Detailed Information on the
President's Emergency Plan For AIDS Relief: Global Fund Assessment

Improving the Global Fund's policies governing Local Fund Agent responsibilities and performance.

Working with the Global Fund Secretariat to improve its performance-based systems to include reporting on program activity by budget amount and reporting on sub-recipient activity.

Working with the Global Fund Secretariat and other donor countries to develop annual performance measures that demonstrate the Fund's impact and capture data reportedly collected by each grantee.

Improving the Global Fund's financial management practices of recipients.

Conducting an evaluation of Technical Assistance provided directly by the U.S. (OGAC) for Global Fund grants.

Measure: Number of insecticide-treated bednets (ITNs) distributed to prevent malarial infections worldwide through Global Fund grants.

Explanation: Each annual target represents a cumulative number of units.

Measure: Percent of targets reached by all grantees in Phase One (first 18 months).

Explanation:Each grantee sets an individual target to reach with their grant.

Measure: Global Fund operating expenses as a percentage of total expenditures

Explanation:

Measure: Number of people receiving ARV treatment worldwide through Global Fund grants, represents the aggregate of individual grant results

Explanation:Baselines represent global numbers receiving ARV through Global Fund grants. Together, PEPFAR and the Global Fund to Fight AIDS, Tuberculosis and Malaria support antiretroviral treatment in low- and middle-income countries. As a result, some of the treatment numbers overlap due to the strong country-level partnership between PEPFAR and the Global Fund in support of host nations. Each annual target represents the number of people currently on ARV treatment.

Measure: Number of TB cases successfully treated with Directly Observed Therapy (DOTS) through Global Fund grants worldwide

Explanation:Each annual target represents the cumulative number of people on DOTS. The DOTS strategy consists of five components for TB care: political commitment, quality-assured bacteriology, standardized treatment, effective drug supply and management system, and monitor and evaluation system and impact measurement.

Is the program purpose clear?

Explanation: The purpose of the Global Fund to Fight AIDS, Tuberculosis and Malaria is to attract, manage and disburse resources to reduce infections, illness and death from AIDS, tuberculosis (TB) and malaria. The purpose of the United States' involvement in the Global Fund is to contribute to a multilateral effort to address these diseases and to encourage other countries to increase their contributions. The President's principles for the organization when announced in 2001 were that the Global Fund be based on partnerships among many stakeholders and donors, adopt an integrated approach toward prevention, care and treatment, be performance-based, adhere to best practices and be lean and efficient outside the United Nations (UN) system, subject its proposals to independent, scientific review, and respect intellectual property rights.

Evidence: Evidence includes the framework document of the Global Fund, the G8 Communique, UN statements and declarations, and current Global Fund mission documents.

Does the program address a specific and existing problem, interest, or need?

Explanation: The program addresses the specific and existing problems of illness and death from HIV/AIDS, TB and malaria. HIV/AIDS, TB and malaria are responsible for six million deaths each year. These diseases cause economic and familial disruption and increased mortality at all stages of life and have resulted in slowed economic development and increased poverty. The Global Fund also addresses the problem of insufficient resources in developing countries to adequately address these diseases and their causes and sequelae and the subsequent need for a well-coordinated international response and for additional financial contributions from developed countries.

Evidence: Tuberculosis causes an estimated two million deaths per year (June 8 edition of the Journal of the American Medical Association (JAMA)). Malaria kills over one million people each year, primarily children (World Health Organization (WHO)). An estimated 2.9 million people die of AIDS related conditions globally every year and only 400,000 of the five to six million people in the advanced stages of AIDS had access to antiretroviral therapy in developing countries at the end of 2003 (WHO).

Is the program designed so that it is not redundant or duplicative of any other Federal, state, local or private effort?

Explanation: The program is designed so that it is not duplicative of any other international, Federal, state, local or private enterprise to address HIV/AIDS, TB and/or malaria. There are multiple international, bilateral and private efforts contributing to the reduction of these diseases, including UNAIDS, bilateral efforts, the Gates Foundation, WHO, and others. The Global Fund is the only multilateral fund designed to increase, manage and disburse contributions from across the developed world and is the only demand driven, international effort for these three diseases. The system of pooling funds serves as an attractive means for countries with smaller amounts of resources to contribute in a coordinated way.

Evidence: The Global Fund works with other multilateral and bilateral organizations involved in addressing these diseases and is designed to not replace or reduce other sources of funding. U.S. Government (USG) personnel are often members of the country coordinating mechanisms in countries in which the Global Fund operates. The Global Fund also extends the reach of the USG, especially for global efforts to combat TB and malaria. The Fund has had less success involving the private sector.

