The Global Fund to Fight AIDS, Tuberculosis, and Malaria (Global Fund, or the Fund) was established in January 2002 as a public-private partnership to provide significant financial support for global responses to HIV/AIDS, tuberculosis (TB), and malaria. At that time, health experts and advocates were particularly concerned about the rapid spread of HIV/AIDS around the world, the massive numbers of deaths that resulted from HIV infection, and limited access to treatments against the three diseases, particularly HIV/AIDS. Health specialists also noted that co-infection seemed to hasten the rate at which people succumbed to any of the three diseases. Despite expanded access to care and treatment over the past decade, HIV/AIDS, TB, and malaria continue to be three of the world's leading causes of morbidity and mortality around the world. The Global Fund was developed to be an innovative financing mechanism that would attract additional financial resources for the global fight against the three diseases in developing countries. It was never intended to directly implement related programs. Several distinguishing characteristics purported to make this new entity a unique one, including with no implementation mandate, the Global Fund would have relatively low overhead expenses; rigorous monitoring and evaluation requirements could ensure performance-based funding; transparency in decision making, including grant funding, could support accountability; and partnerships among governments, the private sector, and civil society would be created and expanded, due in part to the grant development process. The Fund's board meets at least twice annually to discuss governance issues, such as grant approval. Nineteen board seats are rotated among seven donor countries, seven developing countries, and five representatives from civil society and the private sector, including one representative of a non-governmental organization (NGO) from a developing country, one representative of an NGO from a developed country, one representative of the private sector, one representative of a private foundation, and one representative of an NGO who is a person living with HIV/AIDS or from a community living with TB or malaria. The United States holds a permanent board seat. In 2001 and 2002, donors pledged $947.2 million to launch the Global Fund. In its first round of considering grants, the Global Fund committed to support 58 programs in 43 countries, amounting to $616 million for the first two years of implementation. In December 2010, the Global Fund Board announced that it would support the 10 th round of grant proposals, valued at more than $1.7 billion for the first two years of project implementation. Over five years, the Global Fund could expend some $4.7 billion on these grants if performance requirements are met and resources are available. By the end of 2011, the Global Fund had approved roughly $22.6 billion to help 150 countries fight HIV/AIDS, TB, and malaria. As of mid-February, 2012, almost 70% of all approved funding had been disbursed, amounting to over $15 billion. Since its establishment, the Global Fund has become one of the world's largest donors supporting HIV/AIDS, TB, and malaria programs in developing countries. In 2009, the Fund accounted for 21% of global spending on HIV/AIDS, 65% of spending on TB in the 22 high-burden countries, and 65% of global malaria funding. The Global Fund estimated that by the end of 2011, the programs it supports had saved over 7.7 million lives. Grants supported by the Global Fund have reportedly provided AIDS treatment for 3.3 million HIV-positive people, anti-tuberculosis treatment for 8.6 million people, and 230 million insecticide-treated nets for the prevention of malaria. In November 2011, the Global Fund Board announced that due inadequate resources from donors, it would cancel its 11 th round of funding. The Global Fund expects to offer new funding for grants in 2014. Until then, in order to avoid any disruptions in ongoing services, the board has instituted a Transitional Funding Mechanism for programs that face disruption of essential services, currently supported by the Global Fund, and for which no alternative sources of funding can be secured. At the November 2011 board meeting, the Global Fund Board adopted a new five-year strategy for 2012-2016, which supports more aggressive management and oversight of grants, encourages more flexibility in tailoring activities to specific country's needs, and embraces more country ownership of programs through increased involvement of country governments (see Text Box). The board also approved the Global Fund's "Consolidated Transformation Plan," developed to improve Global Fund governance, operations, and fiduciary controls, as recommended by a report released in September 2011 by the High-Level Independent Review Panel on Fiduciary Controls and Oversight Mechanisms of the Global Fund. In January 2012, the Executive Director of the Global Fund announced his decision to step down. In response, the Global Fund created a new position of General Manager, charged with overseeing the implementation of the Consolidated Transformation Plan. The Global Fund was established to extend life-saving measures to the world's poorest. In many of these countries, including post-conflict and fragile states, implementing organizations have