Virtual Mentor. December 2006, Volume 8, Number 12: 839-842.
How Has the Global Fund Affected the Fight against AIDS, Tuberculosis and Malaria?
Josh Ruxin, MPH, PhD
The Global Fund to Fight AIDS, Tuberculosis and Malaria—one of the most important vehicles for delivering life-saving drugs and treatment to the world’s poor—has virtually transformed public health delivery in its four short years of existence. Unfortunately, in spite of its success—it currently has disbursed nearly $3 billion for 371 projects in 129 nations—full funding has not yet been pledged .
The success of the fund largely derives from its operational strategy: it serves as a financial donor but not advisor to countries’ health programs. It is indeed an innovative approach because recipients drive the planning and implementation process. The fund-supported programs are thus tailored to local needs, benefit from the enthusiasm and commitment that comes with a sense of ownership, and help build the managerial expertise and institutional capacity necessary for improving national health care systems.
Unlike the heavy-handed programs of the past, the fund finances projects that tend to be led by government or nongovernmental organizations. The onus is thus on them, not the fund, to deliver results. The fund supports programs that “focus on performance by linking resources to the achievement of clear, measurable and sustainable results” . From the fund’s genesis, it was made clear that when the time came to renew grants, “grantees not producing sufficient positive results would not receive additional funds” .
Why the Global Fund is Good for the World
Many Global Fund programs are meeting or exceeding their targets—programs in countries like China, Ghana, Honduras and Rwanda reached 80 percent of their original two-year goals during their first years of operation . Depending on how one judges, anywhere from one-quarter to one-half of Global Fund recipients have met or exceeded the ambitious goals they set for themselves. And even a 25-percent success rate would be staggering, considering the troubling history of public health endeavors in poor countries. Many of the recipients are worthy of renewed financial support. Sadly, an increase in their funding is not guaranteed.
The primary difference between the successful Global Fund programs and other deserving but underperforming programs is that those in the former group operate in countries where health care systems are already in place. They have hospitals and doctors and competent health ministries; they have mechanisms for running public education campaigns, for setting up testing clinics, for delivering medication to patients. For these countries, the infusion of significant Global Fund money is precisely the key to finally beating AIDS, tuberculosis and malaria. In the less fortunate countries, however, money isn’t enough. Without the expertise and the health systems, the millions of dollars are not spent effectively—and in many cases may not be spent at all.
It is precisely that innovative recipient-driven structure, however, which has led so many of those potentially successful projects to struggle mightily. Ultimately, the problem with autonomy and self-direction is that, within many recipient countries, the necessary expertise and capacity to effect fundamental change simply do not exist. This weakness extends far beyond the well-documented dearth of doctors and nurses in poor countries. Many health ministries in sub-Saharan Africa, long deprived of any real financial support, simply do not know how to handle millions of dollars in grants. On a macro level, they need to learn how to plan a country-wide scale-up of AIDS clinics or a national fight against malaria. On the micro level, they must hire thousands of medical workers, choose recipients for antiretroviral medication, distribute mosquito nets and track patients. Some of the deficiencies result from a lack of training. For example, health ministry workers may not know how to use a computer. Other deficiencies stem from a lack of capital, as when there simply are no computers to use.
Needed: More Human Capital
The solution to these problems is not to cut funding. Rather, we must invest even more capital, this time human, in the fight. Full-time, on-the-ground advisors with backgrounds in business management, public health and government must be enlisted to work with recipient governments and Global Fund projects to craft and implement national health policies, and to train local officials to manage programs big and small.
In Rwanda, Columbia University’s Access Project has helped build capacity for Global Fund programs since 2003. Advisors have worked on both strategic plans and proposals and on implementation. The project was instrumental in writing proposals to improve the lives of people living with HIV and AIDS by engaging entire communities in a solidarity-building mutual health care model, increasing health security through consistent access to care as well as by encouraging the general utilization of health care, and by fostering financial security through micro-projects and income-generating activities. Between 2003 and 2004, the Access Project helped implement a Global Fund-financed program to scale up access to HIV voluntary counseling and testing. Of course it provided big-picture support by helping to develop management plans, report templates and drug distribution mechanisms. In addition, though, it featured day-to-day support, training government officials to create budgets, manage subordinates and coordinate activities that required the input of several partners. When the project began, there were only three places in Rwanda to receive counseling and testing. After 12 months of around-the-clock effort, there were 70, and today that number has increased to nearly 120 Global Fund-financed sites .
In the coming year, the Global Fund will have to make tough choices since it is short $1 billion in pledges for 2006 and another $2.6 billion for 2007 . That means the fund will literally have to turn down good proposals which are slated to save lives immediately. This unacceptable outcome must be fought fiercely by all who care about seeing the end of these diseases and the expansion of health care to the world’s poor. Donor nations, foundations and even the private sector can turn the fund’s financial situation around quickly. Together, they can ensure that the perpetual loss of lives from AIDS, tuberculosis and malaria is ended.
Josh Ruxin, MPH, PhD, is assistant clinical professor of public health at the Mailman School of Public Health and director of the Access Project for the Global Fund to Fight AIDS, Tuberculosis and Malaria at the Center for Global Health and Economic Development—a joint venture of the Mailman School of Public Health and the Earth Institute at Columbia University in New York City. He is also country director for the Millennium Village Project in Rwanda and a member of the Global HIV Prevention Working Group.
The viewpoints expressed on this site are those of the authors and do not necessarily reflect the views and policies of the AMA.
© 2006 American Medical Association. All Rights Reserved.