The Global Fund and PEPFAR in U.S. International AIDS Policy
Released: 2005-11-03T00:00:00

Background

In May 2001, President Bush made the founding pledge of $200 million to a new,yet-to-be-named global fund to fight AIDS at a White House Rose Garden ceremony attended byU.N. Secretary General Kofi Annan and Nigeria's President Olusegun Obasanjo. (7) U.S. officials played aprominent role in the subsequent negotiations on creating the Global Fund, and the new organizationbegan operations in January 2002, with its mission expanded to include tuberculosis and malaria. The Global Fund is an innovative organization in many ways. The Fund's board includesrepresentatives of both donor and recipient governments, NGOs, the private sector, and communitiesaffected by the three diseases. UNAIDS, the World Health Organization (WHO), and the WorldBank also participate. The Fund's Secretariat in Geneva is relatively small, with about 135employees. This is possible because the Global Fund is not an implementing agency, but rather a"financial instrument" designed to mobilize new resources for fighting disease and to manage anddisburse those resources. (8) The CCMs in the recipient countries bring together the interested parties or "stakeholders" to agreeon national priorities and to develop and submit coordinated applications to the Fund. CCMsinclude representatives of government, NGOs, the private sector, multilateral and bilateral aidagencies operating in the country, academic institutions, and people living with the diseases. Theapplications identify one or more Principal Recipients, such as the national health ministry or oneor more NGOs, which are legally responsible for grant implementation. Applications are reviewedby a Technical Review Panel of independent experts, and if a grant is made, the Fund contracts aLocal Fund Agent, typically a large accounting firm, to oversee its implementation. The GlobalFund's grant-making takes place in "Rounds," which are announced when the Fund estimates thatit has funds available to cover the first two years of a large number of new grants. The two-yearrequirement, known as the Comprehensive Funding Policy, is intended to assure that the projectsbeing funded, including treatment projects, are not interrupted for lack of money.

President George W. Bush announced the launching of PEPFAR in his January 2003 Stateof the Union Address. The United States had been implementing bilateral international AIDSprojects through the U.S. Agency for International Development (USAID) since the mid-1980s. TheClinton Administration's 1999 LIFE (Leadership and Investment in Fighting an Epidemic) initiativebrought other agencies, particularly the Centers for Disease Control and Prevention of theDepartment of Health and Human Services, into the effort as well. PEPFAR, which was authorizedin May 2003 by P.L. 108-25 (see above), brought these efforts into a single program headed by aGlobal AIDS Coordinator carrying the rank of Ambassador and based at the Department of State. Randall Tobias, former Chairman, President, and CEO of Eli Lilly, the pharmaceutical corporation,was named to the post by President Bush in July 2003 and confirmed in October.

The PEPFAR initiative promised substantial new resources for fighting AIDS, including $9billion over five years to be committed in 14 (later expanded to 15) of the most afflicted countriesof the world. (9) This newfunding is being channeled through the Global HIV/AIDS Initiative (GHAI) directed by the Officeof the Global AIDS Coordinator (OGAC). PEPFAR also promised $5 billion over five years forongoing bilateral AIDS programs in 105 other countries, (10) as well as $1 billion in contributions to the Global Fund. Officials said that overall, PEPFAR represented $10 billion in "new money," -- that is, $10 billionin additional funds beyond spending that would have occurred if existing programs had simply beencontinued at then-current spending levels.

AIDS activists and others have been impatient with the pace at which PEPFAR and theGlobal Fund have been meeting the difficult challenge of scaling up their efforts to combat the globalAIDS pandemic. (11) However, both are already claiming considerable success. PEPFAR aims at supporting treatmentfor 2 million HIV-infected people by 2008, preventing 7 million new HIV infections, and"supporting care for 10 million people infected and affected by HIV/AIDS, including orphans andvulnerable children." (12) The Office of the Global AIDS Coordinator reports that at the end of March 2005, the PEPFARGlobal HIV/AIDS Initiative was supporting antiretroviral therapy for more than 235,000 AIDSpatients in the focus countries. (13) Through September 2004, 1.7 million were receiving care,including 630,000 Orphans and Vulnerable Children. (14)

