At the opening of the Global Fund Replenishment Conference in New York, Dr. Bintou Dembele, Executive Director of the Malian non-government organization (NGO) ARCAD Santé Plus, which became a Principal Recipient (PR) for community-based HIV and TB grant activities at the beginning of the current cycle (2021), spoke. She recalled the major challenges faced by the Malian population in a security context that has been steadily deteriorating for several years, and the difficulties encountered in continuing to meet the needs in certain areas of the country. Her plea was just a few simple words: "Do not abandon Mali, the people need the Global Fund". And conversely, the Global Fund needs Mali to continue to set itself challenges, to reassure itself that it is fighting for what is worthwhile. For if this global powerhouse, which just a few days ago managed to mobilize $14 billion, is not on the side of the most vulnerable in the countries most affected by poverty, war and climate change, then what good is it? The Global Fund, a major player in health in fragile states Contrary to popular belief, the Global Fund is no longer an organization that works on the margins of humanitarian contexts, focused on the elimination of diseases and sprinkling a few dollars on the health system. It is true that humanitarian actors do not instinctively turn to the Global Fund, accustomed to dealing with ECHO, the emergency funding channels of certain donors or the United Nations, or to mobilizing the generosity of the public through appeals for donations for specific emergencies. Indeed, these donors apply simplified resource mobilization mechanisms, and requests for funds are made on the basis of rapid surveys and immediate needs assessments, rather than on the basis of multi-year programs, as ECHO negotiates annually with humanitarian actors. However, this system has a major weakness: the call for donations is made on an annual basis, and as a result of crises and fatigue in the face of recurrent or long-lasting crises, humanitarian actors are currently struggling to mobilize funding. The table below shows the funding gaps by country, and with the exception of the Central African Republic, no country receives more than 45% of its needs to address the humanitarian crisis it is experiencing.

Table 1. Emergency funding in West and Central Africa, Office for the Coordination of Humanitarian Affairs: status on 3 October 2022.

In many fragile states, where donor fatigue in the emergency sector is felt, the Global Fund is present with large and increasing envelopes, demonstrating a commitment of rare constancy, which should be celebrated. Let's take the example of Mali: OCHA, the Office for the Coordination of Humanitarian Affairs, is concerned about the disaffection of donors, which is leading to growing gaps in the response to needs. The trend has been clear for the past seven years, with needs never being financed beyond 54%, with black years with little funding like 2015 or 2021.

Figure 1. Evolution of humanitarian financing in Mali, 2015 to 2022

In Mali, the gap to be filled widens with each passing year, and the graph above shows that needs are never more than half funded. If we look at the underfunded sectors, we see that health is in a poor position, with only 15% of estimated needs actually being funded.

Figure 2. Humanitarian funding by cluster in 2021

In contrast, the Global Fund continues to support these countries through increasing envelopes, as shown in the case of Mali. Through its three-year planning, it gives visibility to the actors who implement interventions with Global Fund funding. The six humanitarian NGOs that have signed an agreement with the Global Fund to expand their package of services to the three diseases in the central and northern regions of Mali all agree on the opportunity that this partnership represents. On the one hand, they are adding the three pandemics to their minimum primary health care and maternal and child health care packages. This represents an added value for them, as most were not familiar with HIV and TB, and sometimes not even with malaria. On the other hand, they recognized that planning, especially with the help of financial tools, represents a new way of working which certainly requires effort but also rigor and finesse in the design and planning of activities. Finally, because although certain difficulties remain to be resolved, they appreciated the flexibility, the ability to listen and to adapt of the Mali country team and of the Global Fund in general. They hope that the experience will be renewed, with some improvements to address the problems that have emerged in practice. For these organizations, the Global Fund has its place in their ecosystem and they are ready to get closer to the actors supported by the Global Fund, in order to be accountable to the Mali CCM and to improve coordination and exchanges with the PR, ARCAD, to which they are attached. The Global Fund, a humanitarian donor in the making? What good news this would be! The Global Fund would be an outsider in the humanitarian sector, the one that we didn’t see coming, that does not participate in UN clusters, does not hold meetings with ECHO or the United Nations High Commission for Refugees, does not have representation from these entities in its governance bodies. And yet it is becoming a coveted and expanding donor: for the moment, the Global Fund is financing the three-disease package and certain activities to fight gender-based violence (in particular, the creation of two additional One-Stop Centers in Mali to welcome survivors of sexual violence). In the context of increasingly integrated and patient-centered grantmaking, it is likely that activities will fund the health of women of childbearing age and their newborns, and why not nutrition in countries with a rampant food crisis and where the latter represents a health crisis, sometimes the most urgent of all. In Mali, the latest humanitarian actors are noting the resurgence of insecurity and are alarmed by the growing needs. According to the Special Representative of the Secretary-General for Mali, El-Ghassim Wane, more than 1.8 million people in Mali are likely to be in immediate need of food aid by the end of the year, the highest level recorded since 2014. He also recalled that by 2022, 7.5 million people would need humanitarian assistance in the country, up from 5.9 million in 2021 and 3.8 million in 2017. In this context, can the Global Fund stay on the margins? Of course it cannot, especially when the institution promises to decentralize the management of the three diseases to achieve greater impact, supports the structuring of community health (especially in remote areas), and is increasingly integrating other health issues, especially reproductive health. Sceptics will say that this is not the Global Fund's mandate and that the Fund alone cannot address all the problems. This is not wrong, but it is also not true, because the Fund's commitment to the responsibility to save lives and the new Strategy that promotes a patient-centered approach point the way forward. What are the consequences for the Global Fund? This cautious but crucial entry into the humanitarian field requires a change in practice and, of course, an evolution of the risk framework, because activities in unstable areas are by nature risky, and donors who finance the humanitarian sector know this. By embarking on this still relatively unknown sector of the Global Fund, the teams are entering a sector that is itself plagued by the same questions: how to guarantee transparency in the management of funds? How can the impact and quality of humanitarian action be measured? NGOs that receive public and private funding are subject to the same accountability requirements, their relationship with donors is valuable and guarantees regular access to emergency funds. They are therefore not closed on this subject, and they have developed control and good management measures that apply the same risk management principles: the systematic annual audits of projects, internal control department, management controllers in each geographical department, donor committee; many formulas are proposed to avoid fraud as much as possible and to be accountable to public and private donors. If Global Fund country teams want to sustain an implementation model in unstable countries or regions, they need to look for solutions where they exist, rather than trying to fit the risk framework into a context that does not lend itself to it. In terms of programmatic accountability, adjustments are needed as the nature of activities change. In areas where basic services have disappeared (health, education, public administration), and where civil servants have left because of lack of pay and security, it is no longer time to try to strengthen structures. It is above all a question of providing access to a minimum of services delivered "ad hoc" on an emergency distribution basis. The indicators are less fine-tuned than those usually used because the management of the activity itself is a challenge and an achievement in itself. The programs focus on keeping people alive, providing food, essential medicines, and the most needed services, such as reproductive health and child immunization. This means that in these regions, the Global Fund has to adapt its ambitions and performance framework. And it is working at the central level to support the decentralization of health services, in particular through community health. If the security situation were to improve, the Global Fund would still be able to change its modality and return to a different modus operandi. But today, in light of the deteriorating situation in many fragile states, it is no longer time to question the need to work differently: it is time to do so. Open up the discussion of procedures and operational approaches, bring humanitarian actors closer to the Global Fund ecosystem, try new experiments from which we will collectively learn (praise failure, so we often learn more from our successes), accept that we will make mistakes and start over. The lives of millions of beneficiaries depend on it.