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The Global Fund fell short of the US$18 billion target it hoped to receive from donors. The Lancet's North American Executive Editor, Miriam Lewis Sabin, reports from New York. Hosted by US President Joe Biden in New York, NY, USA, on Sept 21, 2021, The Global Fund to Fight AIDS, Tuberculosis and Malaria's 7th replenishment conference raised US$14·3 billion, but the UK and Italy both deferred their pledges, saying theirs would be announced in the coming weeks. The amount raised is just $250·0 million more than what was donated at the 6th replenishment in Lyon, France, in 2019, and fell short of the $18·0 billion that The Global Fund has asked from its donors. Peter Sands, Executive Director of The Global Fund, said in a speech that the increased ask was essential, especially given the service disruptions caused by COVID-19. “We either step up funding and intensify our efforts or give up on the SDG 3 target of finally defeating these pandemics by 2030.” Also problematic for both The Global Fund and donors are soaring costs due to economic inflation and fluctuating currencies in the global markets. WHO Director-General, Tedros Adhanom Ghebreyesus tweeted during the pledging ceremony that, “Despite being focused on the #COVID-19 pandemic, we must ensure that global supplies of tests and treatments for HIV, malaria, and tuberculosis reach the countries and communities that need them the most. We can only meet these challenges together.”

Tedros Adhanom Ghebreyesus tweeted during the pledging ceremony that, “Despite being focused on the #COVID-19 pandemic, we must ensure that global supplies of tests and treatments for HIV, malaria, and tuberculosis reach the countries and communities that need them the most. We can only meet these challenges together.” The Global Fund has saved an estimated 50 million lives since it was founded in 2002, through massive investments in better diagnostics, prevention, and treatment that are stopping people from being infected and dying from HIV, tuberculosis, and malaria. As of June, 2022, The Global Fund has disbursed $55·4 billion to more than 100 countries. The Global Fund's latest investment case estimates that the $18 billion is needed to save another 20 million lives in the next 3 years. The USA, the largest donor in global health, pledged $6 billion for the 2022–24 funding cycle, but the pledge is contingent upon the US matching $1 for every $2 contributed by other donors. US funding is also subject to Congressional approval every fiscal year. President Biden gave an impassioned speech to donors, saying, “This is all about saving lives! It is very hard to maintain your dignity when your child is sick and you can’t control it”, something President Biden has personal experience with following the death of his son Beau Biden due to a brain tumour in 2015 at the age of 46.

iden gave an impassioned speech to donors, saying, “This is all about saving lives! It is very hard to maintain your dignity when your child is sick and you can’t control it”, something President Biden has personal experience with following the death of his son Beau Biden due to a brain tumour in 2015 at the age of 46. The pivotal moment came when the UK deferred its pledge, following the recent appointment of the Conservative Prime Minister Liz Truss. The UK did not give a reason, but said it would “continue to be a strong supporter and contributor to The Global Fund”. It promised to announce its pledge in the coming weeks. Civil society organisations in the UK expressed disappointment at the decision. Martin Edlund, CEO of Malaria No More said in a statement, “Failure to reach the full $18 billion target will ‘leave money on the table’ from the US intended pledge of $6 billion, and it will put The Global Fund's goal of saving an additional 20 million lives at risk.” Aaron Oxley, Executive Director of RESULTS UK, a charity that advocates for global health financing, said that “as a major contributor in the past, the UK must quickly pledge a sum commensurate with its role as a wealthy G7 country—certainly by the end of October [2022]. Failing to do so will not only result in a reduction in international funding overall but will also signal to the rest of the world a significant retreat from the UK's commitments to tackling disease and poverty.”

ly pledge a sum commensurate with its role as a wealthy G7 country—certainly by the end of October [2022]. Failing to do so will not only result in a reduction in international funding overall but will also signal to the rest of the world a significant retreat from the UK's commitments to tackling disease and poverty.” Sophie Harman, Queen Mary University of London, London, UK, told The Lancet that, as one of the biggest donors to global health financing, the UK's lack of commitment to The Global Fund could be a harbinger of leaner times to come. “It could be the UK wants to fund health in a different way (to other institutions, bilaterally etc). But more likely this is part of the wider problems with the UK's economy and could be an indicator that foreign aid cuts will be high on the agenda of the new government.” Italy's deferred pledge seemed to take many more by surprise at the conference, but not those who had been following the election on Sept 25, 2022, which Giorgia Meloni's far-right Brothers of Italy party is expected to win. Harman agrees. “The scary combination of states paying the economic price for their COVID-19 nightmares and soaring energy prices, with more national-facing governments mean further cuts to traditional health assistance are coming.” The fact that government coffers are stretched, including because of COVID-19, was made clear in many governments’ speeches, as was the war against Ukraine and the enormous sums going already from countries to support the Ukrainian war effort.

