Time to make the Global Fund global

Maybe it is time to accept that AIDS is a special case and as such should have a single, separate fund.
Since the first International AIDS Conference in 1985, researchers have come to accept that there is no "magic bullet" to combat this modern plague. But as the fifteenth AIDS conference drew to a close in Barcelona, Spain, last week, it was clear that there is something akin to a magic bullet - money. How to finance the reponse to AIDS turned out to be one of the main themes at this meeting. The fiscal atmosphere in Barcelona was thus an appropriate backdrop to Richard Feachem's first speech as Executive Director of the Global Fund to Fight AIDS, Tuberculosis, and Malaria, since he used this opportunity to announce the development of the Fund's long-awaited financial plan. In October, the Fund's board will publish and widely disseminate the Fund's financial projection estimates and resources needed over the next several years. Pledges to the Fund - almost all of which are from the public sector - currently total just over US$2 billion. The US Government has given $500 million, and Japan, Italy and the UK have pledged $200 million each. The total amount is, of course, derisory in view of the task in hand. Jeffrey Sachs, chairman of WHO's Commission on Macroeconomics and Health, estimates that the Fund requires $5.5 billion in 2003, with $2.5 billion coming from the USA alone. Feachem promised that the Fund's financial projections will be open to public scrutiny. While this pledge towards transparency and openness in the Fund's activities is welcome, it seems odd that the topic chosen for public dissection is financial planning. To be sure, the resource requirements of the Fund are important issues, but surely they are of less immediate public interest than the way in which the resources are to be spent? The call for the second round of proposals is already well underway but, as the Fund's guidelines make clear, only limited information on successful proposals will be disclosed, contrary to earlier statements from the Fund. The Fund states that proposal-specific deliberations will be confidential and information on the reasoning behind the different decisions taken on proposals will be shared only with the authors. Details of the review process may be shared with some other "stakeholders". It is unclear whether these stakeholders include the management consultancy firm who might eventually be charged with overseeing the Fund's disbursements, McKinsey & Company, whose Managing Director Rajat Gupta is the private-sector member of the Fund's board. It is clear, however, that the public, who have provided almost all the money so far, will not be able to see how it is to be spent. Is there a chance that the Fund will embody a genuinely new approach to health financing? It certainly seems likely that, with its focus on AIDS and the high profile of its supporters, the Fund exists within the right conditions to have some degree of success. Ironically, this may work against the wider range of Millennium Development Goals that the world has set itself to achieve by 2015. Although AIDS has pushed health up the international political agenda, it risks eclipsing the poverty-related health issues that needed to be tackled long before AIDS appeared. For example, the United Nation's Economic and Social Council was recently told of deep concern at the slow progress towards the Millennium Goals, notably in reducing child mortality. Maybe it is time to accept that AIDS is a special case and as such should have a single, separate fund. Many of the interventions likely to be successful in AIDS prevention - such as education - have little to do directly with medicine or public health. Sectioning off AIDS would allow another fund - a truly Global (and transparent) Fund - to finance all other health-related aspects of the Millennium Development Goals. There is a further issue. Whatever happened to the proposal from last year's Commission on Macroeconomics and Health to establish a Global Health Research Fund? Without supporting biomedical and health-sciences research on the problems facing the world's poor, the long-term value of these global funds will be severely compromised. The Lancet