Replenishing the Global Fund to Fight AIDS, Tuberculosis, and Malaria
BMJ 2022; 378 doi: https://doi.org/10.1136/bmj.o2320 (Published 30 September 2022) Cite this as: BMJ 2022;378:o2320
- 1Global Health Economics Centre, London School of Hygiene and Tropical Medicine, UK
- 2Department of Economics, School of Humanities and Social Sciences, University of Zambia, Zambia
- Correspondence to: A Vassall Anna.Vassall{at}lshtm.ac.uk
@AnnaVassall on Twitter
The replenishment conference of the Global Fund to Fight AIDS, Tuberculosis, and Malaria on 21 September 2022 aimed to raise $18bn from supporting donors. It got $14.25bn.1 The UK (currently the fund’s third largest donor) did not pledge but stated a commitment to the fund’s work.
While funding fell short of what was requested, the replenishment was seen as a success, with increased support from the US, Canada, France, Germany, Japan, France, and the Gates Foundation, along with new support from low and middle income countries, including Tanzania, Malawi, Indonesia, and Ghana.
The Global Fund was formed in 2002 after a recommendation by the G8 group of high income countries2 and represented a seismic change in how global health was financed: by pooling funding from multiple sources including governments, the private sector, and multilateral agencies. Decades of economic decline had left many low and middle income countries struggling to reform and fund essential health services, ill equipped to deal with the HIV pandemic, and with persistent burdens of tuberculosis (TB) and malaria.34 The Global Fund aimed to ensure stable collective financing of essential health services to a coordinated group of public and private in-country providers, driven by country demand.2 Together, AIDS, TB, and malaria cause over two million deaths a year globally.19
The Global Fund has helped to save around 50 million lives5 since its inception; helped build a stable market for the development of new technologies, such as diagnostics to rapidly identify TB in people with HIV infection6; and promoted community led health services for all three diseases.7
Covid-19 set back the pace of these gains, however. By disrupting routine health services, it is likely to have caused hundreds of thousands of additional deaths from TB.8 The pandemic also slowed the expansion of HIV testing and treatment,9 and reduced condom supply for key populations living with HIV, which may have increased the number of new HIV infections.1011 Furthermore, many countries are now grappling with financial instability, including the threat of economic recession, with substantial consequences for the public funding of health services.
Given these challenges, is the Global Fund still a good investment in a world facing multiple emerging disease threats and an ever growing burden of non-communicable diseases? The case for investment in HIV, TB, and malaria remains powerful—services for these three diseases offer some of the best value for money in terms of health impact per dollar spent.12 And there is a broad consensus that investing in infectious diseases yields high returns in terms of sustainable economic development.13
Funding priorities
But this does not mean that every HIV, TB, or malaria technology or service should be funded for all populations. Although the recent malaria vaccine was a scientific breakthrough, it should not necessarily be prioritised over bed nets or diagnostics that are highly cost effective at preventing more malaria deaths.14 Not all interventions are good buys, and the Global Fund needs to be guided by priorities within countries when taking these decisions. Some countries may prioritise the sexual and reproductive health and rights of women and girls, for example, whereas others may need to tackle emerging drug resistant TB. The fund needs to substantially increase its efforts to assess value for money, aligning with a country’s priorities and supporting capacity in local health technology assessment.15 Donors must continue to demand clear evidence that the fund’s $14.25bn spending aligns with broader national health priorities, beyond the needs of specific grant applicants or interest groups.
Even when priorities are justified and locally driven, the Global Fund’s success depends on the ability of health systems to deliver the required services. As health systems are rebuilt after covid, the fund must ensure that its programmes contribute to strengthening health systems and pandemic preparedness more broadly. The fund has received substantial sums in the past to build stronger health and community systems, but this now needs to be routinely part of disease focused grant applications. Ensuring synergy between investing in specific diseases and in health systems is not easy,16 but the fund must incentivise actions targeting both. HIV, TB, and malaria programmes will need expert help to identify system-wide barriers to care and effective interventions to remove them. Programmes should be required to show the benefits (and costs) of their spending on other areas of the health sector and show effective service integration in their grant applications.
Finally, to remain sustainable, the fund has traditionally relied on transitioning away from countries that become able to pay for their own services.15 We are now facing growing global inequity,17 and the fund will need to adapt as countries make slower progress towards becoming self sufficient. To remain effective, it needs to become ever more efficient and equitable—exploring how it can best support national financing reforms that promote equitable redistribution of wealth and protect citizens against catastrophic health costs, for example.18 This can be done only by ensuring national disease programmes fully engage with those who are working on areas such as health insurance or social services.
The Global Fund and those it funds must further embed their activities within domestic priority setting, further integrate disease programmes with health systems strengthening, and align fully with equity orientated reform of health sector financing.
Footnotes
Competing interests: The BMJ has judged that there are no disqualifying financial ties to commercial companies. The authors declare the following other interests: AV declares an institutional research grant from Johnson and Johnson that is measuring the macro-economic impact of TB in India. She serves on advisory boards for tuberculosis health technology assessment and epidemic and pandemic preparedness and prevention, World Health Organization. She is Joep Lange chair at the Amsterdam Institute of Global Health and Development. Further details of The BMJ policy on financial interests are here: https://www.bmj.com/sites/default/files/attachments/resources/2016/03/16-current-bmj-education-coi-form.pdf.
Provenance and peer review: Commissioned; not externally peer reviewed.