Meaningful change or more of the same? The Global Fund's new funding model and the politics of HIV scale-up

Abstract

As we enter the fourth decade of HIV and AIDS, sustainability of treatment and prevention programmes is a growing concern in an environment of shrinking resources. The Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) will be critical to maintaining current trajectories of scale-up and ultimately, ensuring access to HIV treatment and prevention for people in low/middle-income countries. The authors’ prior research in India, Zambia and South Africa contributed evidence on the politics and impact of new institutional and funding arrangements, revealing a ‘rhetoric-reality gap’ in their impact on health systems, civil society participation, and achievement of population health. With its new funding strategy and disbursement model, the Fund proposes dramatic changes to its approach, emphasising value for money, greater fund predictability and flexibility and more proactive engagement in recipient countries, while foregrounding a human rights approach. This paper reviews the Fund's new strategy and examines its potential to respond to key criticisms concerning health systems impact, particularly the elite nature of this funding mechanism that generates competition between public and private sectors and marginalises local voices. The authors analyse strategy documents against their own research and published literature and reflect on whether the changes are likely to address challenges faced in bringing HIV programmes to scale and their likely effect on AIDS politics.

Keywords:

• Global Fund
• funding model
• aid volatility
• health systems
• human rights

Notes

1. This trend in the decline of rate of new infections has been rather consistent across Asia and Africa except Uganda, where the rate has been stable between 5% and 6%, as per the joint report by WHO, UNAIDS and UNICEF (2011) on the progress with HIV/AIDS response.

2. The term ‘diagonal’ is described by Julio Frenk (2006) as a strategy that utilises explicit intervention priorities to drive the required improvements into the health system across all its functions including human resource development, financing, facility planning, drug supply, rational prescription and quality assurance.