The Global Fund to Fight AIDS, Tuberculosis,
and Malaria: Issues for Congress and U.S.
Contributions from FY2001 to FY2013
Tiaji Salaam-Blyther
Specialist in Global Health
Alexandra E. Kendall
Analyst in Global Health
March 9, 2012
Congressional Research Service
7-5700
www.crs.gov
R41363
CRS Report for Congress
Pr
epared for Members and Committees of Congress
The Global Fund to Fight AIDS, Tuberculosis, and Malaria
Summary
The Global Fund to Fight AIDS, Tuberculosis, and Malaria (Global Fund, or the Fund) was
established in 2002 as a public-private partnership that could provide significant financial support
for global responses to HIV/AIDS, tuberculosis (TB), and malaria. By the end of 2011, the Global
Fund had approved roughly $22.6 billion to help 150 countries fight these three diseases.
According to the Global Fund, from 2002 through 2011, it had supported AIDS treatment for 3.3
million HIV-positive people, anti-tuberculosis treatment for 8.6 million people, and 230 million
insecticide-treated nets for the prevention of malaria, saving about 7.7 million lives.
In November 2011, the Global Fund Board announced that due to inadequate resources from
donors, it would cancel its 11th round of funding, but would maintain support for existing
activities to avoid disruptions in ongoing services. The Fund also announced that it expected to
offer new funding for grants in 2014.
The United States has demonstrated strong support for the Global Fund since making a founding
pledge in 2001. U.S. officials have served on several Global Fund boards, U.S. contributions to
the Fund have surpassed those of any other country, and U.S. global HIV/AIDS, TB, and malaria
programs have been increasingly coordinated with Global Fund activities. Donors last met on
October 4, 2010, to make their pledges for the Global Fund over the next three years. There, the
United States made its first multiyear pledge to the Fund of $4 billion.
Despite rigorous debate on the overall budget and the role of foreign aid in particular, the 112th
Congress has maintained support for the Global Fund. In both FY2011 and FY2012, Congress
appropriated $1.05 billion for the Global Fund, excluding rescissions. In order to meet the $4
billion multiyear pledge made in 2010, the President’s FY2013 budget request included $1.65
billion for the Global Fund, a significant increase from previous years. As part of the budget
request, the Administration requested a transfer of $250 million from the State Department’s
FY2012 bilateral HIV/AIDS funding to the Global Fund, bringing the estimated FY2012 funding
level to $1.3 billion.
Global health advocates urge Congress to meet the President’s FY2013 request for the Fund in
order to support the sustainability of its activities and to encourage continued contributions from
other donors. Although Congress has traditionally been a strong supporter of the Fund, several
issues may affect congressional views about the Fund in the future. Such factors include the
following:
Fiscal austerity. Proposals to reduce federal spending continue to dominate foreign aid debates,
with some Members of Congress aiming to target foreign aid accounts, including those for global
health, in an attempt to balance the budget. At the same time, others argue that cutting back on the
relatively small size of foreign aid (about 1% of total budget authority) will do little to cut the
deficit, but could imperil the lives of millions.
Oversight and transparency. In early 2011, reports about misuse of Global Fund resources in
some grants ignited a debate about corruption in foreign aid in general, and in the Global Fund in
particular. Some have called for donors to withhold support for the Fund until better safeguards
are established. Others argue the Fund should not be penalized for oversight shortcomings, which
are familiar to many aid programs.
Congressional Research Service
The Global Fund to Fight AIDS, Tuberculosis, and Malaria
Role of the Global Fund in U.S. global health policy. When the Global Fund was established,
U.S. bilateral investments in HIV/AIDS, malaria, and TB were relatively small. Since then, U.S.
bilateral investments in fighting these diseases have grown significantly, particularly since the
President’s Emergency Plan for AIDS Relief (PEPFAR) and the President’s Malaria Initiative
(PMI) were launched in 2005 and 2005, respectively. Some observers advocate allocating the
majority of U.S. funds for global HIV/AIDS and malaria to bilateral programs to ensure sufficient
control and oversight of funds. On the other hand, other analysts argue that the Global Fund
represents a more efficient and flexible funding mechanism than bilateral programs and offers the
United States the ability to pool funds and share risk with other donors, which some believe is
particularly important given the challenges of the current fiscal environment.
This report provides background information on the Global Fund, outlines U.S. funding for the
Fund, discusses changes the Global Fund has made to improve the efficiency of its programs and
address allegations of corruption, and analyzes issues Congress might consider as it debates the
appropriate level of U.S support to provide the Fund.
Congressional Research Service
The Global Fund to Fight AIDS, Tuberculosis, and Malaria
Contents
Background...................................................................................................................................... 1
Recent Developments ...................................................................................................................... 2
Global Fund Structure and Performance-Based Funding Process ................................................... 3
U.S. Support of the Global Fund ..................................................................................................... 5
Key Developments within the Global Fund..................................................................................... 7
Evaluating the Global Fund....................................................................................................... 7
Addressing Corruption .............................................................................................................. 9
Reforming Financial Eligibility and Recipient Country Contribution Requirements ............. 12
Simplifying Reporting Requirements...................................................................................... 13
Enhancing Civil Society Participation..................................................................................... 14
Applying Debt Payments to Global Fund Grants.................................................................... 15
Expanding Access to Improved Anti-Malarial Medication ..................................................... 15
Strengthening Supply Chain Systems...................................................................................... 15
Issues for Congress ........................................................................................................................ 16
FY2013 Budget Debate ........................................................................................................... 16
U.S. Leadership in Combating HIV/AIDS, TB, and Malaria.................................................. 18
U.S. Spending Ceilings ..................................................................................................... 18
U.S. Share of Donor Contributions ................................................................................... 18
Coordinating the Global Fund with U.S. Global Health Programs ......................................... 19
Transparency, Monitoring, and Evaluation.............................................................................. 20
Conclusion ..................................................................................................................................... 22
Figures
Figure 1. Performance-Based Funding at the Global Fund ............................................................. 4
Tables
Table 1. Total Global Fund Contributions and Pledges ................................................................... 6
Table 2. U.S. Contributions to the Global Fund, FY2001-FY2013 ................................................. 7
Table 3. U.S. Global HIV/AIDS, TB, and Malaria Funding, FY2001-FY2013 ............................ 17
Appendixes
Appendix. Acronyms and Initialisms............................................................................................. 25
Contacts
Author Contact Information........................................................................................................... 26
Congressional Research Service
The Global Fund to Fight AIDS, Tuberculosis, and Malaria
Background
The Global Fund to Fight AIDS, Tuberculosis, and Malaria (Global Fund, or the Fund) was
established in January 2002 as a public-private partnership to provide significant financial support
for global responses to HIV/AIDS, tuberculosis (TB), and malaria. At that time, health experts
and advocates were particularly concerned about the rapid spread of HIV/AIDS around the world,
the massive numbers of deaths that resulted from HIV infection, and limited access to treatments
against the three diseases, particularly HIV/AIDS. Health specialists also noted that co-infection
seemed to hasten the rate at which people succumbed to any of the three diseases. Despite
expanded access to care and treatment over the past decade, HIV/AIDS, TB, and malaria continue
to be three of the world’s leading causes of morbidity and mortality around the world.
The Global Fund was developed to be an innovative financing mechanism that would attract
additional financial resources for the global fight against the three diseases in developing
countries. It was never intended to directly implement related programs.1 Several distinguishing
characteristics purported to make this new entity a unique one, including
• with no implementation mandate, the Global Fund would have relatively low
overhead expenses;
• rigorous monitoring and evaluation requirements could ensure performance-
based funding;
• transparency in decision-making, including grant funding, could support
accountability; and
• partnerships among governments, the private sector, and civil society would be
created and expanded, due in part to the grant development process.
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 five representatives from civil society and the private sector, including one
representative of a non-governmental organization (NGO) from a developing country, one
representative of an NGO from a developed country, one representative of the private sector, one
representative of a private foundation, and one representative of an NGO who is a person living
with HIV/AIDS or from a community living with TB or malaria.2 The United States holds a
permanent Board seat.
In 2001 and 2002, donors pledged $947.2 million to launch the Global Fund. In its first round of
considering grants, the Global Fund committed to support 58 programs in 43 countries,
amounting to $616 million for the first two years of implementation. In December 2010, the
Global Fund Board announced that it would support the 10th round of grant proposals, valued at
more than $1.7 billion for the first two years of project implementation. Over five years, the
Global Fund could expend some $4.7 billion on these grants if performance requirements are met
1 See Global Fund, The Framework Document of the Global Fund to Fight AIDS, Tuberculosis, and Malaria, 2001,
http://www.theglobalfund.org/documents/TGF_Framework.pdf.
2 For background information on the Global Fund and its structure, see CRS Report RL31712, The Global Fund to
Fight AIDS, Tuberculosis, and Malaria: Background, by Tiaji Salaam-Blyther.
