PEPFAR and Global Fund: A Match Made in Heaven?

One of the many interesting sessions at the International AIDS Conference was on how PEPFAR and the Global Fund could collaborate more strategically to maximize impact. The motivation for this kind of collaboration isn’t news to anyone in global health: at a time of budget austerity and flat lining aid contributions, a great way to maximize impact is to harmonize, coordinate and pool donor resources. Seeing that PEPFAR and the Global Fund together make up over 90 percent of funding for the fight against HIV/AIDS (see here for a map of where both payers operate), a marriage of these two agencies seems to be a match made in heaven.The session, which featured insight from high-level PEPFAR and Global Fund officials, focused on the progress made and challenges faced as the two funding agencies try to increase collaboration, followed by three country-level perspectives from Haiti, Tanzania and Malawi. While these three countries face very different types of HIV epidemics and funding levels, they have had similar experiences in terms of cooperation between the two funders.First, the challenges faced by these three countries, as well as executive offices in Washington DC and Geneva:

• Lack of a single reporting system: Donors require recipients to report how funding is spent, which can put a considerable burden on countries with limited human resources and multiple reporting channels.  For example, PEPFAR and the Global Fund have different reporting guidelines, which also differ from national recording guidelines in terms of frequency and depth of information. As a result, while both organizations champion transparency (Global Fund more so than PEPFAR) publicly available data on what both funders fund is often unavailable and inconsistent (see here).
• Volatility and unpredictable funding: In Tanzania, both donors have had problems with disbursement delays and managing their funding cycles which do not align with national planning cycles. Similarly, in Malawi, the status of the next grant is uncertain as it is set to end in less than two years. Such volatile funding is only exacerbated by incompatible disbursements schedules from both funders.
• Donor funding is still too fragmented and complicated: In Haiti, $40 million of HIV/AIDS funding by the US government has been implemented through 31 partners last year. Malawi suffers from parallel supply chains for HIV commodity procurement, and there is no solid proof that both payers are looking to pool their procurement together and eliminate duplicities in service delivery.

Nonetheless, progress towards resolving these issues, while still on a micro-scale, is encouraging:

• Coordinating technical assistance: In Tanzania, for example, the Global Fund’s country coordinating mechanism, TACAIDS, also coordinates PEPFAR’s efforts in technical assistance and health systems strengthening. PEPFAR has been funding a comprehensive costing and commodity forecasting study, which will benefit both funders. In Haiti, both organizations are mapping contributions, identifying duplicities, and developing cost-sharing principles. In Malawi, PEPFAR has been shifting towards supplying mostly technical assistance, whereas the Global Fund is focusing more on the procurement of commodities.
• Coordinating procurement: The Global Fund has a voluntary pooled procurement mechanism which it’s seeking to expand in the upcoming months. This will complement attempts to reform country coordinating mechanisms to include a PEPFAR liaison. Similarly, the Global Fund is seeking to harmonize supply chain management for more efficient use and coverage, which would help coordinate procurement between the two funders.
• Eliminating duplicities in reporting and increasing data quality: Paul Bouey, Deputy US Global AIDS Coordinator, announced an initiative by PEPFAR and the Global Fund that will seek to harmonize reporting between Global Fund, PEPFAR and UNAIDS. This would eliminate parallel reporting systems and focus resources to strengthen country measurement systems. Currently, Global Fund is creating monitoring and evaluation profiles for its high-impact countries, and PEPFAR is supporting a variety of data collection efforts such as vital registration systems in Malawi, IT integration in Zambia and integration of statistical systems in Namibia and South Africa. Similarly, the Global Fund seeks to move from “checklisting” to “enabling” as it devises an approach tailored by country, which will only be possible with better data.

It was encouraging to hear that representatives from both programs were determined to go beyond current levels of coordination, especially as it has only been two weeks after the US Global Health Initiative – which was set to embody greater coordination within US global health donors –faltered in this noble attempt. As one of the panelists from Haiti said, "If PEPFAR and the Global Fund work together, it’s the country that wins.”The two payers are destined to collaborate, and the US has increased its support to the Global Fund despite slightly cutting PEPFAR funding. So, what’s important is not if the two organizations will work together, but how they will do it. If PEPFAR and the Global Fund are able to scale up greater symbiosis in pooling services and data collection, and better align their funding with national budgetary cycles, both funders and partners will benefit from greater impact for the money. Now that would be a happy marriage.