I’m still not really sure what came out of the Global Fund Replenishment meeting in The Netherlands last week. I sat through two days of donors delivering their talking points, chatted in several corridors during coffee breaks, have read the rather bland Chair’s summary several times, and the big question remains: will there be more money?

The people round the table in Den Haag were the Fund’s friends. These are donor representatives who will encourage their Ministers and bosses to find the money. Through most of the meeting they seemed to accept the case for the Fund to think big and aim for its top scenario to fundraise $20 billion for the next three years (2011-2013). This is the top level that would put a total of 7.5 million people on ARVs and provide annual care for 4.4 million orphans and vulnerable children, and access to PMTCT for 1.1 million women. This is the track to universal access. And as the civil society representatives at the meeting said – this is the minimum requirement.

But by the end of the second day, as the donor representatives settled back in to familiar routines negotiating the Chair’s summary, these ambitious goals seemed to fade.  We started to hear that US$13 billion – the lowest scenario – would be “a significant increase in contributions at a time when budgets were under pressure.” This is the “steady as she goes” scenario leading to no significant scale up. The big global squeeze on budgets was suddenly more present than the lives saved and lengthened. While their hearts were with the Fund and its ambitions, even its best friends started to admit they weren’t sure they could find good enough arguments to convince their superiors.

This was disturbing. Not only because the world needs the money, but because no one seems to doubt that the Global Fund has proven it can and should play an important, effective role delivering that money. This may seem self-evident, but it isn’t. The Replenishment meeting could easily have descended into a series of donor demands for the Global Fund to reform itself to have a chance of getting the money – which was quite a theme at the (UK-hosted) 2005 Replenishment. The Fund is still very young – just eight years old – and I’ve watched it from near and far most of that time. The very first time I met the UK Secretary of State (when I was a very new civil servant) she was screaming about what the Global Fund was and wasn’t doing and how hopeless it all was. There’s a long history of the donors complaining about how the Global Fund operates. A bit of that peeked through at Den Haag, but not much. Of course they asked for improvements (what organization doesn’t need to grow and improve?) but this was tweaking the model, not throwing it out. There was no question around the donor table that the Fund is an important part of global financing on health. The results speak for themselves: 5 million lives saved, 2.5 million people on ARVs, 1.8 billion male and female condoms distributed, 790,000 women accessing PMTCT.

And the results of Global Fund investments are starting to be seen on maternal and child health too. With over half of all maternal deaths in Africa due to AIDS, TB and malaria – and a massive proportion of child deaths also caused by the three diseases – this is hardly surprising. The Global Fund secretariat presented compelling information showing the increasing impact their investments are having on broader maternal and child health indicators. This led to rumbles about whether the Global Fund should now expand to cover all three Millennium Development Goals (MDGs) on health (MDGs 4, 5 and 6). No decisions could be made in Den Haag, but the question of whether the Global Fund should expand its mandate to address maternal and child health as well as the three diseases will be an important part of the Global Fund Board meeting at the end of April. This is one to watch carefully. There are good arguments for building on the obvious synergies – but also real concerns that this will be cost-cutting by another name. Will donors suddenly find the $20 billion – but only if it can be shared among three MDGs, not used to meet one? These concerns aside, what is clear is that anyone trying to force a wedge between AIDS and maternal and child health is playing a losing game. The three health MDGs need to be seen as a package and the idea that you can do one without the other is simply wrong.

So what were the conclusions? We know we need the money. We know the Global Fund has made a major impact with what it’s spent so far. We have faith that it can spend an extra $20 billion well. But no one seems to have a smart idea about where we’ll find it. One idea put on the table – or in fact the video screen – by the civil society delegations was the Financial Transaction Tax. The FTT would raise billions by a tiny tax (0.05%) on financial transactions, probably starting with a currency transactions levy. The donors sat and watched the wonderful video of Bill Nighy’s character trying to wriggle out of accepting this small and brilliant idea. It seemed as if several were convinced – the trick now will be to make sure they don’t wriggle out of pursuing this very promising idea (as Canada seems to be doing). Now is the moment to help these friendly donor reps to persuade their bosses to do the right thing: to increase their direct investments in the Global Fund, and get their governments to sign up to this potentially game changing approach to pulling in the money.

The first round of discussions has been had. Now we need to redouble our efforts. There is no doubt that the Global Fund needs at least $20 billion, has proven it can spend it well and make a real impact, and is centrally placed to maintain the momentum towards universal access. But the real question remains: will the donors find the courage to mobilize the resources to make it happen?