The U.S. & The Glbal Fund t Fight AIDS, Tuberculsis and Malaria The Glbal Fund t Fight AIDS, Tuberculsis and Malaria (Glbal Fund) is an independent, multilateral, financing entity designed t raise significant new resurces t cmbat HIV/AIDS, tuberculsis (TB), and malaria in lw- and middle- incme cuntries. First prpsed in 2001, the Glbal Fund began peratins in January 2002 and receives funding frm bth public and private dnrs t finance prgrams develped and implemented by recipient cuntries using a cuntry-defined r demand-driven mdel (by cntrast, bilateral supprt is prvided frm dnrs directly t recipient cuntry gvernments, nn-gvernmental rganizatins, and ther entities and ften reflects dnr-defined pririties). T date, dnr gvernments, which accunt fr apprximately 95% f ttal financial supprt, have pledged $41 billin, and the Glbal Fund has apprved almst $38 billin in grants t ver 150 cuntries. 1,2 The U.S. has played an integral rle in the Glbal Fund since its inceptin. During the administratin f President Gerge W. Bush, the U.S. prvided the Glbal Fund with its funding cntributin and was invlved in the initial negtiatins n the multilateral rganizatin s design. The U.S. maintains a permanent seat n the Glbal Fund Bard, giving it a key rle in gvernance and versight, and has cnsistently been the Glbal Fund s single largest dnr (see Table 1). 1,2,3 The Glbal Fund has been called the multilateral cmpnent f the U.S. President s Emergency Plan fr AIDS Relief (PEPFAR), 4 serving as an imprtant part f the U.S. gvernment s glbal health respnse, expanding its reach t mre cuntries, and leveraging additinal dnr resurces. During the Obama Administratin the rle f internatinal cperatin and multilateral institutins, including the Glbal Fund, has been highlighted as necessary fr meeting and sustaining the respnse t the wrld s challenges. 5, 6 The administratin has als pledged significant resurces t the Fund. In Octber 2010, the administratin annunced a three-year (FY11-FY13), $4 billin pledge t the Glbal Fund the first time the U.S. made a multi-year pledge t the Glbal Fund. The U.S. hsted the FY14-FY16 replenishment cycle and pledged an additinal $4 billin. 7,8 Mst recently, the administratin annunced a pledge f $4.3 billin fr the FY17-FY19 replenishment cycle. 9 Still, there have been nging questins abut the apprpriate balance f U.S. funding between the Glbal Fund and U.S. bilateral prgrams, the rle f multilateralism in U.S. glbal health plicy, the Glbal Fund s ability t prevent and address crruptin, and the Glbal Fund s sustainability given a shrtfall in the availability f resurces t meet cuntry demand. 10,11
United States $13.2 32.4% $12.0 31.7% France $5.0 12.3% $4.6 12.1% United Kingdm $3.6 8.9% $3.4 8.9% Germany $2.8 6.9% $2.7 7.2% Japan $2.7 6.5% $2.5 6.7% Eurpean Cmmissin $2.1 5.1% $2.0 5.3% Canada $1.9 4.7% $1.7 4.6% All Other Cuntries $7.5 18.2% $6.9 18.2% Nn-Gvt Dnrs $2.1 5.1% $2.0 5.4% *Includes pledges made fr the perid 2001-2016 as well as thse made with year f cmmitment yet t be cnfirmed. Pledge amunts are calculated in U.S. dllars and are, therefre, subject t exchange rate fluctuatins. Amunts were cnverted t U.S. dllars using the Federal Reserve Freign Exchange Rates tables. 12 Ttals may nt sum up due t runding. 13 14 The Glbal Fund was established as an independent fundatin under Swiss law and perates as a multilateral financing entity. Funding is currently prvided t recipient cuntries using a perfrmance-based funding system where a grant is regularly mnitred and evaluated t determine if it shuld be extended r discntinued based n the effectiveness f the prgram. In additin, the Glbal Fund launched a new funding mdel in 2013 that, amng ther things, creates a mre flexible timeline fr eligible cuntries t apply and allws fr a fcus n high disease burden and lw resurce settings. 