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Africa: Global Fund Results

AfricaFocus Bulletin
Jul 15, 2010 (100715)
(Reposted from sources cited below)

Editor's Note

According to a new report from the Global Fund to Fight AIDS, TB, and Malaria, the Fund's efforts have contributed to saving an estimated 4.9 million lives by December 2009. The coming years will see even more results, as half of the total disbursements by the Global Fund were delivered in 2008 and 2009. Much of the US$ 5.4 billion of financing approved in Rounds 8 and 9 will reach countries in 2010 and 2011, and will continue to significantly boost health outcomes.

This is among the findings of a extensive series of detailed reports from the Fund presented at its meeting earlier this year, and available at

This AfricaFocus Bulletin contains the executive summary of the document Innovation and Impact and a summary of one of the additional documents, which analyzes the mixed results of African government pledges to provide additional funding. That report finds that the percentage of the average government expenditure on health, as a percentage of total government expenditure, rose only marginally from 8.8% in 2001 to 9.0% in 2007, despite the 15% commitment of the Abuja Declaration. But a number of countries showed substantially greater increases. By 2007 three countries had met the 15% target (Djibouti, Botswana and Rwanda).

Another AfricaFocus Bulletin, sent out by e-mail today and available on the web at, contains excerpts from a UNAIDS press release and from the 2010 UNAIDS Outlook report, outlining new recommendations for "Treatment 2.0" as well as noting progress in HIV/AIDS prevention, particularly among young people in Africa.

For previous AfricaFocus Bulletins on health issues, see

++++++++++++++++++++++end editor's note++++++++++++++++++++

The Global Fund 2010

Innovation and Impact Results Summary

For this and other reports on the current status and record of Global Fund programs, see

Executive Summary

1. Every day, programs supported by the Global Fund save at least 3,600 lives, prevent thousands of new infections and alleviate untold suffering.

2. The Global Fund to Fight AIDS, Tuberculosis and Malaria is a public-private partnership established in 2002 to mobilize and intensify the international response to three global epidemics and thereby help achieve the Millennium Development Goals (MDGs). From its founding through December 2009, the Global Fund Board approved proposals totaling US$ 19.2 billion, and disbursed US$ 10 billion for HIV, tuberculosis (TB) and malaria control efforts. To maximize impact, every dollar donated goes to fund programs in country. The Global Fund has no country offices, and its operating expenses are almost entirely covered by the interest earned on the Trustee account at the World Bank.

3. The results and impact outlined in the report are the achievements of all the partners that collaborate as part of the Global Fund model. The success of the Global Fund relies on the financial pledges of donors, the technical guidance of - and collaboration with - multilateral partners, and particularly the management and implementation of programs by in-country partners including governments, civil society organizations and the private sector.

4. HIV. At the end of December 2009, programs financed by the Global Fund were providing antiretroviral therapy (ART) to 2.5 million people. Approved HIV proposals have totaled close to US$ 10.8 billion covering 140 countries. The Global Fund is estimated to have contributed about one-fifth of all disbursements by bi- and multilaterals for the HIV response in low- and middle-income countries in 2008. In addition to providing ART, programs funded by the Global Fund have also distributed 1.8 billion male and female condoms and have provided 790,000 HIV-positive pregnant women with treatment to prevent mother-to-child transmission of HIV, as well as 4.5 million basic care and support services to orphans and other children made vulnerable by AIDS, and 105 million HIV counseling and testing sessions. There is a growing body of evidence showing that Global Fund financing - alongside that of other financiers - has resulted in declines in AIDS mortality in countries in which provision of ART has been scaled up rapidly, accompanied by other significant impacts, such as improved survival and productivity of key professionals and other workers, and systemwide improvements in health care delivery.

5. Tuberculosis. Through 2009, programs funded by the Global Fund have provided treatment to 6 million people who had active TB. The Global Fund provides 63 percent of the external financing for TB and multidrugresistant TB (MDR-TB) control efforts in low- and middle-income countries. Approved TB proposals have totaled close to US$ 3.2 billion covering 112 countries, contributing 48 percent of the projected coverage required to achieve the Stop TB Partnership targets for the detection and treatment of new smear-positive TB cases. TB programs supported by the Global Fund have also provided 1.8 million TB/HIV services. In many countries in which the Global Fund supports programs, TB prevalence is declining, as are TB mortality rates.

