Louise Walker, PhD Candidate
Department of Politics and International Studies
louise.walker@warwick.ac.uk
“To anticipate the prospects for global governance in the
Healing Powers
decades ahead is to discern powerful tensions, profound
contradictions, and perplexing paradoxes. It is to search
for order in disorder, for coherence in contradiction, and
for continuity in change. It is to confront processes that
The Global Fund, disrupted multilateralism and
mediated country ownership
mask both growth and decay. It is to look for authorities
that are obscure, boundaries that are in flux, and systems
of rule that are emergent. And it is to experience hope
embedded in despair.”
James N. Rosenau (1995)
‘Governance in the Twenty-first Century’, Global Governance, Vol. 1, pp. 13-43.
How has the Global Fund to Fight AIDS,
Tuberculosis and Malaria changed global and
country level health governance?
Expanding Authority – The Global Fund’s trajectory of change
Traditional Multilateral
Institutional Innovation
Maturing Institution
The World Health Organization (WHO)
Founded 1948
The Global Fund
Founded in 2002
The Global Fund
2010
Scope of activities
Global health leadership for the UN
‘Emergency response’ financing mechanism for:
Policy maker
Yes
No
Implicit
Governed by states
Yes
No
No
Donor government funded
Yes
Country presence and
technical assistance
Yes
No
No
Number of staff
8,500
27
568
Resources allocated to
countries
2010-11 Budget
Grant Rounds 1 and 2 (approved proposals)
Health research
Standards
Policy
Country technical support
Surveillance
Financing mechanism for:
MDG 6 – 3 diseases
MDG 6
MDG 4 (child health) and MDG 5 (maternal health ) related to
3 diseases
Health Systems Strengthening
National Strategies
Scale of and country reliance on grants
Board Delegations:
Donor governments, recipient countries, developed country
NGO, developing country NGO, private foundation, private
sector and people living with or in communities affected by
AIDS, tuberculosis or malaria
Traditional multilateral
Yes
2010 -11
Assessed contributions – 21%
Voluntary contributions – 79%
Yes
2002
95% of initial pledges from governments
5% from the private sector
US$3.1 billion – to country and regional offices
Staff and programmes
Institutional Innovation
Donor government delegations dominate Board votes since
2005
US$4.4 billion
Programmes (government and civil society)
2010 (to 2013)
95% of pledges from governments
5% from the private sector
Grant Rounds 9 and 10 (approved proposals)
US$3.3 billion
Programmes (government and civil society)
Maturing Institution
Ambiguous Country Ownership - Malawi’s HIV/AIDS epidemic
The Global Fund and Malawi’s Scaled
Up HIV/AIDS Response
Global Values and Malawi’s HIV/AIDS
Prevention Strategy
Malawi has the 9th highest HIV/AIDS prevalence rate in the
world – just under 12% of the population
The Global Fund requires that countries set up Country
Coordinating Mechanisms (CCMs) comprised of state and
non-state actors (e.g. international and local NGOs and civil
society) to prepare grant applications and provide oversight
Since 2004 Malawi received US$544 mm in grant awards for
HIV/AIDS from the Global Fund (US$136 mm dispersed as of
June 2010)
The number of people receiving ARVs has increased from
13,000 in 2003 to just over 200,000 in 2010 3
In 2009 Malawi was unsuccessful in its National Strategy
application to the Global Fund
The number of new infections are estimated at 90,000 per
year which continues to outpace the number of people starting
treatment 4
One reason for this failure was the Global Fund’s Technical
Review Panel’s criticism that Malawi’s HIV/AIDS prevention
strategy did not focus enough on men having sex with men
(MSM)
In 2008-09, 43% of Malawi’s government expenditure was
comprised of aid 5
CCM members defended the prevention strategy as evidencebased - Malawi’s epidemic largely affects discordant couples
In 2008-09 the Global Fund was the 3rd largest donor to
Malawi behind the EU and the UK, providing 14.6% of all aid
for all sectors
3Alice Maida (2009)
with Erik Schouten and Joseph Njala, Appraisal Report: Feasibility of
Introducing Revised Global Antiretroviral Therapy Guidelines for Adults and Adolescents in Malawi,
Review Commissioned by the Government of Malawi, Ministry of Health.
4National AIDS Commission (2009)
5 Government
National HIV Prevention Strategy 2009-2013, Lilongwe.
of Malawi Ministry of Finance (2009) Government of Malawi Annual Debt and Aid
Report: July 2008-June 2009, Lilongwe: Government of Malawi
“Go ahead and advocate [for global priorities] but it’s not
evidence -based…[MSM] is not the crux of the epidemic
here…we had a very, very strong, evidence-based,
national prevention strategy and we had experts from all
over the world working on it.”6
Malawi is dependent on Global Fund grants to provide drugs
for those currently on treatment (200,000) and to continue to
scale up its HIV/AIDS response
6Malawi Health Executive
(2010), Interviewed in Lilongwe, July 20, 2010.
Malawi has country ownership without authority
The Global Fund has authority without accountability to those whose lives it affects