Introduction: The Global Fund’s 2023-2028 Strategy in Focus

The Global Fund's

2023-2028 Strategic Performance Reports

set out a detailed roadmap for achieving progress on the Fund’s core mission: to end HIV, TB and malaria as epidemics while building resilient and sustainable health systems worldwide. In reviewing these reports, however, it becomes clear that while progress has been made in many areas, there are several persistent gaps and challenges that could undermine the Global Fund’s ability to meet its ambitious targets by 2030. These reports, including the

Strategic Performance Summary

, the

Strategic Performance Detailed Report

, and the

KPI Framework Adjustments

, reveal both areas of success and areas of concern that warrant a deeper analysis.

The Global Fund's tendency towards verbose and often repetitive reporting risks obscuring critical insights. This analysis aims to cut through that noise, emphasizing where real progress is being made and where the Global Fund may be sidestepping key challenges—particularly around equity, human rights, incidence reduction, and the integration of gender-focused interventions.

1. Mixed Progress in Service Delivery: Meeting Some Targets, Missing Others

The

2023-2028 strategy

underscores the Global Fund’s post-pandemic recovery efforts, with many of the

service delivery KPIs

for 2023 showing strong performance. Notably, the Global Fund emphasizes that it has saved

65 million lives

by the end of 2023, a significant achievement that underscores the continued relevance of its investments across HIV, TB and malaria programs. However, despite these successes, the underlying reports reveal deeper issues that could derail the Fund’s longer-term goals. In Malawi, integration of cervical cancer screening into HIV programs across 75% of antiretroviral therapy facilities demonstrates how resource constraints can be managed effectively with innovative approaches​. Similarly, Nigeria’s TB program increased case findings by 26% through community outreach, providing a model for addressing service delivery gaps​.

Advanced HIV disease (AHD) continues to drive mortality rates, requiring immediate focus. The Global Fund has scaled up

urine LAM testing

, particularly for TB diagnosis in immunosuppressed individuals, and is expanding access to

short-course TB preventive therapies (TPT)

. In pediatric care, the launch of the

pediatric-friendly Abacavir/Lamivudine/Dolutegravir (pALD) fixed-dose formulation

is a major step in simplifying ART for children, with rollout supported across over 50 countries​.

 

1.1 HIV Performance: Strong but Unequal Gains

The performance indicators for HIV show positive progress across multiple areas.

Viral load suppression rates (KPI H3)

are high, particularly among those tested. Moreover,

adolescent girls and young women (AGYW)

reached by prevention programs (KPI H5) have also exceeded targets. This progress is credited to the

standardization of ART regimens

and expanded

community-based testing strategies

, which have helped close the gap in the “first 95” of the

HIV treatment cascade

—getting people diagnosed and linked to care.

However, as successful as these interventions are, they mask a deeper problem:

equity gaps

in access to treatment and care persist, particularly among

key populations

and

children living with HIV

. Pediatric HIV treatment, for instance, remains far behind adult treatment coverage, contributing to higher rates of HIV-related mortality in children. This suggests that while the Global Fund is scaling up its interventions, it is struggling to reach the most vulnerable, often marginalized, populations.

1.2 Tuberculosis: Strong Notifications, Persistent Gaps

The Global Fund reports a significant recovery in

TB notifications (KPI T1)

post-pandemic, with the highest number of notifications ever recorded in 2023. This recovery is attributed to

innovative service delivery models

, including greater

community engagement

and

decentralization of services

. Yet, despite this recovery, the report highlights several key challenges:

• TB treatment and prevention gaps

  persist, particularly in funding for

  preventive therapy (KPI T5)

  , which has fallen far short of targets.

• The

  decentralization of services

  , while effective, is hampered by

  commodity shortages

  , particularly in

  TB diagnostics

  and

  first- and second-line treatments

  , especially in high-burden countries.

• In countries like India, which constitute large parts of the TB burden, data is not yet fully integrated into performance evaluations, leading to potential underreporting of both successes and gaps.

This paints a picture of a TB program that is moving in the right direction but still faces considerable challenges—especially in ensuring equitable access to treatment and prevention for hard-to-reach populations.

