On 12 September, a week prior to the start of the Seventh Replenishment Conference, the Global Fund set the scene by launching its 2022 Results Report and thereby demonstrating why investing in the Global Fund has an impact. According to the Results Report, in 2021 the Global Fund provided 30% of all international funding to HIV, 76% of all international funding to TB and 63% of all international funding to malaria. As of June 2021, 72% of Global Fund investments were directed to sub-Saharan Africa, 19% to Asia and the Pacific, 3% of Eastern Europe and Central Asia, 3% to Latin America and the Caribbean and 2% to North Africa and the Middle East. However, in 2020, the COVID-19 pandemic had a devastating effect on the fight against the three diseases, leading to the decline of key programmatic results across HIV, TB and malaria (HTM) for the first time in the history of the Global Fund. When the COVID-19 pandemic hit countries where the Global Fund works, the partnership rapidly mounted a response to deliver additional resources. This year, the new report shows those investments paid off and recovery is underway. By the end of 2021, says the Report, programs supported by the Global Fund partnership had saved 50 million lives. Since 2002, investments in HTM together with health system strengthening, have cut the combined death rate from the three diseases by more than half.

Figure 1. Life expectancy in 15 sub-Saharan African countries

Increase from 2002 to 2019

Every life saved, and every infection averted, has a multiplier effect across families, communities and entire nations. The Global Fund goes on to praise the diverse actors who comprise the Global Fund partnership – communities, governments, the private sector, civil society and technical partners –  and are essential to the organization’s success.
Report highlights

The Global Fund provides 30% of international financing for HIV programs. In countries where the Global Fund invests, AIDS-related deaths reduced by 70% between 2002 and 2021. The percentage of people in need of antiretroviral therapy (ART) who received it has significantly increased over the past decade, from 23% in 2010 to 75% in 2021. When COVID-19 interrupted HIV services, the Global Fund partnership put measures in place to mitigate its impact through an additional funding stream, the COVID-19 Response Mechanism (C19RM). In Global Fund-supported countries, HIV testing services for groups in greatest need as well as prevention services started to recover in 2021.

The Global Fund provides 76% of international financing for TB programs. In countries where the Global Fund invests, TB deaths (excluding PLHIV) dropped by 21% between 2002 and 2020. Together with technical partners and implementing countries, the Global Fund continues to spearhead approaches to accelerate TB testing and treatment and identify more “missing” people with TB. Thanks to the Global Fund partnership, TB programs began to recover in 2021 from the impact of the COVID-19 pandemic, with gains in the number of people on treatment for TB.

The Global Fund provides 63% of international financing for malaria programs. In countries where the Global Fund invests, malaria deaths reduced by 26% between 2002 and 2020. In 2021, progress continued in offering malaria prevention services such as mosquito nets and seasonal malaria chemoprevention to more people at risk of the disease. In 2021, Global Fund-supported programs recovered from declines in 2020, with testing and treatment for malaria registering gains.

Strengthening systems for health
Resilient and sustainable systems for health support the Fund’s determination to defeat today’s infectious diseases and respond to future threats. The Global Fund is the world’s largest multilateral provider of grants for strengthening systems for health. Over the 2021-2023 implementation period, it is investing $4.9 billion, or $1.5 billion a year, in formal and community health systems through core grants and C19RM – about one-third of its total investments. During the allocation period 2020-2022 the Global Fund invested $16 million to support civil society and communities most affected by the three diseases to participate and engage in Global Fund and related national processes across the grant cycle. This includes country dialogue, funding request development, grant-making, and grant implementation and oversight. In many rural areas, community health workers are the cornerstone of the formal health system. Their vital role in communities became even more apparent during the COVID-19 pandemic and, as a result, the Global Fund doubled its investment in community health worker systems in the current funding cycle to $377 million. It aims to further increase its investments in this area. Given the critical role that community systems play in the fight against infectious diseases, and the importance of addressing human rights abuses and gender-based violence, the Global Fund has put a particular focus on supporting initiatives in these areas as part of C19RM investments.
COVID-19 and other crises
To end HTM as public health threats and address emerging dangers to global health security, the Global Fund needs to reach the most vulnerable people with prevention and treatment services, wherever they are. That means greater attention on challenging operating environments – countries or regions that experience infectious disease outbreaks, natural disasters, armed conflicts or civil unrest, weak governance, climate change-related crises and/or mass displacement. The Global Fund responded swiftly to COVID-19, providing significant funding to country responses through C19RM and leveraging its expertise and strong global networks. Since March 2020, the Global Fund has invested more than $4.4 billion to fight the pandemic and mitigate its impact on HTM, as well as allowing flexibilities regarding reprogramming existing grant activities. The funding enabled countries to rapidly adapt existing programs, purchase personal protective equipment, diagnostics, treatments and medical supplies and deploy prevention campaigns. This quick response helped avoid the worst-case scenario of a surge in deaths and cases across the three diseases.

