The Global Fund to Fight AIDS, Tuberculosis, and Malaria: Progress Report and Issues for Congress








Prepared for Members and Committees of Congress



The Global Fund to Fight AIDS, Tuberculosis, and Malaria, headquartered in Geneva,
Switzerland, is an independent foundation that seeks to attract and rapidly disburse new resources
in developing countries aimed at countering the three diseases. The Fund is a financing vehicle,
not an implementing agency. The origins of the Fund as an independent entity to fight the three th
diseases lie partly in a French proposal made in 1998, in ideas developed in the 106 Congress,
and in recommendations made by United Nations Secretary-General Kofi Annan in April 2001.
Though the Global Fund was established in January 2002, President Bush pledged $200 million
to such a fund in May 2001.
As of July 17, 2008, donors have pledged more than $20.2 billion to the Fund, of which more
than $10.2 billion has been paid. The fund has approved support for more than 500 grants totaling
some $10 billion for projects in 136 countries. Each year, the Fund awards grants through
Proposal Rounds. The Fund launched its eighth Round on March 3, 2008. In 2005, the Fund
approved Round 5 grants in two tranches, because initially there were insufficient donor pledges
to approve all the recommended proposals. The Fund approved the first group of Round 5
proposals in September 2005 and the second in December 2005, after donors pledged to make
additional contributions. The Global Fund only approves proposals if it has sufficient resources
on hand to support the first two years of a proposed project. This policy is designed to avoid
disruptions to projects due to funding shortages. Funding lapses can cause interruptions in
treatment regiments, which could lead to treatment-resistant strains of the diseases or death.
The United States is the largest single contributor to the Global Fund. From FY2001 through
FY2008, Congress has made available an estimated $3.6 billion to the Fund, including $840.3
million in FY2008, the single largest U.S. contribution to date. Of those funds, $545.5 million
would come from the State Department, and $294.8 million from the Department of Health and
Human Services (HHS). The President requested $500 million for a FY2009 contribution to the
Global Fund.
There has been some debate about the level of U.S. contributions to the Fund. Some critics argue
that the United States should temper its support to the Fund, because the Fund has not
demonstrated strong reporting and monitoring practices; because contributions made to the Fund
in excess of the President’s request are provided at the expense of U.S. bilateral HIV/AIDS, TB,
and malaria programs; and because they maintain that the Fund needs to secure support from
other sources, particularly the private sector. Supporters of current funding levels counter that the
Fund has improved its reporting and monitoring practices, greater U.S. contributions to the Fund
parallel increases in U.S. bilateral HIV/AIDS, TB, and malaria programs, and the Fund has
attempted to raise participation of the private sector through the launching of Product Red™. This
report, which will be periodically updated, discusses the Fund’s progress to date, describes U.S.
contributions to the organization, and presents some issues Congress might consider.






Backgr ound ..................................................................................................................................... 1
Global Fund Progress to Date..........................................................................................................1
Funding Procedure..........................................................................................................................2
Suspended, Discontinued, or Cancelled Grants...............................................................................3
Suspended Grants......................................................................................................................3
Ukraine........................................................................................................................ ........ 3
Discontinued Grants..................................................................................................................4
Nige ria ................................................................................................................................ 4
Paki stan ............................................................................................................................... 4
Senega l ........................................................................................................................ ........ 4
South Africa........................................................................................................................5
Uganda ......................................................................................................................... ....... 5
Terminated Grants.....................................................................................................................6
Burma (Myanmar)..............................................................................................................6
Projected Financial Needs...............................................................................................................7
Meeting Millennium Development Goals.................................................................................7
Meeting Escalating Grant Requests..........................................................................................8
Congressional Actions.....................................................................................................................9
Issues for Congress........................................................................................................................10
Strengthen Reporting and Monitoring.....................................................................................10
Reauthorize Limits on U.S. Contributions to the Global Fund...............................................12
Consider Proportion of Support for the Fund to Support for Other Bilateral Programs.........13
Figure 1. U.S. Contributions to the Fund and All U.S. International HIV/AIDS, TB, and
Malaria Spending.......................................................................................................................15
Figure 2. U.S. Contributions to the Fund as a Percentage of All U.S. International
HIV/AIDS, TB, and Malaria Spending......................................................................................16
Table 1. Grant Agreement Totals to Date........................................................................................2
Table 2. Funding Requirements, 2008-2010...................................................................................8
Table 3. U.S. Appropriations to the Global Fund............................................................................9
Table 4. U.S. Pledges to the Fund as a Percentage of All Fund Pledges.......................................12
Table 5. Total Global Fund Contributions and Pledges, 2001-2008..............................................13
Table 6. Total U.S. Global HIV/AIDS, TB, and Malaria Appropriations......................................14
Table 7. Glossary of Abbreviations and Acronyms.......................................................................16





Author Contact Information..........................................................................................................17






In January 2002, the Global Fund to Fight AIDS, Tuberculosis, and Malaria (Global Fund) was
established as an independent foundation in Switzerland to support country efforts to curb the
number of illnesses and deaths caused by HIV/AIDS, tuberculosis (TB), and malaria. Each year,
the three diseases kill some 6 million people, mostly in Africa. The Fund’s Board meets at least
twice annually to discuss governance issues, such as grant approval. Nineteen Board seats are
rotated among seven donor countries, seven developing countries, and one representative from
each of a developed country non-governmental organization (NGO), a developing country NGO, 1
the private sector, a foundation, and affected communities. The United States holds a permanent
Board seat. In its first five years, the Fund aimed to support:
• treatment for 1.8 million HIV-positive people, 5 million people infected with TB,
and 145 million malaria patients;
• the prevention of HIV transmission to 52 million people through voluntary HIV
counseling and testing services (VCT);
• the purchase and distribution of 109 million insecticide-treated bed nets to
prevent the spread of the malaria; and
• care for 1 million orphans.2

As of July 11, 2008, the Global Fund has approved proposals for 519 grants in 136 countries 3
totaling $10.8 billion (Table 1). About half of those funds have been disbursed. As of December
2007, the Fund-supported grants have been used to treat an estimated 1.4 million HIV-positive
people and 3.3 million people infected with TB, and to distribute 46 million insecticide-treated 4
bed nets to prevent malaria transmission. An estimated 58% of Global Fund grants support
HIV/AIDS interventions, about 17% fund anti-TB programs; some 24% sustain anti-malaria 5
projects, and 1% strengthen health systems. According to the Global Fund, in 2005, its support
represented more than 20% of all global HIV/AIDS spending, some 67% of global TB funds and 6
about 64% of all international support for malaria interventions.