1.3 Malaria: Strong Vector Control, But Resistance Looms

For malaria, the distribution of

insecticide-treated nets (ITNs)

has been a major success, with 227 million ITNs distributed, covering 96% of the target population. Likewise, performance in

malaria testing (KPI M2)

and treatment has remained strong across both public and private healthcare settings.

However, emerging

artemisinin resistance

in East Africa poses a severe threat to malaria control efforts. While the Global Fund is working on diversifying

artemisinin-based combination therapies (ACTs)

, including the deployment of

multiple first-line therapies (MFT)

, it is constrained by the high cost of newer treatments and the overall

fiscal limitations

within many country programs. Furthermore, performance on

IPTp3 (intermittent preventive treatment during pregnancy, KPI M4)

was weaker, driven in part by low utilization of antenatal care in some regions.

This suggests that while the Global Fund is making strong progress in vector control and case management, it is vulnerable to emerging drug resistance and struggles to address health system gaps that prevent pregnant women and other vulnerable groups from accessing critical preventive treatments. Data-driven malaria interventions are advancing subnational elimination efforts. These include tailored campaigns integrating

nutrition screening and vitamin A supplementation

, which enhance health outcomes while addressing local context-specific needs.

2. Equity, Gender, and Human Rights: Slow Progress on Critical Fronts

One of the areas where the Global Fund’s reports reveal significant ongoing struggles is in addressing

equity, gender inequality, and human rights

barriers. These issues are central to the Global Fund’s strategy, yet progress here has been

uneven and incomplete

.

Gender equity remains a cornerstone of Global Fund strategies. Through the

Global Alliance to End AIDS in Children

, targeted investments in antenatal care and early infant diagnosis are bridging service gaps in regions like West and Central Africa. Investments in harm reduction programs for people who use drugs also underscore a growing focus on underserved key populations​.

2.1 Community Engagement and Gender Equality

The Global Fund has repeatedly emphasized the importance of

community engagement

in improving health outcomes. Yet, the reports indicate that performance on

community engagement KPIs

is well below target. For example, the

community engagement target (75%)

has not been met, even though it was expected to be achieved in the

first stage

of the funding cycle. This failure is particularly troubling given the Global Fund’s repeated commitment to ensuring that communities are empowered to take an active role in

health governance and service delivery

.

Similarly, while the Global Fund has increased its focus on gender equality, progress has been slow, particularly in addressing legal and policy environments hostile to LGBTQ+ rights. For instance, South East Asia emphasized that one-third of people with HIV lack access to life-saving treatments​. The

KPI for gender equality

continues to lag far behind the expected targets, particularly in countries where

legal and policy environments

are hostile to gender equality and LGBTQ+ rights. Stakeholders at the 51st Board meeting had raised concerns that the Global Fund is not doing enough to

move beyond expressions of concern

regarding

human rights violations

, urging more active intervention and advocacy. This continued at the 52^nd Board meeting as well. The call to

enhance gender equality initiatives

, particularly in regions facing

backlash against gender equity

, reflects the need for stronger actions beyond simply meeting numerical targets.

2.2 Structural Barriers to Access

Persistent

structural barriers

, including

stigma

,

discrimination

, and

criminalization

, continue to hinder access to HIV, TB and malaria services. Constituencies have called for an ombudsperson and mandatory CCM inclusion to address these barriers more systematically​.

Legal barriers

around LGBTQ+ rights in some countries prevent effective health interventions, and the Global Fund’s strategy for addressing these issues remains underdeveloped. Similarly,

gender-based violence (GBV)

and

gender inequality

remain significant barriers to accessing HIV prevention and treatment, particularly for women and girls in sub-Saharan Africa.

Despite the Global Fund’s emphasis on human rights and equity, these barriers are being tackled slowly, and the

low prioritization

of community engagement suggests that more needs to be done to incorporate

local voices

and

civil society actors

into the decision-making process.