Figure 2. COVID-19 Response Mechanism awards by type of intervention, as July 2022

N.B. The “Other” category includes activities such as building human resources capacity, technical assistance, surveillance and laboratory systems strengthening, mitigation of the impact to HTM programs, as well as other health and non-health equipment.
Decades of experience in fighting HIV, TB and malaria allowed many low- and middle-income countries to respond to COVID-19, using the same laboratories, disease surveillance, community networks, trained health workers and supply chains that were already in place to fight HTM. In many countries, health systems including community systems that were originally put in place to tackle HTM have been instrumental in responding to COVID-19. These systems made a remarkable difference in the fight against the pandemic and in mitigating the knock-on effect on other diseases. By continuing to strengthen underlying systems and capacities, the Global Fund partnership can overcome today’s diseases and prepare for future ones .
Domestic financing
The Global Fund requires all countries to progressively invest more on health and to gradually take up program costs. In addition, a minimum of 15% – up to 30% in some countries – of Global Fund allocations are subject to additional co-financing commitments. from countries for each grant. This mechanism has proved remarkably successful in incentivizing increased domestic investments in health. As a result of the Global Fund’s strong role in advocating and catalyzing increased domestic investments in health, lower middle-income countries (LMICs) have made progress in increasing their domestic investments in health, including higher investments in HIV, TB and malaria. The Report notes that much of the Global Fund’s financing comes from governments, which historically provide more than 94% of total funding and the most fundamental component of health financing is the investments made by LMICs in their health programs. The Global Fund’s policy on sustainability, transition and co-financing has played a crucial role in accelerating progress in co-financing. As of May 2022, in countries where the Global Fund invests, it had recorded a 30% increase in domestic commitments for the 2020-2022 period compared with the 2017-2019 period. Fifteen countries in the Global Fund’s High Impact Africa portfolio and 35 countries in the Africa Middle East (AME) portfolio have co-financing commitments in the 2021-2023 period. Compared with 2018-2020, domestic spending on the three diseases and RSSH is expected to increase by about 6% in High Impact Africa and by about 16% in AME. However, that progress is much higher in some countries: In 27 countries across the two regions, domestic investments in HIV, TB, malaria and RSSH are expected to increase by over 25%.
The prognosis: no room for complacency
Thanks to the mobilization of countries and communities and generous support from partners, C19RM is delivering results and HIV and malaria programs have recovered to exceed the 2019 levels. Results achieved in the fight against TB are also on the rise. But 2019 levels are not where the Global Fund had planned to be in 2021, meaning countries are still off track to reach the Sustainable Development Goal targets of ending the three diseases. Additionally, the world is now confronted by the prospect of a new global health crisis, triggered by the impact of conflict and climate change on food and energy. The Seventh Replenishment Conference, hosted by President Biden on behalf of the United States Government, took place in New York between 19 and 21 September. The Global Fund had estimated that an amount of $18 billion would save 20 million lives over 2024-2026, cut HTM deaths by almost two-thirds and strengthen health and community systems to reinforce pandemic preparedness. In fact, and at the time of writing, the Seventh Replenishment had raised $14.25 billion to fund its next three-year cycle of grants.