Global Fund Board adopted a new global disease split

11 Nov 2021
The 46th Global Fund Board meeting increased potential resources for tuberculosis while protecting HIV and malaria

Always a hot topic, this Board meeting had to discuss and decide on the global disease split as the Strategy Committee’s (SC) earlier discussions on 5 and 6 October did not lead to any recommendation. As readers will know, we reported on the divisiveness this proposed change has already caused in our special pre-Board issue last week (Proposed global disease split causes much controversy and Will the change in the Global Fund disease split reduce TB deaths?)

Global Disease Split

Since the Global Fund launched its allocation model in 2013, the global disease split has remained fixed at 50% for HIV, 18% for TB and 32% for malaria. Nearly 10 years later, the context has changed. Relative disease burden has shifted with a rise in the tuberculosis (TB) share of deaths and, more recently, progress against all three diseases has been dramatically reversed with the onset of the COVID-19 pandemic.

Considering TB’s increased share in mortality, reliance on Global Fund financing, and resources diverted for COVID-19, the SC concluded there was a need for greater financing for TB and a justification to consider a change in the global disease split to provide TB with a greater share of allocations than the current 18%. However, it was recognized that all three diseases have significant resource needs, and all have essential life-saving interventions supported by the Global Fund.

TB advocates often highlight the disparity of TB deaths across the world. About 10 million people are affected by TB annually resulting in about 1.5 million deaths. Those numbers contrast with 38 million people who live with HIV and among whom about 680,000 die every year; and the 220 million cases of malaria per year with more than 400 thousand deaths.

The SC were asked to analyse the following before they made a recommendation to the Board. The first concerns Directionality: Does the latest evidence indicate the global disease split should change? The second relates to the Degree: What are the parameters to define how much the disease split could change? Finally, members will discuss the Options: What are the options in changing the global disease split?

SC members noted that HIV, TB, malaria and systems for health all require additional funding to reach the Sustainable Development Goals (SDG) targets and that the Global Fund is working with partners to raise additional domestic, donor and innovative financing to increase impact. The slides presented to the SC did not discuss these critical efforts but focused on the global disease split decision and why it had to be made now.

Figure 1 depicts the timeline for the Strategy approval, the post-2022 Strategy development and the key decisions ahead on the global disease split, catalytic investments, technical considerations and the overall allocation methodology.

Figure 1. Timeline for Eligibility Policy & 2023-2025 Allocation Methodology

The Global Disease Split approach built on conclusions from the July 2021 SC meeting.

Options: What are the options in changing the global disease split?

The Secretariat proposed two options :

Option 1: change the global disease split based on available funding according to the following approach: (1) apply the existing global disease split to the first $11 billion available for country allocations, and (2) apply a new global disease split of 45% for HIV, 25% for TB and 30% for malaria to additional amounts of funding over $11 billion.

Option 2: maintain the existing global disease split of 50% for HIV, 18% for TB and 32% for malaria.

The Secretariat recommended Option 1. This option was also appreciated by TB advocates as it would offer more resources for TB programs. Some constituencies, both donor and government, opposed Option 1 and preferred Option 2. They argued that the change would move money from low-income countries and Africa, which can ill-afford reduced resources, amid the devastating impact of COVID-19. They also explained that it was possible to fund increased resources for TB out of catalytic funds or innovative financing.

After lengthy discussions, the SC could not agree on any recommendation and sent the issue to the Board to decide.

Meanwhile, the Secretariat sent two signals: the first was the importance of deciding on the change at this Board meeting and not postponing the decision. The second was that a unanimous decision during the Board would help the investment/business case and replenishment efforts.

The donor group proposed a compromise

After the strategy committee and during the lead time to the Board meeting, the donor group proposed a compromise. The proposed decision raised the ceiling to $12 billion before applying the new split rule (instead of the $11 billion earlier proposed by the Secretariat). This proposal gave none of the parties all they wanted but provided a middle ground. There would be more funding for TB while minimizing the impact on the existing programs and providing some room to scale up.

After a tense debate and first efforts failed, the Board approved the Global Disease Split

The Global Disease Split was on the agenda of the Global Fund Board meeting on Day 2. Constituencies were to approve (or not) the decision point which was to use the existing split up to $12 billion. These changes were considered to be ‘friendly amendments.’

During the Global Fund Board discussions, most constituencies explained why they supported or disagree with the decisions. But during the first vote, while all donors approved the decision, five implementer constituencies abstained. The vote did not pass as at least seven approvals were needed from each group (donors and implementers).

The Board was reminded of the need to obtain a consensus that will help make the case for the 7th Replenishment and postponed further discussion for Day 3. It was also mentioned that the Secretariat will approach those who abstained to prove ide them with more information as necessary and answer any questions they might have.

