The Battle for Limited Global Fund Resources
18 October 2024
TB has received the lowest Global Fund disease allocation for years. But now, ahead of a board decision in November, TB advocates want a fairer split. Their petition has so far garnered over 10,000 signatures.
Civil society organizations are petitioning the Global Fund to Fight AIDS, Tuberculosis and Malaria to end its “discriminatory” practice and increase its funding for tuberculosis ahead of a board decision in November.
The Global Fund provides the lion’s share of international funding for TB at 76%. But for years, advocates say the portion TB is getting as part of the fund’s global disease split — the percentage of funding that goes to each of its three priority diseases — is significantly behind HIV and malaria despite TB having the most deaths among the three diseases. In 2022, 1.3 million people died from TB while 630,000 and 608,000 died from HIV and malaria, respectively.
Now TB advocates want a fairer split — 33% for each of the diseases. Their petition has so far garnered over 10,000 signatures.
“If Global Fund cannot … explicitly give us data or give us reason for the disease split in terms of where we are now … then [we’re asking] do it equitably, so that everybody can have access to the same level of resources,” Austin Obiefuna, executive director of Afro Global Alliance, told Devex.
The Global Fund said it considers multiple factors when deciding on the split. While it acknowledged more resources are needed for TB, it cautioned this should not come at the cost of HIV and AIDS, and malaria, which also require increased resources.
Efforts to increase TB funding
Since 2013, TB has received the lowest share of the fund’s allocations at 18%, while HIV got 50% and malaria 32% under the global disease split.
In 2021, the fund considered several options and proposals to accommodate an increase in TB allocation.
In the end, they retained the traditional split for resources of up to $12 billion, and a new split of 45% for HIV, 30% for malaria, and 25% for TB for resources above $12 billion. That means that out of the $13.1 billion available for country allocation for 2023-2025, TB received $2.4 billion in total, an increase of $154.2 million from the last allocation period and the largest increase among the three diseases.
But TB still lagged behind in total funding with HIV receiving $6.5 billion and malaria $4.2 billion.
An independent evaluation commissioned by the fund found there’s a need to adjust the disease split “to better reflect the current epidemiological landscape and re-balance the distribution of funding across the three diseases to give more weight to TB.”
While deaths due to HIV and AIDS, TB, and malaria have declined since 2009, deaths due to TB remain the highest among the three diseases. TB also caused more people to lose years of their lives due to ill health, disability, or premature death. Using these factors in calculating alternative disease splits, the evaluation found that TB would have gotten a bigger portion of the funding than what it was allocated for 2023-2025. However, the Global Fund management wrote in response that the evaluation didn’t address the question of where the increased TB share should come from.
A Global Fund spokesperson told Devex that apart from the TB-specific disease allocation, TB also benefits from other sources of funding from the organization. For example, its COVID-19 funding was partly used to buy digital X-rays and molecular testing platforms that can run tests to diagnose TB. Its market-shaping work also helped reduce prices for TB tests and medicines, such as bedaquiline, a key multidrug-resistant TB drug.
The spokesperson said the Global Fund Secretariat has proposed an increase in funding for TB and malaria for the 2026-2028 allocation period, which the board will decide on in November. Much of it is dependent on the amount of funding raised in its next replenishment conference in 2025.
A spokesperson for Global Affairs Canada, the sixth largest country donor to the Global Fund and a member of the board, acknowledged the needs for TB and other diseases “outweigh the available resources” as shown in Global Fund annual reports, but that they have “consistently advocated for an increase in resources for both TB and malaria.”
A well-resourced fund “is key to ensuring strong responses to TB and other diseases,” wrote the spokesperson.
The options
According to Dr. Lucica Ditiu, executive director of the Stop TB Partnership who sits on the Global Fund board as a nonvoting member, the secretariat has proposed four options for the board’s consideration.
The first retains the current split where TB gets 18% for resources up to $12 billion, with incremental increases as more resources become available — an option that Stop TB said “must be totally rejected.” Under the second, third, and fourth options, TB will receive a 25% share if the available resources for country allocation reach $15 billion, $17 billion, and $18 billion, respectively, according to Stop TB.
Ditiu is concerned the options are pegged on high replenishment targets, which are “unrealistic” amid a challenging fundraising environment. For a country allocation of $18 billion, the Global Fund will need to raise at least $20 billion in its replenishment, she said. This is because a small portion of the money received during a replenishment is set aside for the organization’s operating expenses and other investments.
The Global Fund’s Strategy Committee is suggesting the third option to the board, she added.
In its last replenishment, the Global Fund asked donors for $18 billion but only secured pledges of $15.7 billion. Experts say the fund could lose 1.2 billion more, as the U.S. by law cannot provide more than a third of all pledges to the fund.
“A $12 billion replenishment is more of a realistic one, to be very honest with you,” Ditiu told Devex. “A low scenario will be $11 billion, in which case, indeed, everybody will be in … deep shit.”
But even at higher replenishment figures, TB will still receive the least amount among the three diseases, she said. Under the third option, for example, a country allocation of $17 billion will result in a split of 25% for TB, 40% for HIV, and 35% for malaria.
Obiefuna likened the current predicament to a lottery, with additional resources for TB based on how much the Global Fund ends up fundraising.
“Why on probability?” he said.
The bigger question
The Global Fund spokesperson said the organization is “extremely concerned about TB.” But while the death toll of the three diseases is a critical factor in determining the disease split, it’s not their only consideration. They also consider disease morbidity, the relative importance of Global Fund resources in the overall effort against each disease, the potential of the affected countries to fund their own programs, and the impact of any reduction in funding.
The Global Fund sees higher funding in its next replenishment as key to growing the funding for TB, and it’s looking for a diversified set of donors to amp up its fundraising.
But in a crowded fundraising space with too many competing needs, and shrinking aid budgets, some experts said agencies like the Global Fund need to rethink the way they do business overall.
One way this can be done is through a “New Compact” between donors and countries, according to Pete Baker, deputy director of the global health policy program at the Center for Global Development. Under this New Compact, countries set their own health priorities and finance those, with aid serving as support rather than the main means through which health services are financed in countries.
This helps crowd in instead of crowd out domestic public spending for health, which is important for the sustainability of health services but also in support of calls for country ownership.
The Global Fund has a co-financing policy that is meant to get countries to increase their domestic spending on health focused on HIV, TB and malaria, although it isn’t clear if countries are actually increasing their spending, based on a recent expert analysis. The paper noted: “How “co-financing” is reported and measured de facto is unknown, indicating little validation or accountability.”
“The basic fundamental problem is if you’ve got a lot of money covering HIV, TB, malaria, it is entirely rational for countries to spend their own money on other things,” Baker said. “Until a kind of new compact, or a new agreement between countries and donors is reached, I think it is hard for some of these little tweaks on the policies to make much of [an] impact.”
By Jenny Lei Ravelo
Source: Devex