1 For more on the Global Fund, see CRS Report RL31712, The Global Fund to Fight AIDS, Tuberculosis, and Malaria:
Background, by Tiaji Salaam-Blyther.
2 Global Fund Webpages about HIV/AIDS, TB, and malaria, at http://www.theglobalfund.org, visited on December 10,
2007.
3 Global Fund, Current Grant Commitments and Disbursement, July 11, 2008, at http://www.theglobalfund.org/en/
funds_raised/reports/, visited July 11, 2008.
4 Global Fund,Monthly Progress Update—January 31, 2008,” at http://www.theglobalfund.org/en/files/publications/
basics/progress_update/progressupdate.pdf, visited January 8, 2008.
5 Global Fund,Distribution of Funding After Six Rounds,” at http://www.theglobalfund.org/en/funds_raised/
distribution, visited January 15, 2008.
6 Global Fund, Resource Needs for the Global Fund: 2008-2010. 2007, at http://www.theglobalfund.org/en/files/about/
replenishment/oslo/Resource%20Needs.pdf. The Henry J. Kaiser Family Foundation (KFF) estimates that Global Fund
spending represented about 19% of all international HIV/AIDS commitments in 2005. KFF, International Assistance
for HIV/AIDS in the Developing World, July 2006, at http://www.kff.org/hivaids/upload/7344-02.pdf, visited January
15, 2008.






In 2005, the Fund approved Round 5 grants in two tranches, because there were no sufficient
donor pledges to support all recommended proposals at the time of grant approval. Its
Comprehensive Funding Policy (CFP) specifies that the Fund can only sign grant agreements if
there are sufficient resources to support the first two years of grant activities. The policy is
designed to avoid disruptions in funding that might interrupt project activities. Financial delays
can cause people to miss treatments, potentially leading to drug-resistance, susceptibility to
secondary diseases, or death.
Table 1. Grant Agreement Totals to Date
($ U.S. current millions)
Grants Approved Funds Disbursed
Phase I Phase II Total Phase I Phase II Total
Round 1 576.3 1,076.6 1,652.9 549.9 548.7 1,098.6
Round 2 851.6 1,120.8 1,972.4 821.8 586.9 1,408.7
Round 3 634.1 770.6 1,404.7 605.8 366.2 972.0
Round 4 1,014.5 1,786.3 2,800.8 986.5 463.5 1,450.0
Round 5 781.6 218.4 1,000.0 578.4 17.8 596.2
Round 6 879.6 0.0 879.6 354.3 0.0 354.3
Round 7 1,115.7 0.0 1,115.7 46.4 0.0 46.4
TOTAL 5,853.4 4,972.7 10,826.1 3,943.1 1,983.1 5,926.2
Source: Global Fund website, Current Grant Commitments and Disbursements, July 11, 2008.
The Fund distributes grants through a performance-based funding system. Under this system, the
Fund commits to financially support the first two years (Phase I) of approved grants, though it
disburses the funds quarterly if grants meet their targets. As the end of Phase I approaches, the
Fund reviews the progress of the grant to determine if it should support the third through fifth
years (Phase II).
In November 2006, the Board established the Rolling Continuation Channel (RCC). This funding 7
channel, which began in March 2007, permits Country Coordinating Mechanisms (CCMs) to
request additional funding for grants that are performing well but set to expire. The application
process for the RCC is not as rigorous as the Round process. RCC-approved grants can receive
support for up to an additional six years, with the funds being awarded in three-year intervals.
The channel is intended only for those grants that have demonstrated a significant contribution
“to a national effort that has had, or has the potential to have in the near future, a measurable 8
impact on the burden of the relevant disease.”

7 CCMs are comprised of individuals from governments, NGOs, the private sector, and affected populations. The
CCMs develop and submit grant proposals to the Fund. After grant approval, they oversee progress during
implementation.
8 Global Fund, Report on the Final Decisions of the Fourteenth Board Meeting, October 31- November 3, 2006, at
http://www.theglobalfund.org/en/files/boardmeeting14/GF-BM-14_Final_Decisions.pdf, visited January 16, 2008.






