In January 2002, the Global Fund to Fight AIDS, Tuberculosis, and Malaria (Global Fund) was established as an independent foundation in Switzerland to support country efforts to curb the number of illnesses and deaths caused by HIV/AIDS, tuberculosis (TB), and malaria. Each year, the three diseases kill some 6 million people, mostly in Africa. 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 one representative from each of a developed country non-governmental organization (NGO), a developing country NGO, the private sector, a foundation, and affected communities. The United States holds a permanent Board seat. In its first five years, the Fund aimed to support: treatment for 1.8 million HIV-positive people, 5 million people infected with TB, and 145 million malaria patients; the prevention of HIV transmission to 52 million people through voluntary HIV counseling and testing services (VCT); the purchase and distribution of 109 million insecticide-treated bed nets to prevent the spread of the malaria; and care for 1 million orphans. As of July 11, 2008, the Global Fund has approved proposals for 519 grants in 136 countries totaling $10.8 billion ( Table 1 ). About half of those funds have been disbursed. As of December 2007, the Fund-supported grants have been used to treat an estimated 1.4 million HIV-positive people and 3.3 million people infected with TB, and to distribute 46 million insecticide-treated bed nets to prevent malaria transmission. An estimated 58% of Global Fund grants support HIV/AIDS interventions, about 17% fund anti-TB programs; some 24% sustain anti-malaria projects, and 1% strengthen health systems. According to the Global Fund, in 2005, its support represented more than 20% of all global HIV/AIDS spending, some 67% of global TB funds and about 64% of all international support for malaria interventions. In 2005, the Fund approved Round 5 grants in two tranches, because there were no sufficient donor pledges to support all recommended proposals at the time of grant approval. Its Comprehensive Funding Policy (CFP) specifies that the Fund can only sign grant agreements if there are sufficient resources to support the first two years of grant activities. The policy is designed to avoid disruptions in funding that might interrupt project activities. Financial delays can cause people to miss treatments, potentially leading to drug-resistance, susceptibility to secondary diseases, or death. The Fund distributes grants through a performance-based funding system. Under this system, the Fund commits to financially support the first two years (Phase I) of approved grants, though it disburses the funds quarterly if grants meet their targets. As the end of Phase I approaches, the Fund reviews the progress of the grant to determine if it should support the third through fifth years (Phase II). In November 2006, the Board established the Rolling Continuation Channel (RCC). This funding channel, which began in March 2007, permits Country Coordinating Mechanisms (CCMs) to request additional funding for grants that are performing well but set to expire. The application process for the RCC is not as rigorous as the Round process. RCC-approved grants can receive support for up to an additional six years, with the funds being awarded in three-year intervals. The channel is intended only for those grants that have demonstrated a significant contribution "to a national effort that has had, or has the potential to have in the near future, a measurable impact on the burden of the relevant disease." The Fund uses a performance-based funding system that permits it to temporarily suspend support for grants if it finds significant problems with project performance, such as accounting inconsistencies. In some instances, the Fund restored support to grants once key concerns were resolved. For example, in November 2006, the Fund suspended support for grants in Chad. After undertaking audits of the grants, the Fund reportedly discovered evidence of "misuse of funds at several levels and the lack of satisfactory capacity by the Principal Recipient and sub-recipients to manage the Global Fund's resources." In August 2007, the Fund announced that it had lifted the suspension, "after a series of investigation and negotiations between the Global Fund and national authorities ... and after efforts and strong commitment of all relevant stakeholders which guaranteed that the issues have been addressed and better systems with clarified responsibilities will be put in place. As part of the [Global Fund's] mitigation—besides other measures—a fiduciary agent will guarantee for an interim period of 12 months adequate financial monitoring and accounting for our grants." The Fund might discontinue support for grants in Phase II if it finds that they did not sufficiently meet their targets. Countries whose grants have been discontinued can apply and have secured funding in subsequent Rounds (see Nigeria below). In extreme cases, the Fund will immediately cancel financial support. If funds are immediately revoked, the Fund might invoke its continuity of services policy, which ensures that life-extending treatment is continued for suspended or cancelled grants or for those whose terms have expired until other financial support is identified. To