Italy's deferred pledge seemed to take many more by surprise at the conference, but not those who had been following the election on Sept 25, 2022, which Giorgia Meloni's far-right Brothers of Italy party is expected to win. Harman agrees. “The scary combination of states paying the economic price for their COVID-19 nightmares and soaring energy prices, with more national-facing governments mean further cuts to traditional health assistance are coming.” The fact that government coffers are stretched, including because of COVID-19, was made clear in many governments’ speeches, as was the war against Ukraine and the enormous sums going already from countries to support the Ukrainian war effort. Andriy Klepikov, Executive Director of the Alliance for Public Health, a non-governmental organisation that works with The Global Fund in Ukraine and eastern Europe on harm reduction services and treatment for infectious diseases, told The Lancet that it is crucial that The Global Fund is fully funded. “When the Russian war against Ukraine started on Feb 24, 2022, The Global Fund was the first donor to react quickly and effectively [and] provided additional emergency funding to support ongoing programmes.”

and treatment for infectious diseases, told The Lancet that it is crucial that The Global Fund is fully funded. “When the Russian war against Ukraine started on Feb 24, 2022, The Global Fund was the first donor to react quickly and effectively [and] provided additional emergency funding to support ongoing programmes.” In this replenishment, donors were asked to increase their previous commitments by 30%. Japan did so with a pledge of $1·1 billion in advance of the conference. Germany, Canada, and France also fulfilled the request (table ). Ireland, which is not one of the top 10 donors, received cheers and applauds following the UK's deferral, for their 30% increase to €65·0 million from €50·0 million in 2019.TableTop ten donors at the sixth and seventh replenishments of the Global FundPledge for 2020-22Pledge for 2022–24USA$4·7 billion$6·0 billionUK£1·4 billionPledge deferredFrance€1·3 billion€1·6 billionGermany€1·0 billion€1·3 billionJapan$840·0 million$1·1 billionBill & Melinda Gates Foundation$760·0 million$912·0 millionCanadaCAN$930·0 millionCAN$1·2 billionEuropean Commission€550·0 million€715·0 millionSweden2·9 billion kr3·0 billion krNorway2·0 billion kr2·0 billion krDenmark350·0 million kr375·0 million krData sourced from The Global Fund. Top ten donors at the sixth and seventh replenishments of the Global Fund Data sourced from The Global Fund.

In this replenishment, donors were asked to increase their previous commitments by 30%. Japan did so with a pledge of $1·1 billion in advance of the conference. Germany, Canada, and France also fulfilled the request (table ). Ireland, which is not one of the top 10 donors, received cheers and applauds following the UK's deferral, for their 30% increase to €65·0 million from €50·0 million in 2019.TableTop ten donors at the sixth and seventh replenishments of the Global FundPledge for 2020-22Pledge for 2022–24USA$4·7 billion$6·0 billionUK£1·4 billionPledge deferredFrance€1·3 billion€1·6 billionGermany€1·0 billion€1·3 billionJapan$840·0 million$1·1 billionBill & Melinda Gates Foundation$760·0 million$912·0 millionCanadaCAN$930·0 millionCAN$1·2 billionEuropean Commission€550·0 million€715·0 millionSweden2·9 billion kr3·0 billion krNorway2·0 billion kr2·0 billion krDenmark350·0 million kr375·0 million krData sourced from The Global Fund. Top ten donors at the sixth and seventh replenishments of the Global Fund Data sourced from The Global Fund. Overall, more than $72 million was pledged by countries, mainly in Africa, that are also recipients of Global Fund grants. Mark Edington, Head of Grant Management at The Global Fund, clarified that “It's not a requirement, it's their choice. It's worth noting that it is often done by the Head of State as a powerful demonstration of how much they value The Global Fund and a reflection of their political will for ending these diseases in their country.”

