[Ip-health] Richard Horton in The Lancet - Offline: Can the Global Fund survive?

Thiru Balasubramaniam thiru at keionline.org
Fri Jul 6 04:18:30 PDT 2018


Offline: Can the Global Fund survive?

Richard Horton

Published: 07 July 2018

DOI: https://doi.org/10.1016/S0140-6736(18)31552-6

France will host the Sixth Replenishment Conference for the Global Fund to
Fight AIDS, Tuberculosis and Malaria in 2019. The result may make or break
the Global Fund. Although the date of the conference is not formally
confirmed, it is likely to be sometime between June, when France will host
the G7, and September (the UN General Assembly in New York). With a
pre-replenishment conference expected around January, the investment case
for donors needs to be ready by the end of 2018. And, with a crucial Global
Fund Board meeting in November, there are only 4 months left to decide the
broad outlines of that case. This terrifyingly narrow time window matters
because the Fund remains uncertain about its argument for replenishment.
Uncertainty before one of the most important moments in the Fund's history
is not a good place to be.

The Global Fund has a choice. It could pursue a strategy of more of the
same. The Fund has been the most successful financing instrument in global
health since its creation in 2001. It has delivered impressive returns on
its investments and has built confidence among donors. The Fund could
reprise its past successes next year and argue that donors should continue
to support those successes. But such an approach carries serious risks. The
world has changed since the Fund's inception. The US and UK, once champions
of global health and the Fund, are now indifferent bystanders, preoccupied
by their own psychic dramas. Post 2007–08, money is tight. Demands on
governments have expanded. The Fund has another choice. A creature of the
MDG era, the Fund could present a plan and investment case for how it will
reinvent itself in an SDG era. It could argue that the global health agenda
is now much broader, requiring a very different response from the Fund. Is
it ready to make such a major strategic shift?

The Fund's Executive Director, Peter Sands, together with the Chair of the
Board, Aida Kurtović, must seize the opportunity to write a new narrative
for the Fund to enable it to adapt to its new political and economic
environment. The days when donor contributions outstripped spending are
long gone. The 2019 replenishment cannot be business as usual. Here is the
argument they might consider. The present era is about one big
idea—sustainability. In health, that means universal health coverage (UHC):
strong health systems based on effective primary health care. AIDS-focused
institutions, including the Global Fund, must broaden their mandates to
address this larger objective of global health. This means an “ATM plus”
strategy: AIDS, tuberculosis, and malaria plus UHC. Two conditionalities
are important. First, this approach does not mean cutting existing
resources for ATM and redirecting money to health systems. Instead, it
means a step change in the financing “ask” to meet future ATM needs and to
begin to address the UHC funding gap. But the ask should not be the
bottomless pit of UHC. All experience tells us that calls to invest in
health systems are met with scepticism by donors. Instead, the Fund should
be specific: health workers, health information, and governance and
accountability. All three priorities are crucial to deliver UHC, and they
do much to guarantee the effectiveness, efficiency, and value for money of
the Fund's existing ATM programmes. This strategy should be based, as it
was in 2001, on the economic and security case for investment. There are,
of course, other questions the Fund must consider. How far should it
embrace the private sector? What is its strategy for middle-income
countries? How can the Fund leverage domestic investments, especially to
cover costs of treatment? How can the Fund be a better partner with other
global health initiatives? Replenishment of the Global Fund will not only
be a test of confidence in the Fund. It will also be a test of donor
commitment to multilateralism. In the Trump–Brexit era of strategic
withdrawal, Europe has the opportunity to reinvigorate a spirit of
cooperation among nations, with hard financial deeds matching warm admiring
words. The next 4 months will be a time to decide whether the Global Fund
has the courage to change its narrative. It will also be the time when
Europe has the opportunity to lead not only the strengthening of the Global
Fund, but also the birth of a new era of global leadership for the

Thiru Balasubramaniam
Geneva Representative
Knowledge Ecology International
41 22 791 6727
thiru at keionline.org

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