Is the program design free of major flaws that would limit the program's effectiveness or efficiency?

Explanation: There are multiple strengths in the design of the Global Fund and there is no evidence that an alternative program design would be more effective in achieving the Fund's objectives. The authorizing legislation for the US contribution to the Global Fund stipulates that the US cannot contribute more than 33% of the total cumulative contributions to the Global Fund from FY 2004 through FY 2008. This provision serves as an incentive for the Global Fund and for other countries to increase investments from other partners. Other provisions in the authorizing legislation include limitations on administrative expenses. The Fund has established multiple levels of review for grant approvals. The Fund has established a system to collect performance information from grantees and tracks progress for quarterly reporting. The design also ensures transparency, including publicly available performance information by grantee, a locally controlled approach and allowance for continued improvement.

Evidence: Evidence includes GAO 03-601, the framework document of the Global Fund and the Global Fund Business Model. The board consists of a rotating chair, 18 voting members and five nonvoting members. The 18 members include seven from donor countries, seven from developing countries, one representative each from a developing country nongovernmental organization (NGO), developed country NGO, the private sector and private foundations. The nonvoting members are from WHO, UNAIDS, the World Bank, a person representing communities with citizens affected by HIV/AIDS, TB or malaria and a Swiss citizen.

Is the program design effectively targeted so that resources will address the program's purpose directly and will reach intended beneficiaries?

Explanation: The program's design is effective for reaching intended beneficiaries and not subsidizing activities that would occur without contributions from the program. Intended beneficiaries are the people living in countries assisted by the Fund affected by HIV/AIDS, TB or malaria and not merely the Principal Recipients, or grantees. As is described further in section III, there are issues with implementation. For example, the USG is working with the Fund to improve its use of data in making performance-based funding decisions. Improvements related to implementation of the Fund's design are also needed to ensure disbursements reach the intended beneficiaries in a timely manner without being held by the Principal Recipients. The USG has also expressed specific concerns about some large initial disbursements to Principal Recipients that have later sat unspent for long periods of time. However, the design of the Global Fund is sound and also ensures timely incorporation, commitments, and disbursements.

Evidence: Global Fund has approved $3.1 billion to 310 grants in 127 countries with over 60% of funding for Africa, 18% for East Asia, South East Asia and Oceania, 9% for Latin America, 7% for Eastern Europe and Central Asia, and 5% for South Asia, Middle East and North Africa. The break-down by disease is 56% toward HIV/AIDS, 31% toward malaria and 13% toward TB (Investing in the Future: The Global Fund at Three Years, March 2005). Seventy percent of grants resources are reaching intended beneficiaries and targets and 22% show potential (Progress Report, 2005). As is described further in section III, the Fund has taken some steps to focus additional efforts on resolving slow delivery of grant dollars at the local level. It is too early to assess the design's impact on achieving program results.

Does the program have a limited number of specific long-term performance measures that focus on outcomes and meaningfully reflect the purpose of the program?

Explanation: The long-term measures utilized by the Emergency Plan to monitor the performance of the Global Fund are divided into three categories, HIV/AIDS, TB and Malaria. 1) HIV/AIDS: By 2008, 2 million people on ARV treatment (2003 baseline: 400,000 people on ARV treatment) 2) TB: 7.3 million TB cases successfully treated with Directly Observed Therapy- Short Course (DOTS) (2003 baseline: 3.8 million successfully treated with DOTS), 3) Malaria: 120.6 million bed nets (2003 baseline: 12.6 million bed nets).

Evidence: Evidence includes the following reports: 1) Technical Review Panel and the Secretariat on Round Four Proposals, GFATM 8th Board Meeting, Geneva, June 2004. 2) The Resource Needs of the Global Fund 2005 - 2007, March 2005. 3) GFATM Monitoring & Evaluation Strategy, November 2004. 4) Investing in the Future: The Global Fund at Three Years, March 2005, pages 14-27.

Does the program have ambitious targets and timeframes for its long-term measures?

Explanation: The 2008 goals established by the Global Fund are ambitious, consisting of targets and timelines of a scale that will have a significant impact on the incidence, morbidity and mortality of the three diseases.

Evidence: Evidence includes the following reports: 1) Investing in the Future: The Global Fund at Three Years, March 2005, and 2) GFATM has advanced in key areas, but difficult challenges remain, GAO report, May 2003, pages 32-36.

Does the program have a limited number of specific annual performance measures that can demonstrate progress toward achieving the program's long-term goals?

