RF: The Global Fund was always intended to stop the spread of three pandemics — HIV/AIDS, tuberculosis, and malaria. At the time of its creation, it was clear that these three diseases had reached epidemic proportions, and that their spread had a disproportionate impact on the developing world.

PND: Tell us about the fund's key programs?

RF: In three rounds of proposals, the fund has approved grants to one hundred and twenty-one countries plus three territories, including those with the greatest present disease burden. A total of $2.1 billion has been allocated to support two hundred and twenty-four programs in these countries and territories. Of this amount, 60 percent will go to Africa, 20 percent to Asia and the Middle East, and 20 percent to Latin America and Eastern Europe.

The key programs aim to place seven hundred thousand people on anti-retroviral treatment, tripling current coverage in developing countries; extend voluntary counseling and testing to thirty-five million clients; extend care and support to over one million orphans supported through medical services, education, and community care; detect and treat nearly three million additional tuberculosis cases with DOTS; triple treatment of multi-drug resistant tuberculosis, with more than eight thousand new treatments; deliver twenty-two million artemisinin-based combination drug treatments for resistant malaria; and provide sixty-four million bed nets to protect families from transmission of malaria.

PND: Are there certain eligibility requirements that have to be met before a country can receive aid from the fund?

RF: As of the third round of proposals in May 2002, the fund adopted criteria to give priority to proposals from countries and regions in greatest need. Applications for funding were accepted only from countries classified by the World Bank as low or lower-middle income, or as upper-middle income but facing an exceptionally high burden of disease.

PND: Does the fund partner with health organizations in recipient countries or does it provide its own staff and experts?

RF: The fund is a financing mechanism, not an implementing agency. It employs about one hundred staffers in its secretariat, which is based in Geneva, Switzerland. But it mainly exists to provide financing through a broad partnership of stakeholders at the country level known as a "country coordinating mechanism," or CCM. The CCMs are intended to be multi-sectoral and involve broad representation from government agencies, NGOs, community- and faith-based organizations, private-sector institutions, people living with the diseases, and multilateral agencies.

PND: Early on, the fund had trouble securing donations from the international community and at one point almost ran out of money. How are its finances now? Is it able to meet its commitments?

RF: To date, the Global Fund has received pledges through the end of 2004 totaling $3.1 billion, with an additional $1.9 billion pledged for 2005 to 2008. While significant, pledges through 2004 are not enough to finance new funding rounds, or the renewal of grants approved in rounds one to three. Our projected resource needs are $1.6 billion in 2004 and $3.6 billion in 2005.

PND: In his January 2003 State of the Union address, President Bush announced a $15 billion plan to fight AIDS in Africa and Haiti, and indicated that $1 billion of that amount would be earmarked for the Global Fund, while the rest would go to U.S. programs in fourteen countries. Did the $1 billion pledge to the fund come with strings attached?

RF: There has been movement toward increasing funding from the United States beyond the initial $200 million per year for five years. The United States' pledge to the fund for 2004 is $547 million, and that has substantially increased our resources, with current projections suggesting that at least $900 million will be available for the fourth round of funding, to be awarded at our board meeting in June.

Funding needs for the fourth round are likely to be high to cover a drastic global scale-up in AIDS treatment, increased efforts to fight TB and an ambitious agenda to roll back malaria. The U.S. contribution is conditional on it not exceeding 33 percent of total paid-in contributions to the fund in 2004. Assuming full payment of current pledges from other donors, the U.S. contribution for 2004 will be maximized if the fund is able to raise another $120 million in non-U.S. pledges.

In addition to scaling up its own funding, the fund will work to reconcile efforts to fight HIV/AIDS with President Bush's Emergency Plan for AIDS Relief to ensure that the additional U.S. funding will complement and strengthen programs in countries receiving money from both sources. We warmly welcome the new infusion of resources through the U.S. initiative and will make sure we maximize their impact by preventing overlapping efforts and conflicting priorities.

PND: In January, the fund suspended funds to a program in the Ukraine, citing poor management. What happened there? Was it an unusual situation?

RF: There were a number of different management and governance issues which lay at the root of our decision. They differ greatly between the three different recipients who were affected, but overall the fund came to the conclusion that the Ukrainian CCM and the three recipients needed time to sort out their problems and strengthen their management. In order to speed up the work we finance in the Ukraine and ensure that the original targets for getting people on treatment and building effective outreach and information programs on HIV/AIDS are reached, the fund is asking a reliable organization temporarily to take over implementation of the programs.

It was an unusual situation, and I think it shows that we closely monitor every CCM to ensure that grants are disbursed to sub-recipients as agreed.

PND: How do you monitor recipients?

RF: The fund has established three levels for monitoring the performance of its recipients. First, each country that applies for a grant must do so through a CCM. The CCM ensures that applications are consistent with the country's policy frameworks and plans and is responsible for identifying the principal recipient and for holding it accountable in terms of performance. We believe that the broad composition of CCMs ensures accountability and delivery of agreed-upon results.

