The Global Fund at Ten Years: Reflecting on its Impact and Looking Forward to Challenges Ahead

Tuesday, April 24, 2012

Debrework Zewdie examines the Global Fund's impact on global health, its current crisis, and efforts to strengthen internal governance and improve risk management.

YANZHONG HUANG: Good afternoon. Can you hear me?

Welcome to the Council on Foreign Relations. I'm Yanzhong Huang. It's pronounced as Hwawng (ph), not Hwang (ph). (Chuckles.) We had that experience last week. I was in Boston. You know, I was on a standby list. You know, they were calling Hwang (ph), Hwang (ph), and I -- who? -- (laughter).

So -- I'm a senior fellow for global health at the Council on Foreign Relations. This is our fourth meeting of the new Emerging Powers in Global Health Governance Roundtable Series. And on April 9th, our third roundtable meeting, in New York, had Chris Elias speaking about the role of Gates Foundation in global health.

Today we focus on another major player in global health, the Global Fund, which is the world's largest player -- funder of AIDS, TB and malaria projects, and also maybe, arguably, the most viable multilateral providing funding for global health. And this meeting will examine the Global Fund's contribution to global health over the past decade and its ongoing efforts to transform the organization into a more effective and accountable one.

We are privileged to have Debrework Zewdie, deputy general manager and head of strategy, investment and impact division of the Global Fund. As a former World Banker with a doctorate degree in immunology, Debrework has dedicated the past 28 years to mitigating the impact of infectious diseases in her diverse capacities as a scientist, strategist, manager, policymaker, program implementer, advocate and activist. Have I missed anything? (Laughter.)

So we'll begin with brief remarks from Debrework, and after her remarks we will open the floor up to questions and discussions.

And just as housekeeping rules, this meeting is on the record. That means you can feel free to use and quote today's discussion. And also don't forget to turn off your cell phones.

OK, so I'm going to start with Debrework. You have 15 minutes.

DEBREWORK ZEWDIE: Thank you, Huang. I hope I said it properly.

HUANG: Yes. That's perfect.

ZEWDIE: And good afternoon. First of all, thank you for inviting me, and thank you to all of you for coming. Most of you are my friends who I haven't seen in the last 2 1/2 years when I've been housekeeping in Geneva.

I have been asked to focus on three things. The first one is the fund's contribution to global health. I'm going to spend a very short time on it. The second one, it says current crisis. If at the end of this meeting I did not convince you that the Global Fund is not in crisis, then we would -- our time will not be worth it. And then the third one will be our efforts to strengthen the Global Fund. That's where I want to spend most of my time.

As most of you know -- and I'm not going to repeat most of the things which you will be able to read, and spend our time more on the transformation -- is that it is a fund which to date has approved over $23 billion in AIDS, tuberculosis and malaria and building health systems. We have programs in about 150 countries, and we have to date disbursed more than $15 billion, and 80 percent of it just in the last five years. So that it gives you a perspective.

More than half, about 60 percent, of our funding goes to sub-Saharan Africa, where the disease burden is disproportionate. We have a number of statistics which -- and you will be able to read from our website -- are putting over over 3 million people on antiretrovirals, and we are the major funders of DOTS for TB and MDR-TB.

In malaria we have distributed bed nets and drugs. I think the only thing I want to mention about results is the Global Fund has contributed -- and I use that for -- that word very carefully -- contributed to the decline in new infections in many of the countries in HIV and also the decrease in under-5 mortality in malaria. So that's the results.

Is the Global Fund in crisis? Is it not. 2011 was a very difficult year. You know -- you have seen what happened to the fund. What we are doing now is to use this event that we had in 2011 as an opportunity to change the fund, which has been working very well, to make it even better, to make it more accountable, to make it more innovative and to make it more effective and efficient. For those of you who know, when the Global Fund was established, we were supposed to be simple, efficient and effective. We are nothing like those things now.

So there are a number of fundamentals that we are transforming, and our focus is three areas. One is strengthening our foundation, and the second one is implementing the 2011-2016 strategy, and the third and probably one of the most important ones is securing enough resources so that we continue to do what we do.

How are we going to do this? We have defined distinct work areas. The first one -- we call it organizing to deliver. The second one is the quality and timelines in proposal development and grant processing, and the third one is simplification of in-country implementation of grants and risk management.

What do I mean by organizing to deliver? Under the leadership of the new general manager, who -- whose detail is to come and reform the Global Fund, we have established a new organizational structure. And we have rebalanced the staff and the resources that the Global Fund has.

Essentially what we have done is to make sure that the institution is a grants-making institution. That's the core business. Sometime in early 2011, we had an expert group to look into the workings of the Global Fund, and they came up with a figure of about 50-50 split on the resources and staff that we have in grant management versus other functions. In about 60 days we have changed that to 75 to 25.

