This week, the Board of the Global Fund to Fight AIDS, Tuberculosis, and Malaria was set to name the organization’s new executive director. Instead, after the shortlist of candidates appeared in the New York Times, some in the global health community anonymously expressed concerns about the selection process and its results—and the Board abruptly announced it would restart the process from scratch.

Although the Global Fund is lawfully a private Swiss Foundation, its Board should not act as such. Advocates exert strong influence over the Global Fund through the media and big donors have veto—so its ED selection process should acknowledge the realpolitik and vet candidates broadly and in the public domain, while giving due consideration to candidates’ capacity to navigate difficult political and financial headwinds.

As the executive director search reboots, I am looking for candidates that have clarity, concrete plans, and capacity to make progress in three areas—the big 3—that are essential to the Fund’s survival: results, efficiency, and money.

1. Results

While much progress has been made, the big picture for the Fund’s three diseases remains daunting. Although HIV/AIDS mortality is declining, HIV incidence remains mostly flat, meaning that the number of people living with AIDS continues to grow and the fiscal burden for their treatment grows in tandem. Malaria and TB have seen more unambiguous success, but the need to maintain and even scale up efforts is imperative to sustain the gains. For all three diseases, growing resistance to first-line medicines implies that HIV and TB treatment adherence is less than optimal, and that prevention must be the priority going forward.

The Fund’s rhetoric on results has always been great—its new website is amazing—but the organization still does not carry out rigorous, representative, and independent verification of program performance, even in its largest country programs. It’s great if life-saving medicines are purchased, but do these medicines make it to health providers in disease hot spots? Are the medicines taken regularly so that the HIV virus is suppressed and transmission is halted? Are prevention interventions working to halt disease spread? Our two independent working groups identified weak performance verification as a main challenge to be addressed, and suggested practical, low-cost ways to deliver. Over at the World Bank, a new Fund—the Global Financing Facility—is doing better on performance verification; are there opportunities to work jointly?

The new ED needs to acknowledge the problem and take the necessary steps to improve performance verification and evaluation.

2. Efficiency

After nearly two decades of easy money in global health, the party is over. Doubling down on better value-for-money is now a priority to maximize results and minimize waste. Significant progress has been made in the procurement of medicines and supplies—notably through the launch of wambo.org and volume guarantees—but much more can be done to select products based on cost-effectiveness criteria and deploy other market shaping tools to assure affordability and greater co-financing from recipients.

Historically, the Technical Review Panel—a group that reviews the technical merit of country proposals submitted to the Fund—has been weak or silent on efficiency issues. That is beginning to change, with the Global Fund now providing some limited support to countries to plan for cost-effective resource allocation. Nonetheless, these analyses remain the exception, not the rule, and their recommended allocations are not necessarily adopted by the Country Coordinating Mechanisms (CCM)—the body with final say on how money will be deployed within a program. CCMs themselves have some major design flaws that need to be addressed; sometimes non-governmental recipients allocate resources amongst themselves, creating inertial patterns of resource allocation that may not optimize impact.  

Again, lots of suggestions in our two working group reports here and here.

3. Money

The US contribution—accounting for about one-third of the Global Fund’s resources—is now at risk. While the US Congress may hold the line on some budget cuts, most programs, including PEPFAR, will likely take a haircut, and pressure is likely to build over time. How much will PEPFAR pass on the cuts to the Global Fund? Other bilateral donors are also under pressure; the UK’s new performance agreement is a clear signal that future replenishments may be challenging.

All this means that the new ED must generate the results and efficiencies necessary to convince the bilaterals and mobilize the advocates, while also implementing aggressive measures to raise more private funding—currently just 10 percent of total contributions. Creating clearer incentives for recipient co-financing of programs is also essential. Here again, the rhetoric is on target, but the reality is that many countries still don’t co-finance significantly even when they have fiscal capacity.

Implementing this agenda requires the ability to manage a Board and a set of interests and advocates that all point in different, sometimes contradictory, directions. For its part, the Board needs to recognize the crisis now faced, and empower the ED—once selected—to focus on the big 3, even if that means letting other issues take the backseat for a time.