OGAC estimates that in FY2004 it reached 120 million people in the focus countries withprevention messages focusing on abstinence and being faithful. In addition, 96 million condomswere purchased and shipped to focus countries for programs directed toward people who engage inhigh risk behavior. (15) The Global Fund reports that the 316 grants it had approved in 127 countries through July 2005 hadput 220,000 patients on HIV therapy, provided HIV testing and counseling for 2.5 million people,and provided 397,000 orphans with social, medical, and educational support. (16) Some patients receivingtreatment for AIDS are participating in programs supported by both PEPFAR and the Global Fund. This overlap was estimated at 63,000 in 2004. (17)

Global Fund Resource Gap

The Global Fund estimates that it needs $3.3 billion in 2006 and 2007 to cover all existinggrants through the end of 2007. In addition, it is seeking $3.7 billion, for a total of $7 billion, inorder to respond to anticipated applications in Rounds 6 through 8 during the two-year period. (18) At a pledging conferenceheld in London in September 2005, donors pledged a total of $3.7 billion. Unless additional pledgesare made, the Global Fund will have the resources to do little more than fund its existing grants. Itwill not be able to bring new resources to bear in fighting the AIDS pandemic. Resource constraintswere evident when the Global Fund's board met in Geneva at the end of September 2005 to discussRound 5 grants. The Board decided to approve 26 grants costing $382 million over the first twoyears. Another 37 grants costing $344 million were provisionally accepted pending additionalpledges in the first half of 2006. If sufficient pledges are not received by the end of June 2006, the37 grants will be denied final approval. (19) The Board did not schedule a sixth Round.

U.S. Contributions

The United States made initial contributions to the Global Fund totaling $275 million fromappropriations for FY2001 and FY2002 ( Table 1 ). For FY2003 through FY2005, theAdministration requested $200 million annually, but Congress provided more than requested in eachyear. A $200 million request is in keeping with the PEPFAR promise of $1 billion over five years,but for FY2006, the Administration raised its request to $300 billion. Some speculated that thisreflected recognition on the Administration's part that Congress favored larger contributions. Houseand Senate versions of FY2006 appropriations would again provide more for the Global Fund thanrequested.

Table 1. Funding for U.S. Contributions to the GlobalFund

($ millions)

Global Fund contributions have been funded principally through the Foreign Operations Appropriations legislation and the appropriations for the Departments of Labor, Health and HumanServices, and Education (Labor/HHS). The amounts reported in Table 1 for appropriations inFY2003 through FY2005 reflect rescissions included in these appropriations bills. In FY2004, asshown in line 3, $87.8 million of the amount appropriated for the Global Fund was not provided dueto legislative provisions limiting the U.S. contribution for FY2004 through FY2008 to 33% of theamount contributed by all donors. (20) The FY2005 Consolidated Appropriations legislation directedthat these withheld funds be provided to the Global Fund in FY2005, subject, like the remainder ofthe U.S. contribution, to the 33% proviso. The amount reported in the Senate-passed ForeignOperations bill for FY2006 ( H.R. 3057 ) includes $100 million transferred from theEconomic Support Fund under Sec. 6118, added as a floor amendment during debate.

The one-third rule governing contributions is not an issue in 2005, when the U.S.contribution is estimated at about 29% of total contributions for the calendar year (see below, Table2) . At the September 2005 pledging conference in London, U.S. Global AIDS Coordinator RandallTobias said that the United States would pledge a total of "at least" $600 million ($300 million ineach year) in 2006 and 2007. (21) Tobias noted, however, that the final amount would bedetermined by Congress -- a remark that was interpreted as suggesting that he expected theultimate U.S. contribution to be larger. The $600 million offered by Tobias represents 16% ofamounts pledged for the two years, and was second to the French pledge of $631 million. America'sEuropean partners together pledged $1.6 billion, including the French pledge. (22) The $600 million for theGlobal Fund in FY2006 in the Senate-passed version of the Foreign Operations Appropriation --without considering any additional amount for FY2007 -- would double the Administration requestfor the year and put the U.S. contribution at approximately 28% of the total.

