France will host the Sixth Replenishment Conference for the Global Fund to Fight AIDS, Tuberculosis and Malaria in 2019. The result may make or break the Global Fund. Although the date of the conference is not formally confirmed, it is likely to be sometime between June, when France will host the G7, and September (the UN General Assembly in New York). With a pre-replenishment conference expected around January, the investment case for donors needs to be ready by the end of 2018. And, with a crucial Global Fund Board meeting in November, there are only 4 months left to decide the broad outlines of that case. This terrifyingly narrow time window matters because the Fund remains uncertain about its argument for replenishment. Uncertainty before one of the most important moments in the Fund’s history is not a good place to be.
The Global Fund has a choice. It could pursue a strategy of more of the same. The Fund has been the most successful financing instrument in global health since its creation in 2001. It has delivered impressive returns on its investments and has built confidence among donors. The Fund could reprise its past successes next year and argue that donors should continue to support those successes. But such an approach carries serious risks. The world has changed since the Fund’s inception. The US and UK, once champions of global health and the Fund, are now indifferent bystanders, preoccupied by their own psychic dramas. Post 2007–08, money is tight. Demands on governments have expanded. The Fund has another choice. A creature of the MDG era, the Fund could present a plan and investment case for how it will reinvent itself in an SDG era. It could argue that the global health agenda is now much broader, requiring a very different response from the Fund. Is it ready to make such a major strategic shift?
The Fund’s Executive Director, Peter Sands, together with the Chair of the Board, Aida Kurtović, must seize the opportunity to write a new narrative for the Fund to enable it to adapt to its new political and economic environment. The days when donor contributions outstripped spending are long gone. The 2019 replenishment cannot be business as usual. Here is the argument they might consider. The present era is about one big idea—sustainability. In health, that means universal health coverage (UHC): strong health systems based on effective primary health care. AIDS-focused institutions, including the Global Fund, must broaden their mandates to address this larger objective of global health. This means an “ATM plus” strategy: AIDS, tuberculosis, and malaria plus UHC. Two conditionalities are important. First, this approach does not mean cutting existing resources for ATM and redirecting money to health systems. Instead, it means a step change in the financing “ask” to meet future ATM needs and to begin to address the UHC funding gap. But the ask should not be the bottomless pit of UHC. All experience tells us that calls to invest in health systems are met with scepticism by donors. Instead, the Fund should be specific: health workers, health information, and governance and accountability. All three priorities are crucial to deliver UHC, and they do much to guarantee the effectiveness, efficiency, and value for money of the Fund’s existing ATM programmes. This strategy should be based, as it was in 2001, on the economic and security case for investment. There are, of course, other questions the Fund must consider. How far should it embrace the private sector? What is its strategy for middle-income countries? How can the Fund leverage domestic investments, especially to cover costs of treatment? How can the Fund be a better partner with other global health initiatives? Replenishment of the Global Fund will not only be a test of confidence in the Fund. It will also be a test of donor commitment to multilateralism. In the Trump–Brexit era of strategic withdrawal, Europe has the opportunity to reinvigorate a spirit of cooperation among nations, with hard financial deeds matching warm admiring words. The next 4 months will be a time to decide whether the Global Fund has the courage to change its narrative. It will also be the time when Europe has the opportunity to lead not only the strengthening of the Global Fund, but also the birth of a new era of global leadership for the continent.
By Richard Horton