How did we do that? First of all, we expanded what we used to call country programs and it's now called grant management. And we focused it into -- we have what we call high-impact regions. So we have two for Africa, one for Asia, seven countries each. These are countries, whether you -- whether use -- HIV, malaria or TB -- where you -- we call high-impact countries.

What this does is, our efforts will be focused in these areas hopefully to move the needle in public health in all these three epidemics.

At the same time, what was hurting smaller countries was -- for example, if you have Nigeria and DRC on your portfolio, forget about the rest of the countries. That is consuming in and of itself.

So by creating a different department for the rest of Africa, Asia, Europe and Latin America, those countries will have much more focus and involvement in what we do.

So today a fund portfolio manager in a high-impact country, for example, would be dealing with one country, whereas earlier a fund portfolio manager -- it's not unusual to have five, seven countries under the same portfolio. So that's what we are doing.

The second and equally important is, for those of you who knew the Global Fund, we had a department called Strategy, Policy and Evaluation. We have changed it into Strategic Investment and Impact Evaluation Department. And a hundred percent of these people are working on grant management. These are the people who will implement -- which takes me to the next point, which is implementing the strategy -- and what we are working towards is what we call strategic investment for impact. So these are the people whose job it is to make sure that every single penny in the Global Fund is invested properly.

We have moved the monitoring and -- the monitoring function from this unit to grant management because they -- those are the people who should be working with the country team, whereas we have kept evaluation because we are going to focus more on impact evaluation. So all these two -- these are the two biggest departments in the Global Fund and they'll be focused on grant management.

Simplification of in-country monitoring of grants and risk, we have -- the general manager has put two projects in place. Because he's a banker, he gives this -- it different names and every time we say this is not a public health vocabulary changer. One, he calls it, manufacturing of grants. And I was shocked a bit when he first said it, but actually it makes sense because if you have a system of bringing out this, the fundamentals of a glass, right, then you can change it into a whiskey glass, a wine glass, et cetera. So that's essentially what it is. The second one -- he calls it unclogging the pipes. We have existing programs in place which we need to make sure that they move as they're supposed to move.

The third one is the quality and the timeliness in proposal development and grant processing. As most of you remember, the 2011-2016 strategy was endorsed in Accra. We also canceled Round 11 for reasons which maybe we will go into when we discuss. That was replaced by what we call a transitional funding mechanism. This is to help countries who would have got the resources from Round 11 to keep them going until we go to the next and most important phase, which is what we call the two-step process.

Before I go away from the transitional funding mechanism, the proposals have come in by the 31st of March. Twenty-five percent of them came from Africa. The initial upper limit for all these 61 grants is about a little bit more than $600 million and we will be able to fund that.

The second one, which many of you pay attention to, is what we call grant renewal or Phase 2. We have about $8 billion worth of Phase 2. To just give you an example on May 2, we will have a meeting to determine about 15 renewals worth about $700 million. The change in Phase 2 is, instead of internally doing it by ourselves, we have opened it up to our partners so that they have a say in helping us do strategic investment because the renewal -- the Phase 2 grant renewal is a good window to straighten up our processes when we go to our two-step process.

The last point which I want to mention -- and I have been told 15 minutes -- is we have also established what we call disease committees. Again, in the general manager's analogy, he says if you are at war, at least once a month you want to talk to your allies and say, where is this going? So we will establish an HIV/AIDS committee, malaria committee, TB committee. It is not going to discuss about which is the best proposal, but it is, where is the gap?

So that's where we're going, and I'll be happy to respond to any questions so that we can -- I can elaborate on some of these things. Thank you.

HUANG: Thank, Debrework. You just used 10 minutes. (Chuckles.) So if you want to say more, you can. But -- (laugh) --

ZEWDIE: I thought I heard the bell or something.

HUANG: OK, so I'm going to use my privilege as a presider to ask the first question --


HUANG: -- if I may.

Let's rewind the travails of 2011.

ZEWDIE: (All right ?).

HUANG: In January, AP covered the story that these -- about the (probable ?) corruption and misuse of the fund money for African countries. The Global Fund did investigation and found -- and made actions to recover much of the misappropriated funds. But instead of praising the fund for its initiative and attempts to correct (holes ?) in this process, well, the fund's reputation was tarnished --

ZEWDIE: Right.

HUANG: -- and some of European donors actually suspended their funding.

So this is interesting because it's often presumed that the transparency promotes accountability and international institutions promoting greater transparency will result in higher levels of public and donor support of these institutions. But, in the case of the Global Fund, this seems to be the opposite, right? Greater transparency actually lowers levels of donor confidence and potentially challenges the legitimacy of the organization.

So this incident, you know, in my opinion, might send a signal to many similar organizations/institutions that if they admitted that corruption or fraud has happened somewhere within the vertical donor process, funders will withdraw, right? So organizations are afraid to say that they make mistakes and thus make the same mistakes over and over again. So the end result is that these organizations may become even less accountable.

So I'm curious, what's your comment on this what I would call accountability dilemma?

