GFO Issue 468, Article Number: 3
ABSTRACT
This article presents the Global Fund's new direction for the midterm review of Grant Cycle 7 (GC7). Due to declining international funding, especially after USAID's withdrawal, the Fund is urging countries to reprioritize their interventions by focusing resources on critical services such as HIV, tuberculosis, malaria, and community systems, while postponing secondary activities. The goal of this review is to ensure continuity of essential care while preparing for Grant Cycle 8 (GC8) based on four principles: integration, cost-effectiveness, equitable access, and sustainability.
The Global Fund recently published an update to its document, "Guidance on redefining priorities and the mid-term review of GC7."
This "exercise in truth," undertaken by the primary global financial instrument in the fight against HIV, tuberculosis, and malaria, represents a shift in perspective. Rather than making technical adjustments, the focus is on adapting to cuts and partner withdrawals, reevaluating what can be achieved, and ensuring access to essential services, even if it means postponing or abandoning less critical activities. The framework document explicitly states that the redefinition of priorities stems from the suspension or postponement of activities beginning in April 2025. The focus is on preserving vital interventions for the three diseases, as well as within health and community systems. This includes "filling gaps" left by partners who have defaulted or withdrawn. This "pivotal moment" serves as a springboard to the next cycle. Planning for adjustments to GC7 will help countries prepare for GC8. This preparation should focus on four key principles: integration, cost-effectiveness, equitable access, and sustainability. This will allow countries to embed HIV, TB, and malaria responses in primary care and community systems while maintaining long-term financial sustainability. In fact, the Executive Board debated this gradual shift in the spring of 2025. The board prioritized access to life-saving interventions and adapted and reprogrammed within the current cycle while keeping impact in mind. The backdrop, however, is challenging: development aid for health is projected to decline by approximately 21% between 2024 and 2025, due to a drop of around $9 billion in US funding, according to IHME monitoring . And the "end of USAID" – beyond the symbol – produced concrete disruptions, from the citizen recovery of a stock of contraceptives threatened with destruction in Belgium to the establishment, by former agents, of an emergency mechanism to save projects with high health returns .
The framework and philosophy of the revision
If we now enter into the proposed mechanism, the logic of the Secretariat combines a systemic reduction of the amounts (documented by notification letter) and an eligibility filter for revisions : depending on the extent of the changes induced by the redefinition of priorities, countries will proceed either with a revision of the programmatic scope, or with a revision of the budget, possibly combined with other adjustments (private funds, Climate × Health, etc.).
This "sorting gate" is standardized: any change to the goals/objectives or any addition/removal (including "effective removal") of interventions that substantially alters the design of the grants constitutes a programmatic scope modification; materiality is judged with regard to thresholds, internal governance and a simple precautionary principle – in case of disagreement between country team and strategic investment, the arbitration shifts towards the programmatic scope revision.
The safeguards for proportionality are clear. Interventions under $100,000 (excluding "community-related" interventions) require an assessment by the country team. Those over $100,000 require an enhanced review, and those exceeding $1 million (or even $5 million) require additional approval and reporting stages up to the grant’s approval committee. The procedural architecture is designed for speed: three working days for "no objection" decisions from the grant’s approval committee and approximately ten working days for a remote TRP opinion, if requested.
In terms of documentation, the core framework remains budgetary (summary and detailed) and pharmacologic (standard document for managing health products). Only in exceptional cases is there an update to the performance framework, and at this stage, there is no revision of targets, as the institution assumes that lower performance ratings may appear in a context of reduced funding without being interpreted as sanctions. This "non-punitive" approach is a welcome shift because it shields primary recipients from financial and reputational risks when results deteriorate due to external factors.
Procedure, deadlines and governance
The pace is tight, almost military. For portfolios undergoing a scope review, the implementation letter must be signed and sent by October 7, 2025. Purely budgetary revisions must be finalized by October 30, 2025. When the revision formalizes a grouping of subsidies within the same PR, it must be completed by the end of August and signed by September 30, 2025.
The same requirement was expressed for the implementation letter, which had to be signed "as soon as possible" and countersigned before the operation was officially "completed" (purchase order updated and recorded in the systems). This strict timeframe is coupled with a political imperative: the inclusive and traceable participation of the CCM (country coordinating mechanisms), with an explicit focus on consulting communities and CSOs. If necessary, the ALFs may be requested to "verify the reality" of this participation, including a quality survey conducted by the post-submission secretariat.