15,16 The Glbal Fund s rganizatinal structure includes a brad set f stakehlders, and the U.S. gvernment is invlved in many f its cre structures: Bard. The Bard guides plicy and strategic decisins and apprves all funding. There are 20 vting and 8 nn-vting members as fllws: Develping cuntries: 7 members, 1 frm each f the six WHO regins and an additinal member frm Africa; Dnrs: 8 members, including the U.S. which has a permanent Bard seat, and has served as Bard Chair in the past. The U.S. is currently vice-chair f the Strategy Cmmittee and sits n the Audit and Finance Cmmittee as well as the Ethics and Gvernance Cmmittee. 17 Civil Sciety/Private Sectr: 5 members. Nn-vting: 8 members, including the Glbal Fund Executive Directr, the Bard Chair and Vice-Chair, ne representative frm Glbal Fund partner rganizatins, ne representative each frm WHO, UNAIDS, the Wrld Bank, and a Swiss citizen as required by Swiss law. Secretariat. Based in Geneva, the Secretariat manages day-t-day peratins. Because the Glbal Fund finances but des nt implement prgrams, it des nt maintain any in-cuntry staff. The U.S. & The Glbal Fund t Fight AIDS, Tuberculsis and Malaria 2
Technical Review Panel (TRP). An independent bdy f glbal health and develpment experts (which has included U.S. gvernment experts) appinted by the Bard t evaluate the merits f all prpsals and make funding recmmendatins t the Bard. Technical Evaluatin Reference Grup (TERG). An independent bdy f glbal health and develpment experts appinted by the Bard t prvide versight n the Fund s evaluatin effrts, including evaluatin f the Glbal Fund business mdel, investments, and impact. Office f the Inspectr General. An independent bdy f the Glbal Fund that reprts directly t the Bard thrugh its Audits and Ethics Cmmittee, the Office f the Inspectr General prvides the Bard with audits and investigatins f the Funds activities, in an effrt t prmte gd practices, reduce funding risks, and reprt n ptential abuse. Cuntry Crdinating Mechanisms (CCMs). The cuntry-level entity cmprised f public and private sectr representatives, such as gvernments, businesses, and nn-gvernmental rganizatins (NGOs), that submits prpsals t the Glbal Fund and versees funded grants within a cuntry. U.S. representatives sit n CCMs in almst all PEPFAR fcus cuntries and ften help with prpsal develpment. The U.S. has als entered int MOUs in several cuntries t bring tgether PEPFAR with Ministries f Health and the Glbal Fund t clarify cllabratin and partnership activities, particularly in the area f antiretrviral drug prcurement. Principal Recipients (PR). The legal entity chsen by the CCM t receive Glbal Fund disbursements, implement prgrams r cntract with sub-recipients, and prvide regular reprts and prgress updates t the Secretariat. Lcal Funding Agents (LFA). Since it des nt have an in-cuntry presence, the Glbal Fund cntracts with a lcal entity (usually an accunting firm) t mnitr prgram implementatin, ensure financial accuntability, and prvide funding recmmendatins t the Secretariat. As f September 2016, the Glbal Fund had apprved mre than $37 billin in funding and disbursed apprximately $31 billin t ver 120 cuntries, including cuntries that als receive U.S. bilateral supprt fr HIV, tuberculsis, and/r malaria, but als many thers that d nt (see Table 2). 1,2 Funding supprts a wide range f care, treatment, and preventin activities and health systems develpment and strengthening. The Sub- Saharan African regin has received the largest share f apprved funding (65%), fllwed by the Asia and the Pacific regin (19%). 18 Mst apprved funding has supprted HIV prgrams, fllwed by malaria and TB (see Table 2). The Glbal Fund, which was the secnd largest dnr t health prgrams in 2014 (the U.S. was the largest), 19 estimates that, since 2002, its grants have helped avert the deaths f 20 millin peple wh wuld have therwise died due t cmplicatins frm AIDS, tuberculsis, r malaria. 20 The U.S. & The Glbal Fund t Fight AIDS, Tuberculsis and Malaria 3