ZEWDIE: When I thought I had used up 15 minutes, what I left off was something which I will start with.

The donors are coming back. As you know, the European Commission had its own investigation. The Germans were leading in the investigation, and then the board put in place what they called the high-level panel.

The -- without going into what happened at the beginning, what's happening now is when we also showed turning around -- as I told you, we had moved 75 percent of our resources to grant management. And there are a number of steps that we have taken to tighten the systems and, more importantly, to work better with the Office of the Inspector General. We don't have a problem with the principle, the independence, or having an office of an inspector general. It is good for us. It's good for our grants.

But it had to work in a seamless manner, which is what we are doing now, as a result of which Germany was the first country to come back. Japan -- as you well know, they had their own problem with the tsunami, but they came and paid not only for the previous year, but for the current year as well. Last week the general manager addressed the U.K. Parliament, and the United Kingdom has committed its resources and consistently up to the next three years. Spain, that has a challenge, is coming back and paying as well.

So they have come -- they have recognized -- you don't blame someone for misunderstanding or misperceiving something. I think if when you see the evidence you turn it around, that's also a good thing. So it is -- that was one of my concluding remarks, which I wanted to do -- including the U.S., who is the largest donor that we have. Today they have much more confidence in what we are doing and much more support, which is much more (strengthened ?). So that's what the current situation is. And this is what I meant when, at the beginning, I said the Global Fund is not in crisis.

What are the lessons what from happened in January? The lessons are the following: One, I think the world is looking very carefully how development resources are being used, and that's what happened with the Global Fund. Probably we are the first ones to be subjected to this. Well, if you are inside, if you are a staff member like I was, it's a traumatizing experience, especially because we were not hiding anything. All those information was on our website. But from where I sit today, it provided a fantastic opportunity for us to change the Global Fund around. I don't know any other transformation that has happened in 60 days where we moved the staff from doing something else to focusing on grants.

The litmus test is going to be in couple of months, and at a minimum a year, countries saying the Global Fund is simple, they listen to us, we can work with them, it makes a difference. If all this has helped us to move in that direction, I think it's not bad. But when it hits you, it is -- it's not a good experience to go through.

HUANG: So I might be a little bit too pessimistic -- (chuckles) -- on this.

So we're going to open up the floor for questions and discussions. The -- please -- well, I saw that -- (chuckles) -- Sherry (sp) already have the -- flipped her (tin card ?). So please flip your (tin card ?) to indicate that you have a question. And we also allow the one-finger rule, if you have any quick follow-up remarks. So Sherry (sp).

QUESTIONER: OK. Thanks. Leave it to the reporter to be the first to raise their hand. (Chuckles.) Thank you for coming and giving us this update. I was just curious if you could talk a bit about the impact of the cancellation of the round on the ground. And for example, at the most extreme, are people going without their medicines?

ZEWDIE: OK. No, they're not.

This is -- the way the Global Fund works is countries come in with at least a five-year proposal. So in December when we consult round 11, most of the countries were in their second or third year of program. But they were thinking ahead, and they were requesting money for the subsequent years.

Even before we consult round 11, there is a modality within the World Bank structure that we don't cut funding from countries. There is what we call a continuity of service, which gives the countries enough time, especially to make sure that antiretroviral treatment for people does not get -- (inaudible).

Did -- what happened to programs because of round 11? To my knowledge, there is none of the countries had run short of money and were just left to -- high and dry. That was exactly why we came up with a very short way of -- the Transitional Funding Mechanism was put in place exactly to protect those kinds of countries. It's a two-year window, so all of them have come -- mainly, these proposals are either for antiretroviral treatment or for PMTCT or for the replenishment of bed nets for malaria.

So this funding will take these countries to 2014, when we would start with what we call now the two-step iterative process. The -- part of the significant change in the new strategy is currently, countries spend a lot of money in producing a proposal, and the chance of success is 40 percent, 50 percent, and especially for HIV/AIDS, much less. The two-step process will help countries before investing a whole lot of resources to see if the proposal is viable or not. That's only -- only after knowing that will they come into the second process. So we expect almost a 99 percent approval process for these countries.

So we have made sure that the countries had money, came in with the Transitional Funding Mechanism, which will take them to the two-step iterative process. So none of the programs, to my knowledge, whether it's malaria, HIV/AIDS or TB or health systems, have suffered because we cancelled round 11.

HUANG: But what about those countries that made ineligible for the funding, countries -- I know Chinese government announced that that would continue fund-supported programs, but what about those countries like Mexico and Indonesia? Are they going to -- the government going to foot their bills?

ZEWDIE: So one of the things which everybody realized is remember at the beginning of the fund, proposals come in. If they are viable, they are funded. And then when we looked into our data, we found out that resources were going not necessarily only to the poorest countries. So that is when this dilemma of what do we do with countries who have the capacity and the resources to take care of the problem. And it's not a complete cut-out. It is a phased process where the country will promise to come and pick up the programs and go.