Congressional Research Service
1
The Global Fund to Fight AIDS, Tuberculosis, and Malaria
and resources are available.3 By the end of 2011, the Global Fund had approved roughly $22.6
billion to help 150 countries fight HIV/AIDS, TB, and malaria. As of mid-February, 2012, almost
70% of all approved funding had been disbursed, amounting to over $15 billion.4
Since its establishment, the Global Fund has become one of the world’s largest donors supporting
HIV/AIDS, TB, and malaria programs in developing countries. In 2009, the Fund accounted for
21% of global spending on HIV/AIDS, 65% of spending on TB in the 22 high-burden countries,
and 65% of global malaria funding.5 The Global Fund estimated that by the end of 2011, the
programs it supports had saved over 7.7 million lives. Grants supported by the Global Fund have
reportedly provided
• AIDS treatment for 3.3 million HIV-positive people,
• anti-tuberculosis treatment for 8.6 million people, and
• 230 million insecticide-treated nets for the prevention of malaria.6
Recent Developments
In November 2011, the Global Fund Board announced that due inadequate resources from donors,
it would cancel its 11th round of funding. The Global Fund expects to offer new funding for grants
in 2014. Until then, in order to avoid any disruptions in ongoing services, the Board has instituted
a Transitional Funding Mechanism for programs that
• face disruption of essential services, currently supported by the Global Fund, and
• for which no alternative sources of funding can be secured.7
At the November 2011 board meeting, the Global Fund Board adopted a new five-year strategy
for 2012-2016, which supports more aggressive management and oversight of grants, encourages
more flexibility in tailoring activities to specific country’s needs, and embraces more country
ownership of programs through increased involvement of country governments (see Text Box).8
The Board also approved the Global Fund’s “Consolidated Transformation Plan,”9 developed to
improve Global Fund governance, operations, and fiduciary controls, as recommended by a report
released in September 2011 by the High-Level Independent Review Panel on Fiduciary Controls
and Oversight Mechanisms of the Global Fund.10
3 Global Fund, Report of the Technical Review Panel and the Secretariat on Round 10 Proposals, December 13-15,
2010, http://www.theglobalfund.org/documents/board/22/BM22_13TRPRound10_Report_en.pdf.
4 Global Fund website, Grant Portfolio, accessed on February 13, 2012, http://portfolio.theglobalfund.org/.
5 Global Fund, Making a Difference: Global Fund Results Report, May 2011, p. 4, http://www.theglobalfund.org/
documents/publications/progress_reports/Publication_2011Results_Report_en.pdf.
6 Global Fund, “Global Fund Welcomes U.S. Secretary of State Hillary Clinton’s Support for Global Fund,” press
release, November 9, 2011, http://www.theglobalfund.org/fr/mediacenter/pressreleases/2011-11-09; and Global Fund,
“Global Fund Supported Programs See Strong Results Amid Funding Challenges,” press release, November 30, 2011,
http://www.theglobalfund.org/en/mediacenter/pressreleases/2011-11-30.
7 Global Fund, Transitional Funding Mechanism (TFM) Information Note, December 12, 2011.
8 Global Fund, The Global Fund Strategy 2012-2016: Investing for Impact, November 2011.
9 Global Fund, Consolidated Transformation Plan, Twenty-Fifth Board Meeting, November 21-22, 2011.
10 Turning the Page from Emergency to Sustainability, The Final Report of the High-Level Independent Review Panel
(continued...)
Congressional Research Service
2
The Global Fund to Fight AIDS, Tuberculosis, and Malaria
In January 2012, the Executive Director of the Global Fund announced his decision to step down.
In response, the Global Fund created a new position of General Manager, charged with
overseeing the implementation of the Consolidated Transformation Plan.
Highlights of The Global Fund Strategy 2012-2016: Investing for Impact
The 2012-2016 Global Fund strategy outlines how the Global Fund will build on past successes, address new
challenges, and better “invest for impact.” The strategy sets new targets of saving 10 million lives and preventing 140-
180 million new infections from HIV/AIDS, TB, and malaria between 2012 and 2016. To reach these goals, the
strategy outlines five strategic objectives:
1. Invest more strategical y in areas with high potential for impact and strong value for money, and fund based on
countries’ national strategies.
2. Evolve the funding model to provide funding in a more proactive, flexible, predictable, and effective way.
3. Actively support grant implementation success through more active grant management and better engagement with
partners.
4. Promote and protect human rights in the context of the three diseases.
5. Sustains the gains, mobilize resources—by increasing the sustainability of supported programs and attracting
additional funding from current and new sources.
Global Fund Structure and Performance-Based
Funding Process
The Global Fund was established to extend life-saving measures to the world’s poorest. In many
of these countries, including post-conflict and fragile states, implementing organizations have
weak programmatic and oversight capacity. In light of these conditions, the Global Fund
developed a performance-based system that has served as a cornerstone of its operations since the
effort was launched. The system relies on seven main actors, including the
• Country Coordinating Mechanism (CCM), a country-level partnership of
stakeholders, responsible for developing and submitting grant proposals,
nominating Principal Recipients, and providing oversight to grant
implementation.
• Principal Recipient, the designated in-country organizations chosen by the
CCM to receive funding from the Fund, implement programs, and distribute
funds to sub-recipients.
• Sub-Recipient, an organization contracted by the Principal Recipient of the grant
to assist in implementing program activities.
• Local Fund Agent, a contracted entity that provides independent and routine
monitoring and financial audits of the Global Fund disbursements and activities.
(...continued)
on Fiduciary Controls and Oversight Mechanisms of the Global Fund to Fight AIDS, Tuberculosis and Malaria,
September 19, 2011.
Congressional Research Service
3
The Global Fund to Fight AIDS, Tuberculosis, and Malaria
• Secretariat, responsible for day-to-day operations, including mobilizing
resources, overseeing grant implementation, providing support to the Board, and
reporting on the Fund’s activities to the Board and the public.
• Technical Review Board, an independent panel of experts in health and
development who review eligible grants proposals for technical merit.
• The Global Fund Board, responsible for overall governance of the Fund.
Through the performance-based system, the Global Fund has integrated grant oversight at various
levels, including
• internal control mechanisms instituted by Principal Recipients;
• independent in-country verification and oversight mechanisms established by
Local Fund Agents;
• annual audits of principal and sub-recipients by an external, independent body;
• monitoring of grant implementation by the Secretariat;
• audits and investigations conducted by the Office of the Inspector General; and11
• oversight provided by Global Fund Board and its committees.
Upon approving grant proposals, the Global Fund commits to providing sufficient resources to
finance the first two years of the program. In order to receive subsequent financing, programs
must demonstrate results against performance targets that are spelled out in the grant proposals
(Figure 1). 12
Figure 1. Performance-Based Funding at the Global Fund
Source: Global Fund, Performance-Based Funding at the Global Fund, http://www.theglobalfund.org/en/
performancebasedfunding/grantlifecycle/, February 2012.
11 The Office of the Inspector General was established by the Board of the Global Fund to Fight AIDS, Tuberculosis,
and Malaria in July 2005. The Office of the Inspector General operates as an independent unit of the Global Fund,
reporting directly to the Board. The Office of the Inspector General provides the Global Fund with independent and
objective assurance over the design and effectiveness of controls in place to manage the key risks impacting the Global
Fund’s programs and operations.
12 Unless otherwise indicated, information in this section was taken from Global Fund, Performance-Based Funding at
the Global Fund, November 2009, http://www.theglobalfund.org/documents/performance/Performance-
based_Funding_brochure.pdf, and the Global Fund website, Performance-Based Funding at the Global Fund,
http://www.theglobalfund.org/en/performancebasedfunding/grantlifecycle/, February 2012.
Congressional Research Service
4
The Global Fund to Fight AIDS, Tuberculosis, and Malaria
Over the lifetime of a grant, performance-based indicators are developed and monitored in four
key stages:
1. Proposal development. Applicants develop and submit proposals to the Global
Fund Secretariat that include output, outcome and impact indicators, and targets
defined by the countries themselves. If the proposal is approved, these form the
basis for measuring the performance of a grant.
2. Grant negotiation. Upon approval, the Global Fund negotiates the terms of
grant agreements, legally binding contracts that clearly indicate time-bound
targets to measure the performance of the grants. At this stage, monitoring and
evaluation systems are also assessed. The Global Fund recommends that 5%-10%
of grant budgets are used for monitoring and evaluation.
3. Performance-based disbursements. Over the course of a grant’s life cycle, the
Principal Recipient reports regularly to the Global Fund on results, expenditures,
and any deviations from or corrective actions to program activities. The Local
Fund Agent, an independent contractor based in the country, verifies the Principal
Recipient’s programmatic and financial reports and makes recommendations to
the Global Fund on the amount to be disbursed for the next period of
implementation. The Secretariat evaluates the overall performance of the grant,
assigns a rating, and decides on the next disbursement amount. Lack of progress
triggers a request by the Secretariat for corrective action and may also result in
reduced disbursements.
4. Grant renewal. Toward the end of Phase 1 (first two years of implementation),
the Global Fund evaluates each grant to ensure that funding is managed and spent
efficiently and programs are achieving expected results. At this point, the Fund
decides whether to continue funding grants, reduce funding, direct investments in
systems strengthening, or stop funding altogether.13 Grants demonstrating
potential for significant and sustainable impact can receive additional funding for
up to six years through the “Rolling Continuation Channel.”
Consistent with its performance-based model, the Global Fund reports that it has terminated,
suspended, or discontinued grants or replaced principal recipients in cases of uncorrected
inadequate performance.
U.S. Support of the Global Fund
Since the Global Fund was established, the United States has been a strong supporter of the
organization. Officials from the Department of State, the United States Agency for International
Development (USAID), and the United States Department of Health and Human Services (HHS)
were all engaged in the creation of the Global Fund, and former Secretary of HHS Tommy
Thompson was later elected as the second Chair of the Global Fund’s Board. At present, U.S.
officials from various agencies sit on several Global Fund Boards.
13 If a grant is terminated, the Global Fund ensures that lifesaving treatments are continuously dispersed for up to 21
months under the Global Fund’s Continuation of Services policy. This policy was invoked to give countries sufficient
time to find replacement funding and to avoid treatment interruptions, which can lead to death or drug resistance.