Explanation: The Global Fund has developed a list of ten standard annual performance indicators to measure the number of people reached by the Fund's services. The indicators will allow for measuring the Fund's progress in achieving its goals in an aggregated format for the first time. Disease appropriate indicators are built into each grant depending on the disease the grant is designed to address. Utilizing the ten indicators, the Fund, Board members, donor governments, and other interested parties can collect a greater amount of detailed information on the program's performance than they would by simply measuring the Fund's annual progress on reaching its three long-term targets. At present the Global Fund aggregates data annually for three of the ten performance indicators (the first three listed below: number of people receiving ARV therapy, 2) number of people with TB receiving directly observed therapy (DOT), 3) number of insecticide treated nets (ITNs) distributed. The USG is in the process of developing additional process monitoring annual performance indicators which it will recommend to the Replenishment conference for their review. If adopted, they will allow the USG and other donor governments to better evaluate overall Fund performance and report to interested constituencies.

Evidence: "These ten indicators are as follows: 1) Number of people currently receiving antiretroviral therapy 2) Number of smear positive TB cases under directly observed therapy- short course (DOTS) 3) Number of insecticide treated nets (ITNs) distributed 4) Number of people counseled and tested for HIV 5) Number of HIV positive pregnant women receiving a full course of ARV prophylaxis to reduce mother to child transmission (PMTCT) 6) Number of people receiving antimalarial treatment (specificy ACT/non-ACT) 7) Number of condoms distributed 8) Number of people benefiting from outreach community programmes (specifying a. Prevention, b. Orphan Support and c. Home based care and external support) 9) Number of people receiving treatment for infections associated with HIV (specifying a. Opportunistic infections, b. HIV/TB and c. STIs with counseling) 10) Number of people trained (specifying a. Health and related services and b. Peer and community prevention) "

Does the program have baselines and ambitious targets for its annual measures?

Explanation: The Fund has established baselines and annual targets for three of its ten annual indicators cited above (these three indicators are identical to the long-term measures, as the program has established yearly targets for each of them). In addition, the USG is in the process of establishing benchmarks and targets for the performance measurement indicators still in development.

Evidence: Baselines represent global numbers receiving ARV. Each annual target represents an additional unit added to the baseline.

Do all partners (including grantees, sub-grantees, contractors, cost-sharing partners, and other government partners) commit to and work toward the annual and/or long-term goals of the program?

Explanation: Global Fund partnerships have been developed at all levels of the program and reflect the Fund's commitment to participatory decision-making, with a strong focus on local ownership of the program's activities. Global Fund partners include the Secretariat and the Board of the Fund, which represents all major constituencies (including the U.S.) and technical and government partners, as well as in-country partnerships with Country Coordinating Mechanisms (CCMs) and Local Fund Agents (LFAs) that take on the responsibility of grantee oversight. All partners work towards the targets embedded in the Global Fund grants, and progress against these targets is measured regularly with a review at 20 months of each grant to determine whether the Board commits to Phase II funding.

Evidence: "Evidence includes the following documents: 1) United States Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003, Section 201-202. 2) The "Three Ones" Key Principles: "Coordination of National Responses to HIV/AIDS" Guiding principles for national authorities and their partners, April 2004. 3) Consultation on Harmonization of International AIDS Funding, End-of-Meeting Agreement, UNAIDS, Washington, DC April 2004. 4) Investing in the Future: The Global Fund at Three Years, March 2005, pages 22-25. "

Are independent evaluations of sufficient scope and quality conducted on a regular basis or as needed to support program improvements and evaluate effectiveness and relevance to the problem, interest, or need?

Explanation: Several independent evaluations of sufficient scope and quality have been conducted on a regular basis in an effort to evaluate the effectiveness of Global Fund activities and to make recommendations on program improvements. The General Accounting Office (GAO) has conducted two evaluations of the Fund, in addition to other independent (government, private, non-profit) organizations such as: 1) Britain's Department of International Development, the 2) Kaiser Family Foundation's Center for Strategic and International Studies (CSIS) Task Force on HIV/AIDS, and UNAIDS, and 3) The System wide Effects of the Fund Research Network: Measuring the Effects of the Global Fund on Broader Health Networks.

Evidence: "Evidence for this answer can be found in the following reports: 1) GFATM has advanced in key areas, but difficult challenges remain, GAO report, May 2003. 2) Global Fund Country Case Studies Report, Britain's Department for International Development (DFID), January 2003. 3) Kaiser Family Foundation's Center for Strategic and International Studies (CSIS) Task Force on HIV/AIDS, and UNAIDS. 4) The Systemwide Effects of the Fund Research Network: Measuring the Effects of the Global Fund on Broader Health Networks, January 2005. "

Are Budget requests explicitly tied to accomplishment of the annual and long-term performance goals, and are the resource needs presented in a complete and transparent manner in the program's budget?

