Combating disease: A stretched safety net

In deciding where best to tackle the world’s 800,000 annual death toll from malaria, China is seldom the first place that comes to mind. For that very reason, the country has become a big talking point, however, as international donors debate how to spend their increasingly squeezed funds.

Over the past decade, the UN-backed Global Fund to Fight Aids, Tuberculosis and Malaria has pledged it $144m to fight the parasite. Yet China is not only one of the world’s fastest-growing economies but is also where most of the sweet wormwood grows that provides the most effective cure. Never mind that, in the world’s most populous nation, a mere dozen people a year die from the ailment.

Since its creation by governments at the turn of the millennium, as a revolutionary new way to channel their aid to tackle the world’s big killer diseases, the Geneva-based Global Fund has pledged $22bn from governments to save millions of lives in poorer countries around the world.

After a period of fast expansion, and strong progress in tackling Aids, TB and malaria alike, the fund has become a target in the era of austerity. With a shift in power between the world’s traditional and emerging economies, and donors seeking ways to cut support, billions of dollars and millions of lives are at stake.

In the week the organisation should have been celebrating its 10th anniversary at a board meeting in Ghana, it instead had its most bruising ever gathering. It scrapped its next round of grant applications and imposed on itself an intense internal restructuring against a backdrop of demands for improved efficiency. “We’ve got to be a much smarter in how we give out money,” says Brian Brink, medical director at Anglo-American, the southern African mining group, and a director of the Global Fund, who fiercely defends its achievements to date but supports a wide-ranging overhaul for the future. “We must have value for money.”

Allegations of corruption this year triggered calls for reform by a high-level panel of politicians and officials – recommendations that were adopted this week. But China highlights a different issue: how much the Global Fund and its counterparts gave too easily to the wrong countries, for the wrong diseases, to pursue the wrong policies and in the wrong way. To survive, the organisation will need to overhaul how it is governed, who receives money and how it is spent.

When it was created in 2001 as a way to channel donor money from richer countries to poorer ones with a heavy burden of infectious disease, the fund was pioneering. Sir Richard Feachem, its founding executive director, says: “The Global Fund has not only achieved remarkable impact in tackling disease and death, but also successfully implemented a new business model for development finance. However, on its 10th anniversary and in the face of declining income, significant reforms are overdue.”

From the start, the organisation was distinctive in several ways. One is transparency: funding requests, results, audits and board minutes are all published on its website. Its openness has made it the sometimes disproportionate target of critics, while counterparts – from the UK’s Department for International Development to the US Agency for International Development and the World Bank – are shielded by greater opacity.

A second was its ability to provide long-term support through regular “rounds”, or requests for funding from countries in need. That created stability compared with conventional short-term bilateral aid, which is subject to annual budgetary reviews.

The third characteristic was its hands-off approach. Donors are often accused of dictating aid programmes seen as patronising, self-interested and faddish. By contrast, Global Fund programmes are “country-led”. Recipient nations themselves set the priorities and are given places on the governing board alongside donors.

However, since the global financial crisis, the context has radically changed. Craig McClure from the World Health Organisation says: “In the first few years, the Global Fund was an emergency response to diseases drastically underfunded for two decades. There was not a lot of focus on which were the best interventions to be funded. Now, apart from the economic challenges, we have learnt a lot and need to be more efficient.”

PEPFAR: ‘We’ve created huge savings with no drop in quality’

Its objectives – and recent funding pressures – may be identical to those of the Global Fund but the operations of Pepfar, the US government’s bilateral Aids relief agency, have been the mirror opposite.

Where the Global Fund is a hands-off conduit for financing HIV prevention and treatment programmes across the developing world, Pepfar has chosen to run its own programmes in a small number of low-income countries where the virus inflicts a big burden.

Launched under President George W. Bush, it has brought unprecedented American support to tackling Aids in the developing world, saving millions of lives. Pepfar also provided the model for a similarly top-down US disease programme for malaria.

The advantage has been in its ability to push aggressively to implement its chosen policies and manage them tightly. That has allowed it to implement efficiency savings at a time of US political pressure to limit spending – such as centralised drug procurement, the use of lower-cost transport and a single system for managing clinics.

“We’ve been confronted with an economic decline and taken every opportunity to be smart and efficient while saving the maximum number of lives,” says Eric Goosby, its head. “We’ve created huge savings with no drop in quality, increasing the number of lives saved with a budget that didn’t change.”

Critics point out that Pepfar has a high cost base, including a substantial overhead in employing many US-based charities with expatriates to manage its projects. Its priorities have also been dictated partly by political views, including the former Republican administration’s belief in promoting sexual abstinence among schoolchildren as a big priority.

But few studies have attempted to compare the costs and results of the Pepfar and Global Fund programmes, which are often intertwined. The two agencies agreed several years ago to avoid “double counting” and share a total estimate of how many Aids deaths they had jointly prevented.

The Global Fund, with its small staff, sometimes “piggy-backed” on Pepfar officials for local help, including when medicines ran out of stock. Recipients of Pepfar grants are now concerned that, just as demand for its projects is rising, a drop in funds threatens the sustainability of their programmes.