Congressional Research Service
5
The Global Fund to Fight AIDS, Tuberculosis, and Malaria
The Obama Administration has signaled its intention to maintain that support. In a March 2011
statement14 and at a House hearing, the U.S. Global AIDS Coordinator, Ambassador Eric Goosby,
linked the success of U.S. bilateral HIV/AIDS programs under the President’s Emergency Plan
for AIDS Relief (PEPFAR) to the continuance of the Global Fund:
Our dependency on the Global Fund is a real one.... The Global Fund creates a platform and
conduit for other countries who do not have bilateral programs to contribute to the care and
prevention and treatment dollars for HIV/AIDS as well as TB and malaria.... We plan
together and look at how we can converge in any given country to where Global Fund is
doing one thing, we’re doing something that is complementary or expansive or other than
they are doing so our programmatic imprint is amplified in our ability to impact the diseases
that both the Global Fund focuses on as well as the HIV/AIDS and TB. Without them, our
footprint and impact would diminish.15
In the Fund’s first budget period, U.S. donations accounted for 33% of all contributions to the
Fund, with the United States having provided $300 million of the $894.3 million contributed in
the 2001-2002 budget period. Since then, the United States has remained a key contributor to the
Fund (Table 1). On October 4, 2010, when Global Fund donors met to make 2011-2013 pledges,
the United States made its first multiyear pledge to the Fund of $4 billion.
Table 1. Total Global Fund Contributions and Pledges
(current $ U.S. millions and percentages)
Paid as of
Total Pledges as of
% of Total
Contributor
01/31/2012
% of Total Paid
01/31/2012
Pledges
United States
6,079.9
28.0% 9,506.9
31.0%
European Union Countries
9,763.7
44.9% 12,834.8 41.8%
European Commission
1,351.3
6.2% 1,634.1 5.3%
Other Countries
3,528.1
16.2% 5,000.2
16.3%
Non-Governmental Donors
1,010.2
4.6% 1,700.0 5.5%
Total 21,736.7
100.0% 30,676.0
100.0%
Source: Global Fund, Pledges and Contributions, See http://www.theglobalfund.org/en/about/donors/.
Congress has historically appropriated U.S. contributions to the Global Fund through two
appropriations bills: State, Foreign Operations; and Labor, Health and Human Services, and
Education. The conference reports (H.Rept. 112-331) accompanying the FY2012 Consolidated
Appropriations Act (P.L. 112-74) specified that appropriations for the Global Fund would be
funded in whole through Division I (Department of State, Foreign Operations, and Related
Programs.) During the Bush Administration, Congress consistently exceeded budgetary requests
for the Global Fund and appropriated roughly $3.6 billion for the Fund from FY2001 to FY2008.
Congressional support for the Global Fund has continued through the Obama Administration,
with appropriations exceeding requested levels each year, except in FY2012 (Table 2). Despite
14 See Department of State, “Statement by Ambassador Eric Goosby, U.S. Global AIDS Coordinator, U.S. Department
of State, on the Appointment of the Global Fund Independent Review Panel Co-Chairs,” press release, March 16, 2011,
http://www.pepfar.gov/press/releases/2011/158413.htm.
15 U.S. Congress, House Committee on Appropriations, Subcommittee on State, Foreign Operations, and Related
Programs, FY2012, 112th Cong., 1st sess., March 31, 2011.
Congressional Research Service
6
The Global Fund to Fight AIDS, Tuberculosis, and Malaria
this support, appropriations for the Global Fund have remained constant since FY2010. In
FY2011 and FY2012, appropriations for the Fund remained at $1.05 billion.
Table 2. U.S. Contributions to the Global Fund, FY2001-FY2013
(current U.S. $ millions)
FY2001-
FY2003
FY2004 FY2005 FY2006 FY2007
FY2008
FY2009
FY2010
FY2011
FY2012
FY2013
Actual
Actual
Actual
Actual
Actual
Actual
Actual
Actual
Actual
Estimate Request
Foreign
398.4 397.6 248.0 445.5 625.0 545.5 700.0 750.0 748.5 1,300.0 1,650.0
Operations
Labor/HHS
224.0 149.1 99.2 99.0 99.0 294.8 300.0 300.0 297.3 0.0
0.0
FY2004
n/a (87.8)
87.8
n/a
n/a
n/a n/a n/a n/a n/a n/a
Carryover
Total 622.4 458.9 435.0 544.5 724.0 840.3 1,000.0 1,050.0 1,045.8
1,300.0 1,650.0
Source: CRS analysis of appropriations legislation and congressional budget justifications.
Notes: As of February 14, 2012, the Global Fund reports having received $6.0 billion of the $6.7 billion the
United States pledged to provide through FY2011. According to the Fund, the United States pledged to pay $2.7
billion in 2001-2007, $808.2 million in 2008, $1.0 billion in 2009, $1.05 billion in 2010, and $1.05 bil ion in 2011.
See http://www.theglobalfund.org/documents/pledges_contributions.xls.
The $87.8 million deducted from the FY2004 total reflects language in the U.S. Leadership Against HIV/AIDS,
Tuberculosis, and Malaria Act (P.L. 108-25) that prohibited U.S. contributions to the Fund from exceeding 33%
of contributions from al sources (discussed below). Through the FY2005 Consolidated Appropriations (P.L. 108-
447), Congress replaced the $87.8 million and added it to the FY2005 contribution.
In order to meet his multiyear pledge to the Fund, made in 2010, as part of the FY2013 budget
request, President Obama requests that the Fund receive an addition $250 million in FY2012
through a transfer of funds from the State Department’s bilateral HIV/AIDS funding from that
year. Likewise, despite proposing reductions for most bilateral global health programs, the
Administration requests $1.65 billion for the Global Fund in FY2013, some 57% higher than
FY2012-enacted levels, and 27% higher than FY2012 estimated levels, which take into account
the $250 million transfer.
Key Developments within the Global Fund
A founding principle of the Global Fund is to consistently evaluate and adapt its operations,
architecture, and grants according to changing needs and circumstances. The section below
highlights key developments within the Global Fund that have followed independent evaluations,
feedback from various stakeholders, and discussions about misuse of Global Fund resources.
Evaluating the Global Fund
The Global Fund’s Board decided at its sixth meeting in October 2003 to hire an independent
team of experts to conduct a five-year evaluation of its grants. The purpose was to ascertain the
extent to which the Global Fund had reached its performance goals and adhered to its founding
principles. In November 2006, the Board approved the launch of the five-year evaluation, which
was overseen by Board-appointed public health experts, known as the Technical Evaluation
Congressional Research Service
7
The Global Fund to Fight AIDS, Tuberculosis, and Malaria
Reference Group (TERG), and conducted between April 2007 and October 2008 by a separate
team of independent consultants who assessed three key areas:
• the efficiency and effectiveness of the Global Fund’s structure,
• the effectiveness and impact of the Global Fund’s partnership system, and
• the impact of Global Fund grants on the three diseases.
It is important to note that independent expert teams have conducted eight different evaluations
since the Fund was established, all of which have inspired reforms. However, the five-year
evaluation provided the first comprehensive assessment of the Global Fund.16 In March 2009, the
team of evaluators published its overall assessments and recommendations, which focused on
• improving the sustainability of Global Fund grants;
• sustaining spending by recipient countries on HIV/AIDS, TB, and malaria in
light of increased donor spending;
• strengthening health systems;
• improving monitoring and evaluation indicators; and
• enhancing donor coordination.
Since the release of the five-year evaluation report in 2009, the Global Fund has instituted several
changes based on its recommendations, and other recommendations made following additional
external reviews and internal assessments. In September 2010, the Secretariat consolidated those
and previously launched initiatives into a reform agenda for a more efficient and effective Global
Fund.17 At the Global Fund’s 22nd Board Meeting in December 2010, the Board approved the
reform agenda and established a Comprehensive Reform Working Group (CRWG) to further
develop ongoing efforts and define a more comprehensive plan for Global Fund reform. At the
Global Fund Board’s 23rd Meeting, held in May 2011, the Board approved a series of measures
recommended by the reform working group, including
• strengthening the accountability framework—enhancing fiduciary control and
risk management, improving the tailoring of risk management approaches to
local contexts, and applying stronger standards for implementers;
• strengthening partnerships—at the country level, introducing formal
agreements on technical and management assistance and at the global level,
better clarifying partnership roles;
16 Evaluations overseen by the TERG include (1) Assessment of the Country Coordinating Mechanisms (CCMs); (2)
Assessment of the Proposal Development and Review Process; (3) 360 Degree Stakeholder Assessment; (4) Global
Fund Portfolio Review; (5) Evaluation of the Local Fund Agent System; (6) Five Year Evaluation Study Area 1: Global
Fund Organizational Efficiency & Effectiveness; (7) Five Year Evaluation Study Area 2: Global Fund Partner
Environment; and (8) Five Year Evaluation Study Area 3: Health Impact of Scaling Up Against HIV, TB & Malaria;
Links to all evaluation materials for the studies overseen by the TERG can be found at http://www.theglobalfund.org/
en/terg/.
17 For further details on the reforms, see Global Fund, An Agenda for a More Efficient and Effective Global Fund,
September 2010, http://www.theglobalfund.org/documents/replenishment/2010/.
Congressional Research Service
8
The Global Fund to Fight AIDS, Tuberculosis, and Malaria
• enhancing value for money—leveraging the Global Fund’s market-shaping role
to improve price, quality, and availability of key health products, and encourage
reprogramming of funding toward more cost-effective interventions;
• improving governance—reviewing the Global Fund Board’s governance
structures and operating procedures to ensure more efficient and effective
decision making; and
• adapting the Global Fund business model—moving from one-size-fits-all
solutions to better take into account the grant performance record,
implementation risks, and the extent of Global Fund support in countries relative
to other health financing.
These reforms are each reaffirmed in the 2012-2016 Global Fund Strategy.
Since 2009, the Global Fund has also been developing a common platform for funding and
planning programs that strengthen health systems with the Global Alliance for Vaccines and
Immunization (GAVI) and World Bank.18 The purpose of this new platform is to develop (1)
common funding policies for health systems strengthening, (2) common country eligibility
criteria, (3) joint review mechanisms for proposals and program oversight, (4) harmonization of
technical support, and (5) a common framework for measuring performance.19 Some of the
expected benefits of the joint platform include reduced transaction costs, increased global focus
on health systems strengthening, enhanced predictability of donor funding, and improved
harmonization and alignment of funding and programming for health systems strengthening.20
This platform will be implemented starting in 2014.
