Mr. William Paton, Director of Country Programs shared with APACHA his views from the perspectives of the Global Fund to Fight AIDS, Tuberculosis and Malaria.

1. What has been your experience while working with the Global Fund to Fight AIDS, Tuberculosis and Malaria and what major challenges have you witnessed?
   
   It has been new, fresh and exciting. The Global Fund to Fight AIDS, Tuberculosis and Malaria model and actions are new in the sense that there has never before been such an approach nor has there been such extraordinary funding for focused health work.
   
   The Global Fund has invested almost USD$ 15 billion in just more than 5 years in Millennium Development Goal No.6: ‘Combat HIV/AIDS and Malaria and other Diseases’. But it has also been surprisingly successful in contributing to reaching Millennium Development Goal No.4: ‘Reduce Child Mortality’; and, No. 5: ‘Improve Maternal Health’.
   
   The Global Fund has contributed to a dramatic reduction of child mortality and improved life expectancy of children as a result of prevention of mother-to-child-transmission of HIV and maternal health services. Thus, the effects of Global Fund financing are much wider and stretch beyond the three diseases.
   
   The Global Fund is fresh because it addresses health and development in way that is determined by countries themselves and that prioritizes countries’ engagement, consistently high performance and obtaining results.
   
   The Global Fund’s work at country level is proposed by the countries themselves. Countries write proposals based on their needs and in consultation with the partners who they choose - who often contribute to and review these proposals before submission.
   
   Disbursement of funds is based on verifiable successful performance. This combination of country involvement and focus on performance has led to impressive results.
   
   When the Global Fund started, the number of people receiving antiretroviral treatment (ART) was miniscule. Today, three million people receive ART worldwide, and the Global Fund supports programs that are responsible for two million of those beneficiaries.
   
   The Global Fund’s impact on malaria is very clear: we see now that in a couple of years, mortality due to malaria has fallen 50-90% in some countries in East and Central Africa.
   
   In addition, many countries - particularly in Asia - are halting and reversing the trend of the TB epidemic.
   
   
2. It is said that the Global Fund is largely focused on implementing programs where as not giving adequate attention to the CCMs functioning. Don’t you think this is a major governance crisis? Unless and until the governance mechanism is addressed, how can we claim that the funding has reached the communities?
   
   While there are a number of issues, I would not say that there is a ‘crisis’. On the contrary, the Global Fund is reaching communities and people in a way that no other funder has done previously. Countries should be proud for turning funding from the Global Fund into amazing results: life-saving services that are reaching the far corners of the world.
   
   Of course, one of the main challenges is to have CCMs work better and have better representation. We do recognize that there are a few CCMs that genuinely struggle with implementing transparent and open systems of governance.
   
   Although the Global Fund introduced - through the CCM model - a radically new concept for implementing health strategies, the responsibility will always be with the countries: it is the responsibility of the stakeholders in each country to ensure that the promise of the Global Fund is turned into reality. The Global Fund may help to facilitate this process but ultimately the responsibility belongs to the countries. We should remember, however, that globally most CCMs are doing relatively well in fulfilling their governance role.
   
   In 2009, the Secretariat hopes to reach out further to CCMs and provide greater assistance to improve governing functions and grant oversight: two areas that were identified as needing greater focus in both the Five Year Evaluation of the Global Fund and the recently published CCM case study report on governance and civil society.
   
   We encourage partners to work with CCMs in using the governing tools currently available (and others) for the better functioning of the CCM. The Global Fund Secretariat posts its guidelines on the internet, provides regular updates on governing tools derived from best practices, and works with consultants and other donor partners to provide on-going technical support to CCMs that request it.
   
   
3. Global Fund mechanisms and process are said to be bureaucratic in nature and countries are finding problems in tackling with them. However, the Global Fund seems to be reluctant to listen to these issues coming up from the ground. How do you react to this?
   
   This is a growing complaint and signal from implementing countries, and we are concerned about this perception of growing complexity.
   
   The Global Fund is based on a set of simple principles as opposed to a set of rules: it was meant to be flexible, fast and simple in its operations.
   
   However, as we have today grown to some 600 grants in 140 countries, a number of rules, policies and procedures have grown organically and are beginning to reach a point that is working against our core principles in some cases.
   
   We are doing our outmost to make grant implementation more streamlined, and easier to harmonize.
   
   The good news is that we are working toward greater harmonization by moving toward a single stream of funding, which is an expected key feature of the new Global Fund architecture. We also hope that the move towards National Strategy Applications will further simplify grant management and implementation.
   
   
4. How do you rate the Asian government’s response to the epidemic at a time when the most of the ongoing HIV/AIDS programs in the region are supported by the donor raising a serious question of sustainability?
   
   We need to keep in mind that the Global Fund was created to provide long term financing to the poorest countries that are not on their own able to sustain an effective response to the three diseases. We understand and accept the principle that we may have to support some countries for many years to come.
   
   There is though a positive trend in funding: more and more, the international donor community and individual countries work in a more complementary way. Previously, the majority of the HIV/AIDS funding was external in most countries in Asia. Now, the funding reality is changing and some countries are funding more than 50% of the HIV/AIDS response.
   