The Fund uses a performance-based funding system that permits it to temporarily suspend
support for grants if it finds significant problems with project performance, such as accounting
inconsistencies. In some instances, the Fund restored support to grants once key concerns were
resolved. For example, in November 2006, the Fund suspended support for grants in Chad. After
undertaking audits of the grants, the Fund reportedly discovered evidence of “misuse of funds at
several levels and the lack of satisfactory capacity by the Principal Recipient and sub-recipients to
manage the Global Fund’s resources.” In August 2007, the Fund announced that it had lifted the
suspension, “after a series of investigation and negotiations between the Global Fund and national
authorities ... and after efforts and strong commitment of all relevant stakeholders which
guaranteed that the issues have been addressed and better systems with clarified responsibilities
will be put in place. As part of the [Global Fund’s] mitigation—besides other measures—a
fiduciary agent will guarantee for an interim period of 12 months adequate financial monitoring 9
and accounting for our grants.”
The Fund might discontinue support for grants in Phase II if it finds that they did not sufficiently
meet their targets. Countries whose grants have been discontinued can apply and have secured
funding in subsequent Rounds (see Nigeria below). In extreme cases, the Fund will immediately
cancel financial support. If funds are immediately revoked, the Fund might invoke its continuity
of services policy, which ensures that life-extending treatment is continued for suspended or 10
cancelled grants or for those whose terms have expired until other financial support is identified.
To date, the Fund has only terminated grants in Burma. When the Fund decided to terminate
support for grants in Burma, policy analysts debated how best to serve humanitarian needs in
politically unstable countries.
On January 30, 2004, the Global Fund announced that it had temporarily withdrawn its grant in
Ukraine. Citing the slow progress of Fund-backed HIV/AIDS programs, the Fund stated that it
would ask “a reliable organization to take over implementation of the programs for several
months, to give Ukraine the opportunity to address concerns of slow implementation, 11
management, and governance issues.” Nearly a month later, on February 24, 2004, the Fund
announced that the suspension had ended, and that a temporary principal recipient had been
identified. The Fund hoped that if a new Principal Recipient (PR) were used, project performance 12
would improve and related problems would be resolved. In July 2005, the Fund announced that

9 Global Fund, Grant Performance Report: Chad, August 23, 2007, at http://www.theglobalfund.org/search/docs/
3TCDH_614_249_gpr.pdf, visited on March 20, 2008.
10 Global Fund, Report from the Policy and Strategy Committee at the 14th Board Meeting, October 31-November 3,
2006, at http://www.theglobalfund.org/en/files/boardmeeting14/GF-B14-7_Report%20of%20the%20PSC_FINAL.pdf,
visited January 15, 2008.
11 Global Fund,The Global Fund Acts to Secure Results for its Programs in Ukraine,” Press Release, January 30,
2004, at http://www.theglobalfund.org/en/media_center/press/pr_040130.asp, visited May 30, 2007.
12 Global Fund,Global Fund Signs Letter of Intent to Relaunch Ukraine HIV/AIDS Grant,” Press Release, February
24, 2004, at http://www.theglobalfund.org/en/media_center/press/pr_040224.asp, visited May 30, 2007.





the new PR was successfully implementing the grant and that it had approved additional funds for 13
the grant’s Phase II activities.

In May 2006, at its 13th board meeting, the Fund decided to discontinue support for Nigeria’s
HIV/AIDS programs awarded in Round 1. In previous board meetings, the Secretariat 15
recommended that the Fund not award Nigeria additional support for Phase II. The Board th
disagreed. At the 12 Board meeting, the Board and Secretariat agreed to create an Independent
Review Panel to review the grants and report back to the Board. Following its investigation, the
Panel presented similar findings and agreed with the Secretariat that the grants were performing
poorly. The Board agreed not to fund Phase II of the grants, but committed to support
procurement of HIV treatments for up to two years. Although those grants were discontinued, the 16
Fund awarded Nigeria different HIV/AIDS grants in Round 5.
Staff at the Global Fund report that the Fund discontinued support for Pakistan’s malaria projects
in Round 2 because of weak project implementation, slow procurement of health products, poor
data quality, and slow spending of project funds. Specifically, the Secretariat found that 8 of the 17
grant’s 10 targets had not been reached and only 15% of the insecticide-treated nets (ITNs) had 18
been distributed.
On March 1, 2005, the Global Fund announced that it would not approve funding for the second
phase of Senegal’s malaria project, which was originally funded in Round 1. A Fund press release 19
indicated that the project “was found to have systemic issues that resulted in poor performance.”

13 Based on correspondence with Dr. Itamar Katz, Strategic Information Officer, Performance & Evaluation
Department, the Global Fund, on May 11, 2007, and January 21, 2008.
14 Other grants that were discontinued include Bolivia, East Timor, and Sierra Leone. For more information, see Global
Fund webpage on discontinued grants, at http://www.theglobalfund.org/en/funds_raised/gsc/nogo/, visited on March
20, 2008.
15 For information on the functions of the Board and Secretariat, see CRS Report RL31712, The Global Fund to Fight
AIDS, Tuberculosis, and Malaria: Background, by Tiaji Salaam-Blyther.
16 Global Fund, Report from the Communities Living with HIV/AIDS, TB and Affected by Malaria to the Global Fund
at the 13th Board Meeting, April 2006, at http://www.theglobalfund.org/en/files/partners/civil_society/articles/th
report_communities_bm13.pdf. Also see Global Fund, Operations Update at the 14 Board Meeting. October 31-
November 3, 2006, at http://www.theglobalfund.org/en/files/boardmeeting14/GF-BM-14_04_Operations Update.pdf,
visited January 16, 2008.
17 For a description of the targets, see Global Fund, Proposal Form, July 2002, at http://www.theglobalfund.org/search/
docs/2PKSM_130_144_full.pdf, visited January 16, 2008.
18 Correspondence with the Global Fund on April 13, 2007.
19 Global Fund,Global Fund Cuts Funding for Malaria Grant,” Press Release, March 1, 2005, at
http://www.theglobalfund.org/en/media_center/press/pr_050301.asp, visited May 15, 2007.





