nineteen Board seats are
rotated among seven donor countries, seven developing countries, and one
representative from each of a developed country non-governmental organization
(NGO), a developing country NGO, the private sector, a foundation, and affected
communities.1 The United States holds a permanent Board seat. In its first five
years, the Fund aimed to support:
! treatment for 1.8 million HIV-positive people, 5 million people
infected with TB, and 145 million malaria patients;

! the prevention of HIV transmission to 52 million people through
voluntary HIV counseling and testing services (VCT);
! the purchase and distribution of 109 million insecticide-treated bed
nets to prevent the spread of the malaria; and
! care for 1 million orphans.2
1 For more on the Global Fund, see CRS Report RL31712, The Global Fund to Fight AIDS,
Tuberculosis, and Malaria: Background, by Tiaji Salaam-Blyther.
2 Global Fund Webpages about HIV/AIDS, TB, and malaria, at [http://www.theglobalfund.
org], visited on December 10, 2007.

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Global Fund Progress to Date
The Global Fund has thus far approved proposals for 527 grants in 136 countries
totaling $10.12 billion (Table 1). About half of those funds have been disbursed.3
As of December 2007, the Fund-supported grants have been used to treat an
estimated 1.4 million HIV-positive people and 3.3 million people infected with TB,
and to distribute 46 million insecticide-treated bed nets to prevent malaria
transmission.4 An estimated 58% of Global Fund grants support HIV/AIDS
interventions, about 17% fund anti-TB programs; some 24% sustain anti-malaria
projects, and 1% strengthen health systems.5 According to the Global Fund, in 2005,
its support represented more than 20% of all global HIV/AIDS spending, some 67%
of global TB funds and about 64% of all international support for malaria
interventions.6
Funding Procedure
In 2005, the Fund approved Round 5 grants in two tranches, because there were
not sufficient donor pledges to support all recommended proposals at the time of
grant approval. Its Comprehensive Funding Policy (CFP) specifies that the Fund can
only sign grant agreements if there are sufficient resources to support the first two
years of grant activities. The policy is designed to avoid disruptions in funding that
might interrupt project activities. Financial delays can cause people to miss
treatments, potentially leading to drug-resistance, susceptibility to secondary
diseases, or death.
3 Global Fund, Current Grant Commitments and Disbursement, March 20, 2008, at
[http://www.theglobalfund.org/en/funds_raised/reports/], visited March 20, 2008.
4 Global Fund, “Monthly Progress Update — January 31, 2008,” at
[http://www.theglobalfund.org/en/files/publications/basics/progress_update/
progressupdate.pdf], visited January 8, 2008.
5 Global Fund, “Distribution of Funding After Six Rounds,” at
[http://www.theglobalfund.org/en/funds_raised/distribution/t], visited January 15, 2008.
6 Global Fund, Resource Needs for the Global Fund: 2008-2010. 2007, at
[http://www.theglobalfund.org/en/files/about/replenishment/oslo/Resource%20Needs.pdf].
The Henry J. Kaiser Family Foundation (KFF) estimates that Global Fund spending
represented about 19% of all international HIV/AIDS commitments in 2005. KFF,
International Assistance for HIV/AIDS in the Developing World, July 2006, at
[http://www.kff.org/hivaids/upload/7344-02.pdf], visited January 15, 2008.

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Table 1. Grant Agreement Totals to Date
($ millions, current )
Grants Approved
Funds Disbursed
Phase I
Phase II
Total
Phase I
Phase II
Total
Round 1
$576.3
$838.5
$1,414.8
$544.7
$477.4
$1,022.1
Round 2
$851.6
$964.0
$1,815.6
$813.2
$491.9
$1,305.1
Round 3
$635.1
$770.8
$1,405.9
$599.4
$238.1
$837.5
Round 4
$1,014.5
$1,623.5
$2,638.0
$907.0
$236.8
$1,143.8
Round 5
$777.1
$19.6
$796.7
$468.5
$0.0
$468.5
Round 6
$874.4
$0.0
$874.4
$255.3
$0.0
$255.3
Round 7
$1,120.2
$0.0
$1,120.2
$0.0
$0.0
$0.0
TOTAL
$5,849.2
$4,216.4
$10,065.6
$3,588.1
$1,444.2
$5,032.3
Source: Global Fund website, Current Grant Commitments and Disbursements. January 15, 2008.
The Fund distributes grants through a performance-based funding system. Under
this system, the Fund commits to financially support the first two years (Phase I) of
approved grants, though it disburses the funds quarterly if grants meet their targets.
As the end of Phase I approaches, the Fund reviews the progress of the grant to
determine if it should support the third through fifth years (Phase II).
In November 2006, the Board established the Rolling Continuation Channel
(RCC). This funding channel, which began in March 2007, permits Country
Coordinating Mechanisms (CCMs)7 to request additional funding for grants that are
performing well but set to expire. The application process for the RCC is not as
rigorous as the Round process. RCC-approved grants can receive support for up to
an additional six years, with the funds being awarded in three-year intervals. The
channel is intended only for those grants that have demonstrated a significant
contribution “to a national effort that has had, or has the potential to have in the near
future, a measurable impact on the burden of the relevant disease.”8
7 CCMs are comprised of individuals from governments, NGOs, the private sector, and
affected populations. The CCMs develop and submit grant proposals to the Fund. After
grant approval, they oversee progress during implementation.
8 Global Fund, Report on the Final Decisions of the Fourteenth Board Meeting, October 31-
November 3, 2006, at [http://www.theglobalfund.org/en/files/boardmeeting14/GF-BM-14_
Final_Decisions.pdf], visited January 16, 2008.

