Introduction The Global Fund Results Report, June 2024 in its replenishment year, shows how it has given more bang for its donor bucks in fulfilling its mission of ending HIV, tuberculosis (TB) and malaria. Global Fund investment in programs to prevent and treat HIV and AIDS totals $6.6 billion and another $5.5 billion goes towards TB/HIV programs; $9.9 billion goes to preventative and care programs for the TB-afflicted and $1.9 billion in TB/HIV programs; and more than $19.1 billion in malaria programs. The Global Fund has become the largest contributor to international funding for TB and malaria, and continues to be a major partner in eliminating HIV. Overall, its share of contribution has increased in HIV and malaria and declined by a percentage point for TB in the last two years post-Covid-19 (Figure 1).  

Figure 1: Global Fund Share in International Financing for the three diseases

  The results are impressive: 65 million lives have been saved and the cumulative mortality rate from the three diseases has declined by 61% since 2002. Among the recent successes, which the Global Fund acknowledges are the result of government commitment and the drive of the communities, Estwatini, Africa reduced AIDS as a public health threat, It attaining the 95-95-95 targets (95% of people living with HIV know their HIV status, 95% of people who know that they are living with HIV are on lifesaving antiretroviral therapy, and 95% of people who are on treatment are virally suppressed). And Cape Verde, Africa is free of malaria as of 2024. Post-Covid, in 2023, the TB programs are also back on track sustaining the recovery and acceleration of 2022 and ensuring speedier efforts to detect undiagnosed people as inequitable access leads to avoidable deaths.   But the Global Fund also admits that many countries are off track to attain the SDG 2030 Goals. Given the number of years that the Global Fund has been trying to attain the goal of eliminating the three diseases as a public health threat, it’s time to ask what may be the missing link. The answer may lie in a statement from the report: “The Global Fund remains the biggest multilateral grants provider for health systems strengthening by investing in health product value chains and securing increased supply capacity and lower health product prices through market shaping as well as investing in community health workers ($1.5 billion).” In this article, drawing from other earlier articles and other sources, we attempt to examine this further by pointing out that health systems strengthening is more than that.   Undue focus on the three diseases The Global Fund’s investment in health and community systems amounted to $1.8 billion in 2023 alone. And the report cites investments in “primary health care facilities, laboratories, supply chains, oxygen provision and community health workers”. A footnote mentions what the investments also included: “direct investments in resilient and sustainable systems for health (RSSH) and contributions to RSSH through investments in the fight against HIV, TB and malaria.”   An Aidspan critique asked the Global Fund to do its homework on resilient and sustainable systems for health. We pointed out that the focussed attention on HIV and TB, for instance, in the reports of the Global Fund, fails to take note of the other diseases that need to be “grafted onto existing platforms: diabetes, hypertension, maternal and neonatal health, cardiovascular diseases.” This is not an isolated criticism. Ilona Kickbusch, World Health Summit Council Co-Chair and Founding Director, Global Health Center, Graduate Institute of International and Development Studies, in her opinion piece for the World Health Summit Newsletter, August 2024 stated that with the focus often on the Global North’s “fear of importing diseases and viruses”, there is “very little concern raised about the export of disease from the Global North to the Global South, where the burden of disease related to obesity, diabetes, substance use disorders is already high and growing.”   The MOPAN review of the Global Fund in 2022 pointed out that the Global Fund was falling short in its health systems work and had urged the Global Fund to deliver on “facilitating country engagement focused on National Strategic Plans (NSPs), senior government leadership support, representation of Country Coordinating Mechanisms (CCMs) and Principal Recipients (PRs) with joint partner engagement.” However, as our critique noted, with the Global Fund receiving funds from various partners, who also independently finance health systems strengthening, “proposals overlap with multiple duplication” and there is a lack of alignment among the competing donors. Moreover, the Global Fund’s contributory review by the Office of the Inspector General (OIG) and its own Technical Review Panel instead suggest a prescriptive approach to setting priorities about what the Global Fund will cover in the Grant Cycle 8 in health systems strengthening rather than leaving priority setting to the respective countries.   The Global Fund in its Results Report, 2024 also talks of its “people-centered” services and programs. This reiterates the MOPAN wording of “integrated, people-centered quality services”. However, what is “people-centeredness”? The WHO in its framework for health system performance assessment (Figure 2) for Universal Health Coverage (UHC) defines people-centeredness as an “approach to care that consciously adopts the perspectives of individuals, carers, families and communities as participants in, and beneficiaries of, trusted health systems that are organized around the comprehensive needs of people rather than individual diseases, and respects social preferences” [emphasis added]. Moreover, in the Results Report, 2024, UHC finds only a solitary mention under the heading of “Strengthening Health and Community Systems”.  

Figure 2: WHO Framework for Health System Performance Assessment for Universal Coverage

Source: The HSPA Framework for UHC, WHO 2022 (pp. 199)

  The Global Fund needs to truly engage with partners for their expertise and knowledge to attain SDG goals. This was pointed out by the Global Fund’s Strategic Review 2023 (SR2023) conducted under the oversight of the Global Fund’s own Independent Evaluation Panel (IEP), which we had covered under Global Fund needs replenishment, not just funds knowledge too. It specifically gave examples where the Global Fund could do with expertise, one of which included learning from the technical expertise of Gavi, the Vaccine Alliance about health systems strengthening. Currently, there is a Joint Working Group (JWG) in place with Gavi and the Global Financing Facility, which seeks to unite forces for global health but the action plans are awaited. Once again, there were calls from the stakeholders to also include the WHO in the JWG.   Conclusion It is to be noted that the Global Fund derives its funding largely from the USA, and began as a public-private partnership with US government funding. A Commonwealth Fund study on US health care in a global perspective, 2022 found that among high-income countries, USA has the lowest life expectancy, the highest rate of avoidable deaths, its adults are more likely to have multiple chronic conditions, the highest obesity, and despite having the highest health care spending, both per person and as a share of the GDP, it remains the only country without universal health coverage. It is perhaps time to ask whether under US influence, the hitherto siloed focus on three diseases without addressing the health landscape in a unified manner has contributed to the continued impasse on eradication of the three diseases even as antimicrobial resistance has already become a larger public health threat than the three diseases put together.