On Day 3, the Board meeting started with an executive session closed to the public and all observers. Finally, it was announced that the decision had passed unanimously. However, this has raised questions regarding the Global Fund's transparency.

Major disagreements that question the governance of the discussion and the vision of the constituencies

Several constituencies have highlighted what they consider to be a lack of inclusion and transparency in the use of data to help analyze the situation, and in the discussions that were held to achieve the current disease split proposal. But they also underlined the lack of more in-depth discussions where partners and Constituencies, with more time and less pressure, could have expressed their views to find a consensus.

There were two kinds of points of division:

  • Governance and priorities: some Constituencies considered that their voice had been insufficiently heard and that the time necessary to debate, analyze evidence, and make a collective decision, was not enough.  They called for a process that would view the allocation of resources in a holistic way and have a more transparent discussion and modelling using the combination of catalytic funds, Strategic Initiatives, multi-country grants, portfolio optimization, and quality unfunded demand as means to address specific high value for money investments in reducing TB and TB/HIV incidence and mortality without impacting negatively on HIV and malaria. Several Constituencies expressed their concern as it seemed continents would be opposed, as well as diseases.
  • Content: for some constituencies, the proposed Global Disease Spilt changed the geographical and socioeconomic distribution as the increase of the funds dedicated to TB would favour middle-income countries (MICs), and decrease funding in lower-income countries (LICs) with less ability to pay. According to them, the initial Global Disease Split that dedicates 18% to TB was sufficient, given that no evidence has been shown that the increase in resources for TB would accelerate case finding and improve adherence to treatment. Others, on the contrary, considered that 25% was not enough, given the lack of funding of TB and the challenges met by people affected by TB in terms of access to treatment, discrimination, loss of their jobs and isolation.

Beyond the Board leadership’s satisfaction for the consensus achieved, there was a clear message sent by the constituencies to the Secretariat that major decisions, where the Board is expected to vote, have to be addressed with more inclusiveness and transparency. Even more so when the operational consequences are so critical for the achievement of the 2030 targets and objectives.

Decision Point GF/B46/DP04: Global Disease Split

Based on its review of the Secretariat’s analysis and recommendations on the global disease split for the 2023-2025 allocation period, and the Strategy Committee’s related deliberations, the Board:
1. Acknowledges that the total amount of funds available for country allocation (including approved sources of funds for country allocation and any additional funds approved as available for country allocation) will be decided by the Board in November 2022, based on the recommendation of the Audit and Finance Committee following announced replenishments results from the 7th Replenishment;
2. Approves that the apportionment of available country allocation funds across disease components (“Global Disease Split”) for the 2023-2025 allocation period will be determined by the total amount of available funds for country allocation for the 2023-2025 allocation period approved by the Board;
3. Acknowledging the increased share of deaths from tuberculosis among the three diseases, approves the following Global Disease Split for the 2023-2025 allocation period, which increases funding for tuberculosis while preserving funding and potential for scale-up for HIV and malaria:

a. Any available funds for country allocation up to and including US$ 12 billion will be apportioned as follows: 50% for HIV/AIDS, 18% for tuberculosis, and 32% for malaria; and
b. Any additional available funds for country allocation above US$ 12 billion will be apportioned as follows:
i. 45% of such funds will be apportioned to HIV/AIDS;
ii. 25% of such funds will be apportioned to tuberculosis; and
iii. 30% of such funds will be apportioned to malaria.
4. Recognizing the need to further increase funding for tuberculosis and maximize the quality and impact of tuberculosis programs in line with the ambition of the Global Fund Strategy Narrative, requests the Secretariat, partners and committees, as relevant, to propose and implement specific options to address these needs, including:
a. Presenting to the Board, at its 47th meeting, a proposal to leverage catalytic investments for the 2023-2025 allocation period to mobilize additional resources to reduce deaths from tuberculosis;
b. Aggressively exploring, on an ongoing basis, evidence-based portfolio optimization and prioritization opportunities in order to more effectively address tuberculosis incidence and mortality in high burden countries;
c. Continuing to pursue and monitor domestic co-financing commitments required to increase overall financing for tuberculosis; and
d. Continuing to pursue innovative finance opportunities to increase funding to tuberculosis in high burden countries.

5. Requests the Global Fund’s Independent Evaluation Function to commission, in consultation with the Strategy Committee, technical partners and Secretariat, an external evaluation of the Global Fund’s approach to resource allocation to maximize impact, to inform evidence-based decision making on these issues ahead of the 8th replenishment, and to support more effective delivery of the Global Fund Strategy.

Budgetary implications (included in, or additional to, OPEX budget): None


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