Second, the fund has appointed reputable audit and accounting agencies as local fund agents, or LFAs, to be its ears and eyes on the ground and ensure that country procedures are consistent with fund-approved protocols. The LFAs are directly accountable to the fund.

Third, the disbursement of grants is not front-loaded. Funds for the first six months of a work plan are disbursed upfront. Subsequent disbursements are made on request, accompanied by a financial account of resources received previously, a report of results achieved to date, and clear plans for the requested funds. The report is then reviewed by the secretariat before a decision is made to disburse further funds. Where the process is slow, or where doubt exists, the fund reserves the right to intervene and review the situation.

PND: Where has the fund had the most impact?

RF: In my view, the fund represents a new paradigm in development assistance. For the last several years, donor countries have set priorities for developing countries from the perspective of policy makers in their capitals. This has not had the desired effect. Through the Global Fund, the paradigm is shifting to a recognition that responsibility for development must reside in the hands of policy makers in the affected country themselves. Developing countries should set their own priorities and request funds to implement those priorities.

In addition, through the fund's principle of broad partnership at the country level, governments are continuously opening up space and broadening stakeholder participation in policy and program decisions. Previously, in most of the countries in which we fund, NGOs, FBOs, the private sector, academia, and people living with disease simply did not come together at the policy level to discuss health development issues. Today, in contrast, there is dialogue in all those countries, albeit more in some than in others. And while the engagement has not yet reached our level of expectations, the good news is that there is positive movement in this direction and increasing demand for inclusion in the CCM by the various stakeholders.

PND: Can you describe the impact the fund has had in combating the spread of AIDS, malaria, and tuberculosis? And do you remain hopeful that the spread of those diseases can be slowed or even halted?

RF: It is still early to talk about results. By the end of 2003, only one grant, to Ghana, had been in implementation for a full year. In the interim, the best source of data on progress in this regard is disbursement requests, which report briefly on results as a way of justifying continued financing by the fund. Those requests do reveal progress by recipients in building the infrastructure necessary to expand service delivery to large populations, as well as the initial coverage of those services.

In Ghana, for example, the training of health care staff has proceeded as a critical first step to scaling up voluntary HIV counseling and testing services, mother-to-child transmission prevention programs, and access to antiretroviral treatment. By the end of the first quarter of 2003, the targeted counselors, supervisors, laboratory technicians and midwives had received training and the program's next phase was under way. In addition, detection and treatment of tuberculosis treatment commenced, following the renovation of more than twenty centers providing those services and the training of private practitioners to extend the delivery of tuberculosis programs from the public sector.

The AIDS grant to Haiti also is having an impact on the ground. By the end of 2003, more than 2,500 pregnant women had been tested for HIV, of whom nearly seventy percent were diagnosed as HIV-positive and enrolled in a mother-to-child transmission prevention program. Additionally, recipients there increased the number of centers offering voluntary counseling and testing from three to thirteen. And from a baseline of only fifty patients, more than two thousand people living with HIV were receiving antiretroviral treatment by the end of the year.

In Honduras, a grant to prevent and treat HIV/AIDS has wiped out the waiting list for antiretroviral treatment. Ghana will use its grant to build sixteen voluntary testing and counseling centers, provide MTCT prevention services to six hundred mothers a year, and begin antiretroviral therapy for two thousand people living with HIV/AIDS. In addition, the grant will make it possible for an additional twenty thousand TB patients to be treated using DOTS over the next two years. A quarter of these patients will be treated in private health clinics in order to strengthen the capacity of the private sector to work with the public sector to fight TB.

But while progress in Ghana, Haiti, and Honduras has been steady, the pace of implementation in Tanzania has been slow, with only $500,000 disbursed to date — that's only 4 percent of the two-year commitment — and few results to report. Tanzanian recipients are working to increase the pace of implementation, but their experience affirms the role of a performance-based funding approach, where outflows are only made as additional resources can be used.

So yes, I remain hopeful — enthusiastically so. The Global Fund represents a once-in- a-lifetime opportunity to respond to a global health crisis in a unique way. If we can show good returns on our initial investments by achieving impact at the grassroots level, I believe the global community will continue to support the fund.

PND: What lies ahead for the fund? Do you have any new programs planned?

RF: The fund is entering the implementation phase, which is new for us. Grants have been signed; disbursements have begun and are moving ahead rapidly. By the end of 2004, up to $1 billion will have been disbursed. The challenge ahead is to demonstrate that those resources are making a difference, that they are being used appropriately and in a transparent way, and that the growth of good program governance at the country level by a broad-based, representative CCM argues for the future viability of the fund.

Given the WHO/UNAIDS call to put three million people on anti-retroviral therapy by 2005, the fund expects a rapid increase in the number of people seeking such therapy and will continue to fund prevention, much of it focused on school-aged children and youth.

PND: Well, thank you very much for speaking with us today.

RF: My pleasure. Thank you.

Kevin Kinsella, PND's managing editor, interviewed Dr. Richard Feachem in February. For more information on the Newsmakers series, contact Mitch Nauffts, PND's editorial director, at mfn@fdncenter.org.