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CRS-4
Suspended, Discontinued, or Cancelled Grants
The Fund uses a performance-based funding system that permits it to
temporarily suspend support for grants if it finds significant problems with project
performance, such as accounting inconsistencies. In some instances, the Fund
restored support to grants once key concerns were resolved. For example, in
November 2006, the Fund suspended support for grants in Chad. After undertaking
audits of the grants, the Fund reportedly discovered evidence of “misuse of funds at
several levels and the lack of satisfactory capacity by the Principal Recipient and sub-
recipients to manage the Global Fund’s resources.” In August 2007, the Fund
announced that it had lifted the suspension, “after a series of investigation and
negotiations between the Global Fund and national authorities ... and after efforts and
strong commitment of all relevant stakeholders which guaranteed that the issues have
been addressed and better systems with clarified responsibilities will be put in place.
As part of the [Global Fund’s] mitigation — besides other measures — a fiduciary
agent will guarantee for an interim period of 12 months adequate financial
monitoring and accounting for our grants.”9
The Fund might discontinue support for grants in Phase II if it finds that they did
not sufficiently meet their targets. Countries whose grants have been discontinued
can apply and have secured funding in subsequent Rounds (see Nigeria below). In
extreme cases, the Fund will immediately cancel financial support. If funds are
immediately revoked, the Fund might invoke its continuity of services policy, which
ensures that life-extending treatment is continued for suspended or cancelled grants
or for those whose terms have expired until other financial support is identified.10 To
date, the Fund has only terminated grants in Burma. When the Fund decided to
terminate support for grants in Burma, policy analysts debated how best to serve
humanitarian needs in politically unstable countries.
Suspended Grants
Ukraine. On January 30, 2004, the Global Fund announced that it had
temporarily withdrawn its grant in Ukraine. Citing the slow progress of Fund-backed
HIV/AIDS programs, the Fund stated that it would ask “a reliable organization to
take over implementation of the programs for several months, to give Ukraine the
opportunity to address concerns of slow implementation, management, and
governance issues.”11 Nearly a month later, on February 24, 2004, the Fund
announced that the suspension had ended, and that a temporary principal recipient
9 Global Fund, Grant Performance Report: Chad, August 23, 2007, at
[http://www.theglobalfund.org/search/docs/3TCDH_614_249_gpr.pdf], visited on March
20, 2008.
10 Global Fund, Report from the Policy and Strategy Committee at the 14th Board Meeting,
October 31-November 3, 2006, at [http://www.theglobalfund.org/en/files/boardmeeting
14/GF-B14-7_Report%20of%20the%20PSC_FINAL.pdf], visited January 15, 2008.
11 Global Fund, “The Global Fund Acts to Secure Results for its Programs in Ukraine,”
Press Release, January 30, 2004, at [http://www.theglobalfund.org/en/media_center/press/
pr_040130.asp], visited May 30, 2007.

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CRS-5
had been identified. The Fund hoped that if a new Principal Recipient (PR) were
used, project performance would improve and related problems would be resolved.12
In July 2005, the Fund announced that the new PR was successfully implementing
the grant and that it had approved additional funds for the grant’s Phase II activities.13
Discontinued Grants14
Nigeria. In May 2006, at its 13th board meeting, the Fund decided to
discontinue support for Nigeria’s HIV/AIDS programs awarded in Round 1. In
previous board meetings, the Secretariat recommended that the Fund not award
Nigeria additional support for Phase II.15 The Board disagreed. At the 12th Board
meeting, the Board and Secretariat agreed to create an Independent Review Panel to
review the grants and report back to the Board. Following its investigation, the Panel
presented similar findings and agreed with the Secretariat that the grants were
performing poorly. The Board agreed not to fund Phase II of the grants, but
committed to support procurement of HIV treatments for up to two years. Although
those grants were discontinued, the Fund awarded Nigeria different HIV/AIDS grants
in Round 5.16
Pakistan. Staff at the Global Fund report that the Fund discontinued support
for Pakistan’s malaria projects in Round 2 because of weak project implementation,
slow procurement of health products, poor data quality, and slow spending of project
funds. Specifically, the Secretariat found that 8 of the grant’s 10 targets17 had not
12 Global Fund, “Global Fund Signs Letter of Intent to Relaunch Ukraine HIV/AIDS Grant,”
Press Release, February 24, 2004, at [http://www.theglobalfund.org/en/media_center/
press/pr_040224.asp], visited May 30, 2007.
13 Based on correspondence with Dr. Itamar Katz, Strategic Information Officer,
Performance & Evaluation Department, the Global Fund, on May 11, 2007, and January 21,
2008.
14 Other grants that were discontinued include Bolivia, East Timor, and Sierra Leone. For
more information, see Global Fund webpage on discontinued grants, at
[http://www.theglobalfund.org/en/funds_raised/gsc/nogo/], visited on March 20, 2008.
15 For information on the functions of the Board and Secretariat, see CRS Report RL31712,
The Global Fund to Fight AIDS, Tuberculosis, and Malaria: Background, by Tiaji
Salaam-Blyther.
16 Global Fund, Report from the Communities Living with HIV/AIDS, TB and Affected by
Malaria to the Global Fund at the 13th Board Meeting, April 2006, at
[http://www.theglobalfund.org/en/files/partners/civil_society/articles/report_
communities_bm13.pdf]. Also see Global Fund, Operations Update at the 14th Board
Meeting. October 31-November 3, 2006, at [http://www.theglobalfund.org/en/files/board
meeting14/GF-BM-14_04_Operations Update.pdf], visited January 16, 2008.
17 For a description of the targets, see Global Fund, Proposal Form, July 2002, at
[http://www.theglobalfund.org/search/docs/2PKSM_130_144_full.pdf], visited January 16,
2008.

