“We need to work with the OIG more on AMAs [agreed management actions] to try to make the timelines and deliverables more realistic,” Marijke Wijnroks says in her progress report to the Board. Wijnroks has served as Interim Executive Director since Mark Dybul’s term as Executive Director concluded at the end of May. This article summarizes what Wijnroks said about AMAs and about supply chain transformation; grant-making; “Fit for the Future”; Gavi and the Global Health Campus; and the transition to the new E.D., Peter Sands. Agreed management actions (AMAs) In 2017, as of the end of September, the Secretariat completed and closed 57 AMAs emanating from the audits and investigations conducted by the Office of the Inspector General (OIG), while 84 AMAs remain open. Of those, 35 are classified as overdue, and 19 as long overdue (i.e. more than 180 days). “If you look only at the timeline for overdue AMAs,” Wijnroks said, “you might reasonably conclude that there is a problem, and you might wonder how it is that country programs supported by the Global Fund can achieve such impressive results.” “The answer,” Wijnroks said, “is that AMAs are admirably ambitious, and often strive to get at the root causes of implementation problems in the national systems in countries where we invest.” Successfully addressing AMAs usually requires participation from partners and from governments whose officials are balancing competing political demands, Wijnroks said. Many AMAs take far longer to conclude than originally conceived, she said. In many cases, the majority of elements in an AMA is achieved, but the AMA remains on the docket until it is 100% complete. In addition, Wijnroks said, every time an OIG audit or investigation report is issued, new AMAs are added to the list. The number of AMAs grew from 375 in September 2016 to 450 a year later. Wijnroks cited an example that she said is typical of the challenges the Secretariat faces: An AMA related to an audit conducted in the Democratic Republic of Congo (DRC) called for the Secretariat to present an analysis to the Global Fund’s Supply Chain Task Force of ongoing and planned actions and pilot initiatives to strengthen the DRC supply chain for HIV and malaria health products financed by the Fund. The analysis was to include expected results, timelines and the geographical focus of the actions, covering warehousing, distribution and the last-mile delivery arrangements managed by partner organizations. The analysis was also to include a risk assessment and mitigation response options of the current last mile distribution arrangements for artemisinin combination therapies and antiretrovirals, and to present options for the Fund, in collaboration with other partners, to sponsor a transformative supply chain project for essential medicines under the leadership of the Government of DRC. “The AMA was due for completion by 28 February 2017,” Wijnroks said, “but that deadline turned out to be too ambitious. The country team, which has supported very impressive progress on many fronts in DRC, has not yet succeeded in securing the comprehensive solution envisioned by the original AMA. The work continues, but we cannot realistically set a target date for 100% completion.” “We need to work with the OIG more on AMAs to try to make the timelines and deliverables more realistic,” Wijnroks said. Supply chain transformation Between 2014 and 2016, Wijnroks reported, the Global Fund invested more than $10 billion to support countries responding to HIV, TB and malaria and strengthening health systems. Half of that amount went to procurement and management of health products. The Global Fund began investing heavily in procurement four years ago, Wijnroks said. “An important next step is to improve on time and in full (OTIF) deliveries,’” she added. “To meet the goals set in the Global Fund Strategy, reforming supply chain is fundamental.” In 2016, the Fund launched a new supply chain initiative. In addition to developing a supply chain strategy, the initiative involves conducting in-depth diagnostics in up to 20 high-risk countries by 2019, and working with government and private sector partners to implement a supply chain transformation program. Wijnroks said that the Fund’s new strategic approach has the following objectives:

• significantly improve product availability to patients at the point of service;
• reduce wastage of products;
• reduce supply chain costs;
• significantly improve forecast accuracy and also increase inventory turnover; and
• build responsive supply chains that achieve faster replenishment of products.

As reported earlier in GFO, a new Supply Chain Department has been established within the Grant Management Division. Grant-making To date, Wijnroks reported, funding requests representing 88% of the $10.3 billion in funds allocated for 2017-2019 have already been approved for grant-making. One-third of this funding is for RSSH. (See Figure 1.)  Wijnroks also said:

• in the first two windows about $2.4 billion has been added to the Unfunded Quality Demand (UQD) Register;
• to date, 40 matching funds requests have been approved, representing 58% of the $346 million in matching funds available for 2017-2019; and
• the Global Fund has attracted an estimated $1.7 billion in additional domestic investments in health in 2015-2017, and $3.4 billion in additional domestic commitments for 2018-2020. (See Figure 2.).

As Figure 2 shows, the largest increases in domestic investments are in low-income and lower lower-middle-income countries, while the smallest increases are in upper lower-middle-income and upper-middle-income countries. (The Global Fund splits the lower-middle-income category into two parts.)

Figure 1: Funding requests

Figure 2: Minimum previous co-financing requirements vs. actual spending, by income group ($ billion)