Apprved Grant Funding (billins) $18.8 $5.8 $10.5 $0.72 % f Apprved Grants 50.8% 15.8% 28.2% 1.9% # Cuntries Receiving Grants* 120 107 80 14 Nte: Jint HIV/TB grants, which accunted fr $1.2 billin (3.2%) in apprved grant funding, are nt included. *Represents cuntries that received apprved grant funding; Ksv and Zanzibar are nt cunted and are cnsidered part f Serbia and Tanzania, respectively. ** Other refers t what was previusly classified as Health Systems Strengthening. In additin t U.S. gvernance and versight f the Glbal Fund, U.S. financial supprt has been significant and a key cmpnent f U.S. invlvement (see Figure 1). 2 The U.S. first cntributed t the Glbal Fund in FY 2001 thrugh annual apprpriatins bills. 21 All U.S. supprt fr the Glbal Fund was then incrprated int PEPFAR when it was created in 2003. 22 At that time, Cngress authrized up t $1 billin fr the Glbal Fund fr FY 2004 and such sums as may be necessary fr FY 2005-2008. 23 In the 2008 reauthrizatin f PEPFAR, Cngress authrized up t $2 billin in FY 2009, and such sums as may be necessary fr FY 2010-2013. 4 In 2013, Cngress again reauthrized PEPFAR including such sums as may be necessary fr the Glbal Fund thrugh 2018. Cngress earmarks supprt fr the Glbal Fund each year as part f PEPFAR apprpriatins, and funding is typically prvided thrugh the State Department, althugh funding has als been prvided thrugh USAID and NIH. Between FY 2001 and FY 2016, Cngressinal apprpriatins t the Glbal Fund have ttaled $14.0 billin, including $1.35 billin in FY 2016. President Obama requested $1.35 billin fr FY 2017. 2 Cngress has histrically matched r prvided mre t the Glbal Fund each year than the President has requested, but it has als placed restrictins n U.S. cntributins and raised cncerns abut mnitring and evaluatin: 2,4,10,24 Figure 1 U.S. Glbal Health Funding: The Glbal Fund, FY 2001- FY 2017 Request $100 In Millins $175 $347 $547 $347 $545 $724 $840 $1,050 $1,046 $1,000 $1,300 $1,650 $1,569 $1,350 $1,350 $1,350 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 Request NOTES: : Includes Glbal Fund cntributins prvided thrugh the State Department, USAID, and NIH. Includes base and supplemental funding. FY13 includes the effects f sequestratin. SOURCE: Kaiser Family Fundatin analysis f data frm the Office f Management and Budget, Agency Cngressinal Budget Justificatins, Cngressinal Apprpriatins Bills, and U.S. Freign Assistance Dashbard [website], available at: www.freignassistance.gv. Requiring that ttal U.S. cntributins d nt exceed 33% f ttal cntributins frm all dnrs, a prvisin that was part f the riginal PEPFAR authrizatin and maintained in the reauthrizatin. Designed t leverage U.S. cntributins t increase supprt frm ther dnrs and t limit the U.S. The U.S. & The Glbal Fund t Fight AIDS, Tuberculsis and Malaria 4
frm becming the predminant dnr t the Glbal Fund, it was invked nly nce, in FY 2004 when apprpriated funds were held back until the fllwing fiscal year when the 33% cap wuld nt be exceeded. Setting aside 5% f U.S. cntributins t cver the cst f technical assistance t Glbal Fund grantees, a prvisin first included in freign peratins apprpriatins bill language in 2005 and in subsequent years. Authrizing the Secretary f State t withhld 20% f the U.S. cntributin until the Glbal Fund culd demnstrate imprved versight and accuntability in grant disbursement; first required as part f freign peratins apprpriatins in 2006 and again in 2008, this prvisin was reduced t 10% in the 2009 apprpriatins, was nt included in the 2010 and 2011 apprpriatins, and was reinstated at 10% in the 2012 apprpriatins, and has remained at that amunt since then. Requiring, as part f the FY 2012 thrugh FY2016 apprpriatins bills, that the Administratin cnsult with Cngress prir t making multi-year funding pledges. While the Glbal Fund has cntributed t significant glbal scale-up f resurces, service delivery, and cverage t cmbat HIV, TB, and malaria, 25 and been described as cmplementing PEPFAR bjectives, 26 the extent f U.S. invlvement in