Global Programs Struggle

At a January meeting in Geneva, the Global Fund to fight AIDS, Tuberculosis, and Malaria (GFATM)-set up last year by an alliance of private donors, nongovernmental organizations (NGOs), foundations, national governments, and intergovernmental organizations-elected its directors, announced its funding criteria, and approved its first call for funding proposals.

GFATM officials shrug off suggestions that its donors have been less than generous. Kofi Annan, secretary-general of the United Nations, who championed the fund after it was first initiated 18 months ago at the G-8 summit in Okinawa, recently said up to $7 billion is needed to tackle those diseases, which kill more than six million people annually. With the recent announcement of a $200 million donation from the US government, the fund has been pledged $1.9 billion so far-well short of Annan's target-but its officials say Annan never saw it as the only vehicle for tackling AIDS, TB, and malaria.

The fund's board has a broad composition, with members elected by their own constituencies. The NGO seats, one from a developing country and one from an industrialized one, belong to the German Institute for Medical Mission and to Health Rights Action from Uganda. The private sector has two seats, one held by the Gates Foundation, and the other by Goran Lindahl, deputy chairman of the South African mining company Anglo-American.

Donor countries represented on the board are France, Italy, Japan, Sweden, the United Kingdom, and the United States. The European Commission is also represented, and other seats will rotate among countries. The seven developing countries represented include China, Brazil, Nigeria, Pakistan, Thailand, Uganda, and Ukraine. The Joint United Nations Program on HIV/AIDS (UNAIDS) and the World Health Organization (WHO), along with the World Bank, which handles the fund's finances, hold nonvoting seats.

Some $700 million is available for programs this year, and the fund hopes to make its first awards in April to finance projects in severely affected countries as well as in areas with growing epidemics. Officials will favor plans from countries that have demonstrated the greatest political commitment to eradicating the target diseases. They will also finance projects that seem most likely to demonstrate measurable success.

The International Federation of Pharmaceutical Manufacturers Associations (IFPMA) issued a statement denying suggestions in a Wall Street Journal article that the appointment of Lindahl to the board was a setback for the pharma industry. Dr. Harvey Bale, IFPMA director-general, says pharma industry representatives participated in the selection of a private sector member of the fund's board and that IFPMA decided "for several reasons" that it did not want to be represented on the board.

The criticisms leveled at another group, the Global Alliance for Vaccines and Immunizations (GAVI), may be one reason. Save the Children says the governance structure of GAVI-which was set up in 1999 and has resources of more than $1 billion for 2001-2005-allows for potential conflicts of interest.

In an evaluation of GAVI, conducted with the London School of Hygiene and Tropical Medicine, Save the Children says the fund has the following problems:

• low levels of support for healthcare systems

• transaction costs involved in applying for GAVI support

• the pressure countries have been under to make quick, supply-led decisions about vaccine selection

• the relationship between new vaccine promotion and the Expanded Program of Immunization

• the implications of private sector vaccine developers sitting on the board of governance.

The report says the commercial interests represented on the board should not compromise GAVI's independence.