So we have a wonderful relationship with China. Yes, it could have been handled better in December. But we have rebound where they will be carrying out the programs. It's the same thing with -- for Mexico and Indonesia.

HUANG: Good to hear that.

OK, I think Victoria.

QUESTIONER: Victoria Fan from the Center for Global Development. Debrework, it's such a pleasure to hear this, and very encouraging overall. I'm very -- particularly interested in the Strategic Investment and Impact Evaluation group or division, whatever it's called now. This is -- there's many uses of impact evaluation. One might be for learning lessons in general for specific disease interventions. But another might be potentially to link it to performance-based financing. Is that currently what you're -- I mean, I'm curious to learn more about how you might envision impact evaluation being incorporated.

ZEWDIE: The unit is new, the Strategic Investment and Impact Evaluation unit. That doesn't mean the work has not been done earlier on. We tried, but we tried in a -- in a more or less ad hoc manner. That's what we are trying to correct.

We are also using partners and expertise appropriately. For example, we have what we call the TERG, the Technical Evaluation and -- Reference Group. These are eminent people from different parts of the world. We haven't used them effectively. So instead of them coming and advising us on what to do, we are allowing them to help us develop how we will be doing impact evaluation in a -- in a meaningful way.

Performance-based funding is something which the -- it's one of the cornerstones of the Global Fund. Absolutely, it will be tied with strategic investment and impact.

We are trying to staff that department. We do not have all the skills, and I look to all of you to help us identify these people very quickly so that we can translate this into action.

HUANG: Thank you, Debrework.


QUESTIONER: Thanks very much, and welcome, Debrework. My name is Lisa Carty. I'm from the UNAIDS office here in Washington. So actually a two-part question: I was wondering if you could elaborate a little more on the country-level impacts of the reform process because as I understand it, that was a very important goal was to make operations at country level smoother and more transparent and address some of the issues involving principal recipients -- (inaudible) -- recipients.

And the second -- I'd just be interested in your opinion and thoughts going forward -- is your having traveled recently in Africa and looked a little bit at some of these questions -- you know, I think the reality is now that 10 years into the Global Fund's life cycle, programs are very deeply integrated in so many countries. You know, and early on in the Global Fund, there were places that were clearly Global Fund-funded entities. And now, you know, almost any site you go to will have U.S. money, Global Fund money, host country money.

So, you know, the reality is that if the Global Fund sneezes, everyone else is going to sort of catch that cold. And you know, I'm wondering, as you're taking this forward, how you're thinking about what the coordination and collaboration mechanisms are going to be, both at country level and globally, because this next year sounds very critical. So what's the vision for try to make sure that everybody moves forward in the same general direction?

ZEWDIE: Thank you. On the first one, one of the departments in the Strategic Investment and Impact division is strategic investment and partnerships. What that means is, for example, the HIV/AIDS person's job, which is to be running around attending meetings and helping, in a piecemeal way, the fund portfolio managers. They have two distinct jobs: one, the technical expertise should come from our partners. That was how the Global Fund was established in the first place. So we are translating that into action. So this person's job is not going and giving advice to the fund portfolio manager, but globally connect with the partner and institutions and make that connection at global level. The fund portfolio managers will be the entry point at country level for partnership.

So we are coming at it from two different directions. And now because of the reorganization, they have time to pay attention to partnerships, to make sure that they don't go to a capital city, talk to the LFN (ph), come back. They have a dialogue; they create a relationship, and at global level, the institutions would monitor it.

Integration -- that's exactly what the Global Fund is supposed to do. And when we do strategic investment in the two-step iterative process, we are going to look at it in a holistic manner: Who is there; what is -- what are they doing; what is the gap? And then we come in and fill the gap and have an integrated way of working together.

So it's not -- fortunately, the Global Fund has never waved its flag. But it became a common thing to do for countries. That's what happened. I remember in the early days, they were not even supposed to put "Global Fund" on the cars. But you see them everywhere now. That is what we are trying to consolidate and give more -- (inaudible) -- we will allow our partners to impregnate us -- so opening the doors, making sure that integration happens and technical assistance happens from the technical units and not internally driven. That's how we could move 75 percent of the staff to move into grant management and not to do -- (inaudible) -- or WHO, which we have done in the last couple of years.

HUANG: OK, we have -- it looks like we have many questions here. Yasmin (sp).

QUESTIONER: Sir, my thanks to the council for hosting this timely discussion. And Debrework, thank you for your comment. My question actually follows nicely from Lisa's, which is about partnership. So you said that the world is watching closely how dollars are being spent in global health. Well, the world is also watching closely how the global health key donors play together. And I'd be really interested from a -- (inaudible) -- country perspective, from a strategic perspective: What is this relationship and standing of the Global Fund in relation to particularly the USG and the giant donors? And how much of the strategic development early in the year -- how much has this impacted on the scrutiny to the Global Fund? And what does this mean for the field of global health in terms of partnerships?