the Glbal Fund is an nging discussin, ne that takes n new imprtance as the Administratin, Cngress, and the Glbal Fund make decisins in a resurce cnstrained setting. These issues include: The future f U.S. financial cmmitments t the Glbal Fund, including questins abut the U.S. fair share relative t ther dnrs, particularly in light f demand frm recipient cuntries; The apprpriate balance between U.S. supprt fr multilateral effrts, such as the Glbal Fund, which allw fr the leveraging f available resurces, greater reach, and enhanced crdinatin, and bilateral prgrams, which allw fr increased cntrl and versight; The ability f the U.S. and the Glbal Fund t crdinate and cmplement effrts t address the impacts f HIV, TB, and malaria when the availability f resurces has becme cnstrained. The U.S. & The Glbal Fund t Fight AIDS, Tuberculsis and Malaria 5
1 The Glbal Fund: http://www.theglbalfund.rg/; as f September 2016. 2 Kaiser Family Fundatin Analysis. 3 White Huse. President Annunces Prpsal fr Glbal Fund t Fight HIV/AIDS, Malaria and Tuberculsis; May 11, 2001. 4 U.S. Cngress. Public Law N: 110-293; July 30, 2008. 5 White Huse. Statement by the President n Glbal Health Initiative; May 5, 2009. 6 White Huse. Fact Sheet: U.S. Glbal Develpment Plicy, September 22, 2010. 7 U.S. State Department. Obama Administratin s Pledge t Glbal Fund t Fight HIV/AIDS, Malaria and Tuberculsis. Octber 5, 2010. 8 The Glbal Fund. Furth Vluntary Glbal Fund Replenishment Pledges. December 2013. 9 The U.S. pledge t the Glbal Fund fr the FY17-FY19 perid is t match ne dllar fr every tw dllars in pledges made by ther dnrs up t $4.3 billin (see White Huse, Office f the Press Secretary. Statement by Natinal Security Advisr Susan E. Rice n the United States' Glbal Fund Pledge; August 31, 2016). Final funding amunts are dependent n Cngressinal apprval. 10 U.S. Senate Cmmittee n Freign Relatins (Minrity Staff Reprt). Fraud and Abuse f Glbal Fund Investments at Risk withut Greater Transparency; April 5, 2011. 11 The Glbal Fund. The Glbal Fund Strategy 2012-2016. Nvember 2012. 12 Federal Reserve. Freign Exchange Rates. Accessed August 2016 frm https://www.federalreserve.gv/releases/h10/hist/. 13 The Glbal Fund. The Glbal Fund t Fight AIDS, Tuberculsis & Malaria: By-laws, As Amended; Nvember 21, 2014. 14 Center fr Glbal Develpment, Overview f the Glbal Fund t Fight AIDS, Tuberculsis and Malaria. 15 The Glbal Fund. Glbal Fund Launches New Funding Mdel; February 28, 2013. 16 The Glbal Fund. Funding Mdel Overview; Accessed February 3, 2016. 17 The Glbal Fund. Electrnic Reprt t the Bard: Appintment f the Vice-Chair f the Finance and Operatinal Perfrmance Cmmittee. May 2015. 18 The Glbal Fund. Glbal Fund Results Reprt 2016; September 2016. 19 Kaiser Family Fundatin Analysis f OECD DAC CRS database; September 2016. 20 The Glbal Fund. Glbal Fund Reprt Shws 20 Millin Lives Saved; September 1, 2016. 21 Cngressinal Research Service. The Glbal Fund t Fight AIDS, Tuberculsis, and Malaria: Issues fr Cngress and U.S. Cntributins frm FY2001 t the FY2012 Request; July 1, 2011. 22 U.S. Cngress. Public Law N: 108-25; May 27, 2003. 23 The Glbal Fund. Strategic Investments fr Impact: Glbal Fund Results Reprt 2012; September 2012. 24 U.S. Cngress. Public Law N: 112-74; December 23, 2011. 25 Kaiser Family Fundatin, Dnr Funding fr Health in Lw- & Middle-Incme Cuntries, 2002-2013; Nvember 2015. 26 Cngressinal Research Service. The Glbal Fund and PEPFAR in U.S. Internatinal AIDS Plicy; Nvember 3, 2005. The Henry J. Kaiser Family Fundatin Headquarters: 2400 Sand Hill Rad, Menl Park, CA 94025 Phne 650-854-9400 Washingtn Offices and Barbara Jrdan Cnference Center: 1330 G Street, NW, Washingtn, DC 20005 Phne 202-347-5270 www.kff.rg Email Alerts: kff.rg/email facebk.cm/kaiserfamilyfundatin twitter.cm/kaiserfamfund Filling the need fr trusted infrmatin n natinal health issues, the Kaiser Family Fundatin is a nnprfit rganizatin based in Menl Park, Califrnia.