How did the Global Fund allocation model strategically respond to the Global Fund's strategic objectives and the country’s needs? A mixed method study

Abstract

AbstractThe Global Fund is the world's largest global health financing organization to fight AIDS, tuberculosis, and malaria, which provides about $4 billion annually to support countries and organizations fighting the three infectious diseases. However, no literature has been published to give a detailed assessment of its allocation model. This study examines the Global Fund's allocation process for the 2020-2022 cycle, using both qualitative and quantitative methods to explore whether the Global Fund’s allocation model can effectively respond to its strategic objectives and the needs of the countries. After the 207-2019 allocation, the Global Fund reported effective fund absorption across HIV, tuberculosis, and malaria, employing measures like "portfolio optimization," mid-cycle fund reprogramming, and intentional overallocation to stimulate optimal fund utilization and prevent returns to the central pool. Experts provided a positive assessment of the allocation process, emphasizing consistency in disease split percentages (HIV=50%, TB=18%, Malaria=32%) and adjustments to address historical issues. Challenges encompassed human costs, data quality, financial issues, and factors beyond epidemiology. The disease split design, unchanged since 2014-2016, historically favored HIV due to the Global Fund's initial focus on AIDS. Suggestions for dynamic disease split percentages in future cycles were made, acknowledging challenges in adjusting the split and potential impacts on underfunded programs. Financial need assessment aimed for equitable fund distribution, considering disease burden, economic capacity, and other indicators. Prevention needs focused on disease burden and key populations, while community delivery needs were treated as implementation issues. Countries' specific needs evolved annually, necessitating continuous evaluation. However, experts expressed pessimism, asserting that current allocations did not cover all essential services due to significant funding gaps attributed to the COVID-19 pandemic, inflation, and political issues. Quantitative analysis of allocation data from 112 countries, totaling $12,659,254,481, revealed a disease split following the Global Fund's methodology, with regional variations. Strong correlations were observed globally and continentally between Allocation and Budget, Allocation and Disease Burden, and Budget and Disease Burden for the three diseases. The analysis found weak correlations for malaria at the continent level in LAC. The budget for the 2020-2022 cycle exceeded the allocation by $3,605,274,211 due to carry-over and additional COVID-19 Response Mechanism resources. Africa received the largest budget, especially in HIV, Malaria, TB&HIV, and standalone RSSH components. EECA did not receive Malaria and standalone RSSH budgets. The global standalone RSSH budget constituted about 4.16% of the total budget. Combining HIV, TB, and TB/HIV components, the budget for total HIV and TB represented 66% of the total budget, with Africa receiving the largest budget for the three disease components. The Global Fund's implementation currently relies heavily on government and civil society organizations to ensure country ownership. Governments, representing nations at the international level, contribute to negotiations and resource allocation, leveraging their larger resources for stable and sustainable support. Civil society organizations, with a better understanding of local needs, enhance realistic project implementation. However, private sector involvement is limited due to potential profit prioritization and concerns about regulation and transparency. While the private sector may be necessary in certain projects, alignment with the Global Fund's objectives and values is crucial. At the country level, the response to diseases like AIDS faces human resource shortages, affecting healthcare access and fund absorption delays. This study underscores the intricate interplay between qualitative and quantitative aspects in the Global Fund's allocation process, recognizing ongoing efforts to address challenges, balance disease and RSSH priorities, and adapt to changing global circumstances.