Explanation: Under the Emergency Plan, the President committed USG resources to the Global Fund as an incentive to leverage other donors in the infancy of the Fund. Currently, neither the Administration's budget requests for the U.S. contribution to the Global Fund nor the Fund's request for international contributions are explicitly tied to accomplishment of the Fund's annual and long-term goals. Efforts are underway to set the stage for linking budget and performance information for the U.S.'s contribution to the Global Fund. The U.S. delegation to the Global Fund Board has taken the lead in working with other Board donor delegations to develop performance indicators in the context of the Global Fund voluntary replenishment mechanism.

Evidence:  

Has the program taken meaningful steps to correct its strategic planning deficiencies?

Explanation: The Fund has taken meaningful steps to correct problems raised in relation to several strategic planning deficiencies. This includes the recent recruitment of a strategic planning manager and, at the urging of the USG, a Deputy Executive Director. In addition, the Executive Director has commissioned an independent review of the Board structure, with steps underway to tackle uncovered deficiencies. In addition, as was stated above in question 2.4, the Fund is in the process of developing baselines and targets for seven of its ten recently developed standardized indicators.

Evidence: "Report of the Executive Director, GFATM 10th Board meeting, April 2005."

Does the agency regularly collect timely and credible performance information, including information from key program partners, and use it to manage the program and improve performance?

Explanation: A core principle of the Fund is performance-based funding and the implementation design of the Fund requires independently reviewed performance information of grants for them to receive disbursements. However, board members have cited inconsistent data collection, late quarterly reporting, and exceptions to performance information requirements for disbursements. Even though the fiduciary arrangements and timely provision of performance information are described in Global Fund documents, and embedded in the legal agreements with all grantees, evidence does not prove that the structure the Fund has established for collecting timely and credible performance information is being implemented effectively or used to manage the program and improve performance. However, the Secretariat is working to improve its efforts to track and make available information on funding levels provided by the PR to sub-recipients for all grants. The USG Global Fund Core Team monitors performance information both informally and formally through website reviews, field reports, and an interagency technical review panel which reviews proposals submitted to the Fund for Board approval.

Evidence: GFATM Fiduciary Arrangements for Grant Recipients, July 2003. GFATM Guidelines for Performance Based Funding, July 2003. Grant Scorecard available on Global Fund Website: www.theglobalfund.org/en/funds_raised/reports/.

Are Federal managers and program partners (including grantees, sub-grantees, contractors, cost-sharing partners, and other government partners) held accountable for cost, schedule and performance results?

Explanation: In keeping with Office of Personnel Management and Foreign Service Act requirements, the USG has established performance standards for personnel within the Department of State who interact with the Global Fund. The Global Fund, during the November 2004 Board meeting, also adopted a results based performance criterion to be applied to both the Executive Director as well as the rest of the organization. A full performance review cycle has not been completed at the Global Fund; therefore, it is unclear how the criterion will be utilized. The Global Fund structure was developed to ensure that all recipients and grantees are held accountable for cost, schedule and performance results directly in their grant agreements, which are reviewed independently by Local Fund Agents. USG statute also provides accountability through withholding provisions based on Fund performance criteria.

Evidence: "1) The Framework document of the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM), December 2001. 2) GFATM Fiduciary Arrangements for Grant Recipients, July 2003. 3) GFATM Guidelines for Performance Based Funding, July 2003. 4) Investing in the Future: The Global Fund at Three Years, March 2005, page 22. "

Are funds (Federal and partners') obligated in a timely manner and spent for the intended purpose?

Explanation: A primary concern of the USG is that Global Fund reporting policies are not being rigorously implemented. For example, despite being required by the Fund as part of the grant agreement, grantee Principal Recipients have not reported data on expenditures on a consistent basis and reporting of expenditures by Sub-Recipients is frequently very hard to obtain. Progress reports on the meeting of targets have also been inconsistent with the Global Fund's principles of performance-based funding, although the Secretariat is putting measures in place to improve this. The Global Fund and the USG use different definitions for obligations and disbursements. When the Global Fund's Board of Directors approves a grant for the five year duration, a budget ceiling is established that initially commits a full two years of funding for that project. The Secretariat obligates funds for the entire amount of a grant commitment immediately on execution of each grant agreement. In a few, select cases, Fund grant money has run the risk of being diverted from its intended purpose; in each case, after communications from the USG and other donors, the Fund Secretariat has intervened to take corrective action, including changing the Principal Recipient of the project or recommending the termination of the project at its two year point. Finally, USG Federal funds are obligated to the Global Fund in a timely manner and in accordance with the guidelines established by legislation, with a clear, auditable trail to the World Bank, which serves as Trustee of Global Fund finances.

