Fuelling the Global Fund

Lancet Infectious Diseases
Feb 2019   Volume 19  Number 2  p113-216, e39-e62

Fuelling the Global Fund
The Lancet Infectious Diseases
On Jan 11, 2019, the Global Fund to Fight AIDS, Tuberculosis and Malaria announced the fundraising target for its next 3 year replenishment cycle —“The single most important public health measure of 2019”, according to a blog by Jeffrey Sachs and colleagues published at the time of the announcement. The investment case was launched in Paris by French President Emmanuel Macron and calls for US$14 billion of donations—largely from national governments in wealthy countries—to cover the Global Fund’s sixth investment period of 2020–22. The $14 billion is just part of an estimated $83 billion that needs to be spent to fight the diseases over the 3 year period, most of which will come from domestic government budgets in affected countries. The full investment case will be presented at a meeting in New Delhi, India, on Feb 8, 2019, and France will host the Global Fund’s Sixth Replenishment Conference in Lyon on Oct 10, 2019.

The Global Fund was established in 2002 to support affected countries in controlling HIV/AIDS, tuberculosis, and malaria, and to bring the best science and management practices to bear on the diseases. Since 2002 there have certainly been major reductions in deaths and disease: the Results Report published on Sept 12, 2018, claims 27 millions lives saved as the result of partnerships in which the Global Fund has invested since its launch—ie, a fall by one-third in the number of deaths. In 2017 alone, nearly $4 billion was invested in partner countries, with 17·5 million people on antiretroviral therapy to treat HIV/AIDS, 5 million people treated for tuberculosis, and 197 million mosquito nets distributed. Maintaining this progress is vital to end the three epidemics as public health threats and meet Sustainable Development Goal 3—health and wellbeing for all—by 2030.

There are, however, challenges to be faced in staying on track towards the 2030 target. Although HIV/AIDS is gradually being brought under control via a treatment-as-prevention approach based on antiretroviral therapy, there is a risk of the response losing momentum, as discussed in our January, 2019, Editorial. Deaths from malaria have stopped declining, there has been a recent year-on-year increase in cases, and control is complicated by emerging resistance to insecticides and to artemisinin-based treatments. For tuberculosis, incidence of new cases is falling at about 2% per year, well shy of the 4–5% needed to bring the epidemic under control by 2030, and drug-resistant disease (more than half a million new cases per year) is a growing threat.

Political challenges must also be overcome for the next round of Global Fund replenishment to be a success. The USA has historically been the biggest donor, providing nearly a third of contributions. But at a time when the US administration seems more concerned with building barriers between people than uniting them, the future level of contribution remains uncertain. The Trump administration has requested $925 million for the Global Fund in 2019, down from $1·35 billion in 2018, but Congress usually provides more than the president requests, and the administration has said that pledges to the Global Fund are a “smart investment”. The UK has been the third largest donor (about 9%), but although the government commitment to keep international development funding at 0·7% of gross national income remains for now, while the country’s politics is preoccupied with the self-inflicted wounds of Brexit nothing can be guaranteed. Even the commitment of France, the second largest donor (12%), cannot be taken for granted at a time of national popular protests against the policies of Macron’s government.

Perhaps it’s time for the governments of rapidly growing economies to take up some of the slack from traditional donors. Sachs and colleagues suggest that China, a former recipient of Global Fund support but now the world’s second largest economy, should become a donor. These authors also suggest that to achieve its targets the Global Fund should be asking for at least twice the $14 billion it has requested, and that this gap in funding should be filled by donations from the pockets of the world’s billionaires.

Such broad philanthropy seems unlikely, except for a few enlightened individuals among the super-rich and their foundations. Nevertheless, at the very least the current level of support for the Global Fund needs to be maintained or we risk losing the gains that have been made, in which case the money will eventually have to be spent again. The Global Fund estimates that every dollar it spends brings $19 in health gains and economic returns—that seems a worthwhile investment in anyone’s terms.