ZEWDIE: OK, the good thing is I have somebody here from the USG who knows it much better than me, John (sp).

The relationship between the Global Fund and the USG has been very strong from the beginning, almost to a point of sacrificing a lot of things from PEPFAR to support the Global Fund. That's the kind of relationship we have. Are we doing that in all 150 countries? No, it depends on individuals; it depends on the relationship, which is what we are trying to correct now. So that's one answer.

The second one -- the USG is also trendsetter. So the resources that we get from the U.S. government is the resource that everybody is looking at. It is also a challenge for the rest of the world. That's why the funding and the support we get from the USG is almost the livelihood of the Global Fund, which encourages the other countries to come in and support us.

We are starting with PEPFAR now in two countries to pilot a better way of working together, and we have chosen Nigeria as one of the examples. So it's not going to be just a good talk that I give or Gabrielle (sp) or Mark (sp) gives. It is something which we are going to start on the ground and see what works, what doesn't work, so that we move further. But John --

HUANG: John, do you have any quick follow-up remarks? (Chuckles.)

QUESTIONER: Well, I'd -- I just -- I guess I'd say a couple things. I'm John Monahan from -- special adviser for global health partnerships at State. And two -- I -- two things I -- I'm sorry; I'll try to be quick -- but the first point is I just have to thank Gabrielle (sp), Debrework and their team. I mean, what -- get what -- as you know, the U.S. government's commitment to the Global Fund has been strong and consistent throughout this period of time of incredible change. We're very excited by the kinds of changes that Debrework outlined, the possibility of the fund executing these transformations and becoming the more strategic investor that she talked about is incredibly powerful.

And so thank you for the report. This is very helpful.

In terms of the partnership, we see it as an -- as an enormous opportunity -- and Lisa's (sp) is exactly right -- in country, you know, the integration on -- in -- on the ground happens everywhere. The interdependence between PEPFAR and the Global Fund we see what I think's an opportunity here is the kinds of reforms Debrework's talking about and the approach that Gabrielle (sp) and the team have taken allows us both to be better partners. It's both -- the Global Fund, I think, is in a very different position in terms of how it's organized, and I also think that it's a challenge to us to -- Ambassador Goosby's been leading this initiative -- to increase our efficiency and the effectiveness of the bilateral programs and the opportunity here to work in a really integrated way, country by country, is enormous here. So thank you for your presentation. But we see this as a -- as a huge opportunity.

HUANG: I was told that the Global Fund was the most efficient organization because with 600 staff, you manage, like, $30 billion of money. Is that still the case?

ZEWDIE: We are actually decreasing the number of staff. So, by making that shift from the control and administrative purposes to grant management, what we have done is to increase the efficiency on the core business of the Global Fund (and ?) shrinking the other nice things you can have if you have a lot of time and money. So the number of the Global Fund staff will decrease. The quality and the type of staff that we are going to put in, for example, for strategic investment, will change. And we have also promised the board that we are going to do the transformation with the budget that we have been given. So that's where we are maximizing both the resources and also the efficiency.

HUANG: Wonderful.

Chris (sp)? OK.

QUESTIONER: Thanks for the presentation, Debrework, and thanks for organizing this. It's always a pleasure.

Actually I want to pick up on Lisa's question a little bit of -- you -- Debrework, you raised a -- that simplification, simplifying things was an important goal, and I was wondering if you can elaborate a bit more. From the country perspective -- the recipient country respective (sic), how exactly is the new Global Fund going to be simpler for them to engage with and to meet the requirements?

ZEWDIE: I'm going to show you something, which is what I'm looking for, to make that point. We have -- can you see this? This is 120-page -- 1,200 pages of documentation for one grant, OK? That's horrendous.

Frankly, countries work with us because they need the money and they have a huge epidemic. It's not because we're simpler. Every decision that has been taken by the board and the secretariat made sense when the decision was made. But, cumulatively, when you look at them, they -- it doesn't serve any purpose, neither for the secretariat nor for the countries.

So what we are trying to do now is to look into the whole life cycle from beginning to end and cut all this unnecessary back and forth. Of course, when we start the two-stage iterative process, this would -- this would shorten by itself. But now the requests that goes back and forth between the countries and ourselves from grant signing to disbursement is horrendous. So that is what we are working on now.

So the first thing was to settle staff. Transforming a 600 -- over a 600-staff organization in 60 days is -- you can imagine how we were working. Now by the end of the month everybody would have settled, all the departments and all the staff. Immediately, we embark on this unclogging the pipe and manufacturing the grant (banking ?) system. That's when we cut all these unnecessary things that have been added. So simplification would be the first thing that we'd -- we would be focusing on.

QUESTIONER: Do you have a timeline where -- you had 60 days to accomplish the first task; have you set a timeline of we have 120 days to accomplish the second (one ?)?

ZEWDIE: Yes, we do, and we also have milestones in between. When we go to the board in May, there are certain things that we have promised the board which we will deliver on. And then by the next board, these processes would have already kicked in. And what we expect from the second board is countries saying yes, it is simple now.

