Public Health The Global Fund to Fight AIDS, Tuberculosis, and Malaria was established in January, 2002, to attract, manage, and disburse additional resources worldwide to control these three diseases, which are having a devastating effect in poor countries, especially in sub- Saharan Africa. The Global Fund is an independent organisation, governed by a board of 18 voting and five non-voting members and supported by a secretariat of about 70 staff in Geneva. Countries apply for fund support by submitting proposals, which are reviewed by a technical review panel of independent experts and considered for approval by the board. By March, 2004, pledged donations were far short of the additional annual US$22 billion in donor aid, of which US$8 billion should go through the Global Fund, recommended by the WHO Commission on Macroeconomics and Health. 1 Countries applied for Global Fund support in March, 2002, September, 2002, May, 2003, and April, 2004. 121 received approval for about US$2 billion over 2 years, for rounds one to three. 2 By March, 2004, two-thirds of approved countries had signed grant agreements, and around US$260 million had been disbursed. 3 So far, sub-Saharan Africa has been approved for over half the committed funds, with about 60% earmarked for HIV/AIDS activities. If donations to the Global Fund are sufficient, the achievement of its goal will be dependent on the effectiveness of individual country systems and the new structures that recipient countries are required to have in place to manage funded activities; these include a country coordinating mechanism (CCM), principal recipients, and a local fund agent. 3 The CCM is a country-level partnership that prepares proposals for Global Fund support and oversees implementation of successful applications. The Fund requires CCMs to include a broad representation from governments, non- government organisations, civil society, multilateral and bilateral agencies, and the private sector. 4 A principal recipient is a country organisation that receives funds, implements and monitors programmes, and is accountable for how funds are used. The local fund agent is an independent professional organisation, contracted by the Global Fund to provide oversight and verification of progress and financial accountability within the countries receiving funding. Approach We are tracking early implementation of the Global Fund in four sub-Saharan African countries: Mozambique, Tanzania, Uganda, and Zambia. Table 1 summarises the burden of disease due to HIV/AIDS, tuberculosis, and malaria in these countries and the outcome of country applications for Global Fund support. We selected these countries on the basis of high burden of disease and poverty, submission of proposals to the Global Fund in round one, support The Global Fund: managing great expectations Ruairí Brugha, Martine Donoghue, Mary Starling, Phillimon Ndubani, Freddie Ssengooba, Benedita Fernandes, Gill Walt The Global Fund to fight AIDS, Tuberculosis, and Malaria was created to increase funds to combat these three devastating diseases. We report interim findings, based on interviews with 137 national-level respondents that track early implementation processes in four African countries. Country coordinating mechanisms (CCMs) are country- level partnerships, which were formed quickly to develop and submit grant proposals to the Global Fund. CCM members were often ineffective at representing their constituencies and encountered obstacles in participating in CCM processes. Delay in dissemination of guidelines from the Global Fund led to uncertainty among members about the function of these new partnerships. Respondents expressed most concern about the limited capacity of fund recipients—government and non-government—to meet Global Fund conditions for performance-based disbursement. Delays in payment of funds to implementing agencies have frustrated rapid financing of disease control interventions. The Global Fund is one of several new global initiatives superimposed on existing country systems to finance the control of HIV/AIDS. New and existing donors need to coordinate assistance to developing countries by bringing together funding, planning, management, and reporting systems if global goals for disease control are to be achieved. Lancet 2004; 364: 95–100 Department of Public Health Policy, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK (R Brugha MD, M Donoghue PhD, M Starling MSc, Prof G Walt PhD); Institute of Economic and Social Research, University of Zambia, Zambia (P Ndubani PhD); Institute of Public Health, Makerere University, Uganda (F Ssengooba MPH); and National Institute of Health, Mozambique (B Fernandes MM) Correspondence to: Ruairí Brugha Ruairi.brugha@lshtm.ac.uk www.thelancet.com Vol 364 July 3, 2004 95 Summary of study approach ● Semi-structured interviews done over 5 weeks in every country, from April 1 to July 31, 2003, with a common interview guide based on a review of Global Fund and other published and unpublished documents. ● CCM members named in round 1 proposals formed initial country sampling frames; CCM respondents were asked to name other government and non-government individuals with a major involvement in early national Global Fund processes or responsibility for implementing funded proposals. ● 137 national-level respondents across the four countries, covering an average of 65% of CCM members and including senior technical staff responsible for HIV/AIDS, tuberculosis, and malaria control (see table 2); only one refusal. ● Data were recorded mainly by note taking with some interviews tape recorded; researchers attended CCM and other national-level meetings as non-participant observers (table 2); a coding framework was devised based on a content analysis of interview transcripts.