The outcomes of last week’s Global Fund Board meeting brought relief and joy. Many people, fearful that planned discussions about prioritizing and financing for the next round of funding could damage the Global Fund’s collaborative spirit, went into the meeting thinking it could be the toughest yet.
Against a tough back drop of financial uncertainty, the Board’s decision to launch Round 10 on 20 May with an innovative new fund to support programmes for marginalized populations proved to be an important step forward in the Global Fund’s maturation.
As usual, the Board meeting made for an intensely busy week with late-night gatherings proving key to working through the issues at hand. Global Fund Chair, Ethiopian Health Minister Tedros, agreed that IAS could attend the meeting as an Observer. We hope this role will continue, given the importance of the Fund’s work to our membership, who play a central role reviewing applications on the Technical Review Panels, serving on Country Coordinating Mechanisms and delivering programmes supported by the Global Fund.
Setting funding priorities is inherently about choices. In the lead-up to the meeting it looked as though the Board would face tough choices that could pit low- and middle-income countries against one another, knowing that resolution on prioritization was key to deciding whether, when and how 10 would be launched. With a cap? With a waiting list? And who would be first on that list? These questions are most acute now because with the Replenishment process kicking off, no one knows how much money will be in the bank at the start of next year – and the Fund is only allowed to make grants up to the amount of real cash it holds.
One of the real beauties of the Fund – which also causes the most tensions – is that the Board brings together real diversity: donors, recipient countries, NGOs and community. This is not a funding instrument where the people with the money wield all the power. The Fund decision-making model is a heady mix of debate between governments with money, foundations with money, the private sector (which brings less money than it should…) and countries and communities in need of that money. And the countries and communities in need do not fit neatly into the traditional development assistance box. Of course most are from the poorest countries of the world where there is acute need for external resources to reach the whole population. But increasingly the Board gives voice to a complex range of middle-income countries where external resources are needed to tackle AIDS in marginalized communities – communities which are often in need because they are neglected by their own government.
The sticking point - that this Board meeting had to tackle - was who comes first: the poorest countries, or those richer countries whose governments aren’t doing the right thing by their gay, transgender, drug-using, or sex-working citizens. Surely their governments should just step up to the mark and do the right thing by all their people, rather than asking for money from the Fund? Well this is a nice theory (one I used to hold when I worked for DfID!) but is it anywhere near reality?
These tensions were highlighted clearly by the recent unwillingness of the Russian Government to take over the funding of successful HIV programmes for people who use drugs. After their refusal, at the last Board meeting the Global Fund stepped back in and continued funding evidence-based programmes in Russia – and stated clearly that this should not set a precedent for the future.
As the Board meeting approached, real fears emerged that the Fund’s lack of financial certainty would mean that a waiting list would have to be imposed, and tough choices would be taken in favour of the poorest countries. Many people, especially those representing Latin America and Eastern Europe, stressed the point that the Global Fund has become the “safety net” which people turn to for funding when there is no hope. There was a real risk that Board discussions could turn into a nasty fight about whose needs are greatest.
Through deft late-night negotiations a compromise was brokered and an ugly debate avoided. A once-off $75 million fund for “MARPs” – most at-risk populations – has been established for Round 10, accompanied by an agreement that all of Round 10 (including the MARPs Fund) will be resourced by money pledged in, and for use in, 2011. There’s a new complex prioritization rule for what to do if the number of quality applications exceeds the money available – but without the risk that this could end up with only low-income countries funded. .
Simon Bland, the UK/Australia representative to the Board noted during the discussions, “At the beginning, the Global Fund was supposed to be simplicity, simplicity, simplicity; this week the proposals were complicated, complicated, complicated; now we have compromise, compromise, compromise.” While compromises are not always ideal, this is a smart one which gives a green light to Round 10 being launched on 20 May with applications due in by 20 August – and with no cap on funding, as some had feared. The Global Fund has never set a limit on a round of funding and discussions about capping Round 10 had been worrisome. With the decision not to cap Round 10, the Board safeguarded the needs-based principle that has driven the Global Fund’s process from the beginning.
The other big issue on the table last week was whether or not the Global Fund should expand its mandate to include maternal and child health (MCH) – to include Millennium Development Goals (MDGs) 4 and 5, as well as its current mandate for MDG 6 (AIDS, TB and malaria). That discussion was led by Lesotho’s Health Minister Dr. Mphu Keneiloe Ramatlapeng, who highlighted the real synergies that the Global Fund’s work is already achieving in this area. There was broad agreement on that point, but the discussion was robust.
If the Global Fund does not expand, there will likely be a new institution created which would prove more expensive and complicate the funding environment. On the other hand, the Global Fund could expand its mandate to cover all of the Health MDGs, but face the real risk that it could not attract sufficient resources to tackle that immense challenge, and weaken its existing strong performance. While most around the table were clear in their articulation that the links between the 3 MDGs are strong, and that competitiveness between them should be avoided at all costs, there was a lack of clarity about the real implications of expansion. The timing of the discussion was not ideal either, in the midst of the Replenishment process. There are growing fears that the Fund’s ambitious call for US$20billion will not be reached. If the Fund suddenly expands, would this play into donors’ hands so they can get three MDGs for the price of one?
The Board agreed that the Global Fund should continue to track the impact of the current funding model on MCH (and results to date are strong) and take time to develop clearer information about how expansion could happened. The Policy and Strategy Committee was charged with taking the process forward in the context of a broader conversation about the Global Fund’s strategy. Clearly, this issue requires thoughtful consideration and robust debates – discussions that I expect and hope will receive a good deal of attention when we gather in Vienna this summer.