n, Head of Grant Management at The Global Fund, clarified that “It's not a requirement, it's their choice. It's worth noting that it is often done by the Head of State as a powerful demonstration of how much they value The Global Fund and a reflection of their political will for ending these diseases in their country.” South Africa's commitment to a 30% increase—from $10·0 million to $13·7 million—also elicited cheers of approval, as did Kenya's pledge, which increased from $6·0 million to $10·0 million. Several countries in west and central Africa, including Burkina Faso, Central African Republic, Cote d’Ivoire, Democratic Republic of the Congo, Guinea, Niger, and Togo pledged a total of $11·7 million. Chikwe Ihekweazu, Assistant Director-General at WHO, who leads the WHO Hub for Pandemic and Epidemic Intelligence, and is a former Director General of the Nigeria Centre for Disease Control, welcomed the contributions. “[It is] great to see many African countries contribute substantially to The Global Fund. This indicates a greater stake by countries around the world in the activities of the Fund, reducing the unhealthy perception of ‘donor’ versus ‘recipient’ countries and defining a narrative of global solidarity to address some of the biggest public health challenges of our time”. He would like to see more African countries contribute to The Global Fund, “both financially and intellectually in shaping its work”.

ucing the unhealthy perception of ‘donor’ versus ‘recipient’ countries and defining a narrative of global solidarity to address some of the biggest public health challenges of our time”. He would like to see more African countries contribute to The Global Fund, “both financially and intellectually in shaping its work”. Major private sector pledges came from the Bill & Melinda Gates Foundation ($912·0 million), followed by $150·0 million from Product (Red), and $33·0 million from the Children's Investment Fund Foundation. Yet, even as it became evident that the $18·0 billion target would not be met, a sense of optimism remained about the amount of money that had been raised. John Nkengasong, PEPFAR Ambassador and former Director of Africa Centres for Disease Control and Prevention, was feeling “very optimistic” and said that what is really important for donors to realise is that “The Global Fund and PEPFAR are the great equalisers”, which “lift the most vulnerable out of poverty, helping to ensure they have a future that is healthy and productive”. The Global Fund's strategy for 2023–28 emphasises pandemic and epidemic preparedness. The Fund aims to make services for people with HIV, tuberculosis, and malaria much more resilient, following the severe disruption during the COVID-19 pandemic, and hopes to leverage its work on these three diseases to make more sustainable health systems for any pandemic. But there are concerns about the increasing fragmentation of global health funding, particularly for pandemic preparedness and response.

silient, following the severe disruption during the COVID-19 pandemic, and hopes to leverage its work on these three diseases to make more sustainable health systems for any pandemic. But there are concerns about the increasing fragmentation of global health funding, particularly for pandemic preparedness and response. Ihekweazu told The Lancet that The Global Fund should have “a renewed focus on building and enabling the capacity of local institutions to deliver on the complex functions needed for pandemic and epidemic preparedness”. He said it would not be helpful if parallel systems, still an artifact of individual donor driven projects, continue. “Developing and sustaining a global health security architecture enshrined in the principles of global collaboration while recognising national ownership and leadership is essential to build trust. Now is the time to focus collectively on building and strengthening these science-led national organisations to partner and deliver on the objectives of the Fund.” He said that WHO is ready to work with The Global Fund to achieve these goals.

le recognising national ownership and leadership is essential to build trust. Now is the time to focus collectively on building and strengthening these science-led national organisations to partner and deliver on the objectives of the Fund.” He said that WHO is ready to work with The Global Fund to achieve these goals. Aligning global health funding, said President Emmanuel Macron of France at the conference should also include “primary health systems [which] must be strengthened as they are the most vulnerable” to economic shocks and future pandemics. The Global Fund has argued that they are well positioned to further strengthen health systems and help to integrate previously standalone pandemic preparedness programmes into The Global Fund's new strategy. It hopes The World Bank will agree when, later this year, The World Bank will allocate funds to strengthen pandemic preparedness through a new Financial Intermediary Fund. It is currently unclear whether The Global Fund will receive money from the scheme. For The Global Fund's investment case see https://www.theglobalfund.org/en/fight-for-what-counts/ For more on the Financial Intermediary Fund see https://www.worldbank.org/en/news/press-release/2022/09/09/new-fund-for-pandemic-prevention-preparedness-and-response-formally-established For The Global Fund's investment case see https://www.theglobalfund.org/en/fight-for-what-counts/ For more on the Financial Intermediary Fund see https://www.worldbank.org/en/news/press-release/2022/09/09/new-fund-for-pandemic-prevention-preparedness-and-response-formally-established