6. Malaria. By the end of 2009, Global Fund-supported programs had distributed 104 million insecticide-treated nets (ITNs) to prevent malaria. They also supported indoor residual spraying of insecticides in dwellings more than 19 million times and treated 108 million cases of malaria in accordance with national treatment guidelines. Approved malaria proposals have totaled US$ 5.3 billion covering 83 countries. In 2008, the Global Fund contributed 57 percent of international disbursements for malaria control. Global Fund investments have played a critical role in introducing and expanding coverage of novel, effective malaria treatments in many countries where drug resistance to older treatments is high. In conjunction with re-energized national and international efforts to combat malaria, increased Global Fund financing is having a substantial impact on malaria morbidity and mortality worldwide, with an increasing number of countries reporting a reduction in malaria deaths of more than 50 percent.

7. The Global Fund supports community-based interventions. Since 2003, these efforts have delivered 138 million community outreach prevention services for at least one of the three diseases and provided 11.3 million "person-episodes" of training for health and community workers.

8. These combined efforts saved an estimated 4.9 million lives by December 2009 and restored hope for the 33 million people living with HIV, the hundreds of millions of people who contract malaria or who are at risk each year, and the 9.4 million who contract active TB annually. The coming years will see even more results, as half of the total disbursements by the Global Fund were delivered in 2008 and 2009. Much of the US$ 5.4 billion of financing approved in Rounds 8 and 9 will reach countries in 2010 and 2011, and will continue to significantly boost health outcomes.

Having a wider impact: Strengthening health systems and contributing to progress on the Millennium Development Goals

9. The Global Fund investments to combat HIV, TB and malaria are having a much wider impact - beyond individuals, their families and communities. They are major investments in health systems - bolstering infrastructure, strengthening laboratories, expanding human resources, augmenting skills and competencies of health workers, and developing and supporting monitoring and evaluation (M&E) activities. These enhancements, in turn, improve the sustainability of services, increase national capacity to expand programs further and increase countries' ability to improve services for other health issues. Ultimately, the investments translate into a healthier population and increased productivity, enabling countries to further their development.

10. These investments have helped accelerate progress towards the MDGs by contributing directly to MDGs 4, 5, 6 and 8, and indirectly to the others. The US$ 19.2 billion of approved investment by the Global Fund is a direct contribution to MDG 6 ("Combat HIV/AIDS and malaria and other diseases"). In addition, major contributions have also been made to MDG 4 (on child mortality) and MDG 5 (on maternal mortality) by reducing the largest causes of mortality among women and children. This is particularly the case in sub-Saharan Africa, where HIV, TB and malaria are responsible for 52 percent of deaths among women of childbearing age and malaria alone accounts for 16 to 18 percent of child deaths.

Achieving results and promoting equity

11. The Global Fund's innovative financing model was designed to respond quickly and effectively to the tremendous need for funding in the countries with the heaviest burdens of AIDS, TB and malaria, while ensuring transparency and broad accountability to donors and recipients. This model has continued to evolve, and in 2009 it tested new ways to strengthen country ownership and governance, increase access to lifesaving medicines and other health products, and promote health equity.

12. Equitable access to services is fundamental to the mission of the Global Fund. In making grants, great weight is assigned to each country's needs, as measured by indicators such as disease burden and poverty level. The Global Fund also works to ensure that the programs it finances address the needs of the poorest, at-risk and marginalized groups, for instance with its new strategies on gender equality and sexual minorities. Further, it has become the world's leading funder of harm reduction services for people who inject drugs, with substantial investments in 42 countries.

13. Between 2005 and 2009, nearly four out of five assessed grants were performing well. Currently, TB grants are the best performers and civil society organizations the best performing Principal Recipients.