The release did not specify what issues it had with the project, though it indicated that “review of
the Senegal grant raised serious concerns” about the effective use of Global Fund resources.
Although the program was discontinued, Fund officials encouraged Senegal to address the issues
that were raised and to apply for new funds in the future. Ultimately, the Fund approved a grant
proposal that Senegal submitted for malaria projects in Round 4.
In December 2005, the Global Fund Board voted to discontinue funding an HIV prevention grant
in South Africa. The Board decided that the grant, implemented by an NGO named loveLife, had 20
failed to sufficiently address weaknesses in its implementation. Press accounts quote a Global
Fund representative explaining that it had become difficult to measure how the loveLife
prevention campaign was contributing to the reduction of HIV/AIDS among young people in
South Africa. Additionally, the representative reportedly stated that the Board had repeatedly
requested that loveLife revise its proposals and address concerns regarding performance, financial
and accounting procedures, and the need for an effective governance structure. A Global Fund
spokesman was quoted as saying that “loveLife is extremely costly, there are programs that have
been very effective, which cost a fraction of what loveLife costs. It would be irresponsible of the 21
Global Fund to spend almost $40 million without seeing results.”
LoveLife officials were reportedly surprised that the Global Fund ultimately decided to
discontinue funding the grant, particularly since there were some reported differences of opinion
regarding the matter between the Fund’s Technical Review Panel (TRP), Secretariat, and the 22
Board. Additionally, loveLife officials reportedly argued that the decision was politically
motivated and influenced by U.S. emphasis on abstinence in HIV prevention efforts. One press
account quoted a loveLife official as saying, “Obviously the strength of conservative ideologies is
spilling over into the field of HIV and HIV prevention and it has direct impact on programs like 23
loveLife.” According to a loveLife press release, the decision to discontinue support for the
program will substantially curtail South Africa’s efforts to prevent HIV infections among young
people, because the Global Fund’s grant supported one third of the program’s budget. However,
the South African government has reportedly provided additional funds to the program to close
the funding gap, and other donors, such as the U.S.-based Kaiser Family Foundation, have
continued funding loveLife HIV-prevention efforts.
On August 24, 2005, the Global Fund announced that it had temporarily suspended all five of its
grants in Uganda. Additionally, the Fund declared that the Ugandan Ministry of Finance would

20 Global Fund,Global Fund Closes Funding Gap,” Press Release, December 16, 2005, at
http://www.theglobalfund.org/en/media_center/press/pr_051216.asp, visited May 11, 2007.
21 UN Integrated Regional Information Networks, “South Africa: Global Fund Withdraws Support for LoveLife,”
December 19, 2005, at http://www.plusnews.org.
22 LoveLife officials allege that after reviewing the revised proposal that loveLife submitted, the TRP recommended
that the Board fund the proposal. See loveLife, “Statement by loveLife on the Decision by the Global Fund to Fight
HIV/AIDS, TB, and Malaria to Discontinue Funding,Press Release, December 21, 2005, at
http://www.lovelife.org.za/corporate/media_room/article.php?uid=805, visited May 17, 2007.
23 Andrew Quin, “S. Africa youth AIDS program faces cash crunch, Reuters Foundation, January 4, 2006, at
http://www.alertnet.org, visited May 22, 2007.





have to establish a new structure that would ensure effective management of the grants before it
considered resuming support. In a press release, the Fund explained that a review undertaken by
PricewaterhouseCoopers revealed serious mismanagement by the Project Management Unit
(PMU) in the Ministry of Health, which was responsible for overseeing the implementation of
Global Fund programs in Uganda. Examples of “serious mismanagement” included evidence of 24
inappropriate, unexplained or improperly documented expenses. Up to that point the Fund had 25
disbursed some $45.4 million of the $200 million approved. Three months later on November
10, 2005, the Fund announced that it had lifted the suspension on all five grants. The PR and the
Ministry of Finance committed to restructure management of the grants and strengthen oversight 26
and governance of Global Fund grants to Uganda. In spite of these actions, the Fund did not
approve support for Phase II activities.
After extensive consultation with the U.N. Development Program (UNDP), the Fund decided to
terminate its grant agreements with Burma effective August 18, 2005. The Fund stated that while
it was concerned about the extensive humanitarian needs in Burma, travel restrictions imposed by 27
the country’s government prevented the Fund from effectively implementing grants. According
to the Fund, travel clearance procedures that the Burmese government instituted in July 2005
prevented the PR, implementing partners, and Global Fund staff from accessing grant
implementation areas. The Fund indicated that the travel restrictions coupled with new
procedures that the government established to review procurement of medical and other supplies
“prevented implementation of performance-based and time-bound programs in the country,
breached the government’s commitment to provide unencumbered access, and frustrated the 28
ability of the PR to carry out its obligations.”
The Global Fund’s decision to discontinue those grants in Burma sparked a larger debate about
providing humanitarian assistance in countries that are politically unstable or governed by
dictatorial regimes. Some were disappointed that the Fund terminated its assistance, citing the
significant humanitarian needs in the country. A Burmese official stated that, “the restrictions on 29
aid workers were only temporary, and ‘do not justify irreversible termination of grants.’” A U.N.
official accused the United States of pressuring the Global Fund to withdraw its support in

24 Global Fund,Global Fund Suspends Grants to Uganda,” Press Release, August 24, 2005, at
http://www.theglobalfund.org/en/media_center/press/pr_050824.asp, visited May 15, 2007.
25 Kaiser Family Foundation, “Global Fund Temporarily Suspends Five Grants to Uganda Citing Evidence of
Mismanagement,” August 25, 2005, at http://www.kaisernetwork.org/daily_reports/
print_report.cfm?DR_ID=32229&dr_cat=1, visited May 16, 2007.
26 Global Fund,Global Fund Lifts Suspension of Uganda Grants,” Press Release, November 10, 2005, at
http://www.theglobalfund.org/en/media_center/press/pr_051110.asp, visited May 9, 2007.
27 Global Fund, “The Global Fund Terminates Grants to Myanmar,” Press Release, August 19, 2005, at
http://www.theglobalfund.org/en/media_center/press/pr_050819.asp. Also see Global Fund, “Termination of Grants to
Myanmar,” Fact sheet, August 18, 2005, at http://www.theglobalfund.org/en/media_center/press/
pr_050819_factsheet.pdf, visited May 10, 2007.
28 Global Fund, “The Global Fund Terminates Grants to Myanmar,” Press Release, August 19, 2005, at
http://www.theglobalfund.org/en/media_center/press/pr_050819.asp, visited June 5, 2007.
29Burma urges UN aid fund to stay, BBC News, August 23, 2005, at http://news.bbc.co.uk/, visited June 6, 2007.