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CRS-6
been reached and only 15% of the insecticide-treated nets (ITNs) had been
distributed.18
Senegal. On March 1, 2005, the Global Fund announced that it would not
approve funding for the second phase of Senegal’s malaria project, which was
originally funded in Round 1. A Fund press release indicated that the project “was
found to have systemic issues that resulted in poor performance.”19 The release did
not specify what issues it had with the project, though it indicated that “review of the
Senegal grant raised serious concerns” about the effective use of Global Fund
resources. Although the program was discontinued, Fund officials encouraged
Senegal to address the issues that were raised and to apply for new funds in the
future. Ultimately, the Fund approved a grant proposal that Senegal submitted for
malaria projects in Round 4.
South Africa. In December 2005, the Global Fund Board voted to discontinue
funding an HIV prevention grant in South Africa. The Board decided that the grant,
implemented by an NGO named loveLife, had failed to sufficiently address
weaknesses in its implementation.20 Press accounts quote a Global Fund
representative explaining that it had become difficult to measure how the loveLife
prevention campaign was contributing to the reduction of HIV/AIDS among young
people in South Africa. Additionally, the representative reportedly stated that the
Board had repeatedly requested that loveLife revise its proposals and address
concerns regarding performance, financial and accounting procedures, and the need
for an effective governance structure. A Global Fund spokesman was quoted as
saying that “loveLife is extremely costly, there are programs that have been very
effective, which cost a fraction of what loveLife costs. It would be irresponsible of
the Global Fund to spend almost $40 million without seeing results.”21
LoveLife officials were reportedly surprised that the Global Fund ultimately
decided to discontinue funding the grant, particularly since there were some reported
differences of opinion regarding the matter between the Fund’s Technical Review
Panel (TRP), Secretariat, and the Board.22 Additionally, loveLife officials reportedly
argued that the decision was politically motivated and influenced by U.S. emphasis
18 Correspondence with the Global Fund on April 13, 2007.
19 Global Fund, “Global Fund Cuts Funding for Malaria Grant,” Press Release, March 1,
2005, at [http://www.theglobalfund.org/en/media_center/press/pr_050301.asp], visited May
15, 2007.
20 Global Fund, “Global Fund Closes Funding Gap,” Press Release, December 16, 2005, at
[http://www.theglobalfund.org/en/media_center/press/pr_051216.asp], visited May 11,
2007.
21 UN Integrated Regional Information Networks, “South Africa: Global Fund Withdraws
Support for LoveLife,” December 19, 2005, at [http://www.plusnews.org].
22 LoveLife officials allege that after reviewing the revised proposal that loveLife submitted,
the TRP recommended that the Board fund the proposal. See loveLife, “Statement by
loveLife on the Decision by the Global Fund to Fight HIV/AIDS, TB, and Malaria to
Discontinue Funding,” Press Release, December 21, 2005, at [http://www.lovelife.org.za/
corporate/media_room/article.php?uid=805], visited May 17, 2007.

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CRS-7
on abstinence in HIV prevention efforts. One press account quoted a loveLife
official as saying, “Obviously the strength of conservative ideologies is spilling over
into the field of HIV and HIV prevention and it has direct impact on programs like
loveLife.”23 According to a loveLife press release, the decision to discontinue
support for the program will substantially curtail South Africa’s efforts to prevent
HIV infections among young people, because the Global Fund’s grant supported one
third of the program’s budget. However, the South African government has
reportedly provided additional funds to the program to close the funding gap, and
other donors, such as the U.S.-based Kaiser Family Foundation, have continued
funding loveLife HIV-prevention efforts.
Uganda. On August 24, 2005, the Global Fund announced that it had
temporarily suspended all five of its grants in Uganda. Additionally, the Fund
declared that the Ugandan Ministry of Finance would have to establish a new
structure that would ensure effective management of the grants before it considered
resuming support. In a press release, the Fund explained that a review undertaken
by PricewaterhouseCoopers revealed serious mismanagement by the Project
Management Unit (PMU) in the Ministry of Health, which was responsible for
overseeing the implementation of Global Fund programs in Uganda. Examples of
“serious mismanagement” included evidence of inappropriate, unexplained or
improperly documented expenses.24 Up to that point the Fund had disbursed some
$45.4 million of the $200 million approved.25 Three months later on November 10,
2005, the Fund announced that it had lifted the suspension on all five grants. The PR
and the Ministry of Finance committed to restructure management of the grants and
strengthen oversight and governance of Global Fund grants to Uganda.26 In spite of
these actions, the Fund did not approve support for Phase II activities.
Terminated Grants
Burma (Myanmar). After extensive consultation with the U.N. Development
Program (UNDP), the Fund decided to terminate its grant agreements with Burma
effective August 18, 2005. The Fund stated that while it was concerned about the
extensive humanitarian needs in Burma, travel restrictions imposed by the country’s
government prevented the Fund from effectively implementing grants.27 According
23 Andrew Quin, “S. Africa youth AIDS program faces cash crunch,” Reuters Foundation,
January 4, 2006, at [http://www.alertnet.org], visited May 22, 2007.
24 Global Fund, “Global Fund Suspends Grants to Uganda,” Press Release, August 24,
2005, at [http://www.theglobalfund.org/en/media_center/press/pr_050824.asp], visited May
15, 2007.
25 Kaiser Family Foundation, “Global Fund Temporarily Suspends Five Grants to Uganda
Citing Evidence of Mismanagement,” August 25, 2005, at [http://www.kaisernetwork.org/
daily_reports/print_report.cfm?DR_ID=32229&dr_cat=1], visited May 16, 2007.
26 Global Fund, “Global Fund Lifts Suspension of Uganda Grants,” Press Release,
November 10, 2005, at [http://www.theglobalfund.org/en/media_center/press/pr_051110.
asp], visited May 9, 2007.
27 Global Fund, “The Global Fund Terminates Grants to Myanmar,” Press Release, August
(continued...)