Continuing to learn, improve effectiveness and innovate

14. The Global Fund always seeks to learn, improve and innovate through its operations, partnerships and valuations. One key opportunity for learning comes from the engagement of different constituencies in Global Fund governance - governments, civil society, the private sector, affected communities and bilateral and multilateral agencies.

15. The Global Fund actively contributes to global efforts to improve aid effectiveness, especially in the area of managing for results, by playing a leading role in monitoring effectiveness and sharing experiences with performance-based funding.

16. Within the Global Fund, the Board, the Board committees, the Executive Management Team, the Technical Evaluation Reference Group and the Office of the Inspector General help identify key areas of the organization's programs and business model in need of evaluation or improvement. The continuous attention to evaluation and learning helps the Global Fund maximize its responsiveness, effectiveness and cost-effectiveness.

17. Ensuring value for money at every stage of the financing chain is a critical priority for the Global Fund. One of the focus areas is to develop and promote, with partners, standardized methods for countries to measure the efficiency and effectiveness of key HIV, TB and malaria services. The comprehensive performance review which occurs by year two of each grant also contributes to value for money by allowing for the reallocation of funds from poorly performing grants to better-performing grants as well as for the identification of efficiency gains. In 2009 alone, nearly US$ 1 billion was freed up for funding new grants. Voluntary pooled procurement is reducing the cost and improving the quality of pharmaceuticals and health products, and collaboration with technical partners is assessing the efficiency of service delivery models in order to expand and optimize access to lifesaving interventions.

18. Through its portfolio of grants in 144 countries, the Global Fund has developed and is strengthening data analysis of unit costs for HIV, TB and malaria services. This analysis will institute savings, reveal best practices and waste, and assist in assessing resource-need estimates in future grant applications.

Maintaining the positive momentum for achieving results and impact

19. The Global Fund is realizing the extraordinary vision of its founders, donors and implementers: it has dramatically intensified the fight against HIV, TB and malaria while contributing to improving health systems and to progress on achieving the MDGs. Virtual elimination of mother-to-child HIV transmission globally by 2015 can be achieved. Massive scale-up of HIV prevention programs and of provision of ART continues, though universal access to comprehensive and evidence-based HIV prevention, treatment, care and support remains distant. Prevalence of TB has significantly decreased over the last decade and the international target of halving TB prevalence could be met by 2015. Unprecedented coverage with ITNs and effective novel treatments have made great inroads in combating malaria. The rapid scale-up of prevention, treatment, care and support for these three pandemics has meant hope and - as the results in this report testify - a positive impact on millions of lives.

20. Such unprecedented progress would not have been possible without the support of donors and partner organizations. In the coming years, continued, substantial increases in long-term financial commitments by donors will be needed to consolidate these gains and to reach the MDGs by 2015 and universal coverage of HIV, TB and malaria services. 2010 is a year that should inspire extraordinary commitments from the public and private sectors to safeguard and build upon the already substantial achievements made over the past decade.

African Countries Face Major Challenges in Bid to Increase Domestic Spending on Health

[Summary provided by Global Fund Observer (GFO), Issue 128: 14 July 2010. For the full Global Fund Observer, see

For the full report, see "Trends in Development Assistance and Domestic Financing for Health in Implementing Countries," available at]

African governments have not lived up to their commitment in the Abuja Declaration to allocate 15% of their annual budgets to health expenditure.

Furthermore, short- to medium-term domestic funding for health in low-income countries in Africa will not be enough to provide the basic package of interventions required by the population, even if African governments were to increase spending on health in line with their commitments in the Abuja Declaration. Any increase in funding will need to draw upon all sources, domestic and international, until the tax bases of African countries grow sufficiently to assume a larger share of the costs.

Meanwhile, in non-African middle-income countries, funding for health comes predominantly from domestic sources, with external funding contributing a negligible proportion.

These are three of the conclusions of "Trends in Development Assistance and Domestic Financing for Health in Implementing Countries," a report prepared by the Global Fund. The report examined health expenditures in 52 African countries (37 low-income and 15 middle-income) and in 20 non-African middle-income countries.