Global Fund and PEPFAR in U.S. Policy

Representatives of the Global Fund and PEPFAR consistently maintain that the two arepartners rather than competitors in the struggle against AIDS. Ambassador Tobias told the Londonpledging conference that the U.S. contribution to the Global Fund is a "strategic priority" of PEPFAR. The operational plan of the Office of the Global AIDS Coordinator for FY2005 states thatthe Global Fund "was conceived to be an integral part of the Administration's global strategy againstthe epidemic." (23) AnAugust 2005 Global Fund press release affirmed that the two programs are partners, noting that"Together, the Global Fund and PEPFAR are the major financial engines to achieve greatly increasedtreatment numbers over the coming years." (24) Jack Valenti, President of Friends of the Global Fight AgainstAIDS, Tuberculosis, and Malaria, which advocates for the Global Fund in the United States,describes the Fund as the "multi-lateral arm of PEPFAR, complementing the work of U.S. bilateralprograms around the world." (25) U.S.-Global Fund cooperation was underscored in January 2003,when then U.S. Secretary of Health and Human Services Tommy Thompson was elected Chairmanof the Fund's Board. Thompson served until April 2005. Ambassador Tobias currently serves ashead of the Global Fund's Policy and Strategy Committee. Many argue that this history ofcooperation represents a significant U.S. policy investment in the Global Fund, and consideredtogether with U.S. financial contributions, gives the United States a significant stake in the Fund'ssuccess.

Those who insist that the Global Fund and PEPFAR are partners also assert that the work ofthe two organizations is complementary. They point out that the Global Fund is the principal vehiclefor mobilizing new resources to fight AIDS outside the 15 Global HIV/AIDS Initiative focuscountries, thus furthering PEPFAR's worldwide objectives. At the same time, the Global Fund isadding resources for treatment and other AIDS relief measures within the GHAI countries. Bycontributing to the Global Fund, the United States is able to "leverage" its investment for fightingthe pandemic because the Fund provides a means for other donors, most of which lack the capacityfor carrying out large bilateral AIDS program, to participate in fighting the pandemic. Many feel thatby working through CCMs, local government ministries, and local NGOs, the Global Fund iscomplementing PEPFAR objectives by helping to build indigenous institutional capacities that willboost the abilities of host countries to deal with health challenges over the long term. PEPFARbilateral programs, meanwhile, complement the work of the Global Fund by bringing the capacitiesof USAID, CDC, and other U.S. agencies to bear on an emergency basis in 15 of the most heavilyaffected countries, where indigenous institutions are not able to cope with the pandemic in the shortterm.

U.S. and Global Fund officials make a point of noting that the two organizations worktogether closely, underscoring their partnership and complementarity. Global Fund staff participatedin the May 2005 annual meeting of PEPFAR field staff, held in Addis Ababa, Ethiopia; and a keyemphasis of the meeting was the importance of cooperation between the two organizations at thelocal level. U.S. embassies in the focus countries report back to Washington on this cooperation. Consultations also take place between the two organizations at the headquarters level. In the field,USAID provides technical assistance to CCMs in setting priorities and formulating proposals to theGlobal Fund. As noted above, there has also been cooperation in providing antiretroviral treatmentto AIDS patients. Officials foresee closer cooperation in the future. For example, W. Brad Herbert,Chief of Operations at the Global Fund, expects U.S. AIDS experts in the field to become moreengaged in helping to monitor the performance of Global Fund-supported projects. (26)