Addressing Corruption
On January 23, 2011, the Associated Press released an article that discussed instances of
corruption discovered by the Global Fund’s Inspector General’s Office.21 The article focused on
allegations of corruption and fraud in 4 of the 145 countries that receive Global Fund grants:
Mali, Djibouti, Mauritania, and Zambia. Shortly thereafter, both critics and supporters of the
Global Fund released statements about corruption in foreign aid in general and the Global Fund’s
response to corruption in particular.22 Although this is not the first time the Global Fund has
uncovered misuse of funds, these recent examples may have increased scrutiny of U.S. support to
the Fund, especially in an austere budget environment.
18 Global Fund, Making a Difference: Global Fund Results Report, May 2011, p. 77.
19 World Bank, GAVI, Global Fund and WHO, “Work Plan for 2010 Health Systems Funding Platform,” March 2,
2010, http://siteresources.worldbank.org/INTHSD/Resources/topics/415176-1251914777461/
HealthSystemsFundignPlatformWorkPlanMarch22010.pdf.
20 Global Fund, Global Fund 2010 Innovation and Impact, Progress Report 2010, p. 88.
21 John Heilprin, “Fraud Plagues Global Health Fund Backed by Bono, Others,” Associated Press, January 23, 2011,
http://www.msnbc.msn.com/id/41221202/ns/health-health_care/.
22 Kaiser Family Foundation, AP Reports On Global Fund Grant Money Lost To Corruption, Global Fund Responds,
January 25, 2011, http://globalhealth.kff.org/Daily-Reports/2011/January/25/GH-012511-Global-Fund.aspx; Roger
Bate, Transparency and the Global Fund’s Healthy Crisis, American Enterprise Institute for Public Policy Research,
February 3, 2011, http://www.aei.org/speech/100188; and Michael Gerson, “Putting Fraud Into Context,” Washington
Post, February 4, 2011, http://www.washingtonpost.com/wp-dyn/content/article/2011/02/03/AR2011020305176.html.
Congressional Research Service
9
The Global Fund to Fight AIDS, Tuberculosis, and Malaria
According to the Global Fund, it has a zero-tolerance policy for corruption and has taken several
actions to address instances of fraud, including freezing disbursements, expenditures, and
activities until measures are taken to account for funds; recovering misused funds; and changing
principal recipients.23 When the situation merits it, grants are terminated, suspended, or placed
under the Global Fund’s Additional Safeguard policies.
On February 4, 2011, the Global Fund announced that it had instituted several measures “to
reinforce its financial safeguards and increase its capacity to prevent and detect fraud and misuse
in its grants, many of which are already underway.”24 These measures included
• expanding the mandate of firms that monitor expenditure in countries in order to
enhance fraud prevention and detection;
• strengthening the role of country coordinating bodies in grant oversight;
• heightening scrutiny of activities at higher risk of fraud, such as training;
• redirecting a proportion of all grants to assess and strengthen financial controls at
country levels;
• increasing the number of the Fund’s staff responsible for financial management;
and
• doubling the budget of the Fund’s independent Inspector General.25
In April 2011, the Senate Foreign Relations Committee released a minority report offering
background information on the Global Fund and a discussion of responses taken by the Global
Fund to address general corruption issues as well as this specific case.26 The report included a
number of recommendations to strengthen the oversight of Global Fund procurement procedures
(see “Transparency, Monitoring, and Evaluation”). The report also noted several steps that the
Fund has taken toward preventing financial mismanagement, including
23 For more information, see Global Fund, Results With Integrity: The Global Fund’s Response to Fraud, April 2011,
http://www.theglobalfund.org/documents/core/whitepapers/
Core_ResultsWithIntegrityResponseToFraud_WhitePaper_en.pdf.
24 Global Fund, “Statement by the Board Chair and Vice-Chair,” press release, February 8, 2011,
http://www.theglobalfund.org/en/announcements/?an=an_110209.
25 Critics of Global Fund’s fiduciary practices have also raised questions about whether the United Nations
Development Program (UNDP) had established adequate protections against corruption. UNDP oversees roughly 12%
of Global Fund grants, primarily in countries emerging from natural disasters, conflicts, or political crises. Detractors
were particularly concerned about allegations that the data UNDP submitted was not comprehensive enough and
prevented Global Fund’s auditors from conducting thorough financial assessments. UNDP announced on February 4,
2011, that it had enhanced its fiduciary mechanisms and that it had taken several steps to strengthen the oversight of its
funds, including recruiting dedicated and specialized fulltime investigators to respond to credible allegations of fraud or
corruption in UNDP-managed Global Fund grants; developing formal “capacity development” initiatives in all
countries where UNDP manages Global Fund grants; allowing the Global Fund to access UNDP audit reports of Global
Fund projects, a privilege currently restricted to UN Member States; and signing a Memorandum of Understanding
between UNDP’s Office of Audit and Investigation and the Global Fund’s Office of the Inspector-General to
strengthen co-operation and information-sharing on investigations into fraud and corruption.
26 U.S. Congress, Senate Committee on Foreign Relations, Fraud and Abuse of Global Fund Investments at Risk
Without Greater Transparency, committee print, A Minority Staff Report, 112th Cong., 1st sess., April 5, 2011, S. Prt.
112-17.
Congressional Research Service
10
The Global Fund to Fight AIDS, Tuberculosis, and Malaria
• increasing the staffing and budgetary support for the Office of the Inspector
General from 19 staff with a 2009 budget of $6.67 million to 30 staff positions
with a proposed budget of $19.79 million for 2011; and
• establishing the Global Fund Comprehensive Reform Working Group, which is
tasked with writing a report that recommends financial reforms. The Working
Group consists of the Chair and Vice Chair of the Board of the Global Fund, the
Executive Director of the Secretariat, three donor representatives (including the
United States), and three representatives from recipient countries.
Also in April 2011, the Global Fund released a report that outlined the steps the Global Fund has
taken to safeguard against misuse of funds.27 According to the report, the Global Fund uncovered
the misuse of funds in 11 countries totaling $44.2 million. About 63% of these misused funds
were identified in four countries: Djibouti, Mali, Mauritania, and Zambia. An October 2011 report
from the Office of the Inspector General found evidence of further misuse of funds in Nigeria.
The Global Fund is reportedly seeking restitution of misused funds and has submitted evidence in
support of criminal investigations in Mali, Mauritania, and Zambia.
At the Global Fund’s May 2011 Board Meeting, the Fund’s Office of the Inspector General (OIG)
raised a number of issues the Board might consider, including the following:
• Reconsidering the relevance of the Global Fund’s model, given the
environment in which the Global Fund is often operating. The OIG proposed that
the Fund reconsider whether to remain just a financing institution, reliant upon
national ownership. If the Board decides to retain that model, the OIG
recommends identifying other options to mitigate the risks of fraud and financial
misappropriation that are currently inadequately addressed.
• Making risk management part and parcel of the grant making process.
• Reevaluating the Key Performance Indicator (KPI) structure. The OIG
asserted that the KPI structure’s emphasis on speed and quantity of
disbursements often compromises quality and adequate consideration of risks.
Further, the OIG recommended that the Board revisit the concept as an
appropriate mechanism for measuring the performance of Fund Portfolio
Managers and Secretariat staff. At the same time, the OIC urged the Board to
consider developing tools to measure the delivery of quality products and the
effective use of resources.
• Establishing minimum acceptable capacity standards to assess Principal
Recipients and develop a system to hold Principal Recipients accountable when
things go wrong.
• Enforcing the policies and guidelines that have not been implemented at
country level.
• Making the Country Coordinating Mechanisms more effective in their
oversight duties and ensuring that they are without conflicts of interest.28
27 For more information, see Global Fund, Results With Integrity: The Global Fund’s Response to Fraud, April 2011.
28 Global Fund, The Office of the Inspector General Progress Report for November 2010-March 2011, 23rd Board
Meeting, May 11-12, 2011, pp. 8-9, http://www.theglobalfund.org/documents/board/23/.
Congressional Research Service
11
The Global Fund to Fight AIDS, Tuberculosis, and Malaria
Further, on June 23, 2011, the Global Fund announced that it had signed an agreement with the
International Aid Transparency Initiative, a multilateral effort (including donors, countries, and
civil society organizations) to publicly disclose aid data in a standardized, timely approach.29
In September 2011, the High-Level Independent Review Panel on Fiduciary Controls and
Oversight Mechanisms of the Global Fund released a report that recommends improving financial
and Board oversight, simplifying the grant application process, and putting in place better
mitigation strategies to identify, assess, and manage risk.30 In November 2011, the Global Fund
Board adopted the report and its recommendations, and released the “Consolidated
Transformation Plan,” which outlines steps toward implementing the recommended reforms,
including
• improved investment of Global Fund resources toward the highest-impact
countries, interventions, and populations;
• increased efficiency and value for money in the use of Global Fund resources;
• more effective identification and management of risks;
• more efficient and flexible management of grants in a consistent, quality-assured
manner;
• enhanced structure and management of the Secretariat and the Board for optimal
performance;
• enhanced engagement of partners at global, regional and country levels, to
support grant performance; and
• increased predictability and sustainability of funding.31
Reforming Financial Eligibility and Recipient Country
Contribution Requirements
At the May 2011 Board meeting, the Board approved the new Eligibility Counterpart Financing
and Prioritization Policy, which affects the way Global Fund resources are provided.32 By
implementing this new policy, the Board agreed to divide Fund resources into two accounts: the
General Funding Pool and the Targeted Funding Pool. Broadly speaking, the General Funding
Pool is intended for countries with large disease burdens and limited domestic resources. Roughly
29 Global Fund, Global Fund Signs International Aid Transparency Initiative, press release, June 23, 2011,
http://www.theglobalfund.org/en/pressreleases/?pr=an_110623. For more information on IATI, see
http://www.aidtransparency.net/.