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CRS-8
to the Fund, travel clearance procedures that the Burmese government instituted in
July 2005 prevented the PR, implementing partners, and Global Fund staff from
accessing grant implementation areas. The Fund indicated that the travel restrictions
coupled with new procedures that the government established to review procurement
of medical and other supplies “prevented implementation of performance-based and
time-bound programs in the country, breached the government’s commitment to
provide unencumbered access, and frustrated the ability of the PR to carry out its
obligations.”28
The Global Fund’s decision to discontinue those grants in Burma sparked a
larger debate about providing humanitarian assistance in countries that are politically
unstable or governed by dictatorial regimes. Some were disappointed that the Fund
terminated its assistance, citing the significant humanitarian needs in the country. A
Burmese official stated that, “the restrictions on aid workers were only temporary,
and ‘do not justify irreversible termination of grants.’”29 A U.N. official accused the
United States of pressuring the Global Fund to withdraw its support in Burma.30 One
U.N. official warned of impending death as a result of the situation, stating that,
“without exaggeration, people are going to die because of this decision.”31 Some,
however, blamed the Burmese government for the Fund’s decision to terminate the
grants. One Washington-based observer stated that, “it needs to be recognized who
causes suffering in that country. It’s not the Global Fund...It’s the regime.”32 A
Global Fund spokesperson stressed that the interrupted aid was not a political
decision, rather one based on effective project implementation.33
Burma has garnered support from other countries and international organizations
to continue programs terminated by the Fund. Australia is reportedly increasing its
aid to Burma by 25%.34 Additionally, the European Union (EU) announced that it had
27 (...continued)
19, 2005, at [http://www.theglobalfund.org/en/media_center/press/pr_050819.asp]. Also
see Global Fund, “Termination of Grants to Myanmar,” Fact sheet, August 18, 2005, at
[http://www.theglobalfund.org/en/media_center/press/pr_050819_factsheet.pdf], visited
May 10, 2007.
28 Global Fund, “The Global Fund Terminates Grants to Myanmar,” Press Release, August
19, 2005, at [http://www.theglobalfund.org/en/media_center/press/pr_050819.asp], visited
June 5, 2007.
29 “Burma urges UN aid fund to stay,” BBC News, August 23, 2005, at
[http://news.bbc.co.uk/], visited June 6, 2007.
30 “Australia to step up AIDS assistance to Burma,” Australian Associated Press, December
7, 2005, at [http://aap.com.au/], visited June 6, 2007.
31 “Misery spreads among political stalemate,” The Miami Herald, December 29, 2005,
visited May 31, 2007.
32 “So Much Need, So Little Help for the Deathly Ill in Myanmar,” The Los Angeles Times,
December 27, 2005, at [http://www.latimes.com/], visited May 31, 2007.
33 Ibid.
34 “Australia to step up AIDS assistance to Burma,” Australian Associated Press, December
(continued...)