In the coming years, a convergence of the two approaches is likely, with the hope of maintaining locally based projects funded by a mixture of bilateral, multilateral and domestic money.

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A first modification many see as necessary is a tightening of focus towards countries and programmes that most merit help. China, India, Brazil and Russia have all received substantial funding, but critics argue that such increasingly rich governments should be supporting their own programmes more – and funding poorer nations.

“You need a set of agreed rules applied to whatever money is available,” says Robert Hecht at the Results for Development Institute, a Washington think-tank. “Funding should not be an entitlement but [ought to] depend on certain criteria such as income levels and disease burden.”

Equally, Global Fund support – like that from other donors – is often not allocated to the most effective projects. In Africa, some funding has promoted sexual abstinence by teenagers, for example, despite scant evidence that it results in a drop in HIV infections. “Voluntary counselling and testing” projects are widespread, but few are linked to treatment, without which the benefit is modest. Patients with HIV also often contract TB, yet are not referred from one medical speciality to the other. Meanwhile, approaches shown to have the greatest impact have been insufficiently funded. These include adult male circumcision, drugs for infected mothers to prevent transmission to newborn babies, and the wider and earlier use of treatment to reduce the spread of HIV.

Although it reviews progress with its grants, and sometimes ceases further support, the Global Fund has largely judged programmes by inputs, processes or outputs – the number of people receiving HIV and TB treatment and the distribution of insecticide-impregnated bed nets to prevent malaria – rather than the ultimate outcomes of a reduction in disease and related deaths.

There has been less attention to whether patients take their medicines properly and remain on treatment, without which drug resistance rises sharply, or ensuring that bed net distribution is accompanied by sufficient education to ensure their proper use.

A second issue for reform is how to reduce the cost of programmes. With nearly 40 per cent of Global Fund grants spent on commodities such as medicines, diagnostics and netting, there is substantial scope for pooled procurement among countries and other methods to negotiate better terms from suppliers. The fund fully underwrites programmes in countries that pay widely varying prices. Until last year, for instance, South Africa was paying more than one-quarter more than the international average price in lower-income countries for antiretroviral medicines.

While the Global Fund encourages countries applying for support to conduct operational research to help identify efficiencies, little money is allocated in this way in practice. Studies have only recently begun analysing the relative costs of providers funded by the agency compared with those backed, for instance, by Pepfar, the US government’s Aids programme. “We need high-quality services at the lowest cost,” says Stefano Bertozzi, head of HIV at the Bill & Melinda Gates Foundation, which supports a range of projects to improve efficiency, from the use of community health workers to reducing medicines’ raw materials costs.

Mead Over, an economist at the Centre for Global Development, a think-tank, calls for “performance-based funding”, which would reward countries that have demonstrated reductions in infections and deaths. Others suggest that the fund should at least set a cap on the price of a standard package of services it will support. Rifat Atun, the Global Fund’s director of strategy, estimates that “reprogramming” $12bn in grants already approved but not yet disbursed could generate efficiency savings of up to 40 per cent by next year, resulting in a similar increase in infections prevented or treated.

The new mantra is “informed demand”, gently steering countries to seek funding for programmes that are likely to deliver better results. “There is no option B,” says Mr Atun. “The direction is clear and the journey has begun. We need the right fuel and the drivers to support the process.”

Others warn against any temptation to withdraw too readily from countries that have made substantial progress. “We have to focus where there is the greatest burden, but in places that have made substantial recent progress like Zambia, cutting support would be like releasing a spring and lead to a resurgence in disease,” says Rob Newman, head of the World Health Organisation’s malaria programme.

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While Global Fund programmes may have limitations, they can have positive results beyond their immediate remit. Paul De Lay, deputy executive director at UNAids, the world body’s agency on the disease, says: “Global Fund money for HIV had incredible leverage in China, opening the door to sensitive issues such as working with sex workers, drug users and addressing issues around human rights.”

For all the fund’s faults, moreover, the danger is that the alternatives are worse. Moscow no longer takes money from the organisation, providing more cash itself instead. But despite an HIV epidemic that in Russia is concentrated among injecting drug users, few programmes there target that segment of the population. The result: an increase in infections, at a rapidity unmatched anywhere in the world.

Russia has outlawed methadone substitution for opiate addicts, one of two approaches demonstrated to work, and frowns on the other: the provision of clean syringes. Anya Sarang, who runs one such project in Moscow, says: “The Global Fund was very helpful. We used to have 80 [fragmented] programmes in Russia. Soon we will have just one or two.”

A final reform for the Global Fund is its governance. Its sprawling board has up till now proved reluctant to support greater targeting of funds. Its directors have often seemed unaccountable, as well as unwilling to plan for the inevitability of donor cuts and authorise a more ruthless pruning of the portfolio of projects.

This week, it approved the appointment of a new top manager and a more professionalised board. Simon Bland, the UK government’s director who has recently taken over as chairman, says: “We do need to do a course correction. That’s clearly been taken on board by the executive. The need to change is no longer in dispute.”