Burma.30 One U.N. official warned of impending death as a result of the situation, stating that, 31
“without exaggeration, people are going to die because of this decision.” Some, however,
blamed the Burmese government for the Fund’s decision to terminate the grants. One
Washington-based observer stated that, “it needs to be recognized who causes suffering in that 32
country. It’s not the Global Fund...It’s the regime.” A Global Fund spokesperson stressed that
the interrupted aid was not a political decision, rather one based on effective project 33
implementation.
Burma has garnered support from other countries and international organizations to continue 34
programs terminated by the Fund. Australia is reportedly increasing its aid to Burma by 25%.
Additionally, the European Union (EU) announced that it had pledged about $18 million to fight 35
HIV/AIDS in the country. In January 2006, Australia, Britain, Sweden, the Netherlands,
Norway, and the European Commission announced that they planned to establish a $100 million,
five-year joint donor program that would replace some of the financial support the country lost
after the Fund had withdrawn. The program, the Three Diseases Fund (3D Fund), was officially 36
launched in October 2006. The donors contend that the funding system maintains the safeguards
established by the Global Fund that ensures the money does not directly support the military
regime.

In September 2000, at the United Nations (U.N.) Millennium Summit, member states adopted the
U.N. Millennium Declaration, which among other things, established a set of time-bound,
measurable goals and targets for combating poverty, hunger, disease, illiteracy, environmental

30 “Australia to step up AIDS assistance to Burma,” Australian Associated Press, December 7, 2005, at
http://aap.com.au/, visited June 6, 2007.
31 “Misery spreads among political stalemate,The Miami Herald, December 29, 2005, visited May 31, 2007.
32So Much Need, So Little Help for the Deathly Ill in Myanmar,” The Los Angeles Times, December 27, 2005, at
http://www.latimes.com/, visited May 31, 2007.
33 Ibid.
34 “Australia to step up AIDS assistance to Burma,” Australian Associated Press, December 7, 2005, at
http://aap.com.au/, visited June 6, 2007.
35 “EU Humanitarian aid to Myanmar increases fourfold, Associated Press, December 12, 2005, at http://www.ap.org,
and “Commission allocates 15 million in humanitarian aid to vulnerable populations in Burma/Myanmar and to
Burmese refugees along the Myanmar-Thai border,European Commission, Press Release, December 22, 2005, at
http://europa.eu/rapid/pressReleas es Action.do ?referen ce=IP /05/
1694&format=HTML&aged=0&language=EN&guiLanguage=en, both visited on June 6, 2007.
36European donors plan to restore AIDS help to Myanmar: diplomats, Agence France Press, January 24, 2006, at
http://www.afp.com/english/home/, and “Myanmars HIV/AIDS, Malaria, TB Fund To Begin Operations on October
12,” Kaiser Family Foundation, October 12, 2006, at http://www.kaisernetwork.org/daily_reports/
rep_index.cfm?hint=1&DR_ID=40356, both visited on June 6, 2007.





degradation and discrimination against women.37 This resolution contains what have become 38
commonly known as the Millennium Development Goals (MDGs).
World leaders who agreed to the MDGs pledged to provide sufficient financial and technical
support to meet the goals. Of the eight goals, the one aimed at HIV/AIDS and malaria commits
world leaders to reverse the spread of the two diseases by 2015. The World Health Organization
(WHO) and the Joint United Nations Program on HIV/AIDS (UNAIDS) estimate that in order to
meet the MDG goal related to HIV/AIDS and malaria, in each year from 2008 to 2010, donors 39
would need to provide between $28 billion and $31 billion. The Global Fund estimates that
during that time period, its annual share of this amount would range from $4 billion to $6 billion.
The Fund estimates that it will need between $11.5 billion and $17.9 billion from 2008 to 2010.40
The range represents the rate at which grant approval could escalate in three different scenarios
(Table 2). In Scenario A, the Global Fund would continue to award new grants at the current rate
of about $1 billion per year and would not experience significant growth. In Scenario B, the Fund
would moderately increase new grant awards, with annual grant awards averaging $5 billion from
2008 to 2010. In Scenario C, the Fund projects that it would meet the MDGs and would need an
average of $6 billion for each year from 2008 to 2010. The Global Fund does not advocate any 41
scenario, because it bases its financial needs on the grant proposals that it receives. However, at
a board meeting in April 2007, the Board estimated that it would need from $6 billion to $8 42
billion by 2010—reflecting Scenarios B and C.
Table 2. Funding Requirements, 2008-2010
($ U.S. current billions)
2008 2009 2010
Phase I Phase II RCC Phase I Phase II RCC Phase I Phases II RCC Total
Scenario A 1.7 1.3 0.3 1.8 1.7 0.4 1.6 2.1 0.6
Subtotal 3.3 3.9 4.3 11.5
Scenario B 2.3 1.3 0.3 2.9 1.7 0.4 3.2 2.2 0.6
Subtotal 3.9 5.0 6.0 14.9
Scenario C 2.8 1.3 0.3 3.9 1.7 0.4 4.7 2.2 0.6
Subtotal 4.4 6.0 7.5 17.9

37 United Nations, United Nations Millennium Declaration, A/RES/55/2, September 18, 2000, at http://www.un.org/
millennium/declaration/ares552e.pdf, visited January 17, 2008.
38 United Nations,The Millennium Development Goals and the United Nations Role,” at http://www.un.org/
millenniumgoals/MDGs-FACTSHEET1.pdf, visited January 17, 2008.
39 Global Fund, Partners in Impact: Results Report 2007, at http://www.theglobalfund.org/en/files/about/
replenishment/oslo/Progress%20Report.pdf, visited January 17, 2008.
40 Global Fund, Resource Needs for the Global Fund: 2008-2010, February 2007, at http://www.theglobalfund.org/en/
files/about/replenishment/oslo/Resource%20Needs.pdf, visited January 17, 2008.
41 Correspondence with Global Fund staff, May 1, 2007.
42 Ibid.