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CRS-9
pledged about $18 million to fight HIV/AIDS in the country.35 In January 2006,
Australia, Britain, Sweden, the Netherlands, Norway, and the European Commission
announced that they planned to establish a $100 million, five-year joint donor
program that would replace some of the financial support the country lost after the
Fund had withdrawn. The program, the Three Diseases Fund (3D Fund), was
officially launched in October 2006.36 The donors contend that the funding system
maintains the safeguards established by the Global Fund that ensures the money does
not directly support the military regime.
Projected Financial Needs
Meeting Millennium Development Goals
In September 2000, at the United Nations (U.N.) Millennium Summit, member
states adopted the U.N. Millennium Declaration, which among other things,
established a set of time-bound, measurable goals and targets for combating poverty,
hunger, disease, illiteracy, environmental degradation and discrimination against
women.37 This resolution contains what have become commonly known as the
Millennium Development Goals (MDGs).38
World leaders who agreed to the MDGs pledged to provide sufficient financial
and technical support to meet the goals. Of the eight goals, the one aimed at
HIV/AIDS and malaria commits world leaders to reverse the spread of the two
diseases by 2015. The World Health Organization (WHO) and the Joint United
Nations Program on HIV/AIDS (UNAIDS) estimate that in order to meet the MDG
goal related to HIV/AIDS and malaria, in each year from 2008 to 2010, donors would
need to provide between $28 billion and $31 billion.39 The Global Fund estimates
34 (...continued)
7, 2005, at [http://aap.com.au/], visited June 6, 2007.
35 “EU Humanitarian aid to Myanmar increases fourfold,” Associated Press, December 12,
2005, at [http://www.ap.org], and “Commission allocates 15 million in humanitarian aid
to vulnerable populations in Burma/Myanmar and to Burmese refugees along the Myanmar-
Thai border,” European Commission, Press Release, December 22, 2005, at
[http://europa.eu/rapid/pressReleasesAction.do?reference=IP/05/1694&format=
HTML&aged=0&language=EN&guiLanguage=en], both visited on June 6, 2007.
36 “European donors plan to restore AIDS help to Myanmar: diplomats,” Agence France
Press, January 24, 2006, at [http://www.afp.com/english/home/], and “Myanmar’s
HIV/AIDS, Malaria, TB Fund To Begin Operations on October 12,” Kaiser Family
Foundation, October 12, 2006, at [http://www.kaisernetwork.org/daily_reports/rep_index.
cfm?hint=1&DR_ID=40356], both visited on June 6, 2007.
37 United Nations, United Nations Millennium Declaration, A/RES/55/2, September 18,
2000, at [http://www.un.org/millennium/declaration/ares552e.pdf], visited January 17, 2008.
38 United Nations, “The Millennium Development Goals and the United Nations Role,” at
[http://www.un.org/millenniumgoals/MDGs-FACTSHEET1.pdf], visited January 17, 2008.
3 9 Global Fund, Partners in Impact: Results Report 2007, at
(continued...)

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CRS-10
that during that time period, its annual share of this amount would range from $4
billion to $6 billion.
Meeting Escalating Grant Requests
The Fund estimates that it will need between $11.5 billion and $17.9 billion
from 2008 to 2010.40 The range represents the rate at which grant approval could
escalate in three different scenarios (Table 2). In Scenario A, the Global Fund would
continue to award new grants at the current rate of about $1 billion per year and
would not experience significant growth. In Scenario B, the Fund would moderately
increase new grant awards, with annual grant awards averaging $5 billion from 2008
to 2010. In Scenario C, the Fund projects that it would meet the MDGs and would
need an average of $6 billion for each year from 2008 to 2010. The Global Fund does
not advocate any scenario, because it bases its financial needs on the grant proposals
that it receives.41 However, at a board meeting in April 2007, the Board estimated
that it would need from $6 billion to $8 billion by 2010 — reflecting Scenarios B and
C.42
Table 2. Funding Requirements, 2008-2010
($ billions, current)
2008
2009
2010
Phase I
Phase II RCC Phase I Phase II
RCC
Phase I
Phases II RCC
Total
Scenario A
$1.7
$1.3
$0.3
$1.8
$1.7
$0.4
$1.6
$2.1
$0.6
Subtotal
$3.3
$3.9
$4.3
$11.5
Scenario B
$2.3
$1.3
$0.3
$2.9
$1.7
$0.4
$3.2
$2.2
$0.6
Subtotal
$3.9
$5.0
$6.0
$14.9
Scenario C
$2.8
$1.3
$0.3
$3.9
$1.7
$0.4
$4.7
$2.2
$0.6
Subtotal
$4.4
$6.0
$7.5
$17.9
Source: Global Fund, Resource Needs for the Global Fund: 2008-2010.
39 (...continued)
[http://www.theglobalfund.org/en/files/about/replenishment/oslo/Progress%20Report.pdf],
visited January 17, 2008.
40 Global Fund, Resource Needs for the Global Fund: 2008-2010, February 2007, at
[http://www.theglobalfund.org/en/files/about/replenishment/oslo/Resource%20Needs.pdf],
visited January 17, 2008.
41 Correspondence with Global Fund staff, May 1, 2007.
42 Ibid.

