Table 1 – Strategic objectives by theme

Theme	Global Fund	Gavi	Unitaid
More products to more people	Maximize impact against HIV, TB and malaria (1)	The vaccine goal: Accelerate equitable uptake and coverage of vaccines (1)	Catalyze equitable access to better health products (2)
Health systems strengthening	Build resilient and sustainable systems for health (2)	The systems goal: Increase effectiveness and efficiencies of immunization delivery as an integrated part of strengthened health systems (2)
		The sustainability goal: Improve sustainability of national immunization programmes (3)
Improved resources	Mobilize increased resources (4)	The market shaping goal: Shape markets for vaccines and other immunization products (4)	Create the right conditions for scale up, so better health products reach all people who need them (3)
Other	Promote and protect human rights and gender equality (3)		Promote innovation (1)

Notably, market shaping is a significant thrust of at least Gavi, Unitaid and the Global Fund.  The Fund has had a specific market shaping strategy since 2007; it was updated in 2011 and 2015. In its 2015 update, the Fund specifically lays out how it partners with other entities that are also engaged in market shaping. Unitaid figures very prominently. In fact, there is specific discussion of the “harmonization” of the Global Fund and Unitaid market shaping frameworks. There are layers to the alignment of these mechanisms’ strategies and approaches, which are only touched on here. On the one hand, it is reassuring to see synergy among the mechanisms.  On the other, it raises reasonable questions about duplication and redundancy of their missions. Recipient countries Strategic objectives are abstract, and open to interpretation. But where the money goes is observable. The alignment in strategies of the mechanisms is matched by the overlap in recipient countries. This makes sense, of course, because each mechanism’s mandate is to direct resources to lower income countries, of which there is a limited universe. We compared the 10 countries which have received the most cumulative funding from the Global Fund, Gavi, and Unitaid. GFF is again an outlier here because it has funded fifteen countries total in its short life, and does not provide funding-level data on them. Nonetheless, GFF shares many of the same recipient countries as the others. Six countries (Democratic Republic of Congo, India, Kenya, Nigeria, Tanzania and Uganda) appear on all three top 10 lists, which means that more than half of the top recipients for each of the Fund, Gavi and Unitaid, are the same countries. Of the 15 countries that appear across the three top 10 lists, only six (Bangladesh, Ghana, Pakistan, Sudan, Zambia and Zimbabwe) appear on just one mechanism’s list of top recipients. See Table 2.

Table 2 – Top-funded countries by mechanism

Country	Global Fund	Gavi	Unitaid
DR Congo
India
Kenya
Nigeria
Tanzania
Uganda
Ethiopia
Malawi
Mozambique
Bangladesh
Ghana
Pakistan
Sudan
Zambia
Zimbabwe

Thus there is significant overlap among the top recipients of aid among the multilateral mechanisms. But that is almost self-evident in an aid context: Those most in need should be getting the most resources. That these moneys and much more should be going to these countries is clear. However, the rationale for having four separate mechanisms to deliver aid with similar goals is not so clear. The waters are further muddied when it is considered that these moneys tend to originate from a lot of the same places. Donor countries Much as the recipient countries are shared among financing mechanisms, similar donors are involved across the group. The Global Fund is the outlier here in that more than fifty countries contribute to its budget. The other mechanisms have more contained donor lists. But if we look at the top Global Fund donors, they are the lead funders of the other three mechanisms as well.  For example, six of the seven total donors to Gavi are among the top eleven Global Fund donors (U.K., U.S., Norway, Sweden, the Netherlands and Canada). Canada, Norway and the U.K. are the only country donors to the GFF, and all three are major donors to at least two of the other three mechanisms.

Seven Donors are the big weight among all four mechanisms Canada – France – the Netherlands – Norway – Sweden – United Kingdom – United States

The donor side of this equation is probably the least straightforward of them all, when thinking about duplication and redundancy. Mobilizing resources of this magnitude is a long and delicate game, and streamlining processes does not necessarily mean better outcomes for the bottom line (i.e. recipients).  So it may be true that posing four discrete asks to national legislatures is the best way to maximize contributions to the efforts represented by the mechanisms. It may also not be true.

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The preceding analysis is admittedly superficial. There are innumerable political, moral and procedural imperatives at play. It will be important to dig much deeper than we have here, but what does this level of analysis tell us about what those outside of global health circles see when they look at health financing? They might see a bunch of organizations that seem to be trying to do the same thing, for the same people, with the same countries footing the bill. Where one person sees harmony, another may see duplication. Which is it? The following questions are directed to GFO readers for reflection and comment with respect to the facts and analysis presented in this article. Your input is welcomed and may help GFO set a course on future analyses of the global health financing arena. 1. If the mechanisms have similar missions and strategic objectives, and many of the same recipients and donors, what is the rationale for separation? Might the objectives and recipients, if not the donors, be best served by consolidation of the mechanisms? 2. Does the political nature of securing contributions to the four mechanisms mean that four asks are better than one?