Despite the emphasis on partnership, complementarity, and cooperation in public statements,some suspect that U.S. officials are not entirely happy with the Global Fund, and may see it as a rivalthat is drawing attention away from the accomplishments of U.S. bilateral programs. Some tracethe suspected estrangement to April 2002, when the Global Fund board chose Dr. Richard Feachem,a Briton, as Executive Director, rather than an American candidate proposed by the UnitedStates. (27) Others arguethat the lead-up to the 2003 war in Iraq brought out sentiments in the Administration that wereunfriendly toward the United Nations and multilateral organizations generally, and that this affectedattitudes toward the Global Fund. (28) The tendency of the Administration to request less for the GlobalFund than Congress was willing to provide may be traced to these anti-multilateral points of view,some believe. At a September 2004 congressional staff briefing on the Global Fund, officials werereportedly highly critical of Fund operations, causing observers to doubt Administration statementsof support. (29) However,even many of those who have been skeptical of the degree of partnership between the Global Fundand PEPFAR now acknowledge that there seems to be a new spirit of cooperation, as symbolizedin the Administration's $300 million request for the Fund in FY2006. This new spirit has come latein the day, some argue, but is welcome nonetheless.

Debate Over U.S. Funding for the Global Fund

Despite increasing cooperation between PEPFAR and the Global Fund, the level of U.S.contributions remains a point of contention. Fund supporters believe that other donors are unlikelyto increase their contributions unless the United States boosts its own level of support. Theymaintain that the one-third rule governing U.S. contributions serves as a benchmark for the otherdonors, who see it as their responsibility to provide two-thirds of the funding while the United Statesprovides the rest. Thus, the United States would have to contribute $2.3 billion in FY2006 andFY2007 combined, rather than the $600 million pledged by Ambassador Tobias, if it is to persuadeother donors to make contributions sufficient to meet the Global Fund's stated need of $7 billion.

Many see an increase for the Global Fund on this scale as unlikely, since there are manycompeting budget priorities and no guarantee that other donors would follow the U.S. lead. Administration officials and others argue that the United States has already been generous towardthe Global Fund, and should not be expected to do more. In July 2004, Ambassador Tobias pointedout to an interviewer in Bangkok, during the biennial International AIDS Conference, that

The United States made the first contribution to theGlobal Fund, and we remain the biggest contributor.... We're contributing nearly twice as much asall other donors combined. (30)

Moreover, the United States is on target to contribute considerably more than the $1 billion over fiveyears initially promised when PEPFAR was announced. There was much criticism of the level ofU.S. funding for the Global Fund at the Bankok meeting, where Tobias said that the United Stateswould not fulfill a request from United Nations Secretary General Kofi Annan for a $1 billion annualcontribution. (31)

Table 2. Contributions to the Global Fund by the G7 andEuropean Commission (%)

Sources: Tables on pledges and contributions at the Global Fund to Fight AIDS, Tuberculosis, andMalaria website; Global Fund Observer , September 7, 2007; press reports. Canada's 2006-2007pledge was made after the London pledging conference.

U.S. officials also note that the United States is contributing by far the largest share of fundsgoing toward fighting the global pandemic, including both its Global Fund contribution and itsbilateral PEPFAR program. A report issued by the Henry J. Kaiser Family Foundation in July 2005found that the United States was contributing 45.4% of the funds committed by the G7 nations andthe European Communities for international AIDS programs. (32) This is more than a fairshare, some believe, and if more funding is needed at the Global Fund it should come from othersources. However, the Kaiser study also pointed out that when bilateral commitments andcommitments to the Global Fund were adjusted for Gross National Income, the United States rankedthird in funding international AIDS programs, behind Britain and Canada, but well ahead of France,Germany, and Japan. UNAIDS estimates the total need for resources to fight AIDS in 2006 at $14.9billion, whereas $8.9 billion is likely to be provided (33) -- suggesting to some that donors generally are falling short oftheir "fair share" contribution to the AIDS struggle.

For those who argue that other donors, rather than the United States, should be doing moreto help the Global Fund, the one-third rule governing U.S. contributions should be seen as asafeguard put in place by Congress, rather than as a benchmark determining what others shouldcontribute. Table 2 suggests that the one-third rule may not be governing pledges by other donorsfor 2006 and 2007, although it is also possible that their pledges reflect an expectation that Congresswill add to the U.S. contribution.

