ARTICLES

The GAVI, Global Fund, and World Bank joint funding platform

On Sept 23, the Taskforce on Innovative International Financing for Health Systems presented its report to the UN GeneralAssembly. It proposed more aid for health systems, recognising that, currently, more than 50% of health aid is for infectious diseases, mostly HIV, with little for basic services. In response, GAVI, the Global Fund, and the World Bank are forming a Joint Funding Platform and significant new financing is expected.

Can these organisations support health systems? GAVI's remit is to improve immunisation and related services. Its systems support is largely for improving the training, supervision, and management of Expanded Program on Immunisation staff, supplies, and infrastructure. The Global Fund's remit is to improve prevention and treatment of HIV, tuberculosis, and malaria, and applicants must show how grants will do so. Although the World Bank can support systems reforms, it provides loans not grants, and few countries can borrow for that purpose. Its record in health systems is not good

Moreover, GAVI and the Global Fund share weaknesses emanating from their roles as funding bodies rather than technical ones. These include little in-house technical capacity, little direct engagement with countries, and weak design and assessment mechanisms. GAVI relies on in-country WHO and UNICEF staff, both better versed in immunisation than in health systems, and the Global Fund relies on country coordinating mechanisms whose members have disease-specific interests, mostly HIV. Both use panels in Geneva—the Independent Review Committee (GAVI) and the Technical Review Panel (Global
Fund)—to assess projects about which they know little. Whereas GAVI promotes good aid principles, the Global Fund requires complex applications and reporting, produces unpredictable funding, and weakens country planning and budgeting processes by bypassing them.

Potential donors should ask how a joint funding partnership could:

• Develop in-house technical capacity and in-country engagement to reduce risk, build capacity in countries, and resolve tensions in favour of system strengthening rather than the status quo of vertical programmes.
• Replace “rounds-based” funding with processes supporting countries' mechanisms and cycles, resulting in predictable funding.
• Reduce the burden of complex application and reporting (joint assessment will not help while participants require disease-specific strategies too).
• Use monitoring indicators relevant to systems strengthening rather than disease outcomes, and tailored to countries' capacities, not to a common global framework. The case for joint funding is overwhelming. But it always has been, and it is unclear how the Global Fund particularly can do this now when it has been unable to participate effectively in sector-wide approaches (eg, in Mozambique).

As conceived, a joint funding partnership risks doing little more than coordinating disease-specific funding. Although desirable, this leaves the glaring global gap of reforming the systems through which services are financed, produced, and delivered—the foundations for improving health for all. Without structural reform themselves, participants in a joint funding partnership are in no position to do this.