The Global Fund was created like a Marshall Plan with huge funding commitment to address the runaway epidemics from three diseases – HIV/AIDS, TB, and Malaria.  The Global Fund was a bold, disruptive initiative in global financing.  The idea was simple.  Establish a major financing mechanism with simple management structure to provide additional resources to support as well as enhance existing country systems to rapidly scale up prevention and treatment services to reduce mortality and morbidity from three diseases. Without scale, impact was not possible. Without major infusion of additional resources, national resources in low income countries were simply inadequate to deal with the diseases. A vertical approach was seen as the best approach to fast track financing and services.  And to implement this plan, donors agreed to follow two critical approaches – the entire process has to be country led & owned, and the Global Fund must be lean to avoid unnecessary bureaucratic burdens that are normally seen with larger donors such as the World Bank.

The Global Fund has achieved major successes over last 15 years.  Vertical programs are now gradually replaced with more integrated approaches and health systems strengthening for sustainable service delivery.  UN partners especially UNAIDS and WHO played critical technical and advocacy role to support Global Fund funded programs and build local capacity.  Transitional funding are now provided to gradually shift the burden of responsibility to countries and national financing.  All these are good.  However, administratively, the Fund became a much cumbersome behemoth with over 700 headquarters staff and Local Fund Agents in every country.  Countries faced major burden of bureaucratic processes and requirements.  In many places, country led processes and systems were replaced by international organization led implementation and management. There were good reasons for that, many countries were fragile and were in conflict and did not have the capacity for large scale implementation.  However,  some of these changes were not part of the initial design but has happened for many reasons.  An innovative financing mechanism was supposed to remain innovative, nimble, simple, and dynamic.  That thinking was lost along the way especially during 2011 and 2012.

This is what Global Fund site describes about the Fund – “The Global Fund is a 21st-century partnership organization designed to accelerate the end of AIDS, tuberculosis and malaria as epidemics… be effective, it must be agile, responsive and committed to serving communities affected by HIV, TB and malaria.” Good words, well articulated. The word agile means “able to move quickly and easily”.  In another place, agile is defined by characteristics such as quickness, lightness, ease of movement, and nimble. Therefore, if we look at the Fund now, it is anything but agile. Its accountability mechanisms are not ideal – Country Coordination Mechanism is a political body and not functioning as originally planned, the Local Fund Agent system has become expensive and time consuming, and its monitoring by its staff have adopted a World Bank style group visit to the countries incurring considerable expenses without the technical depths of World Bank professionals. Teams have expanded without a real look at efficiency.  It takes months to approve grants, continuation funding, and changes in implementation arrangements. It has brought many functions within the organization while the prudent decision would have been to use the expertise and capacity that lies with other organizations. These things happen when an organization becomes staff and process heavy in response to donors’ demands for accountable use of their resources, rather than taking the donors requirements as a challenge to develop systems and management arrangements based on the principles of simplicity, innovation, and ‘agility’.  Its’ not all bad.  The Global Fund is a good institution but its needs remaking, it needs to learn from its private sector partners, it needs to go back to its founding principles of ‘agility’, country ownership, additionality, and ‘sustainable response’.  It needs to look at best practices of GAVI, GPE, Global Innovation Fund and others.  It needs to be bold to be disruptive again, now with its own institutional arrangements and then with the way its business model works with countries. A donor needs to remain cost efficient if it is to ask its implementers to be cost efficient.

In March 2018, a new Executive Director, Dr Peter Sands, was appointed as Executive Director.  Peter comes from the private sector and is also a scientist. Peter now has the challenge to reform the Global Fund to be nimble, agile, and innovative. I know it require disruptive approaches and ideas.  And it is an extremely difficult task it but needs to be done, otherwise donors will find other ways of doing business. An efficient arrangement cannot continue to attract additional resources. I have seven suggestions for the new Executive Director and they are:

1)      New financing innovations such as development impact bond, pay for success, innovation in domestic resource mobilization approaches, and other ideas need to be an integral part of Global Fund financing to leverage private sector and national funds from the countries.  Bilateral and multi-lateral donors do not have enough resources to meet total funds required to meet the goals of 2030 for HIV/AIDS, TB, and Malaria.  With the US slowing reducing its contributions, the challenge becomes even more acute on raising additional resources.  Fortunately, we have new and emerging private sector foundations and philanthrophists ready to step in to fill the gap but they need new thinking.

2)      The Fund needs to become agile organizationally and needs to be much smarter in the way it will deliver financing in the coming years.  This will require gradual shift toward more efficient management arrangements and staffing skills. The skills set that have served the Fund over last 15 years, will not serve its work over next 15 years.

3)      The Fund needs to rely on technical and other comparative advantages WHO, UNAIDS, International NGOs, Academia, and private sector.  The Fund should be ready to fund such agencies for particular work and reduce its own workload.  The fund needs to streamline its work to bring focus on core activities. In order to achieve this change, its need to have simple coordination and partnership arrangements.

4)      The Fund needs to create an ‘innovation lab’ within its own structure so that it can fund new innovation on products and systems quickly and use the successful models to apply to its grants quickly and easily.  Because it will be housed within the Global Fund, it will be less costly to the donors.   The Global Fund Board needs to be convinced to invest in one place for this and not create multiple agencies which is not cost effective.  These are the same donors who fund other entities, thus duplicating efforts and management time.

5)      It needs to embrace the SDG principles of country owned and country-led investment decision making so that countries will invest their own resources along with private sector, other financing organizations, and Global Fund.  Look for innovations in local accountability mechanisms and how to strengthen them.  Look for strengthening national systems down to the community level.

6)      Partner with all countries, especially the ones with upward economic progress, to jointly pursue innovative ways of raising resources for the Global Fund and countries to fight all three diseases to meet 2030 goals.

7)      Finally, it needs to show strong leadership in using technology and innovation to improve management and implementation.  It needs to be the leader to fast track proven innovation in its programs so that countries can benefit from the new technologies, products, and systems.