Formal approval from the CCM is not required for budget revisions, but informing the CCM is mandatory. This streamlines the downstream process for non-material scope adjustments. In short, it is a demanding procedure, simplified where necessary and time-bound.
Political and technical compromises, and red lines
Within this framework, political and technical decisions of paramount importance are made. First, regarding scope, the provided examples distinguish between changes that constitute a change in scope, such as the removal of obsolete interventions or interventions covered by other funders (including C19RM), and changes that do not constitute a change in scope, such as the transfer of activities between existing interventions or subsidies within the same disease component.
Next, the activation of a strengthened review is justified when substantial changes are required to address new gaps since the beginning of GC7; when collaboration with a civil society recipient or sub-recipient is ceased; or when the proportionality of management costs is questioned. An important point is that, in the event of fundamental disagreement between the Fund, PR, and/or CCM regarding the "country" adaptation of the redefinition approach to preserve access to essential services, an independent technical opinion may be required.
Finally, budgetary orthodoxy remains firm on two sensitive issues: co-financing commitments and counterpart funds. GC7 co-financing requirements are not altered by allocation reductions or redefinition exercises. Fulfilling these requirements is essential for impact, sustainability, and the gradual phasing out of aid. Targeted and duly formalized adjustments may be necessary if the external financing ecosystem requires national refocusing.
As for counterpart funds, the plan is to allocate them as a "last resort" after reviewing non-counterpart funding in the priority area. Any reduction must be framed with the relevant legal and technical references to avoid worsening programmatic access conditions that are already under strain.
This approach aligns with the Fund's public doctrine on sustainability and co-financing, which seeks to increase public health spending and gradually absorb key costs domestically - including incentives for fulfilling additional commitments, where applicable.
Figure 1: Overview of the priority redefinition and review process.
Country impacts and operational lessons
What concrete changes does this "revision under constraint" bring to the country? Three scenarios illustrate this. In Zambia, for example, the government has acknowledged the American cuts as a wake-up call to accelerate domestic budget efforts. However, they also recognize the severity of the blow to programs historically supported by the United States, particularly HIV/AIDS programs. An increase in health and pharmaceutical funding has been announced for 2026, though it remains below international benchmarks.
The guidance for a typical Zambian GC7 portfolio calls for safeguarding access to antiretroviral drugs (ARVs), tuberculosis (TB) diagnostics, and malaria supplies; prioritizing modules with immediate health benefits; and documenting any "downgrading" of interventions with delayed effects. If an effective removal of a community intervention costing over $100,000 is planned, a scope review and, where appropriate, a strengthened review is required, with consultation from the Country Coordinating Mechanism (CCM) and, if necessary, Technical Review Panel (TRP) advice (Figure 2).
In the Democratic Republic of Congo, where the historical fragmentation of the PR and the density of community interventions make arbitration sensitive, the "grant pooling" tool could become an efficient solution if the CCM and the PR finalize and sign the revision on time. However, governance must be impeccable to prevent organizational optimization from unfairly contracting the scope of community-based SSR.
In Mozambique, a country highly exposed to the cumulative effects of reduced Official Development Assistance (ODA) for health and climate shocks, the "Climate × Health" lines mentioned by the Secretariat can provide relief to supply chains or entomological surveillance during a scope review. However, they must be strictly framed by the value-for-money matrix (cost-effectiveness and equity) to avoid stripping essential packages in districts with high malaria incidence.
The same common thread runs through all three cases: to make these choices "deliberate," traceable, and inclusive so that they withstand technical admissibility control and the always provisional verdict of implementation.
Figure 2: Procedure for determining if enhanced review is necessary.
Tensions, Limits and Horizon GC8
Above all, this sequence reveals the clash between three rarely aligned requirements: urgency (meeting 2–4-week deadlines for structural decisions), equity (avoiding the concentration of adjustments in vulnerable communities and territories), and sustainability (avoiding the hasty renegotiation of co-financing commitments at the expense of a dangerous ratchet effect for the future). This guidance contrasts with a clear-eyed approach. Performance framework targets are not revised "on the fly" because the national macro-budgetary impact remains uncertain. If performance scores decline in the meantime, they will not automatically incur blame unless broader performance problems are identified.
This represents a welcome departure from the "cult of the indicator" when external uncertainty dominates. However, this caution does not exhaust the political discussion. With the closure of USAID - whose shockwaves continue to reverberate in terms of projected impacts on preventable mortality and reputational effects on the American aid ecosystem - countries are forced to make second-best choices. They must prioritize the continuity of services but also accept that "trust externalities" in public pharmacies, the cold chain, and community networks will erode if partner withdrawals accumulate.