HUANG: Sally.

QUESTIONER: Thanks very much. I'm Sally Cole with PSI. And Debrework, thank you for coming and for your coherent explanation.

The mandate of Gabriel Jaramillo and his team, as I understand, has really been looking intensively at the secretariat and its functions and -- at the country level. What about the board and the IG? I mean, is somebody looking at them as institutions? Are they going to be left where they are? And if so, how will they interact with the reborn secretariat?

ZEWDIE: John, you have to realize Sally is an old friend, but I never, ever told her to ask this question. (Laughter.)

The board -- the board has been transforming itself as the secretariat has been transforming itself. The high-level panel report is something which we all followed to change this fund. As a result already, there is a tremendous change between the Office of the Inspector General and the secretariat.

We have -- we call Monday bureaucracy day. All meetings happen only on Monday in the Global Fund. We start with a management executive committee meeting where the inspector general is invited too. This is when we talk about where is the budget, how do we function, et cetera. Then subsequently, we have another committee which looks into the grant. So every executive committee member would know what's happening in our malaria grant in Ghana, for example, because the country team comes and presents. And the inspector general is also a member of that. The third one is the disease committees, which I mentioned. So that is one way of improving for the Office of the Inspector General. And he comes with his staff to understand what we are doing and also for us to -- for him to tell us how to do this without touching on his independence.

The -- I'm going to let John tell you, because John is a board member, on what the board is doing.

QUESTIONER: I'll -- just briefly, I do -- I have to emphasize how critical the change has been in terms of the relationship between the secretariat and the inspector general from where we sit. The inspector general's function is absolutely critical to the fund and to the transparency and to making sure that we know that resources are going where they're supposed to. But this kind of really effective coordination is fabulous. So it's a very positive step.

In terms of the board -- and the board is on a two-part -- two-stage reform process -- it -- based in part on the recommendation of the high-level panel and in part on work that the board leadership had already undertaken, it restructured what had become a proliferation of multiple working groups and committees to three standing committees: a finance committee, a strategy and investment committee and an audit and ethics committee that, for the first time, will actually include non-board members on the committee -- in fact, a majority of non-board members, including -- chaired by an independent committee member to provide oversight to the inspector general as well as sort of the boarder audit and ethics issues.

The board is also trying to have a mechanism where -- historically, the committees have -- (inaudible) -- independent. They have a coordinating mechanism so that the leadership can -- we can make sure that issues are managed in a more effective and sort of efficient way. I mean, the fund -- among its issues is that governance really had not been managed, I think, systematically, I think would be a fair description.

The critical thing here is to execute, much like what the secretariat's doing now. The board needs to actually make the committees work. The committees have met for the first time within the last two to three months. We are -- and I'm actually quite optimistic that we've moved -- we've streamlined. Now, obviously the next step is there are still major issues remaining in governance. How do we make sure that implementing country voices are as effectively at the table as possible? How do we make sure that the board interacts with the kinds of structural changes that Debrework's described. Both of those are critical. But we're on the right path, in my view, at least.

HUANG: Debrework said Monday is a bureaucratic day. I'm glad that this meeting is scheduled on Wednesday -- (laughter) -- so you have time.

ZEWDIE: Anyway, I'm not allowed to travel -- the executive management team is not allowed to travel on Monday.

HUANG: OK. Next we're going to have three -- actually the next three questions were all from -- they're all from Robert. We have -- actually, we have four Roberts in this room, at least. (Laughter.) First Robert?

QUESTIONER: Is that me?

HUANG: Yeah, that's you. (Laughter.)

QUESTIONER: (Inaudible) -- Robert 1 or Robert 2?

HUANG: We have kind of identity crisis here.

QUESTIONER: Help me out a little bit. I'm Robert --

QUESTIONER: Whatever you say -- (off mic). (Laughter.)

QUESTIONER: I don't know if this is working. I'm Robert Hecht from the Results for Development Institute. Debrework, thank you. The changes you describe are very impressive. They're ambitious, they're exciting, and they sound very positive. So congratulations on that.

We all have seen organizations that went through a difficult period, especially around financial management or lack of top-notch management, I even think at our own shared institution at the World Bank in the past around the trust funds, the donor trust funds, where there was some question about proper use of funds.

Often the reaction is to come down very hard with lots of financial controls, and those are understandable, but they can also have negative -- unintended negative effects, especially for the staff. You talked about changing the staff and improving the staff, but being able to work in an organization where you're allowed to be creative, where you can be entrepreneurial, where it's fun to go to work, where people are not looking over your shoulder all the time is also important. And you also talk about making sure that the staff can focus on impact, value for money, getting them most public health benefit and development benefit.

How are you and Gabriel thinking about a possible trade-off there, or how you avoid the trade-off so that you correct the financial issues, which have come out very prominently and obviously need to be high on the agenda, and at the same time create an organization that is fun, creative, entrepreneurial and focusing on development impact and health impact and not only on making sure that every euro and dollar is accounted for?