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CRS-11
Congressional Actions
At the launching of PEPFAR, the Administration proposed that over the Plan’s
five-year term, $1 billion be contributed to the Global Fund. Because President Bush
made his first request for the Global Fund in FY2003, the Administration has
requested $1.8 billion for the Fund from FY2004 to FY2009, $200 million in each
of FY2004 and FY2005, $300 million in each of FY2006 through 2008, and $500
million in FY2009. Congress has consistently provided more to the Fund than the
Administration has requested through PEPFAR, appropriating some $3 billion from
FY2004 through FY2008 (Table 3). In FY2008, Congress provided $840.3 million
to the Fund, the single largest U.S. contribution to date. Of those funds, $545.5
million would funded through the State Department, and $294.8 million through the
Department of Health and Human Services (HHS).
Table 3. U.S. Appropriations to the Global Fund
($millions, current)
FY2001-
FY2002 FY2003 FY2004 FY2005 FY2006 FY2007 FY2008 FY2008 PEPFAR Total FY2001- FY2009
Actual
Actual Actual Actual Actual
CR
Request Estimate FY2004-FY208 FY2008 Request
Foreign Operations
$320.0 $248.4 $397.6 $248.0 $445.5 $625.0
$0.0
$545.5
$2,261.6
$2,830.0
$200.0
Labor/HHS
$100.0
$99.3 $149.1
$99.2
$99.0
$99.0 $300.0
$294.8
$741.1
$940.4
$300.0
FY2004 Carryover
n/a
n/a
($87.8)
$87.8
n/a
n/a
n/a
n/a
n/a
n/a
n/a
TOTAL
$420.0 $347.7 $458.9 $435.0 $544.5 $724.0 $300.0
$840.3
$3,002.7
$3,770.4
$500.0
Source: Appropriations legislation and budget requests.
Notes: The Global Fund reports having received less from the United States than what was appropriated. The
Global Fund reports having received $300 million in 2001 and 2002 combined, $322.7 million in 2003, $458.9
million in 2004, $414.0 million in 2005, $401.7 million in 2006, $724.0 million in 2007, and a pledge of
$841.0 million for 2008. Language in P.L. 108-25 authorizes the President to withhold a portion of U.S. funds
from the Fund that might be spent in countries that support terrorism.
In FY2005, Foreign Operations appropriations provides for the United States to transfer 5% of funds appropriated
to the Fund to support USAID technical assistance efforts related to the Fund. In FY2006, Foreign Operations
appropriations language requires the Secretary of State to withhold 20% of the U.S. Global Fund contribution
until she certifies to the Appropriations Committees that the Fund has strengthened oversight and spending
practices. FY2008 Consolidated Appropriations provided that up to 5% of the funds made available to the
Global Fund be made available to USAID for technical assistance activities related to the Global Fund and that
up to $13 million of Global Fund appropriations be made available for administrative expenses of the Office
of the Global AIDS Coordinator.
The withdrawal of $87.8 million in FY2004 illustrated in Table 3 reflects requirements in P.L. 108-25, U.S.
Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003, which stipulates that U.S. contributions
to the Fund for fiscal years 2004 through 2008 not exceed 33% of Fund contributions from all sources
(discussed below). P.L. 108-447, FY2005 Consolidated Appropriations, adds this amount to the 2005
contribution, subject to the same 33% limitation.

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CRS-12
Issues for Congress
Strengthen Reporting and Monitoring
Some critics of the Fund have expressed concern about particular aspects of the
Fund’s financial policies. Observers contend that the Fund’s oversight mechanisms
are not strong enough to protect against wasteful spending, particularly in countries
that have a well documented history of corruption and poor financial management.
Fund supporters counter that the organization’s website provides an abundance of
information related to its funding process, grant project proposals and budgets, grant
spending trends, and results of board meetings, which include decisions regarding the
suspension of grants. Fund advocates also argue that the Fund’s decisions to suspend
temporarily, and in some cases, discontinue poor performing grants demonstrate the
effectiveness of the Fund’s oversight and funding mechanisms.
In June 2005, the U.S. Government Accountability Office (GAO) reported that
the Fund had a limited capability to monitor and evaluate grants, raising questions
about the accuracy of its reported results. GAO also indicated that the Fund’s
documents had not consistently explained why it provided additional funds for grants
or why it denied disbursement requests.43 In October 2006, the Center for Global
Development (CGD) Global Fund Working Group reported similar findings and
made a number of recommendations, including strengthening the performance based
funding system.44
In an effort to strengthen oversight of the Fund’s grants, Congress included a
provision in Section 525 of P.L. 109-102, FY2006 Foreign Operations
Appropriations, that required 20% of the U.S. contribution to the Global Fund be
withheld until the Secretary of State certified to the Appropriations Committees that
the Fund had undertaken a number of steps to strengthen oversight and spending
practices. The act allows the Secretary to waive the requirement, however, if she
determines that a waiver is important to the national interest. At a March 2007
hearing on TB held by the Subcommittee on Africa and Global Health,
Representative Adam Smith expressed his reservations about the Fund’s oversight
capacity, stating that
The information and accountability that Congress has come to take for granted
through bilateral programs are not available through the Global Fund, and that
many of the primary recipients of the Global Fund grants are governments with
a history of corruption and fraud and/or limited capacity to properly manage
large sums of money in their health sectors. One could argue that the absence in
the Global Fund of a robust reporting and monitoring mechanism, at both the
primary and sub- recipient levels, is an open invitation for waste in these
43 GAO, The Global Fund to Fight AIDS, TB, and Malaria is Responding to Challenges but
Needs Better Information and Documentation for Performance-Based Funding, GAO-05-
639, June 2005, at [http://www.gao.gov/new.items/d05639.pdf].
44 Global Fund Working Group, Challenges and Opportunities for the New Executive
Director of the Global Fund: Seven Essential Tasks, CGD, October 2006, at
[http://www.cgdev.org/doc/HIVAIDSMonitor/GlobalFund_sevenTasks.pdf].