In this context, the Global Fund's position on the "final touch" to counterpart funds is consistent. It protects leverage engines, which are often oriented toward key populations or catch-up projects, from an overly abrupt procyclical adjustment.
The horizon remains. The Secretariat has confirmed that this GC7 exercise directly informs the preparation of GC8, whose milestones have been shifted (candidate materials in November 2025, allocation letters in late February/early March 2026), against a backdrop of a later eighth reconstitution and persistent uncertainties . The political question, therefore, is not simply "what to cut?" but "what to (re)build?" Here, recent literature argues for trade-offs based on value-for-money in the strictest sense (savings, effectiveness, efficiency, equity, sustainability) applied to the RSSH and community modules, so that the announced integration does not mean the disappearance of targeted services, but rather an opportunity to better link the fight against disease to primary care and the community channels that deliver real access.
For a country heavily dependent on HIV aid, such as Zambia, the steps are clear. In the short term, secure necessary resources and access to them (ARVs, LDs, and targeted prevention), reassure community-based PR/SRH services, and document actual service cuts. In the medium term, allocate the promised increase in the domestic budget to absorption lines (salaries, consumables, and the supply chain), and replenish "flexibility funds" within the SRH framework to absorb partner volatility. This is precisely the intended logic of the guidance: rapid, proportionate, and transparent revisions supported by CCM participation that is neither formal nor selective and a finalized dossier with no governance gray areas, including an up-to-date DEIS, timely signatures, and adherence to budgetary guidelines.
Conclusion
Ultimately, these orientations signal a deliberate shift: an acknowledgment that, in a turbulent world - where one of the historical pillars of American aid has been dismantled and where health ODA is declining - the optimal approach lies in a frank, rapid, and equitable "re-prioritization," rather than homeopathic adjustments that allow access to erode. The Global Fund is careful to balance high standards with pragmatism: firmness on sustainability (co-financing, counterpart funding), disciplined procedures and timelines, but a rejection of punitive index-based approaches and recognition of the central role of communities. In the short term, this is a strategy of service continuity under constraints.
In the medium term, this is a policy of reconstruction: preparing for the eighth fiscal consolidation (GC8) by leveraging this mapping of "essentials," in order to present, from the outset, integrated packages with high health and social benefits. The condition for success? That this "wartime economy" of public health remains transparent and co-produced by the countries – and that the eighth reconstitution does not simply plug the gaps, but finances the promised transformation.
The Global Fund recently published an update to its document, "Guidance on redefining priorities and the mid-term review of GC7."
This "exercise in truth," undertaken by the primary global financial instrument in the fight against HIV, tuberculosis, and malaria, represents a shift in perspective. Rather than making technical adjustments, the focus is on adapting to cuts and partner withdrawals, reevaluating what can be achieved, and ensuring access to essential services, even if it means postponing or abandoning less critical activities. The framework document explicitly states that the redefinition of priorities stems from the suspension or postponement of activities beginning in April 2025. The focus is on preserving vital interventions for the three diseases, as well as within health and community systems. This includes "filling gaps" left by partners who have defaulted or withdrawn. This "pivotal moment" serves as a springboard to the next cycle. Planning for adjustments to GC7 will help countries prepare for GC8. This preparation should focus on four key principles: integration, cost-effectiveness, equitable access, and sustainability. This will allow countries to embed HIV, TB, and malaria responses in primary care and community systems while maintaining long-term financial sustainability. In fact, the Executive Board debated this gradual shift in the spring of 2025. The board prioritized access to life-saving interventions and adapted and reprogrammed within the current cycle while keeping impact in mind. The backdrop, however, is challenging: development aid for health is projected to decline by approximately 21% between 2024 and 2025, due to a drop of around $9 billion in US funding, according to IHME monitoring . And the "end of USAID" – beyond the symbol – produced concrete disruptions, from the citizen recovery of a stock of contraceptives threatened with destruction in Belgium to the establishment, by former agents, of an emergency mechanism to save projects with high health returns .
The framework and philosophy of the revision
If we now enter into the proposed mechanism, the logic of the Secretariat combines a systemic reduction of the amounts (documented by notification letter) and an eligibility filter for revisions : depending on the extent of the changes induced by the redefinition of priorities, countries will proceed either with a revision of the programmatic scope, or with a revision of the budget, possibly combined with other adjustments (private funds, Climate × Health, etc.).