Source: Global Fund, Resource Needs for the Global Fund: 2008-2010.

At the launching of PEPFAR, the Administration proposed that over the Plan’s five-year term, $1
billion be contributed to the Global Fund. The Administration has requested $1.3 billion for the
Fund from FY2004 through FY2008: $200 million in each of FY2004 and FY2005, and $300
million in each of FY2006 through 2008. Congress has consistently provided more to the Fund
than the Administration has requested through PEPFAR, appropriating some $3 billion from
FY2004 through FY2008 (Table 3). In FY2008, Congress appropriated $840.3 million for a U.S.
contribution to the Fund, the single largest U.S. contribution to date. Of those funds, $545.5
million would be funded through the State Department, and $294.8 million through the
Department of Health and Human Services (HHS). The President requested $500 million for
FY2009.
Table 3. U.S. Appropriations to the Global Fund
($U.S. current millions)
PEPFAR
FY2001-FY2002 FY2003 FY2004 FY2005 FY2006 FY2007 FY2008 Total FY2004-FY2001-FY2009
Actual Actual Actual Actual Actual Actual Estimate FY208 FY2008 Request
Foreign 150.0
Operations 248.4 397.6 248.0 445.5 625.0 545.5 2,261.6 2,660.0 200.0
Labor/HHS 125.0 99.0 149.1 99.2 99.0 99.0 294.8 741.1 965.1 300.0
FY2004 n/a
Carryover n/a (87.8) 87.8 n/a n/a n/a n/a n/a n/a
TOTAL 275.0 347.4 458.9 435.0 544.5 724.0 840.3 3,002.7 3,625.1 500.0
Source: Appropriations legislation and interviews with Administration officials.
Notes: As of July 17, 2008, the Global Fund reports having received $2.5 billion from the United States.
According to the Fund, it received $300 million in 2001 and 2002 combined, $322.7 million in 2003, $458.9
million in 2004, $414.0 million in 2005, and $513.0 million in 2006. The United States pledged $724.0 million in
2007 and paid $531.0 million. In 2008, the United States pledged $840.3 million and has not yet sent a payment
to the Fund.
In FY2005, Foreign Operations appropriations provides for the United States to transfer 5% of funds
appropriated to the Fund to support USAID technical assistance efforts related to the Fund. In FY2006, Foreign
Operations appropriations language requires the Secretary of State to withhold 20% of the U.S. Global Fund
contribution until she certifies to the Appropriations Committees that the Fund has strengthened oversight and
spending practices. FY2008 Consolidated Appropriations provided that up to 5% of the funds made available to
the Global Fund be made available to USAID for technical assistance activities related to the Global Fund and
that up to $13 million of Global Fund appropriations be made available for administrative expenses of the Office
of the Global AIDS Coordinator. The act also authorizes the President to withhold a portion of U.S. funds from
the Fund that might be spent in countries that support terrorism.
The withdrawal of $87.8 million in FY2004 illustrated in Table 3 reflects requirements in P.L. 108-25, U.S.
Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003, which stipulates that U.S. contributions to
the Fund for fiscal years 2004 through 2008 not exceed 33% of Fund contributions from all sources (discussed
below). P.L. 108-447, FY2005 Consolidated Appropriations, adds this amount to the 2005 contribution, subject
to the same 33% limitation.






Some critics of the Fund have expressed concern about particular aspects of the Fund’s financial
policies. Observers contend that the Fund’s oversight mechanisms are not strong enough to
protect against wasteful spending, particularly in countries that have a well documented history of
corruption and poor financial management. Fund supporters counter that the organization’s
website provides an abundance of information related to its funding process, grant project
proposals and budgets, grant spending trends, and results of board meetings, which include
decisions regarding the suspension of grants. Fund advocates also argue that the Fund’s decisions
to suspend temporarily, and in some cases, discontinue poor performing grants demonstrate the
effectiveness of the Fund’s oversight and funding mechanisms.
In June 2005, the U.S. Government Accountability Office (GAO) reported that the Fund had a
limited capability to monitor and evaluate grants, raising questions about the accuracy of its
reported results. GAO also indicated that the Fund’s documents had not consistently explained 43
why it provided additional funds for grants or why it denied disbursement requests. In October
2006, the Center for Global Development (CGD) Global Fund Working Group reported similar
findings and made a number of recommendations, including strengthening the performance based 44
funding system.
In an effort to strengthen oversight of the Fund’s grants, Congress included a provision in Section

525 of P.L. 109-102, FY2006 Foreign Operations Appropriations, that required 20% of the U.S.


contribution to the Global Fund be withheld until the Secretary of State certified to the
Appropriations Committees that the Fund had undertaken a number of steps to strengthen
oversight and spending practices. The act allows the Secretary to waive the requirement, however,
if she determines that a waiver is important to the national interest. At a March 2007 hearing on
TB held by the Subcommittee on Africa and Global Health, Representative Adam Smith
expressed his reservations about the Fund’s oversight capacity, stating that
The information and accountability that Congress has come to take for granted through
bilateral programs are not available through the Global Fund, and that many of the primary
recipients of the Global Fund grants are governments with a history of corruption and fraud
and/or limited capacity to properly manage large sums of money in their health sectors. One
could argue that the absence in the Global Fund of a robust reporting and monitoring
mechanism, at both the primary and sub- recipient levels, is an open invitation for waste in
these countries and a tragic loss of opportunity to save lives. The implementation of a system
that provides accountability and transparency would seem vital, absolutely necessary, in my
view, to continue the expanded donor support of the Global Fund in the future.