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CRS-13
countries and a tragic loss of opportunity to save lives. The implementation of
a system that provides accountability and transparency would seem vital,
absolutely necessary, in my view, to continue the expanded donor support of the
Global Fund in the future.
GAO re-evaluated the Fund and released a report in May 2007, which
acknowledged that the Fund had improved its documentation of funding decisions,
but also determined that the process needed improvement.45 The report indicated that
while each grant that GAO reviewed included an explanation of associated funding
decisions, the explanations did not detail what criteria the Fund used to determine
whether to disburse funds or renew support, as it had found in 2005. GAO
recommended that the Fund strengthen oversight of Local Fund Agents (LFAs) and
standardize performance benchmarks to improve the quality of grant monitoring and
reporting.46
In FY2008, Congress placed additional monitoring and oversight provisions to
Global Fund appropriations. The FY2008 Consolidated Appropriations required that
20% of U.S. contributions to the Fund be withheld until the Secretary of State
certifies to the Committees on Appropriations that the Global Fund
! releases incremental disbursements only if grantees demonstrate
progress against clearly defined performance indicators;
! provides support and oversight to country-level entities;
! has a full-time, independent Office of Inspector General who is fully
operational;
! requires LFAs to assess whether a principal recipient has the
capacity to oversee the activities of sub-recipients;
! is making progress toward implementing a reporting system that
breaks down grantee budget allocations by programmatic activity;
! makes the reports of the Inspector General publicly available; and
! tracks and encourages the involvement of civil society, including
faith-based organizations, in country coordinating mechanisms and
program implementation.
45 GAO, Global Fund to Fight AIDS, TB, and Malaria Has Improved Its Documentation of
Funding Decisions but Needs Standardized Oversight Expectations and Assessments, GAO-
07-627, May 2007, at [http://www.gao.gov/new.items/d07627.pdf].
46 The Global Fund does not maintain staff in recipient countries. Instead, it hires Local
Fund Agents to oversee, verify and report on grant performance. For more information, see
Global Fund, “Local Fund Agents,” fact sheet, at [http://www.theglobalfund.org/en/about/
structures/lfa/], visited January 17, 2008.

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CRS-14
The FY2008 Consolidated Appropriations also required the Secretary of State to
submit a report within 120 days of enactment to the Appropriations Committees that
details the involvement of faith-based organizations in Global Fund programs.
Some in Congress have long advocated for stronger oversight of Global Fund
spending. Supporters of this idea have welcomed the provisions. Some Global Fund
supporters contend, however, that such action is unnecessary in light of the strides
that the Fund continues to make in improving its reporting and monitoring practices.
As Congress considers whether to continue supporting the Global Fund, Members
might debate whether the Fund is sufficiently adhering to congressional mandates or
if additional provisions are necessary.
Reauthorize Limits on U.S. Contributions to the Global Fund
P.L. 108-25, U.S. Leadership Against HIV/AIDS, Tuberculosis, and Malaria
Act, prohibits U.S. government contributions to the Fund from exceeding 33% of
contributions from all donors. Congress instituted the contribution limit to encourage
greater global support for the Fund. There is some debate about whether the 33%
provision should be interpreted as the amount the United States should provide to the
Fund or as the maximum amount the United States can contribute. Supporters of the
Fund contend that Congress instituted the 33% mandate in recognition of the moral
responsibility that the United States holds as one of the wealthiest countries in the
world. Opponents of this idea assert that if U.S. contributions to the Fund were to
reflect its share of the global economy, then U.S. contributions would and should
range from 20% to 25% of all contributions.
Some Global Fund advocates who disparage the 33% restriction argue that the
differing fiscal cycles of the Fund and the United States complicate efforts to
leverage support. Opponents to the 33% restriction contend that the requirement is
harmful to the Fund, because the U.S. fiscal year concludes some three months before
the Fund’s. Critics most often point to FY2004 to substantiate their position. In that
fiscal year, nearly $88 million of the U.S. contribution was withheld from the Fund
to prevent the funds from exceeding 33%. Advocates of the restriction assert that the
33% cap was intended to suspend portions of U.S. contributions, where necessary.
Proponents of the cap note that the Fund was not significantly affected, as the
withheld portion was released at the end of the calendar year, when the Fund secured
sufficient funds to match the U.S. contribution. Supporters of the provision contend
that the Fund benefits from the policy, because it encourages other donors to increase
their contributions, as happened in FY2004. Except in FY2004, U.S. contributions
to the Fund have not yet reached 33% (Table 4).

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CRS-15
Table 4. U.S. Pledges to the Fund as a Percentage of
All Fund Pledges
($millions, current and percentages)
FY2001- FY2005 FY2006 FY2007 FY2008
FY2004
Total
Actual
Actual Estimate Estimate
Actual
U.S. Pledges to the Global Fund
$1,081.6
414.0a
$513.0
$724.0
$841.0
$3,573.6
All Pledges to the Global Fund
$3,405.6 $1,506.8 $2,030.1 $2,725.9 $2,794.3 $12,462.7
U.S. Contributions as % of All Pledges
31.8%
27.5%
25.3%
26.6%
30.1%
28.7%
Sources: Global Fund, Pledges and Contributions, December 28, 2007.
Notes: The Global Fund reports pledge levels that are less than what Congress appropriated. From
FY2001-FY2004, Congress made $1,226.6 million available to the Fund, $435.0 million in FY2005,
$544.5 million in FY2006, $724.0 million in FY2008, and $840.3 million in FY2008.
Debate on the 33% contribution cap has also focused on the limited amount of
support that the private sector and others have provided to the Fund (Table 5). Since
its inception, the Fund has struggled to secure support from non-government donors.
The Bill & Melinda Gates Foundation remains the largest single contributor among
non-government donors. As of March 18, 2008, the foundation accounts for some
86% ($650.0 million) of all non-governmental pledges ($753.6 million) and more
than 75% ($350.0 million) of all payments to the Fund by non-governmental donors
($464.4 million).47 Some Fund supporters had hoped that the Product Red campaign,
launched in January 2006 by co-founder Bono,48 would lead to significant increases
in contributions made by the private sector.49 As of March 18, 2008, Product Red™
has contributed $62.4 million to the Fund, comprising about 13% of non-government
contributions, double what it contributed in April 2007.
47 Global Fund, “Pledges and Contributions,” December 28, 2007, at
[http://www.theglobalfund.org/en/files/pledges&contributions.xls], visited January 17, 2008.
48 Stage name for singer Paul David Henson.
49 The initiative is a branding mechanism which commits companies that use the Product
Red brand to share a percentage of their profits with the Fund. For more information on
Product Red, see [http://www.joinred.com/], visited January 17, 2008.