In the 2001 Abuja Declaration, African countries agreed to allocate at least 15 percent of their annual budgets to the health sector. From the perspective of the Global Fund, this is an important commitment because the programmes currently supported by the Global Fund can only become sustainable if implementing countries gradually assume a bigger share of the burden of financing these programmes.

An examination of national health account data revealed that for all 52 African countries, the average government expenditure on health, as a percentage of total government expenditure, rose only marginally from 8.8% in 2001 to 9.0% in 2007, despite the 15% commitment of the Abuja Declaration. Twenty-five countries recorded increases in the percentage of total government expenditures devoted to health between 2001 and 2007; the remaining 27 countries reported reductions.

Some countries fared better than others. While, in 2001, none of the countries were spending 15% or more of their national budgets on health, by 2007 three countries had met the 15% target (Djibouti, Botswana and Rwanda).

In addition, three African countries (Liberia, Malawi and Burkina Faso) had surpassed the 15% target for at least some of the years between 2001 and 2006 (though not in 2007).Over the period 2001-2007, 10 countries (Benin, Botswana, Burkina Faso, Djibouti, Gabon, Malawi, Mali, Namibia, Rwanda, and Tanzania) consistently allocated, on average, above 12% of total government expenditures to health. This list includes both middle- and low-income countries. At the opposite end of the spectrum, the average allocations for health for this period in Angola, Guinea, Eritrea, Guinea Bissau and Nigeria was consistently less than 5% of total government expenditure.

In terms of how the data breaks down by sub-region within Africa, between 2001 and 2007, spending on health (as a percentage of the national budget) rose noticeably in East Africa, but declined significantly in North Africa, with little change in West, Central, and Southern Africa.

The data shown above relate to health spending as a percentage of national expenditures. The report from the Global Fund also looked at other ways to analyse health expenditures in Africa. The following are some of the findings:

  • Health expenditures as a percentage of GDP: Total expenditure on health as a percentage of GDP rose in nearly two-thirds of the African countries between 2001 and 2007, with Namibia, Zimbabwe, Democratic Republic of Congo, Rwanda and Burundi all recording increases of 30% or more. Half of the 52 countries examined devoted at least 5% percent of their GDP to health. (In comparison, the total expenditure on health as a percentage of GDP in the WHO South East Asia and Eastern Mediterranean regions was 3.4% and 4.5%, respectively.)
  • Funding from external sources as a percentage of total health expenditures: The average external funding proportion of total health expenditure in all 52 African countries grew from a level of 15.3% in 2002 to 20.1% in 2006. Thirty seven African countries recorded increases in external contributions over this period.
  • Per capita total expenditure on health: The per-capita total expenditure on health in the WHO African Region in 2006 was $111. However, if the middle-income countries are removed from the calculation, the amount drops to $65. This compares to $85 for the WHO South East Asia Region and $791 globally.

The report found that there is no significant difference in the allocation of national budgets to health between the African middle-income countries and the middle-income countries from other regions selected for the study. In both sets of countries, government expenditure on health as a percentage of total government expenditure is clustered between 8% and 12%.

The report said that "while external aid has its risks in terms of long term sustainability and aid dependency, the dilemma faced by the African lower-income countries is the absence of effective alternatives. Domestic tax bases and alternative revenue sources remain modest in Africa and in lower-income countries elsewhere."

The report said that although several African countries have increased their financial resources following the Abuja Declaration, they still do not have enough money to fund programs at levels that will enable them to attain universal access targets and the Millennium Development Goals. In addition, the report said, "even a significant push by African countries to achieve the 15 percent target would lead to only a marginal increase in their per-capita health expenditures, particularly in the countries already devoting above-average proportions of their resources to health."

Finally, the report concluded that "significant development assistance for health flows to African countries will remain critical for the countries to attain the required additional per-capita expenditure on health that is needed to scale up national programs."

AfricaFocus Bulletin is an independent electronic publication providing reposted commentary and analysis on African issues, with a particular focus on U.S. and international policies. AfricaFocus Bulletin is edited by William Minter.

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