ZEWDIE: Thank you, Robert. The last point, in the morale of the staff at the Global Fund, was during that time when the AP story broke, because fund portfolio managers had to think twice before they signed on a disbursement. They were terrified. So that actually crippled us more than anything else, which was internally known to us.

So the change now is that -- essentially the empowerment of staff so that they could take action, because we have put -- so if you take six months ago, fund portfolio manager, who is responsible for about four, five countries and there is somebody above him or her, there was a chain that they had to go through because everybody was afraid to commit. What we are doing, especially in the 21 high-impact countries, is there's no chain. There is the fund portfolio manager and there is the regional director directly reporting to the division head, because we want them to pay close attention to this. That's number one.

Number two, we have strengthened what we call a country team. So it's not a fund portfolio manager who is going to take a decision, it is the finance person, the fund portfolio manager, the monitoring and evaluation person, (legal ?), who sit together and who decide on something. So we have taken away the fear factor.

There is also a change from the side of the inspector general. There is more interaction, there is more discussion about them playing the role of almost quality control, which was not -- it was not supposed to be a punishing instrument. So that's one of it.

The other big one is we need to -- Gabriel calls it the soft skills. It is attracting the best staff, mentoring them and also incentivizing performance.

So there are all these milestones that these people have to fulfill. And what management is doing is to arm them with all the instruments that they need so that they could indeed perform. So we had -- this is that -- the biggest task. Once we have settled them, we are going to have coaching -- a very simple but rigorous way of performance evaluation, which is more like the private sector and not like the U.N. system. So we are putting all these things in place, but the problem is we are moving in a very fast speed because we don't have time to put these things in place. So that is already changing. You see a lot of change and a lot of hope in the staff as we move forward in this.

HUANG: OK, we still have lots of questions. So I'm going to collect those questions, actually, in two, maybe -- hopefully three rounds. In the first round, we collected two -- three questions from Robert (sp), Robert and Jen.

QUESTIONER: This Robert (sp). Thank you. We are sort of here to -- reflecting on the success of the -- of the fund after 10 years. And I think there's been unquestioned success of the fund and PEPFAR and the Gates Foundation and other funders as well as other bilateral funding for drugs.

I was recently in Uganda and Malawi and even in the rural areas of those countries and visiting a number of health centers and hospitals. And I was always struck, because I always asked the question, about the availability of drugs. And everyone said, you know, oh, no, we don't have any problems with drugs, which was, to me, a spectacular result -- (inaudible) -- based on just a few years ago, when that would not have been true. We have all benefited, then, from these very coordinated efforts -- and even if they were not coordinated, they were certainly cooperative -- to have this kind of result in many countries that for many years had drug shortages.

However, what I did observe and continue to read about -- and when I do travel in these countries, there are two headwinds that we're yet to tamp down. And I was wondering what lessons you discern from your experience at the World Bank and now at the Global Fund in what we do about the clear, continuous crisis in health worker shortages and the breakdown in technical training for health workers that we do have. And even when our intentions are pretty positive, where we supply equipment, and then when the equipment breaks, we have no funding to fix it, no one trained to fix it. I saw a number of broken-down cars, trucks, ambulances. That's one headwind.

The second headwind is the paradox of success, of having drugs available. What we have seen in some countries -- I got the country report in Uganda, where we are seeing a tick-up of infection in populations where we didn't expect it. And that was marriage-age people, people in their 40s, where we didn't see it before. And someone described that as the paradox of success: People now know that there are drugs available, so the prevention side has suffered a lot. So maybe from your experiences in these two wonderful institutions, you can sort of give us some hope about what we do about these two headwinds.

HUANG: Robert.

QUESTIONER: Hey, I'm Robert Marten with the Rockefeller Foundation. Thank you again for the talk. My question builds on some of the other points that were raised. And it's -- you know, when you look back at the last 10 years, I think again, the Global Fund has been tremendously successful. But you've also seen over these -- the past 10 years a bit of a shift from the more vertical approach to the horizontal. And so I know this question has surfaced many times before, but I just would love to hear your thoughts and where the internal discussion is on this, particularly in this moment of opportunity that you have in terms of broadening the fund's remit beyond HIV, TB and malaria and how those discussions are faring, and then also in terms of the implications for global governance of or for health, however you want to put it. That's a -- maybe a broader second question, but the first question would be particularly important.


QUESTIONER: Jen Kates from the Kaiser Family Foundation. Hello. Good to see you. Two quick things that build on some of what we heard. One is on prevention, and that relates to the UNAIDS new investment framework and just thinking about where prevention is going and how an institution like the Global Fund can -- which is responding to country-driven proposals, but how you're looking at that and figuring out how to be proactive and not just reactive and be on the cutting edge of these changes.