This "sorting gate" is standardized: any change to the goals/objectives or any addition/removal (including "effective removal") of interventions that substantially alters the design of the grants constitutes a programmatic scope modification; materiality is judged with regard to thresholds, internal governance and a simple precautionary principle – in case of disagreement between country team and strategic investment, the arbitration shifts towards the programmatic scope revision.
The safeguards for proportionality are clear. Interventions under $100,000 (excluding "community-related" interventions) require an assessment by the country team. Those over $100,000 require an enhanced review, and those exceeding $1 million (or even $5 million) require additional approval and reporting stages up to the grant’s approval committee. The procedural architecture is designed for speed: three working days for "no objection" decisions from the grant’s approval committee and approximately ten working days for a remote TRP opinion, if requested.
In terms of documentation, the core framework remains budgetary (summary and detailed) and pharmacologic (standard document for managing health products). Only in exceptional cases is there an update to the performance framework, and at this stage, there is no revision of targets, as the institution assumes that lower performance ratings may appear in a context of reduced funding without being interpreted as sanctions. This "non-punitive" approach is a welcome shift because it shields primary recipients from financial and reputational risks when results deteriorate due to external factors.
Procedure, deadlines and governance
The pace is tight, almost military. For portfolios undergoing a scope review, the implementation letter must be signed and sent by October 7, 2025. Purely budgetary revisions must be finalized by October 30, 2025. When the revision formalizes a grouping of subsidies within the same PR, it must be completed by the end of August and signed by September 30, 2025.
The same requirement was expressed for the implementation letter, which had to be signed "as soon as possible" and countersigned before the operation was officially "completed" (purchase order updated and recorded in the systems). This strict timeframe is coupled with a political imperative: the inclusive and traceable participation of the CCM (country coordinating mechanisms), with an explicit focus on consulting communities and CSOs. If necessary, the ALFs may be requested to "verify the reality" of this participation, including a quality survey conducted by the post-submission secretariat.
Formal approval from the CCM is not required for budget revisions, but informing the CCM is mandatory. This streamlines the downstream process for non-material scope adjustments. In short, it is a demanding procedure, simplified where necessary and time-bound.
Political and technical compromises, and red lines
Within this framework, political and technical decisions of paramount importance are made. First, regarding scope, the provided examples distinguish between changes that constitute a change in scope, such as the removal of obsolete interventions or interventions covered by other funders (including C19RM), and changes that do not constitute a change in scope, such as the transfer of activities between existing interventions or subsidies within the same disease component.
Next, the activation of a strengthened review is justified when substantial changes are required to address new gaps since the beginning of GC7; when collaboration with a civil society recipient or sub-recipient is ceased; or when the proportionality of management costs is questioned. An important point is that, in the event of fundamental disagreement between the Fund, PR, and/or CCM regarding the "country" adaptation of the redefinition approach to preserve access to essential services, an independent technical opinion may be required.
Finally, budgetary orthodoxy remains firm on two sensitive issues: co-financing commitments and counterpart funds. GC7 co-financing requirements are not altered by allocation reductions or redefinition exercises. Fulfilling these requirements is essential for impact, sustainability, and the gradual phasing out of aid. Targeted and duly formalized adjustments may be necessary if the external financing ecosystem requires national refocusing.
As for counterpart funds, the plan is to allocate them as a "last resort" after reviewing non-counterpart funding in the priority area. Any reduction must be framed with the relevant legal and technical references to avoid worsening programmatic access conditions that are already under strain.
This approach aligns with the Fund's public doctrine on sustainability and co-financing, which seeks to increase public health spending and gradually absorb key costs domestically - including incentives for fulfilling additional commitments, where applicable.
Figure 1: Overview of the priority redefinition and review process.
Country impacts and operational lessons
What concrete changes does this "revision under constraint" bring to the country? Three scenarios illustrate this. In Zambia, for example, the government has acknowledged the American cuts as a wake-up call to accelerate domestic budget efforts. However, they also recognize the severity of the blow to programs historically supported by the United States, particularly HIV/AIDS programs. An increase in health and pharmaceutical funding has been announced for 2026, though it remains below international benchmarks.
The guidance for a typical Zambian GC7 portfolio calls for safeguarding access to antiretroviral drugs (ARVs), tuberculosis (TB) diagnostics, and malaria supplies; prioritizing modules with immediate health benefits; and documenting any "downgrading" of interventions with delayed effects. If an effective removal of a community intervention costing over $100,000 is planned, a scope review and, where appropriate, a strengthened review is required, with consultation from the Country Coordinating Mechanism (CCM) and, if necessary, Technical Review Panel (TRP) advice (Figure 2).