Nonetheless, there is significant support, often stated in heated terms, for a larger U.S.contribution to the Global Fund. A number of editorials and opinion pieces have strongly urged anincrease for the Fund, (34) and advocacy organizations, such as the, Global AIDS Alliance, have accused the Administrationof a "deliberate, concerted action" to undermine the Fund. (35) Some argue that anincrease is merited precisely because the United States has assumed world leadership in the struggleagainst AIDS. A larger Global Fund contribution would affirm this leadership, and have diplomaticand public relations benefits as well, since it would underscore the U.S. commitment to an importanthumanitarian cause. Supporters of a boost in funding typically praise the Global Fund for itsinnovative features and its multilateral character. They depict PEPFAR's bilateral effort in thefocus countries as a "top down" program run from Washington, and contrast this with the GlobalFund's direct support for programs developed in the field by stakeholders participating in the CCMs. In this way, they argue, the Global Fund is making a major contribution to institution-building indeveloping countries, with potential wider benefits for governance and growth. Many feel that theGlobal Fund should be the primary component of the U.S. response to the pandemic. They agreewith Stephen Lewis, U.N. Special Envoy for HIV/AIDS in Africa, in seeing the Fund, "whatever itsteething problems" as "the most formidable new international financial mechanism in the battleagainst communicable disease." According to Lewis, the Fund "deserves every ounce of support itcan muster." (36)

Many also favor the Global Fund over PEPFAR's bilateral programs because they believe thatPEPFAR has been fettered by various requirements and restrictions which, in their view,inappropriately restrict the program. PEPFAR, for example, is required by law to spend one-thirdof funds allocated for HIV/AIDS prevention in FY2006 through FY2008 onabstinence-until-marriage programs, (37) and PEPFAR contractors must sign a pledge stating that theyoppose commercial sex work and sex trafficking. (38) Some question the effectiveness of abstinence-until-marriageprograms and worry that the prostitution pledge could inhibit the ability of NGOs to work with agroup that is a key vector for HIV. Such requirements do not affect the Global Fund. In May 2005,Ambassador Tobias rescinded an effort to require NGOs receiving U.S. funds indirectly through theGlobal Fund to sign the prostitution pledge, saying that the policy had not been fully cleared.

Those who oppose an increase in the U.S. contribution to the Global Fund tend to describethe PEPFAR's bilateral effort as superior to the Global Fund program. They emphasize thatPEPFAR is funding expanded involvement in the struggle against AIDS by U.S. agencies, primarilyUSAID and CDC, which have years of experience in fighting disease. Spending in the field is underthe direction of personnel based at U.S. embassies, and this results in better coordination, they argue. It is a mistake to see PEPFAR as a "top down" program, because embassy involvement means thatlocal considerations are constantly being taken into account. (39) Moreover, PEPFAR isitself making a major contribution to building local capacity through its training and infrastructureprograms, and by channeling much of its spending through local organizations as contractors orsubcontractors. With PEPFAR oversight and assistance, supporters maintain, local institutions arebecoming more transparent, potentially strengthening the overall quality of governance in the focuscountries. Some also argue that only a large bilateral program under U.S. control could have gainedthe domestic American political support needed for a commitment of $10 billion in additionalresources to fighting AIDS. They believe that the restrictions on the use of PEPFAR funds reflectwidely-held U.S. values, and further that the program might have failed to win majority support inCongress if the restrictions were not in place.

Some PEPFAR advocates maintain that several Global Fund programs have run intodifficulties, and see this as an argument for refraining from larger contributions. In January 2004,for example, the Global Fund suspended grants in Ukraine that were found to be poorly managedand behind schedule, while in August 2005, grants to Uganda were suspended when the Local FundAgent reported mismanagement of one grant by the Ministry of Health. Global Fund supporters,however, argue that such suspensions are a sign that the Global Fund's oversight mechanisms areeffective and transparent, and that they can be an incentive to recipient countries to strengthen their capabilities for grant management. Grants to Ukraine have been resumed conditional onimprovements in governance and adherence to sound business practices on the part of the CCM. Uganda is implementing changes to improve grant management and restore its own eligibility forGlobal Fund grants. Problems in Global Fund grants are most likely to be encountered in the earlystages of grant implementation, some argue, but tend to ease as a country's capacity for grantadministration begins to grow.