weak programmatic and oversight capacity. In light of these conditions, the Global Fund developed a performance-based system that has served as a cornerstone of its operations since the effort was launched. The system relies on seven main actors, including the Country Coordinating Mechanism (CCM) , a country-level partnership of stakeholders, responsible for developing and submitting grant proposals, nominating Principal Recipients, and providing oversight to grant implementation. Principal Recipient , the designated in-country organizations chosen by the CCM to receive funding from the Fund, implement programs, and distribute funds to sub-recipients. Sub-Recipient , an organization contracted by the Principal Recipient of the grant to assist in implementing program activities. Local Fund Agent , a contracted entity that provides independent and routine monitoring and financial audits of the Global Fund disbursements and activities. Secretariat , responsible for day-to-day operations, including mobilizing resources, overseeing grant implementation, providing support to the board, and reporting on the Fund's activities to the board and the public. Technical Review Board , an independent panel of experts in health and development who review eligible grants proposals for technical merit. The Global Fund Board , responsible for overall governance of the Fund. Through the performance-based system, the Global Fund has integrated grant oversight at various levels, including internal control mechanisms instituted by Principal Recipients; independent in-country verification and oversight mechanisms established by Local Fund Agents; annual audits of principal and sub-recipients by an external, independent body; monitoring of grant implementation by the Secretariat; audits and investigations conducted by the Office of the Inspector General; and oversight provided by Global Fund Board and its committees. Upon approving grant proposals, the Global Fund commits to providing sufficient resources to finance the first two years of the program. In order to receive subsequent financing, programs must demonstrate results against performance targets that are spelled out in the grant proposals ( Figure 1 ). Over the lifetime of a grant, performance-based indicators are developed and monitored in four key stages: 1. Proposal development. Applicants develop and submit proposals to the Global Fund Secretariat that include output, outcome and impact indicators, and targets defined by the countries themselves. If the proposal is approved, these form the basis for measuring the performance of a grant. 2. Grant negotiation. Upon approval, the Global Fund negotiates the terms of grant agreements, legally binding contracts that clearly indicate time-bound targets to measure the performance of the grants. At this stage, monitoring and evaluation systems are also assessed. The Global Fund recommends that 5%-10% of grant budgets are used for monitoring and evaluation. 3. Performance-based disbursements. Over the course of a grant's life cycle, the Principal Recipient reports regularly to the Global Fund on results, expenditures, and any deviations from or corrective actions to program activities. The Local Fund Agent, an independent contractor based in the country, verifies the Principal Recipient's programmatic and financial reports and makes recommendations to the Global Fund on the amount to be disbursed for the next period of implementation. The Secretariat evaluates the overall performance of the grant, assigns a rating, and decides on the next disbursement amount. Lack of progress triggers a request by the Secretariat for corrective action and may also result in reduced disbursements. 4. Grant renewal. Toward the end of Phase 1 (first two years of implementation), the Global Fund evaluates each grant to ensure that funding is managed and spent efficiently and programs are achieving expected results. At this point, the Fund decides whether to continue funding grants, reduce funding, direct investments in systems strengthening, or stop funding altogether. Grants demonstrating potential for significant and sustainable impact can receive additional funding for up to six years through the "Rolling Continuation Channel." Consistent with its performance-based model, the Global Fund reports that it has terminated, suspended, or discontinued grants or replaced principal recipients in cases of uncorrected inadequate performance. Since the Global Fund was established, the United States has been a strong supporter of the organization. Officials from the Department of State, the United States Agency for International Development (USAID), and the United States Department of Health and Human Services (HHS) were all engaged in the creation of the Global Fund, and former Secretary of HHS Tommy Thompson was later elected as the second Chair of the Global Fund's Board. At present, U.S. officials from various agencies sit on several Global Fund boards. The Obama Administration has signaled its intention to maintain that support. In a March 2011 statement and at a House hearing, the U.S. Global AIDS Coordinator, Ambassador Eric Goosby, linked the success of U.S. bilateral HIV/AIDS programs under the President's Emergency Plan for AIDS Relief (PEPFAR) to the continuance of the Global Fund: Our dependency on the Global Fund is a real one....