Constituency statements highlighted critical areas for improvement in tackling human rights challenges and gender barriers. For instance, the persistent stigma and discrimination faced by key populations, including people who use drugs and those in mental health facilities, which continues to impede access to TB and malaria services​. The importance of strengthening governance structures to promote the meaningful inclusion of marginalized populations in decision-making processes​ was also underlined.

Constituencies highlighted the intersection of climate crises and health inequities, noting evidence of an 11% rise in HIV transmission during droughts in Africa. Such findings underscore the need for integrating climate resilience into the Global Fund’s equity-focused initiatives​.

2.3 Constituency Insights: Bridging the Gaps

• Equity and Human Rights:

  Constituencies, highlighted the need for intensified collaboration with civil society to address barriers like stigma, discrimination, and legal challenges that hinder equitable healthcare access​​.

• Gender Inequity:

  Constituencies reiterated the lack of specifics in the Global Fund's gender equity reporting. While gender-focused funding (46% of GC7 allocations) was noted, significant gaps in actionable progress, especially in key populations, remain a concern​​.

• Pandemic Preparedness:

  Constituencies stressed the need for robust health information systems and alignment with climate-health frameworks to sustain progress. Concerns about short implementation timelines for COVID-19 Response Mechanism (C19RM) investments were also raised​​.

• Funding and Sustainability:

  Constituencies emphasized better alignment of the Global Fund’s allocation methodology with disease burdens while protecting gains in HIV, TB, and malaria programming​. WHO urged the Global Fund to provide transparent guidance on co-financing requirements, ensuring alignment with government budget cycles and enabling better planning for domestic contributions​

3. Pandemic Preparedness and Resilient Systems for Health: A Work in Progress

A new element of the 2023-2028 strategy is the focus on

pandemic preparedness

and

resilient health systems

. The reports highlight that while the Global Fund is working to strengthen

health management information systems (HMIS)

and enhance

health system resilience

, there is still a long way to go before these systems are fully robust.

Constituencies emphasized the importance of aligning National Adaptation Plans with health systems to tackle vulnerabilities arising from climate change, proposing that these be linked to future catalytic investments for sustainability and resilience​.

3.1 Data Systems and Monitoring Gaps

One of the key challenges in pandemic preparedness is the lack of comprehensive health data systems. Constituencies pointed to supply chain delays and outdated digital systems as additional hurdles to ensuring sustainability in health interventions​. While

targeted Health Facility Assessments (tHFAs)

have been initiated in 18 countries. These assessments are integral to monitoring service delivery quality and enhancing preparedness frameworks across high-priority portfolios​. However, these assessments are still in early phases, with baseline scores expected to be available only by 2025. The delayed rollout of these assessments is indicative of broader capacity issues that could undermine the Global Fund’s ability to respond swiftly to future pandemics.

Moreover, while the Global Fund reports that

COVID-19 effects

on health service delivery have been mitigated, the slow pace of building pandemic-resilient systems suggests that countries may still be vulnerable to future shocks.

Constituencies reiterated the need for integrating climate-health considerations into health system planning, leveraging the WHO-led Alliance for Transformative Action on Climate and Health (ATACH). This collaboration could address resilience gaps and enhance sustainability, particularly for vulnerable populations in climate-vulnerable regions​.

Through strategic procurement, the Global Fund achieved a

25% cost reduction in first-line HIV treatments

and a

30% drop in TB preventive therapy prices

. Such interventions allow countries to expand service delivery while reallocating savings to other pressing health priorities​.

4. Adjustments to the KPI Framework: Changing the Narrative?

The

2023-2028 KPI Framework

adjustments introduced in the reports indicate that the Global Fund is learning from its past reporting cycles. Key changes, such as

KPI R1b

(which tracks co-financing commitment risks), reflect a shift towards more

cumulative reporting

across the allocation period rather than focusing on year-by-year performance. While this change may provide a more comprehensive picture of progress, it also risks

inflating success rates

by counting delayed actions as completed.

Additionally, the shift to

unweighted averages

for

on-shelf availability (KPI S8)

may obscure country-level disparities by treating all countries equally, regardless of the number of facilities being assessed. These changes could create a

rosier picture

of performance than is warranted, leading to less pressure for action where it is needed most.