The ongoing debate between advocates for the Global Fund and for PEPFAR bilateralprograms is unfortunate, some observers maintain, because both programs are making importantcontributions in the struggle against AIDS. In their view, a way should be found to provide theGlobal Fund with the resources it needs from the United States and other donors, without takingresources away from bilateral efforts. The United States has already contributed substantial amountsto the Global Fund, and some believe that a failure by the Fund to mobilize the resources it needsto fight the AIDS pandemic will to some degree be a failure of U.S. policy. Some also doubt thatPEPFAR will be able to meet its own objectives for treatment, prevention, and care unless it bolstersthe Global Fund.

Policy Options

The difficulty in attempting to leverage larger contributions from other donors to the GlobalFund by increasing the U.S. contribution is that the resources available under the two appropriationsbills used to support the fund -- Foreign Operations and Labor/HHS -- are finite. Once an annualbudget resolution is passed and funds are allocated to the Appropriations Committees and then tosubcommittees, increases for one program can only be achieved through decreases for others. (40) In hearings and meetings,according to observers, representatives of executive branch agencies tend to argue most stronglyin support of bilateral programs under their control, even though they may also be supportive ofmultilateral programs. Some also suggest that a similar process occurs in the executive branchbefore the annual budget is submitted to Congress, and that this has tended to limit the request forthe Global Fund. The Global Fund has strong supporters in Congress, and this has led toappropriations above the Administration's request, but these have not been on the scale that GlobalFund advocates believe is needed.

The solution for many Global Fund advocates is a "larger pie" for Foreign Operations and/orLabor/HHS, backed up by a larger budget request from the Administration, leaving room for asubstantially larger contribution to the Global Fund. However, expanding funding for theseappropriations bills to benefit the Global Fund would likely prove problematic in a period ofconcern over the federal deficit as well as high levels of spending for the war in Iraq and hurricanerelief. Some advocates of a larger U.S. contribution to the Global fund believe that legislativeprovisions limiting the U.S. contribution to 33% of all contributions should be repealed, since itcould lead to the withholding of U.S. funds in the future. Others argue that the provision should beretained as an incentive to other donors.

Another option would be a concerted U.S. effort to persuade other donor countries to increasetheir contributions to the Global Fund even in the absence of a large U.S. increase. U.S. officialsmight argue that the United States is using its substantial bilateral capabilities to carry out a largescale effort against AIDS under PEPFAR, and that those lacking these capabilities should participatein the struggle through larger contributions to Global Fund. Some suggest that making this caseshould not be left to Ambassador Tobias and his assistants, but that Secretary of State Rice andPresident Bush should also strongly advocate for the Global Fund in public forums and in theirmeetings with foreign leaders. Skeptics question, however, whether foreign leaders would be willingto make substantially larger contributions unless the United States does so as well.

A third option would be an effort to persuade private sector donors, foundations, and thegeneral public to contribute to the Global Fund. At the September 2005 Global Fund pledgingconference, Ambassador Tobias urged non-government sources, including the private sector, to givegenerously to the Global Fund. Some suggest that popular music events along the lines of the 1985Live Aid concert, which raised funds to fight famine in Ethiopia, could generate new revenues forthe Global Fund. Prior to the July 2005 G8 summit in Scotland, ten "Live 8" concerts in supportof ending world poverty reportedly drew more than a million people around the world, (41) although the concerts didnot specifically raise funds for AIDS. To date, however, non-government sources -- apart from theBill and Melinda Gates Foundation -- have contributed only modest amounts to the Global Fund. The Gates Foundation has given $150 million, but corporations have given just $1.9 million, while individuals, groups, and events have accounted for $3.3 million. These relatively low numberssuggest to some that there is great untapped potential for larger contributions from alternativesources; others see them as evidence that the potential is limited. (42) In any event, manycontinue to believe a way must be found to boost Global Fund resources if U.S. objectives incombating the Global AIDS pandemic are to be fulfilled.