30 The High-Level Independent Review Panel on Fiduciary Controls and Oversight Mechanisms of the Global Fund to
Fight AIDS, Tuberculosis, and Malaria, Turning the Page from Emergency to Sustainability, September 19, 2011,
http://www.theglobalfund.org/en/highlevelpanel/report/.
31 Global Fund, Consolidated Transformation Plan, November 21, 2011, http://www.theglobalfund.org/en/board/
meetings/twentyfifth/.
32 Information about the new financing policies were compiled by CRS from Global Fund, Report of the 22nd Board
Meeting, presented at the 23rd Board Meeting, May 11-12, 2011, p. 35, http://www.theglobalfund.org/documents/board/
23/BM23_02TwentySecondBoardMeeting_Report_en.pdf, and Global Fund, Policy on Eligibility Criteria,
Counterpart Financing Requirements, and Prioritization of Proposals for Funding from the Global Fund, presented at
the 23rd Board Meeting, May 11-12, 2011, http://www.theglobalfund.org/documents/board/23/
BM23_14PICPSCJEligibilityAttachment1_Policy_en.pdf.
Congressional Research Service
12
The Global Fund to Fight AIDS, Tuberculosis, and Malaria
90% of Global Fund resources are available through the General Funding Pool. The Targeted
Funding Pool builds on the dedicated reserve for most-at-risk populations (MARPs) created in
round 10, and now applies to all three diseases (but not for cross-cutting HSS proposals).
Proposals in the Targeted Funding Pool will also have a predefined budget ceiling: $5 million for
the first two years and $12.5 million for a five-year proposal. When submitting a grant proposal,
countries must clearly indicate for which funding pool they are applying. Upper middle-income
countries must be able to demonstrate an extreme disease burden to be eligible for both pools, and
the programs must be focused on MARPs and/or highest impact interventions; those with a high
disease burden are restricted to the Targeted Funding Pool.
In addition, the new policy provides Counterpart Financing requirements that replace the old Cost
Sharing Policy, which applied only to middle-income countries. This new policy requires all
recipient countries, regardless of income level, to show that the government contribution to
relevant national disease programs and to overall health is increasing each year, and to report on
these contributions annually. The minimum contribution each country must provide toward
addressing the related disease follows the following income criteria, with lower middle-income
countries split into two groups:
• low-income countries: 5%
• lower lower-middle-income countries: 20%
• upper lower-middle-income countries: 40%
• upper middle-income countries: 60%
The Global Fund Strategy 2012-2016 further articulated the Fund’s intention to focus on the
highest-impact countries. The Strategy states that “funding decisions are guided by considerations
of potential for impact, including the global distribution of disease and key specifics of individual
country situations ... for the relevant disease.”33 In November 2011, the Global Fund Board also
mandated a revised application and approval process for grant renewals whereby any G-20 upper
middle-income country with less than an extreme disease burden would no longer be eligible for
renewal of grants.34
Simplifying Reporting Requirements
In 2008, at its 18th meeting, the Global Fund Board decided to revise its funding architecture to
simplify its business model and harmonize its grants with those supported by recipient countries
and other donors. One strategy that the Board approved was to begin funding grants through a
Single Stream Agreement (SSA), whereby principal recipients will report on its activities by
disease rather than by round.35 In other words, if a PR has multiple grant agreements for a
disease, the grants will be consolidated into a single agreement and the PR will report on its
progress through one submission.36 The Fund hopes that the strategy will reduce the reporting
33 Global Fund, The Global Fund Strategy 2012-2016: Investing for Impact, November 2011,
http://www.theglobalfund.org/en/about/strategy/.
34 Global Fund, Twenty-Fifth Board Meeting Decision Points, November 21-22, 2011, http://www.theglobalfund.org/
en/board/meetings/twentyfifth/.
35 Global Fund, Twentieth Board Meeting Decision Points, November 9-11, 2009, http://www1.theglobalfund.org/
documents/board/20/GF-BM20-DecisionPoints_en.pdf.
36 Global Fund, New Grant Architecture Concept Note, March 2010, http://www.theglobalfund.org/documents/
(continued...)
Congressional Research Service
13
The Global Fund to Fight AIDS, Tuberculosis, and Malaria
burden on grant recipients and allow countries to more easily align work plans, budgets, and
targets. Adherence to the new funding architecture is voluntary for round 10 and required for
future rounds. The implementation of SSA will discontinue the use of the Rolling Continuation
Channel (RCC) for funding.37
The Board also decided at its 18th meeting to pilot a new grant proposal process known as the
National Strategy Application (NSA).38 The NSA was funded in a limited number of countries
and designed to more closely align Global Fund grant proposals with national health strategies
and fiscal cycles; reduce transaction costs and paperwork for recipient countries; improve
harmonization with other donors who have agreed to use the process; and encourage broad-based
use and support of harmonized funding structures and processes. Countries participating in the
“second wave” of NSA funding are also subject to the Transitional Funding Mechanism criteria,
although these countries will be able to use the jointly assessed strategy, produced for the NSA, as
the basis for their funding request for continuation of essential services.39
Enhancing Civil Society Participation
In 2007, the Board approved the routine use of dual-track financing, which enables grants to be
managed by two primary recipients, one representing national governments and the other civil
society organizations (CSOs) or the private sector. Dual-track financing is not required, though
any application with one primary recipient must include a justification for not using the method.40
The TERG and other health experts have long asserted that CSOs fill key roles in advancing
global health. Such functions include advocacy, demand creation, service delivery, policy-setting,
and accountability. In the long run, many observers maintain that civil society engagement
facilitates sustainability of outcomes, health system strengthening, and country ownership.41
According to the Global Fund, by the end of 2009, 84% of grants managed by CSOs either met or
exceeded expectations.42 Dual-track financing was used in 28 or the 79 proposals approved by the
Technical Review Panel in the 10th funding round.43
(...continued)
grantarchitecture/Architecture_High_Level_Concept_Note_en.pdf.
37 In November 2006, the Board established the Rolling Continuation Channel (RCC). This funding channel, which
began in March 2007, permits Country Coordinating Mechanisms (CCMs) 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.” 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.
38 For more information on the NSA, see Global Fund, Report of the Technical Review Panel and the Secretariat on
funding recommendations for National Strategy Applications of the First Learning Wave, Twentieth Board Meeting,
November 9, 2009, http://www.theglobalfund.org/documents/board/20/GF-BM20-11_TRP_ReportToBoard.pdf.
39 Global Fund, Participating in the Second Wave of NSAs, http://www.theglobalfund.org/en/nsa/participating/.
40 Report of the Policy and Strategy Committee, Global Fund Fifteenth Board Meeting, April 2007,
http://www.theglobalfund.org/documents/board/15/GF-BM15-06_ReportPSC.pdf.
41 Rifat Atun et al., “Venice Statement on global health initiatives and health systems,” The Lancet, vol. 374, no. 9692
(September 5, 2009), p. 784.
42 Global Fund, Global Fund 2010 Innovation and Impact, Progress Report 2010, p. 47. In assessing its grants, the
Global Fund rates the performance of each based on their achievement of pre-established goals and targets. “A1”
connotes exceeding expectations, “A2” meets expectations, “B1” adequate, “B2” inadequate but potential
(continued...)
Congressional Research Service
14
The Global Fund to Fight AIDS, Tuberculosis, and Malaria
Applying Debt Payments to Global Fund Grants
In 2007, the Global Fund launched an initiative called Debt2Health, through which creditors
allow countries to substitute the interest payments on their debt for public health spending via the
Global Fund. By June 2011, the Global Fund had signed four agreements with two creditor
countries and three beneficiary countries. The Fund anticipates that these agreements will channel
$107 million to efforts to fight the three diseases.44
Expanding Access to Improved Anti-Malarial Medication
The Affordable Medicines Facility–malaria (AMFm) initiative, launched in April 2009, was
originally proposed in a 2004 report by the U.S. Institute of Medicine and developed in
consultation with the Roll Back Malaria (RBM) Partnership.45 The initiative aims to improve
access to artemisinin-based combination therapy (ACT) by negotiating lower treatment prices
with drug manufacturers and supporting the proper use of the anti-malarial drug. AMFm
subsidizes a significant portion of the drug, dropping the purchase price from $11 per course to
less than $1. Although the AMFm initiative is managed by the Global Fund, UNITAID, Britain’s
Department for International Development (DFID), and other donors finance and implement the
initiative separately.
Through AMFm, the Global Fund anticipates ACTs supplanting cheaper, commonly used anti-
malarial drugs that have high drug resistance rates. Some observers warn, however, that people
could take ACTs with the onset of symptoms like fever without being diagnosed with malaria. In
light of decreased efficacy of ACTs along the Thai-Cambodia border and that ACTs are the only
anti-malarial drugs without widespread resistance, several health experts urge the Fund to finance
rapid diagnostic tests to complement AMFm activites and prevent drug resistance to ACTs.46
Strengthening Supply Chain Systems
In June 2009, the Global Fund launched the Voluntary Pooled Procurement (VPP) Initiative,
which encourages collective procurement of drugs and related commodities to decrease prices,
expand access to quality medicines, and improve the reliability of drug supplies. The initiative
focuses on four product categories: first-line antiretroviral treatment (ART), second-line ART,
ACT drugs, and long-lasting insecticide treated nets (LLINs). By monitoring prices, cost savings,
(...continued)
demonstrated, “C” unacceptable. Eighty-four percent of CSO-managed grants are rated A1, A2, or B1. For more on
performance ratings, see http://www.theglobalfund.org/cn/performancebasedfunding/methodology/?lang=cn.