But then another question is around the public messaging around the fund, because having you here is great, and I think a lot of the things you shared we've only heard about, you know, on a listserv or some information, and changing the public discourse and dialogues in Washington and probably other capitals is needed.

And I heard something that you said today, and I heard it the other day too, which seems to me big news, which is that the transitional funding mechanism can meet the demand. And that was something that wasn't clear recently, and it seems like big news, and I wonder if you have any plans to get that out there in some fashion.

ZEWDIE: OK. Robert, thank you. The Global Fund -- and I would tie it with the vertical versus horizontal question as well -- is in a very awkward position where its board, rightly, makes sure that we stick to our mandate, whatever that means. So that is where, for example, health worker -- health workforce crisis is a crisis which affects our programs.

I'll give you a very simple example, and this is how development irritates some of us. This was a Phase 2 panel there, from Chad, and the group, the country team, has come in and was presenting to the Phase 2 panel, and they said this cannot be an A grant, it is a B grant, because Chad does not have a good data collection system. And we had it as a conditions precedent for the last two years.

So what do you do? You cut the funding on something which should have been there a long time ago. Everybody was supposed to build the data system of Chad, even before the Global Fund was born.

So we keep every year saying, this doesn't work, that doesn't work. We don't do anything collectively to help these countries to come out of this. So the work -- the health workforce crisis is exactly the same thing. We all talk about it. I don't think there is a concerted effort to bring this thing out, so that all our programs will work well.

I will be lying to you if I say the Global Fund has a special program to do this. We don't. But it affects our programs; you are right.

The second one, the success of treatment versus prevention, I want to tie the prevention questions together. I think about a year, a year and a half ago, there was talk about the Global Fund is only focusing on treatment. That's not true. The funding which goes to prevention and treatment us almost equal.

Now the question comes into the strategic funding of prevention., What is it in prevention that we're funding? Yes, there will be resurgence as people become more and more comfortable with treatment. Then you can't even detect the virus in their blood.

The hope I see is, as you said, the new investment framework, which we are going to follow.

Take circumcision, for example. We knew circumcision works or worked six, seven years ago. But the only time it has taken effect is when PEPFAR and UNAIDS said, we are going to put X amount of money to do it.

So we need those kinds of champions. I was in Sydney talking on the microbicide conference. It's exactly the same things. It takes an -- institutions and people to champion and push this thing forward, unfortunately, because evidence alone is not going to do it.

We are all worried about these countries, like Uganda, who are successful but we need -- because it is going to cost us even more -- to have a concerted effort to making sure that treatment is indeed used as prevention and not a cause to feeding the pipeline with new infections.

The -- again, the board, unless they change their mind, as we look into the future, when our 2011-2016 strategy was being developed, there was huge debate in allowing the fund -- whether to stay within its mandate now or to even go a little bit into reproductive health. The final conclusion was, you stay within your mandate. But you know already -- for example, 40 percent of our funding is going to saving lives of mothers and children. So that is what the thinking is at the board level.

I don't see it moving in any other way now. However, there is a global discussion now as to what is going to happen to it. Do we still go this way? So that may change the Global Fund as well. I have -- I have answered the first part of your question, I hope, Jen.

We don't do a good job when communicating. We have now recruited -- if I was Gabriel, I would say a fantastic person -- (laughter) -- called Seth Fasan (ph). He is very well-known. He has been in crisis communications management. One of the first things he's going to do is to initiate a newspaper. So every week we will send out news to -- if you compare this community with the implementing countries, we are even worse. They have no clue what we are doing because we don't communicate with them.

And that's when we knew we lost the war when the AP story hit us. If a few ministers of health from implementing countries stood up and said, the Global Fund is saving lives in my country, that would have changed the trajectory. We haven't cultivated them. So that's the focus now, to cultivate implementing countries, but more importantly, to share our news as quickly as possible, without having any excuse. The reason why the full funding of the Transitional Funding Mechanism was not disclosed was because of the way we work. We had to disclose to our board yesterday -- I think you got the email yesterday. But you are right. We are not doing a good job. We have to -- we know we have not done a good job, so we will improve.

HUANG: OK. So -- I'm sorry, actually, we are running out of time, even though -- (chuckles) -- we haven't run out of the questions. It is the council's rule that we start in time and end in time. (Laughter.) For those who are unable to have found the time to ask questions, I apologize. Maybe you could ask Debrework after the meeting.

But I'd like to thank Debrework for this very informative and encouraging update. (Applause.) And my best wishes to the reorganization and transformation efforts of the fund.

I'd like to take this opportunity to thank our -- (inaudible) -- the -- Jerouz (ph) and in particular Zoe (sp) for their support -- assistance in making this round-table series possible. And also I would like thank the -- Stuart Patrick (ph), Faroh (ph) -- is Faroh (ph) here? Just -- and the IIGG program and the Robina Foundation for their generous support of this round-table series, and last but not least, you the participants of this meeting, for your -- the questions and insights, for making this such a lively discussion. I appreciate it. Thank you.








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