date, the Fund has only terminated grants in Burma. When the Fund decided to terminate support for grants in Burma, policy analysts debated how best to serve humanitarian needs in politically unstable countries. On January 30, 2004, the Global Fund announced that it had temporarily withdrawn its grant in Ukraine. Citing the slow progress of Fund-backed HIV/AIDS programs, the Fund stated that it would ask "a reliable organization to take over implementation of the programs for several months, to give Ukraine the opportunity to address concerns of slow implementation, management, and governance issues." Nearly a month later, on February 24, 2004, the Fund announced that the suspension had ended, and that a temporary principal recipient had been identified. The Fund hoped that if a new Principal Recipient (PR) were used, project performance would improve and related problems would be resolved. In July 2005, the Fund announced that the new PR was successfully implementing the grant and that it had approved additional funds for the grant's Phase II activities. In May 2006, at its 13 th board meeting, the Fund decided to discontinue support for Nigeria's HIV/AIDS programs awarded in Round 1. In previous board meetings, the Secretariat recommended that the Fund not award Nigeria additional support for Phase II. The Board disagreed. At the 12 th Board meeting, the Board and Secretariat agreed to create an Independent Review Panel to review the grants and report back to the Board. Following its investigation, the Panel presented similar findings and agreed with the Secretariat that the grants were performing poorly. The Board agreed not to fund Phase II of the grants, but committed to support procurement of HIV treatments for up to two years. Although those grants were discontinued, the Fund awarded Nigeria different HIV/AIDS grants in Round 5. Staff at the Global Fund report that the Fund discontinued support for Pakistan's malaria projects in Round 2 because of weak project implementation, slow procurement of health products, poor data quality, and slow spending of project funds. Specifically, the Secretariat found that 8 of the grant's 10 targets had not been reached and only 15% of the insecticide-treated nets (ITNs) had been distributed. On March 1, 2005, the Global Fund announced that it would not approve funding for the second phase of Senegal's malaria project, which was originally funded in Round 1. A Fund press release indicated that the project "was found to have systemic issues that resulted in poor performance." The release did not specify what issues it had with the project, though it indicated that "review of the Senegal grant raised serious concerns" about the effective use of Global Fund resources. Although the program was discontinued, Fund officials encouraged Senegal to address the issues that were raised and to apply for new funds in the future. Ultimately, the Fund approved a grant proposal that Senegal submitted for malaria projects in Round 4. In December 2005, the Global Fund Board voted to discontinue funding an HIV prevention grant in South Africa. The Board decided that the grant, implemented by an NGO named loveLife, had failed to sufficiently address weaknesses in its implementation. Press accounts quote a Global Fund representative explaining that it had become difficult to measure how the loveLife prevention campaign was contributing to the reduction of HIV/AIDS among young people in South Africa. Additionally, the representative reportedly stated that the Board had repeatedly requested that loveLife revise its proposals and address concerns regarding performance, financial and accounting procedures, and the need for an effective governance structure. A Global Fund spokesman was quoted as saying that "loveLife is extremely costly, there are programs that have been very effective, which cost a fraction of what loveLife costs. It would be irresponsible of the Global Fund to spend almost $40 million without seeing results." LoveLife officials were reportedly surprised that the Global Fund ultimately decided to discontinue funding the grant, particularly since there were some reported differences of opinion regarding the matter between the Fund's Technical Review Panel (TRP), Secretariat, and the Board. Additionally, loveLife officials reportedly argued that the decision was politically motivated and influenced by U.S. emphasis on abstinence in HIV prevention efforts. One press account quoted a loveLife official as saying, "Obviously the strength of conservative ideologies is spilling over into the field of HIV and HIV prevention and it has direct impact on programs like loveLife." According to a loveLife press release, the decision to discontinue support for the program will substantially curtail South Africa's efforts to prevent HIV infections among young people, because the Global Fund's grant supported one third of the program's budget. However, the South African government has reportedly provided additional funds to the program to close the funding gap, and other donors, such as the U.S.-based Kaiser Family Foundation, have continued funding loveLife HIV-prevention efforts. On August 24, 2005, the Global Fund announced that it had temporarily suspended all five of its grants in Uganda.