43 Global Fund, Making a Difference: Global Fund Results Report, May 2011, p. 58.
44 Global Fund website, “Debt2Health,” http://www.theglobalfund.org/en/innovativefinancing/debt2health/.
45 The RBM Partnership was launched in 1998 by WHO, the United Nations Children’s Fund (UNICEF), the United
Nations Development Program (UNDP), and the World Bank to provide a coordinated global response to the disease.
Roughly 500 partners are engaged in the initiative. For more on the initiative, see http://www.rollbackmalaria.org/.
46 See WHO, “WHO releases new malaria guidelines for treatment and procurement of medicines,” press release,
March 9, 2010, http://www.who.int/mediacentre/news/releases/2010/malaria_20100308/en/; Rachel Nugent, Emma
Back, and Alexandra Beith, The Race Against Drug Resistance, CGD, 2010, http://www.cgdev.org/files/
1424207_file_CGD_DRWG_FINAL.pdf; and Mohga Kamal-Yanni, “Affordable medicines facility for malaria:
reasonable or rash?” The Lancet, vol. 375, no. 9709 (January 9, 2010), p. 121.
Congressional Research Service
15
The Global Fund to Fight AIDS, Tuberculosis, and Malaria
and market shares, the Global Fund hopes to strengthen national procurement systems and supply
chain management. Between June 2009 and December 2010, the Global Fund procured goods in
over 40 countries worth more than $500 million through this mechanism.47 The Global Fund
reports that additional consultations are underway in 10 more countries that have expressed
interest in receiving capacity-building and supply chain management assistance.48
Issues for Congress
Since making a founding pledge to the Fund in 2001, the United States has strongly supported the
Fund: U.S. contributions have remained higher than any other country, U.S. officials have served
on various Global Fund boards, and Congress has steadily raised appropriations to the Fund. At
the same time, Congress has passed laws that limit U.S. spending on the Fund, such as a
stipulation that prohibits U.S. contributions from exceeding one-third of all contributions.
Despite strong support by past Congresses for global health programs, including the Global Fund,
some Members of Congress have begun to question U.S. spending on non-security foreign aid
and argue for reducing or eliminating development and health aid. Although some Members of
Congress argue that cuts to these programs could yield important savings, others contend that the
cuts would have little impact on the federal deficit, while significantly imperiling the lives of
vulnerable populations reliant on U.S. assistance. The section below discusses issues the 112th
Congress might consider as it debates spending levels for the Global Fund.
FY2013 Budget Debate
The FY2013 budget request included $1.65 billion for the Global Fund, a significant increase
from previous years in contrast to some proposed cuts in bilateral global health programs. Key
questions are whether the 112th Congress will approve the proposed increase while congressional
debate continues to focus on limiting government spending overall, or whether it will agree with
the Administration’s proportional focus on the Global Fund.
Although appropriations for the Global Fund have mostly climbed, spending for the Fund has
become a declining share of total U.S. spending on international HIV/AIDS, TB, and malaria
programs, particularly from FY2007 through FY2011 (Table 3). In FY2012, a slightly larger
share of global HIV/AIDS, TB, and malaria resources went toward the Global Fund. Should
Congress meet the President’s request, the Fund will become an even greater share of U.S. global
HIV/AIDS, TB, and malaria spending in FY2013.
47 Global Fund website, “Procurement Support Services,” http://www.theglobalfund.org/en/procurement/vpp/.
48 Ibid.
Congressional Research Service
16
The Global Fund to Fight AIDS, Tuberculosis, and Malaria
Table 3. U.S. Global HIV/AIDS, TB, and Malaria Funding, FY2001-FY2013
(current U.S. $ millions)
FY2001-
FY2004
FY2005 FY2006 FY2007 FY2008 FY2009 FY2010 FY2011
FY2012
FY2013
Actual
Actual
Actual
Actual
Actual
Actual
Actual
Actual
Estimate Request
U.S. Spending
1,081.7 347.2 544.5 724.0 840.3 1,000.0
1,050.0
1,045.8
1,300.0 1,650.0
Global Fund
U.S. Spending
Bilateral
4,794.2 2,455.3 2,856.2 4,051.0 5,549.5 6,058.6 6,411.2 6,306.1 5,991.6 5,404.5
HIV/AIDS,TB,
Malaria
TOTAL
5,875.9 2,802.5 3,400.7 4,775.0 6,389.8 7,058.6 7,461.2 7,351.9 7,291.6 7,054.5
Global Fund
Share of TOTAL 18.4% 12.4% 16.0% 15.2% 13.2% 14.2% 14.1% 14.2% 17.8% 23.4%
US
Sources: CRS analysis of appropriations legislation and congressional budget justifications.
Debate about supporting the Global Fund has often focused on HIV/AIDS. Nonetheless, some
global health experts urge Congress to consider the impact of the Global Fund on the other two
diseases. The Global Fund estimates that by the end of 2010, it had committed some $12 billion
to HIV/AIDS programs, less than half of U.S. spending levels on related bilateral projects (about
$28.3 billion) during the same time period. The Fund outspent the United States during this time,
however, on global TB and malaria projects. The Global Fund committed approximately 3.3
times as much funding to TB activities and 3.0 times more on malaria interventions than the
United States.
The Global Fund estimates that the $3.6 billion that it committed to TB programs accounted for
65% of all donor spending in 2009, far exceeding the $1.1 billion in U.S. bilateral spending.49
Advocates assert that U.S. support for the Global Fund enables the United States to invest in TB
programs, an area in which the United States has a relatively limited presence. Proponents of
greater spending on TB point to the dire impact of HIV/TB co-infection, particularly in sub-
Saharan Africa, which has complicated efforts to control the spread of tuberculosis and
accelerated the rate at which people die from either disease.
Supporters for a diversified U.S. global health portfolio also point to the role that the Global Fund
plays in eliminating malaria. According to the Fund, it has committed roughly $6.1 billion to
malaria programs since its inauguration, accounting for some 65% of total donor spending
through the end of 2009.50 Since the launch of the President’s Malaria Initiative, U.S. investments
in global malaria programs has increased substantially, though U.S. spending on malaria from
FY2001 through FY2010 amounted to about one-third as much as Global Fund commitments.
Congress may also consider potential advantages of the Global Fund over U.S. bilateral health
programs. Some experts argue that the Fund’s grant process allows for greater country ownership
of programs, more flexibility in tailoring programs to specific country priorities, and supports
interventions that are better integrated with existing national and civil society activities. These
49 Global Fund, Making a Difference: Global Fund Results Report, May 2011, p. 40.
50 Ibid.
Congressional Research Service
17
The Global Fund to Fight AIDS, Tuberculosis, and Malaria
experts argue that these attributes may make these programs more sustainable in the future and
less dependent on U.S. assistance. Some also argue that the fund allows donors to pool and
leverage their resources, reduces overlaps in programming, and has fewer overhead costs.
Alternatively, others argue that the Global Fund model is more unpredictable than bilateral
programs, does not allow for adequate oversight of funds, and is more difficult to track and
measure.
U.S. Leadership in Combating HIV/AIDS, TB, and Malaria
The United States spends more on combating HIV/AIDS than any other country and is a key
donor for international malaria and TB programs. Experts continue to debate whether the United
States should maintain that leadership, including, in particular, the level to which the United
States should be a leader in supporting the Global Fund.
U.S. Spending Ceilings
Many urge Congress to increase appropriations to the Fund, in large part because donors have
begun to follow the lead of the United States in setting their annual contributions. However, U.S.
contributions to the Fund cannot exceed 33% of all contributions, a condition first set through the
U.S. Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act (P.L. 108-25). The law that
extended the authorization of U.S. support to the Fund, the Tom Lantos and Henry J. Hyde United
States Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act of
2008 (P.L. 110-293), maintained this requirement. Many observers speculate that Congress
instituted the contribution limit to encourage greater global support for the Fund. For this reason,
some argue that U.S. ceiling should remain. As of yet, it does not look like the FY2013 request, if
approved, would exceed this spending ceiling.
U.S. Share of Donor Contributions
Advocates of the Fund argue that U.S. support for the Fund has become even more important
since the global financial crisis. The Global Fund announced in November 2009 that it would
reduce the budgets of grants approved in round 9 by 10% for the first two years, and by 25% for
the subsequent years.51 In 2010, the Global Fund published a report that outlined various resource
scenarios and the Fund’s resulting ability to approve new grants. The Fund estimated that it would
need between $13 billion and $20 billion from 2011 to 2013 to maintain programs, and upwards
of $20 billion to scale-up efforts.52
Donors met for two days starting on October 4, 2010, at the United Nations headquarters in New
York City to pledge their support for the next three years of the Global Fund.53 The Global Fund
announced on October 5, 2010, that the international community had pledged to provide some
$11.7 billion to the Global Fund over the next three years, roughly $1 billion less than the Global
Fund’s most conservative funding request. The U.S. pledge accounted for roughly 34% ($4
51 Global Fund, Twentieth Board Meeting, Board Decisions, November 9-11, 2009, http://www.theglobalfund.org/
documents/board/20/GF-BM20-DecisionPoints_en.pdf.
52 Global fund, Resource Scenarios 2011-2013: Funding the Global Fight against HIV/AIDS, Tuberculosis and
Malaria, The Global Fund Third Replenishment (2011-2013), March 2010.