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CRS-16
Table 5. Total Global Fund Contributions and Pledges,
2001-2008
($billions, current)
Paid as of % of Total Total Pledges as % of Total
03/18/2008
Paid
of 03/18/2008
Pledges
United States
$2.5
25.3%
$4.1
21.0%
European Union
$4.5
45.5%
$10.7
54.9%
European Commission
$0.7
7.1%
$1.2
6.2%
Other Countries
$1.7
17.2%
$2.7
13.8%
Non-Governmental Donors
$0.5
5.1%
$0.8
4.1%
Total
$9.9
100.0%
$19.5
100.0%
Source: Global Fund, Pledges and Contributions, March 18, 2008.
Consider Proportion of Support for the Fund to Support for
Other Bilateral Programs
The Administration has argued that any amount that Congress provides to the
Global Fund in excess of its request skews the appropriate balance of aid that the
United States should provide to the Fund and other bilateral HIV/AIDS efforts. At
a FY2005 Senate Appropriations Committee hearing in May 2004, then-Global AIDS
Coordinator Ambassador Randall Tobias argued that the “incremental difference
between what the Administration requested and what was appropriated to the Fund
is money that might have been available” for U.S. bilateral programs.50 Although
appropriations to the Fund have been increasing, the percentage of U.S. global
HIV/AIDS, TB, and malaria appropriations provided for U.S. contributions have
remained mostly level (Table 6 and Figures 1 and 2).
Fund supporters counter that appropriations made to the Fund in excess of
requested levels better reflect what the United States should provide and complement
U.S. bilateral HIV/AID programs, particularly since the Administration and the Fund
have strengthened their coordination. U.S. officials acknowledge that though the
Fund is a critical part of PEPFAR, when making appropriations, Congress should
consider the pace at which the Fund can distribute funds. The Office of the Global
AIDS Coordinator (OGAC) has cited an instance when PEFPAR used some of its
funds to purchase anti-retroviral medication (ARVs) for a Global Fund project that
faced financial delays.51
50 Testimony of Global AIDS Coordinator Ambassador Randall Tobias, in U.S. Congress,
Senate Committee Appropriations, FY2005 appropriations, May 18, 2004.
51 OGAC, The Power of Partnerships: Third Annual Report to Congress on PEPFAR,
2007, p. 74, at [http://www.pepfar.gov/documents/organization/81476.pdf], visited January
(continued...)

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CRS-17
In FY2009, the Administration requested $500 million for U.S. contributions
to the Global Fund through Foreign Operations and Labor/HHS Appropriations. This
amount accounts for almost 8% of all HIV/AIDS, TB, and malaria proposed spending
— about 5% less than FY2008 enacted levels.
Table 6. Total U.S. Global HIV/AIDS, TB, and Malaria Appropriations
($millions, current and percentages)
FY2004 FY2005
FY2006
FY2007 FY2008
FY2009
Actual
Actual
Actual
Estimate Estimate Estimate
Global Fund
$458.9
$435.0
$544.5
$724.0
$840.3
$500.0
Other Bilateral HIV/AIDS, TB, and
$1,852.6 $2,471.0
$2,856.1 $4,059.2 $5,506.7
$5,897.1
Malaria Programs
TOTAL
$2,311.5 $2,906.0
$3,400.6 $4,783.2 $6,347.0
$6,397.1
% of U.S. Global HIV/AIDS, TB, and
19.9%
15.0%
16.0%
15.1%
13.2%
7.8%
Malaria Programs Provided to the Fund
Sources: Prepared by CRS from appropriations legislation figures and interviews with OGAC staff.
Notes: Spending on U.S. global HIV/AIDS, TB, and malaria efforts that is not specified in appropriations language is
not included in this chart, such as those amounts spent on CDC’s international HIV prevention research and global
TB and malaria initiatives.
Figure 1. U.S. Contributions to the Fund and All U.S. International
HIV/AIDS, TB, and Malaria Spending
Source: Prepared by CRS from appropriations legislation figures.
51 (...continued)
17, 2008.

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CRS-18
Figure 2. U.S. Contributions to the Fund as a Percentage of All U.S.
International HIV/AIDS, TB, and Malaria Spending
Source: Prepared by CRS from appropriations legislation figures.

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CRS-19
Glossary of Abbreviations and Acronyms
3D Fund
Three Diseases Fund
ACT
Artemisinin-based Combination drug Treatment
ARV
Antiretroviral Therapy
CCM
Country Coordinating Mechanism
CGD
Center for Global Development
DOTS
Directly Observed Treatment Short-Course
EU
European Union
GAO
U.S. Government Accountability Office
ITN
Insecticide-Treated Net
MDR-TB
Multi-Drug Resistant Tuberculosis
NGO
Non-Governmental Organization
OGAC
Office of the Global AIDS Coordinator
PEPFAR
President’s Emergency Plan for AIDS Relief
PR
Principal Recipient
RCC
Rolling Continuation Channel
TB
Tuberculosis
UN
United Nations
UNDP
United Nations Development Program
VCT
Voluntary Counseling and Testing

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