43 GAO, The Global Fund to Fight AIDS, TB, and Malaria is Responding to Challenges but Needs Better Information
and Documentation for Performance-Based Funding, GAO-05-639, June 2005, at http://www.gao.gov/new.items/
d05639.pdf.
44 Global Fund Working Group, Challenges and Opportunities for the New Executive Director of the Global Fund:
Seven Essential Tasks, CGD, October 2006, at http://www.cgdev.org/doc/HIVAIDSMonitor/
GlobalFund_sevenTasks.pdf.





GAO re-evaluated the Fund and released a report in May 2007, which acknowledged that the
Fund had improved its documentation of funding decisions, but also determined that the process 45
needed improvement. The report indicated that while each grant that GAO reviewed included an
explanation of associated funding decisions, the explanations did not detail what criteria the Fund
used to determine whether to disburse funds or renew support, as it had found in 2005. GAO
recommended that the Fund strengthen oversight of Local Fund Agents (LFAs) and standardize 46
performance benchmarks to improve the quality of grant monitoring and reporting.
In FY2008, Congress placed additional monitoring and oversight provisions to Global Fund
appropriations. The FY2008 Consolidated Appropriations required that 20% of U.S. contributions
to the Fund be withheld until the Secretary of State certifies to the Committees on Appropriations
that the Global Fund
• releases incremental disbursements only if grantees demonstrate progress against
clearly defined performance indicators;
• provides support and oversight to country-level entities;
• has a full-time, independent Office of Inspector General who is fully operational;
• requires LFAs to assess whether a principal recipient has the capacity to oversee
the activities of sub-recipients;
• is making progress toward implementing a reporting system that breaks down
grantee budget allocations by programmatic activity;
• makes the reports of the Inspector General publicly available; and
• tracks and encourages the involvement of civil society, including faith-based
organizations, in country coordinating mechanisms and program implementation.
The FY2008 Consolidated Appropriations also required the Secretary of State to submit a report
within 120 days of enactment to the Appropriations Committees that details the involvement of
faith-based organizations in Global Fund programs.
Some in Congress have long advocated for stronger oversight of Global Fund spending.
Supporters of this idea have welcomed the provisions. Some Global Fund supporters contend,
however, that such action is unnecessary in light of the strides that the Fund continues to make in
improving its reporting and monitoring practices. As Congress considers whether to continue
supporting the Global Fund, Members might debate whether the Fund is sufficiently adhering to
congressional mandates or if additional provisions are necessary.

45 GAO, Global Fund to Fight AIDS, TB, and Malaria Has Improved Its Documentation of Funding Decisions but
Needs Standardized Oversight Expectations and Assessments, GAO-07-627, May 2007, at http://www.gao.gov/
new.items/d07627.pdf.
46 The Global Fund does not maintain staff in recipient countries. Instead, it hires Local Fund Agents to oversee, verify
and report on grant performance. For more information, see Global Fund, “Local Fund Agents, fact sheet, at
http://www.theglobalfund.org/en/about/structures/lfa/, visited January 17, 2008.





P.L. 108-25, U.S. Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act, prohibits U.S.
government contributions to the Fund from exceeding 33% of contributions from all donors.
Congress instituted the contribution limit to encourage greater global support for the Fund. There
is some debate about whether the 33% provision should be interpreted as the amount the United
States should provide to the Fund or as the maximum amount the United States can contribute.
Supporters of the Fund contend that Congress instituted the 33% mandate in recognition of the
moral responsibility that the United States holds as one of the wealthiest countries in the world.
Opponents of this idea assert that if U.S. contributions to the Fund were to reflect its share of the
global economy, then U.S. contributions would and should range from 20% to 25% of all
contributions.
Some Global Fund advocates who disparage the 33% restriction argue that the differing fiscal
cycles of the Fund and the United States complicate efforts to leverage support. Opponents to the
33% restriction contend that the requirement is harmful to the Fund, because the U.S. fiscal year
concludes some three months before the Fund’s. Critics most often point to FY2004 to
substantiate their position. In that fiscal year, nearly $88 million of the U.S. contribution was
withheld from the Fund to prevent the funds from exceeding 33%. Advocates of the restriction
assert that the 33% cap was intended to suspend portions of U.S. contributions, where necessary.
Proponents of the cap note that the Fund was not significantly affected, as the withheld portion
was released at the end of the calendar year, when the Fund secured sufficient funds to match the
U.S. contribution. Supporters of the provision contend that the Fund benefits from the policy,
because it encourages other donors to increase their contributions, as happened in FY2004 (Table

4).


Table 4. U.S. Pledges to the Fund as a Percentage of
All Fund Pledges
(current U.S. $ millions, and percentages)
2001-2004 FY2005 FY2006 FY2007 FY2008
Paid Paid Paid Paid Pledged Total
U.S. Pledges and a
Contributions $1,081.6 414.0 $513.0 $531.0 $840.3 $3,379.9
All Pledges and
Contributions $2,340.1 $1,093.5 $1,519.2 $2,049.8 $2,381.9 $9,384.5
Total $3,421.7 $1,507.5 $2,032.2 $2,580.8 $3,222.2 $12,764.4
U.S. Pledges
Contributions as
% of Total 46.2% 37.9% 33.8% 25.9% 35.3% 36.0%
Sources: Global Fund, Pledges and Contributions, July 17, 2008.
Notes: The Global Fund reports having received $245.2 million less than what the Administration reports it
provided (see Table 3). From FY2001-FY2004, the Administration reports it contributed $1,081.3 million to the
Fund, $435.0 million in FY2005, $544.5 million in FY2006, $724.0 million in FY2007, and $840.3 million in
FY2008.
Total pledges to the Fund reach $20,154.4 when pledges for 2009 and 2010 are included, as indicated in
Table 5.