53 For more details on the pledging conference, see http://www.theglobalfund.org/en/replenishment/hague/documents/.
Congressional Research Service
18
The Global Fund to Fight AIDS, Tuberculosis, and Malaria
billion) of that amount. Subsequent pledges totaling $11.8 million by Luxembourg ($10.8
million) and Rwanda ($1 million) were made following the pledging conference.54
In November 2011, the Global Fund announced that, due to inadequate resources from donors, it
would cancel its 11th round of funding and would not be supporting any new grants until 2014.55
Some experts argue that the lack of new funding from the Global Fund during this time period
could have dire consequences. As the largest donor in the world for TB and malaria efforts, and a
key player in the fight against HIV/AIDS, many believe that a reduction in Global Fund grants
could significantly undercut the potential for progress against these three diseases.56
Despite concerns about the Global Fund’s ability to finance qualified grants from developing
countries, some observers would like the Global Fund to address its own capacity before urging
Congress to increase support for the organization. 57
Coordinating the Global Fund with U.S. Global Health Programs
Since the Global Fund was launched, the United States has sought to better coordinate Global
Fund and related bilateral programs. Through the Global Health Initiative (GHI), the Obama
Administration has affirmed its intention to increase cooperation with the Fund, indicating that
one of the seven basic principles of GHI is to “strengthen and leverage key multilateral
organizations, global health partnerships and private sector engagement” with the purpose of
implementing a coordinated strategy across other major donors and national governments.58 In its
Five-Year Strategy report, the Office of the Global AIDS Coordinator (OGAC) emphasized its
partnership with the Global Fund and outlined several steps to ensure the Fund’s long-term
sustainability, including transferring some PEPFAR programs to the Global Fund and
coordinating and aligning activities related to the funding, monitoring, and evaluation of
PEPFAR, Global Fund, and UNAIDS programs.59
Many observers question the strength of the U.S. commitment to donor coordination. For
example, though U.S. representatives have advocated better alignment of project implementation,
a common framework for such a notion has yet to be formalized. The Global Fund has begun to
develop a joint funding platform for health systems strengthening with other groups, however,
54 Global Fund, “Luxembourg Commits EUR 7.5 Million to the Global Fund,” press release, October 27, 2010,
http://www.theglobalfund.org/en/pressreleases/?pr=pr_101027; and Global Fund, “Rwanda Donates $1 million to the
Global Fund,” press release, November 10, 2010, http://www.theglobalfund.org/en/pressreleases/?pr=pr_101110. CRS
used a currency conversion rate of 7.5€ per U.S. dollar for the Luxembourg pledge.
55 Global Fund, “The Global Fund Adopts New Strategy to Save 10 Million Lives by 2016,” press release, November
23, 2011, http://www.theglobalfund.org/en/mediacenter/pressreleases/2011-11-
23_The_Global_Fund_adopts_new_strategy_to_save_10_million_lives_by_2016/.
56 For example, see Paul Farmer, “Why the Global Fund Matters,” New York Times, February 1, 2012, and International
HIV/AIDS Alliance, Don't Stop Now: How Underfunding the Global Fund to Fight AIDS, Tuberculosis, and Malaria
Impacts on the HIV/AIDS Response, 2012, http://www.aidsalliance.org/includes/Publication/
Alliance%20global%20fund%20report_V6.pdf.
57 Macro International, Inc., The Five-Year Evaluation of the Global Fund to Fight AIDS, Tuberculosis, and Malaria:
Synthesis of Study Areas 1, 2 and 3, March 2009, p. 21.
58 USAID, Implementation of the Global Health Initiative, Consultation Document, pp. 6-7, http://www.usaid.gov/
our_work/global_health/home/Publications/docs/ghi_consultation_document.pdf.
59 OGAC, The U.S. President’s Emergency Plan for AIDS Relief, Five Year Strategy, Annex: PEPFAR and the Global
Context of HIV, December 2009, pp. 13 and 16, http://www.pepfar.gov/documents/organization/133436.pdf.
Congressional Research Service
19
The Global Fund to Fight AIDS, Tuberculosis, and Malaria
like GAVI, the World Bank, and WHO. Though the United States is not party to the platform,
OGAC has expressed limited support for the undertaking.60 Despite OGAC’s support for
increased coordination among donors of health system strengthening efforts, it also contended
that each donor has a unique mandate and role to play in strengthening health systems. WHO and
other health experts urge key donors, including the United States, to align reporting and auditing
requirements, the frequency and type of data collected and reported, and fiscal cycles in an effort
to reduce the transaction costs and staffing requirements of recipient countries.61
Transparency, Monitoring, and Evaluation
Some critics of the Fund 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 release of
evaluations and findings on the Global Fund’s website reflect the Fund’s commitment to reporting
and monitoring its projects. Specifically, the Fund has uploaded onto its website an abundance of
information on grant 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.
Some in Congress have long advocated for stronger oversight of Global Fund spending.
Supporters of this idea have welcomed language included in FY2006 and FY2008 foreign
operations appropriations measures, which required the Secretary of State to withhold up to 20%
of the U.S. contribution to the Global Fund until she determined the Fund had adhered to U.S.
reporting and monitoring standards. In FY2009, the withholding was reduced to 10%. Beginning
in the FY2010 foreign operations appropriations, the Lantos-Hyde Act (P.L. 110-293), which
authorized the extension of PEPFAR programs and funding for U.S. bilateral TB and malaria
programs, required the Secretary of State to withhold 20% of the U.S. contribution to the Global
Fund until she certified that the Fund had met requirements pertaining to the Local Fund Agent
(LFA) performance, a policy of transparency, an independent Office of the Inspector General, and
several other policy and procedural provisions.
Most recently, the FY2012 foreign operations appropriations included language requiring the
Secretary of State to withhold up to 10% of Global Fund support until she determined that the
Fund was implementing a policy of transparency, supporting an independent Office of the
Inspector General, and maintaining an effective whistleblower policy to protect whistleblowers
from retaliation.62 To date, the U.S. government has not withheld funds on the basis of any of the
above provisions, and is currently in the process of making this determination for FY 2011. The
Global AIDS Coordinator has signed this certification, on behalf of the Secretary of State under
delegated authority, in past years. The State Department will report to Congress on the FY2012
provision after the fiscal year reporting period has ended in September 2012.
60 OGAC, U.S. Government Positions on Decision Points for the Twentieth Board Meeting of the Global Fund,
http://www.pepfar.gov/documents/organization/134924.pdf.
61 WHO Maximizing Positive Synergies Collaborative Group, “An assessment of interactions between global health
initiatives and country health systems,” The Lancet, vol. 373, no. 9681 (June 20, 2009).
62 Consolidated Appropriations Act, 2010, P.L. 112-74.
Congressional Research Service
20
The Global Fund to Fight AIDS, Tuberculosis, and Malaria
Some Global Fund supporters contend, however, that such action is unnecessary in light of the
consistent release of information by the Global Fund on grant performance and funding. Global
Fund advocates point to actions by the Global Fund to release information on discoveries of fraud
despite the negative press reports that surfaced in early 2011, as well as subsequent steps taken to
suspend or transfer management of relevant grants.63 Some experts applaud the Global Fund’s
efforts in this area and urge the United States to release similar information on the performance
and funding of its bilateral health programs.64
In light of the vigorous debate regarding responses by the Global Fund to corruption, a number of
recommendations made by the Senate Foreign Relations Committee’s minority staff to strengthen
the oversight of Global Fund grants in particular and U.S. global health spending in general may
receive attention in the 112th Congress.65 These included calls to:
1. Make U.S. contributions to the Global Fund contingent upon the Global Fund
Boards’ adoption of reforms laid out by the U.S. Department of State. The
Department of State would be required to certify to Congress that the reforms
were in place before funds could be released.
2. Withhold all funding to UNDP until it certifies that its internal rules and
procedures have been sufficiently modified to allow the Inspector General of the
Global Fund, the Inspector General of the World Bank, and any investigative arm
of any multilateral organization to which the United States contributes funds full
access to their audits, investigations, records, and personnel.
3. Withhold U.S. contributions from the Global Fund to the UNDP until the United
States receives confirmation of such certification.
4. Instruct the Government Accountability Office to conduct a study regarding the
coordination of the Office of Inspectors General (or equivalent offices) of all
U.S. government entities and multilateral organizations receiving U.S. taxpayer
funds that oversee the integrity of global health programs.
5. Have the U.S. Representative to the Global Fund reiterate in the strongest terms
to the Board of the Global Fund that the United States has no tolerance for fraud
and abuse and that the Office of the Inspector General needs to acquire adequate
resources and personnel to audit and investigate programs on the ground.
63 For example, see Global Fund, “The Global Fund Suspends AIDS Grant in Mali,” press release, March 2, 2011,
http://www.theglobalfund.org/en/pressreleases/?pr=pr_110302, and Global Fund, “Global Fund to Transfer
Management of HIV Grant in Mali,” press release, October 19, 2011, http://www.theglobalfund.org/en/mediacenter/
pressreleases/2011-10-19_Global_Fund_to_transfer_management_of_HIV_grant_in_Mali/.
64 Since the launch of PEPFAR, the United States has become the world’s largest donor to global HIV/AIDS programs.
Little is known, however, about the performance of PEPFAR programs and whether the U.S. Inspector General’s
Office has uncovered any misuse of funds. For more discussion on this, see, Chunling Lu et al., “Absorptive capacity
and disbursements by the Global Fund to Fight AIDS, Tuberculosis and Malaria: analysis of grant implementation,”
The Lancet, vol. 368, no. 9534 (August 5, 2006), pp. 487-488; Nandini Oommann, What Can We Learn from the
Global Fund’s “Massive Fraud”? Center for Global Development, January 25, 2011, http://blogs.cgdev.org/
globalhealth/2011/01/what-can-we-learn-from-the-global-fund%E2%80%99s-%E2%80%9Cmassive-
fraud%E2%80%9D.php.
65 See U.S. Congress, Senate Committee on Foreign Relations, Fraud and Abuse of Global Fund Investments at Risk
Without Greater Transparency, committee print, A Minority Staff Report, 112th Cong., 1st sess., April 5, 2011, S. Prt.
112-17.