   In addition, due to continuous funding efforts and implementation of activities, TB in Asia is already showing a declining trend. The Global Fund contribution has translated into focused funding that assists countries to reach the time-bound targets of the Millennium Development Goals.
   
   The Global Fund approach also capitalizes on other important stakeholder contributions. In Asia, for example, key politicians have shown an interest in the Global Fund’s work in TB and HIV/AIDS. This interest shown by Asian governments and their officials is essential as TB and AIDS-related illnesses remain the largest cause of mortality in the 15- 45 age group.
   
   It is clear that the Global Fund approach, which requires country engagement and participation, has a built in sustainability strategy as it requires countries to define strategies for sustainability.
   
   
5. Though the Global Fund has also focussed on strengthening the health system, the reality is that the public health care system in Asia is getting worse. In the mean time, increasing privatisation in the health sector has raised serious concerns for poor people’s access to health care. What approach has the Global Fund applied to strengthen the health systems?
   
   We may not see the same trends that you are describing. The picture varies across the region. The Global Fund is providing substantial funds for health services and drugs, which are reaching millions of people who previously had no or limited access to these.
   
   Currently, the Global Fund grants allocate approximately 40% of its funding to health system strengthening. In addition, the HIV prevention and AIDS treatment response has pushed all stakeholders to address previously neglected aspects of health system strengthening. One such example is what is referred to as Community System Strengthening (CSS).
   
   Under CSS, the focus is on funding community organisations, people living with HIV (PHL) groups that work on mitigating the obstacles that the poor face in accessing health care services. Examples this type of work done by community organizations and PHL groups are as follows: finding solutions for people who cannot pay transport cost to hospital; NGOs that mobilize, and advocate on the behalf of groups of people who need hospital care and cannot access it due to cost.
   
   The Global Fund model recognizes that in most countries, only a part of the population is reached by health services and treatment. In order to ensure greater equity in terms of access to services, the private sector and other non-government actors have a large role to play.
   
   
6. Global fund is going through a fear psychosis of potential funding gap. What will be the Global Fund strategy to address this issue particularly in the context of the global financial crisis?
   
   This is categorically wrong. The Global Fund is not experiencing a funding crisis. On the contrary, the Global Fund has been so successful that the demand for funding has increased dramatically. We have moved from disbursing USD$ 2.25 billion in 2008 to an expected USD$ 2.9 billion in 2009.
   
   We have long signalled to donors that this increase would be likely. Any potential shortfall will not have any serious consequences for funds already approved. We are confident that we will secure additional resources to the Global Fund and to the response to the three diseases.
7. How do you want to create an open space for more civil society engagement within the global fund mechanism besides creating space for the civil society representation in the GFATM board and at the CCM level?
   
   The Global Fund has provided more opportunities for genuine civil society involvement than any other multilateral institution.
   
   As your question notes, these opportunities exist both at a high-level governing body and in each Country Coordinating Mechanism. Through both of these mechanisms, the Global Fund provides an unprecedented opportunity to marry participation with significant resources. No other financing mechanism has come close to this.
   
   Of course, there is always room for improvement and finding other ways to increase participation to bring better results – to more effectively address HIV/AIDS, TB, and malaria.
   
   Dual track financing will bring more civil society organizations into direct grant management. This is a very positive step forward.
   
   I would also like to highlight the inclusion of Community Systems Strengthening (CSS) in Round 8, which is a concrete mechanism for and commitment to building capacity of Community Based Organizations (CBOs) to play a much stronger role in program implementation.
   
   
8. What do you think is the importance of the networks like APACHA which has the largest multi-sectoral constituencies and how would you like to engage with such networks?
   
   Partnerships are key to the success of the Global Fund’s support to national HIV/AIDS, TB, and malaria programs.
   
   The range of partners is wide as is the type of services and support they offer (e.g., multilateral institutions setting normative standards for evidence-based programming, bilateral donors providing direct support to NGO/CBO’s, international NGO’s providing capacity development of civil society, etc.).
   
   However, it is important to note that the Global Fund is a demand driven financing mechanism and that one of our core principles is country ownership. This principle is critical to how we approach and develop institutional partnerships.
   
   Rooting demand in country-defined proposals makes the funding model less accessible to regional organizations, which sometimes serve as both implementers and technical service providers (regionally and at country level).
   
   To date, the Global Fund’s policy is to encourage countries to build technical support financing into their proposals; we have not developed bilateral relationships with regional organizations to provide technical support (except in limited circumstances where memoranda of understanding have been established with UN organizations). But we have developed a global contracting mechanisms to procure CCM and some grant management consulting services. This global contract was competitively bid in 2007 and will be up for renegotiation in 2010.
   
   Regional partnerships will evolve and depend greatly on what services are being offered and whether in-country programs or CCMs have a willingness to purchase these services. In this respect, regional organizations have a wonderful opportunity to market their local knowledge and expertise contributing to genuine ‘south-south’ collaboration.
   
   The model puts the country (i.e., CCM or Principle Recipient) in the driver’s seat and requires that regional NGO organizations ‘sell their services.’