Debate on the 33% contribution cap has also focused on the limited amount of support that the
private sector and others have provided to the Fund (Table 5). Since its inception, the Fund has
struggled to secure support from non-government donors. The Bill & Melinda Gates Foundation
remains the largest single contributor among non-government donors. As of July 17, 2008, the
foundation accounts for about 86% ($650.0 million) of all non-governmental pledges ($755.1
million) and more than 75% ($450.0 million) of all payments made to the Fund by non-47
governmental donors ($579.6 million). Some Fund supporters had hoped that the Product Red 48
campaign, launched in January 2006 by co-founder Bono, would lead to significant increases in 49
contributions made by the private sector. As of July 17, 2008, Product Red™ has contributed
$69.8 million to the Fund, comprising 12% of non-government contributions, double what it paid
in April 2007.
Table 5. Total Global Fund Contributions and Pledges,
2001-2008
(current $ U.S. billions and percentages)
Paid as of Total Pledges as of % of Total
07/16/2008 % of Total Paid 07/16/2008 Pledges
United States 2.5 23.1% 4.1 20.3%
European Union 5.1 47.2% 10.8 53.5%
European Commission 0.8 7.4% 1.3 6.4%
Other Countries 1.8 16.7% 3.3 16.3%
Non-Governmental 0.6 5.6% 0.7 3.5%
Donors
Total 10.8 100.0% 20.2 100.0%
Source: Global Fund, Pledges and Contributions, July 17, 2008.
The Administration has argued that any amount that Congress provides to the Global Fund in
excess of its request skews the appropriate balance of aid that the United States should provide to
the Fund and other bilateral HIV/AIDS efforts. At a FY2005 Senate Appropriations Committee
hearing in May 2004, then-Global AIDS Coordinator Ambassador Randall Tobias argued that the
“incremental difference between what the Administration requested and what was appropriated to 50
the Fund is money that might have been available” for U.S. bilateral programs. Although
appropriations to the Fund have been increasing, the percentage of U.S. global HIV/AIDS, TB,

47 Global Fund,Pledges and Contributions,” July 1, 2008, at http://www.theglobalfund.org/en/files/
pledges&contributions.xls, visited July 11, 2008.
48 Stage name for singer Paul David Henson.
49 The initiative is a branding mechanism which commits companies that use the Product Red brand to share a
percentage of their profits with the Fund. For more information on Product Red, see http://www.joinred.com/, visited
July 11, 2008.
50 Testimony of Global AIDS Coordinator Ambassador Randall Tobias, in U.S. Congress, Senate Committee
Appropriations, FY2005 appropriations, May 18, 2004.





and malaria appropriations provided for U.S. contributions have remained mostly level (Table 6,
Figure 1, and Figure 2).
Fund supporters counter that appropriations made to the Fund in excess of requested levels better
reflect what the United States should provide and complement U.S. bilateral HIV/AID programs,
particularly since the Administration and the Fund have strengthened their coordination. U.S.
officials acknowledge that though the Fund is a critical part of PEPFAR, when making
appropriations, Congress should consider the pace at which the Fund can distribute funds. The
Office of the Global AIDS Coordinator (OGAC) has cited an instance when PEFPAR used some
of its funds to purchase anti-retroviral medication (ARVs) for a Global Fund project that faced 51
financial delays.
In FY2009, the Administration requested $500 million for U.S. contributions to the Global Fund
through Foreign Operations and Labor/HHS Appropriations. This amount accounts for almost 8%
of all HIV/AIDS, TB, and malaria proposed spending—about 5% less than FY2008 enacted
levels.
Table 6. Total U.S. Global HIV/AIDS, TB, and Malaria Appropriations
(current $ U.S. millions and percentages)
FY2004 FY2005 FY2006 FY2007 FY2008 FY2009
Actual Actual Actual Actual Estimate Request
Global Fund $458.9 $435.0 $544.5 $724.0 $840.3 $500.0
Other
Bilateral
HIV/AIDS, $1,828.6 $2,471.5 $2,858.2 $4,063.7 $5,501.0 $5,897.1
TB, and
Malaria
Programs
TOTAL $2,287.5 $2,906.5 $3,402.7 $4,787.7 6,341.3 $6,397.1
% of U.S.
Global
HIV/AIDS,
TB, and 20.1% 15.0% 16.0% 15.1% 13.2% 7.8%
Malaria
Programs
Provided to
the Fund
Sources: Prepared by CRS from appropriations legislation figures and interviews with OGAC staff.

51 OGAC, The Power of Partnerships: Third Annual Report to Congress on PEPFAR, 2007, p. 74, at
http://www.pepfar.gov/documents/organization/81476.pdf, visited January 17, 2008.





Figure 1. U.S. Contributions to the Fund and All U.S. International HIV/AIDS, TB,
and Malaria Spending
Source: Prepared by CRS from appropriations legislation figures.





Figure 2. U.S. Contributions to the Fund as a Percentage of All U.S. International
HIV/AIDS, TB, and Malaria Spending
Source: Prepared by CRS from appropriations legislation figures.
Table 7. Glossary of Abbreviations and Acronyms
3D Fund Three Diseases Fund
ACT Artemisinin-based Combination drug Treatment
ARV Antiretroviral Therapy
CCM Country Coordinating Mechanism
CGD Center for Global Development
DOTS Directly Observed Treatment Short-Course
EU European Union
GAO U.S. Government Accountability Office
ITN Insecticide-Treated Net
MDR-TB Multi-Drug Resistant Tuberculosis
NGO Non-Governmental Organization
OGAC Office of the Global AIDS Coordinator
PEPFAR President’s Emergency Plan for AIDS Relief
PR Principal Recipient
RCC Rolling Continuation Channel





TB Tuberculosis
UN United Nations
UNDP United Nations Development Program
VCT Voluntary Counseling and Testing
Tiaji Salaam-Blyther
Specialist in Global Health
tsalaam@crs.loc.gov, 7-7677