Congressional Research Service
21
The Global Fund to Fight AIDS, Tuberculosis, and Malaria
6. Have the Global Fund take any steps necessary to ensure that Local Fund Agents
and CCMs are capable of managing grants and are properly trained on how to
spot and mitigate suspected fraudulent activities.
7. Have the U.S. government conduct a top-to-bottom analysis of U.S. investment
and contributions to international organizations and funds, similar to that
conducted by Britain. On March 1, 2011, the United Kingdom Department for
International Development issued a Multilateral Review, which evaluated the 43
international funds and organizations that the United Kingdom contributes with
respect to value for the money and each fund’s and organization’s effectiveness
in combating poverty, taking in account transparency and accountability.66
8. Have the U.S. government work more closely with host governments on
establishing or increasing the country’s commitment to making its own
investments in health programs. When possible, the countries must demonstrate
some commitment in moving toward sustainability and cease complete reliance
on the donor community for the indefinite future.
Since the release of this report, the Global Fund has announced several plans to increase
transparency, monitoring, and evaluation of its programs, particularly through the Consolidated
Transformation Plan.
Conclusion
To date, the Global Fund has approved funding for over 1,000 projects in 150 countries. Through
its treatment, prevention, and care efforts, the Fund estimates that it has saved approximately 7.7
million lives. Despite these achievements, observers raise several issues that could influence U.S.
support for the Fund:
• The appropriate balance between U.S. support for the Global Fund and
bilateral HIV/AIDS, TB, and malaria programs—Since the Global Fund was
created, some have weighed U.S. contributions to the Global Fund against U.S.
spending on bilateral HIV/AIDS, TB, and malaria efforts. The Office of the
Global AIDS Coordinator rejects this notion and presents the Global Fund as a
complement to U.S. bilateral programs. Nonetheless, the 112th Congress will
likely debate the distribution of U.S. support between the Global Fund and
related bilateral programs, especially PEPFAR.67 The President’s FY2013 budget
request may contribute to this debate, as it proposes decreased funding for
bilateral HIV/AIDS, TB, and malaria programs while proposing increased
funding for the Global Fund. Some experts argue that this reflects the relative
efficient and flexible nature of multilateral programs. Others argue that
66 Following the review, Britain reaffirmed its commitment to the Global Fund and considered it “very good value for
the U.K. taxpayer.” See, U.K. Department of International Development, Statement by the Secretary of State for
International Development: the Bilateral and Multilateral Aid Reviews, Oral Statement to the House of Commons,
March 1, 2011, http://www.dfid.gov.uk/Media-Room/Speeches-and-articles/2011/BAR-MAR-oral-statement/.
67 See question posed by Honorable Charlie Dent at U.S. Congress, House Committee on Appropriations,
Subcommittee on State, Foreign Operations, and Related Programs, Global Health and HIV/AIDS Programs, 112th
Cong., 1st sess., March 31, 2011.
Congressional Research Service
22
The Global Fund to Fight AIDS, Tuberculosis, and Malaria
increasing funding for the Fund while decreasing funding for bilateral programs
undercuts the success of more predictable and sustainable U.S. programs.
• How to coordinate Global Fund and bilateral HIV/AIDS, TB, and malaria
programs—When President Obama announced GHI, he expressed his intent to
reshape U.S. global health policy so that global health efforts were better
integrated and coordinated. Despite references throughout the GHI
Implementation Plan to stronger collaboration with the Global Fund, the extent to
which such an effort will occur is not yet clear. While several official U.S.
documents support calls from the Global Fund to enhance donor coordination,
the United States has expressed limited support for a joint funding platform for
health systems strengthening.68 U.S. officials maintain each donor has a unique
mandate and role to play.69
• Growing emphasis on improving health systems—Despite calls by the Global
Fund for more financial support, the team of experts who conducted a five-year
evaluation of the Fund warned that recipient countries might not be able to
continue receiving assistance at current scale without significant investments in
health systems.70 The Global Fund and other donors have increased spending on
improving global health systems, nonetheless challenges in this area persist. One
of the goals of the Global Health Initiative is to improve health systems through
several strategies, such as addressing health system bottlenecks, strengthening
data collection systems, improving human resources for health, and donor
coordination.71 Several global health experts recommend that the Global Fund
and other donors support national health plans and address the major gaps in
basic health service availability and readiness as part of HIV/AIDS, TB, and
malaria efforts.
• Whether Global Fund resources should be used in middle-income
countries—Several observers question the use of Global Fund resources in
middle-income countries. In 2010, 11 countries were considered both donors and
recipients: China, India, Malaysia, Namibia, Nigeria, Romania, Rwanda, Russia,
South Africa, Thailand, and Tunisia.72 China has received the most attention from
all of these countries, due to both the substantial amount of grants it has received
from the Fund and the rapid growth of its economy. The Global Fund awards
grants to lower middle-income countries, but expects them to contribute up to
program costs. For example, as a middle-income country with a per capita
income of $3,650 China is eligible for Global Fund grants and pays roughly 80%
of total program costs.73 The Senate Foreign Relations Committee’s minority
68 OGAC, U.S. Government Positions on Decision Points for the Twentieth Board Meeting of the Global Fund,
http://www.pepfar.gov/documents/organization/134924.pdf.
69 Ibid.
70 Macro International, Inc., The Five-Year Evaluation of the Global Fund to Fight AIDS, Tuberculosis, and Malaria:
Synthesis of Study Areas 1, 2 and 3, March 2009, p. 21.
71 Department of State, Implementation of the Global Health Initiative: Consultation Document, February 1, 2010, pp.
14-16, http://www.pepfar.gov/documents/organization/136504.pdf.
72 For more information on the Global Fund’s policy for supporting middle-income countries, see Global Fund,
Counterpart Financing, http://www.theglobalfund.org/en/application/process/counterpartfinancing/?lang=en.
73 U.S. Congress, Senate Committee on Foreign Relations, Fraud and Abuse of Global Fund Investments at Risk
Without Greater Transparency, committee print, prepared by A Minority Staff Report, 112th Cong., 1st sess., April 5,
(continued...)
Congressional Research Service
23
The Global Fund to Fight AIDS, Tuberculosis, and Malaria
report recommends that as China becomes an upper middle-income country, it
should no longer receive Global Fund resources. In May 2011, the Global Fund
approved a new Eligibility, Counterpart Financing and Prioritization Policy that
limits how much funding middle-income countries could receive through the
Fund and requires all countries to contribute to national disease and health
strategies and demonstrate increased funding for these activities annually. At the
November 2011 board meeting, the Global Fund also implemented a policy
whereby G-20 upper middle-income countries will no longer be eligible for grant
renewals unless they have an extreme disease burden, as defined by the Fund.
• The Fund’s responses to allegations of corruption—The Global Fund’s
announcement that funds from some its grants were misspent has opened a
rigorous debate in the foreign aid community. Some observers applauded the
Global Fund for its transparency and encouraged others to release similar
information, arguing that the Global Fund is not alone in facing these problems.
Advocates also note efforts by the Fund to reform its fiduciary practices and
reduce corruption. On the other hand, some have called for governments to
withhold support for the Global Fund until adequate safeguards are established.
The Global Fund’s release of information on misused funds by its grant recipients
raises several questions. If the Global Fund is penalized for being honest in its
shortcomings, will others hesitate to do so? When allegations of corruption and
malfeasance are discovered, what is the appropriate response? What impact
might reduced funding have on those relying on aid programs for life-saving
treatments?
(...continued)
2011, S. Prt. 112-17.
Congressional Research Service
24
The Global Fund to Fight AIDS, Tuberculosis, and Malaria
Appendix. Acronyms and Initialisms
3D Fund
Three Diseases Fund
AMFm
Affordable Medicine Facility–malaria
ACT
Artemisinin-based Combination drug Treatment
ART Antiretroviral
Therapy
CBJ
Congressional Budget Justification
CCM
Country Coordinating Mechanism
CDC U.S.
Centers
for Disease Control and Prevention
CGD
Center for Global Development
CSO
Civil Society Organization
DOD
U.S. Department of Defense
DOL
U.S. Department of Labor
DOTS
Directly Observed Treatment Short-Course
EU European
Union
GAO U.S.
Government
Accountability Office
GAVI
Global Alliance for Vaccines and Immunization
GHCS
Global Health and Child Survival
GHI
Global Health Initiative
HHS
U.S. Department of Health and Human Services
HSS
Health System Strengthening
IRS
Indoor Residual Spraying
ITN Insecticide-Treated
Net
LFA
Local Funding Agent
LLIN
Long Lasting Insecticide-treated Nets
MDG Millennium
Development
Goals
MDR-TB
Multi-Drug Resistant Tuberculosis
NGO Non-Governmental
Organization
NSA
National Strategy Application
NTD
Neglected Tropical Diseases
OGAC
Office of the Global AIDS Coordinator
PEPFAR
President’s Emergency Plan for AIDS Relief
PMTCT
Prevention of Mother To Child HIV Transmission
PR Principal
Recipient
RBM
Roll Back Malaria
RCC
Rolling Continuation Channel
SR Sub-recipient
SSA
Single Stream Agreement
Congressional Research Service
25
The Global Fund to Fight AIDS, Tuberculosis, and Malaria
TB Tuberculosis
TERG
Technical Evaluation Reference Group
UN United
Nations
UNAIDS
Joint United Nations Program on HIV/AIDS
UNDP
United Nations Development Program
USAID
U.S. Agency for International Development
VCT
Voluntary Counseling and Testing
VPP
Voluntary Pooled Procurement
WHO
World Health Organization
Author Contact Information
Tiaji Salaam-Blyther
Alexandra E. Kendall
Specialist in Global Health
Analyst in Global Health
tsalaam@crs.loc.gov, 7-7677
akendall@crs.loc.gov, 7-7314
Congressional Research Service
26