In the Democratic Republic of Congo, where the historical fragmentation of the PR and the density of community interventions make arbitration sensitive, the "grant pooling" tool could become an efficient solution if the CCM and the PR finalize and sign the revision on time. However, governance must be impeccable to prevent organizational optimization from unfairly contracting the scope of community-based SSR.
In Mozambique, a country highly exposed to the cumulative effects of reduced Official Development Assistance (ODA) for health and climate shocks, the "Climate × Health" lines mentioned by the Secretariat can provide relief to supply chains or entomological surveillance during a scope review. However, they must be strictly framed by the value-for-money matrix (cost-effectiveness and equity) to avoid stripping essential packages in districts with high malaria incidence.
The same common thread runs through all three cases: to make these choices "deliberate," traceable, and inclusive so that they withstand technical admissibility control and the always provisional verdict of implementation.
Figure 2: Procedure for determining if enhanced review is necessary.
Tensions, Limits and Horizon GC8
Above all, this sequence reveals the clash between three rarely aligned requirements: urgency (meeting 2–4-week deadlines for structural decisions), equity (avoiding the concentration of adjustments in vulnerable communities and territories), and sustainability (avoiding the hasty renegotiation of co-financing commitments at the expense of a dangerous ratchet effect for the future). This guidance contrasts with a clear-eyed approach. Performance framework targets are not revised "on the fly" because the national macro-budgetary impact remains uncertain. If performance scores decline in the meantime, they will not automatically incur blame unless broader performance problems are identified.
This represents a welcome departure from the "cult of the indicator" when external uncertainty dominates. However, this caution does not exhaust the political discussion. With the closure of USAID - whose shockwaves continue to reverberate in terms of projected impacts on preventable mortality and reputational effects on the American aid ecosystem - countries are forced to make second-best choices. They must prioritize the continuity of services but also accept that "trust externalities" in public pharmacies, the cold chain, and community networks will erode if partner withdrawals accumulate.
In this context, the Global Fund's position on the "final touch" to counterpart funds is consistent. It protects leverage engines, which are often oriented toward key populations or catch-up projects, from an overly abrupt procyclical adjustment.
The horizon remains. The Secretariat has confirmed that this GC7 exercise directly informs the preparation of GC8, whose milestones have been shifted (candidate materials in November 2025, allocation letters in late February/early March 2026), against a backdrop of a later eighth reconstitution and persistent uncertainties . The political question, therefore, is not simply "what to cut?" but "what to (re)build?" Here, recent literature argues for trade-offs based on value-for-money in the strictest sense (savings, effectiveness, efficiency, equity, sustainability) applied to the RSSH and community modules, so that the announced integration does not mean the disappearance of targeted services, but rather an opportunity to better link the fight against disease to primary care and the community channels that deliver real access.
For a country heavily dependent on HIV aid, such as Zambia, the steps are clear. In the short term, secure necessary resources and access to them (ARVs, LDs, and targeted prevention), reassure community-based PR/SRH services, and document actual service cuts. In the medium term, allocate the promised increase in the domestic budget to absorption lines (salaries, consumables, and the supply chain), and replenish "flexibility funds" within the SRH framework to absorb partner volatility. This is precisely the intended logic of the guidance: rapid, proportionate, and transparent revisions supported by CCM participation that is neither formal nor selective and a finalized dossier with no governance gray areas, including an up-to-date DEIS, timely signatures, and adherence to budgetary guidelines.
Conclusion
Ultimately, these orientations signal a deliberate shift: an acknowledgment that, in a turbulent world - where one of the historical pillars of American aid has been dismantled and where health ODA is declining - the optimal approach lies in a frank, rapid, and equitable "re-prioritization," rather than homeopathic adjustments that allow access to erode. The Global Fund is careful to balance high standards with pragmatism: firmness on sustainability (co-financing, counterpart funding), disciplined procedures and timelines, but a rejection of punitive index-based approaches and recognition of the central role of communities. In the short term, this is a strategy of service continuity under constraints.
In the medium term, this is a policy of reconstruction: preparing for the eighth fiscal consolidation (GC8) by leveraging this mapping of "essentials," in order to present, from the outset, integrated packages with high health and social benefits. The condition for success? That this "wartime economy" of public health remains transparent and co-produced by the countries – and that the eighth reconstitution does not simply plug the gaps, but finances the promised transformation.