Constituencies raised alarms about workforce capacity, noting high burnout rates among Global Fund staff due to excessive workloads and frequent in-country travel demands. These challenges highlight the need for operational reforms to enhance efficiency and sustainability​.

5. Strengthening Country Coordination

Constituencies consistently emphasized the pivotal role of Country Coordinating Mechanisms (CCMs) in ensuring that Global Fund investments translate into tangible health outcomes. There was a call for creating a CCM Advisory Body to strengthen governance and promote data-driven decision-making. Such measures would ensure that CCMs remain a platform for inclusive, participatory health governance, particularly in challenging operating environments​ while safeguarding meaningful engagement from marginalized populations​.

Community-focused initiatives such as

Community Pulse

and

CLM+

aim to empower local organizations in grant monitoring and service delivery. These programs emphasize capacity-building and institutionalizing data-driven advocacy. An independent evaluation in late 2024 will assess their long-term contributions to health governance​.

Investments of $130 million under GC7 and an additional $81 million from C19RM are supporting the development of a sustainable

community health workforce

. These funds focus on improving training, retention, and deployment to ensure continuity in primary healthcare delivery​.

5. Missed Opportunities and Overlooked Challenges

Despite the depth of detail in the reports, there are critical areas where the Global Fund’s reporting remains

insufficient

:

The reports focus heavily on

fund utilization

(85% of in-country absorption for GC6 grants) but provide little analysis on whether these funds are being

efficiently

or

equitably

spent. Financial performance needs to be more closely tied to

impact analysis

to ensure that resources are going where they are needed most.

• Discussions on the quality-of-service delivery, particularly in

  community health systems

  , often

  overlook gaps in equitable resource distribution

  . For instance, constituencies noted that catalytic investments alone cannot sustainably scale best practices, especially in low-resource settings​.

• The reports also gloss over the

  root causes

  of poor performance in equity, gender, and human rights, instead emphasizing

  numeric progress

  on KPIs without sufficient reflection on the systemic barriers that are preventing deeper progress.

Constituencies highlighted innovative approaches like Nigeria’s community-driven TB outreach initiative, which increased case findings by 26% compared to the previous year. This illustrates how targeted community interventions can address service delivery gaps effectively​. Another instance cited was how Niger successfully integrated grant resources into its national finance laws, facilitating tax exemptions and improving absorption rates above 85% despite fiscal constraints. This approach offers a roadmap for better resource integration across Global Fund-supported countries

​

.

Funding gaps remain a critical challenge for TB prevention. Tools like contact tracing and preventive regimens (e.g., 1HP) are underutilized due to high costs and limited resources. Without accelerated funding for the targets set during the 2023 UNHLM, TB outcomes will continue to lag​.

Conclusion: A Call for More Honest Reflection

The Strategic Performance 2023-2028 reports paint a picture of substantial progress in certain areas, but they also reveal troubling

gaps in equity, human rights

, and

pandemic preparedness

. The Global Fund’s emphasis on

KPI success

often obscures deeper, more systemic issues that are preventing true progress towards

ending HIV, TB and malaria

. While

service delivery

is improving, the

incidence reduction targets

are still far off, and the Global Fund risks falling into a pattern of reporting numbers that tell only part of the story.

For the Global Fund to achieve its

2030 goals

, it must take a more

critical, solution-oriented approach

, focusing not just on meeting numerical targets but on tackling the deeper, systemic challenges that are impeding equitable healthcare delivery. This requires

honest reflection

,

stronger partnerships

with

civil society

, and a deeper commitment to

human rights and gender equality

. Only by confronting these issues head-on can the Global Fund truly achieve its mission of ending the epidemics of HIV, TB and malaria.

For further insights into the Global Fund’s KPI performance and strategic planning, see:

• Strategic Insights: Reviewing Performance and Refining Future Goals in the Global Fund​.
• Global Fund Strategic Performance Up to Mid-2023​.
• Community Engagement: A Key Issue Documented by the Rise Study