Evidence: Example of a World Bank Trustee statement and LFA disbursement/performance reports to the Secretariat. Funds disbursed verified through the Global Fund website.

Does the program have procedures (e.g. competitive sourcing/cost comparisons, IT improvements, appropriate incentives) to measure and achieve efficiencies and cost effectiveness in program execution?

Explanation: The Global Fund is, or already has, established a number of procedures/policies with the intent of achieving efficiencies and cost effectiveness in program execution. Some of these include the development of a web-based tool to aid procurement decision-making, actively seeking other donor technical assistance for grants, partnering under the "Three Ones" strategy for donor harmonization and working to establish an Office of the Inspector General. The Secretariat is also establishing a drug purchasing platform to enable grantees to view prices for comparative products as purchased by other grantees. The Monitoring, Evaluation, Finance & Audit (MEFA) committee also tracks several key administrative expense ratios. The USG also tracks the efficiency of the Fund as required in statute. In terms of efficiency goals, the Global AIDS Coordinator's Office is also required by the United States Leadership Act of 2003 to ensure that the Global Fund's expenses for its Governing, Administrative and Advisory Bodies do not exceed 10% of their total expenditures over any two year period.

Evidence: "1) Reports from the most recent Global Fund Board Meeting, 2) MEFA Operating expense review, 3) 2005 Secretariat Budget Report of the Executive Director, 4) GFATM 10th Board meeting, April 2005. 5) GFATM 2004 Operating Expense Review, 10th Board meeting, April 2005. "

Does the program collaborate and coordinate effectively with related programs?

Explanation: The Global Fund has signed Memorandums of Understanding that establish collaboration with the Rollback Malaria Partnership, UNAIDS, the Inter-American Bank, and the International Labor Organization. The Fund and its partners periodically hold regional meetings that include relevant countries and bilateral and international agencies to address solutions to specific problems. In addition, the Global Fund has also actively agreed to support the "Three Ones" strategy for donor coordination. The USG is dedicated to continue to support the Fund as well as coordinate programmatically with the Fund in-country.

Evidence: USG statement on support of the Fund through the Emergency Plan. Global Fund collaborative agreements.

Does the program use strong financial management practices?

Explanation: The USG is concerned about a number of aspects of the Global Fund's financial management practices. The independent LFAs are supposed to verify and report on the expenditures made by Principal Recipients of grants, as described in question 3.3, and these Principal Recipients are further required to provide the Fund with the report of their own external auditors each year. The USG has seen evidence that these reports are not always as timely or as complete as they need to be and that portfolio managers at the Fund Secretariat may not always read or digest the LFA reports that come in from the field. The USG also has great concern about the apparent inability, or unwillingness, of the Fund Secretariat to track disbursements to subrecipients. Given that the Global Fund has only been operational for just over three years, it continues to develop and improve its work in establishing a systemized process for collecting this information.

Evidence: The US has also expressed concerns regarding an account maintained by the Secretariat at Credit Suisse that appears to fall outside these check and balances. When the Fund Secretariat completes its transition from the Administrative Services Agreement with the WHO Secretariat to an independent status as an international organization under Swiss law, the Global Fund Board of Directors will have to remain vigilant that the Fund establishes its own internal financial and human resource procedures and policies that are rigorous and transparent.

Has the program taken meaningful steps to address its management deficiencies?

Explanation: At the Tenth Meeting of the Board of the Global Fund, the Secretariat presented its plan to improve its work to document and capture such information by refining its information management system. This system will allow the Secretariat to maintain regular Grant Performance Reports that provide information on grant disbursements from Principal Recipients to sub-recipients and information on the performance of a grant to meet its targets and objectives. Under the current practice, the Secretariat has written thorough Grant Performance Reports for grants that are up for review by the Board for Phase II renewed funding. Under the new system, the Secretariat will expand this practice of providing to the Board Grant Performance Reports for all grants, regardless of the time span that a grant has been in existence.

Evidence: "The Global Fund Board has appointed Ernst and Young as its independent auditors, who have issued an unqualified audit opinion every year since inception of the Fund. In 2005, after pressure from the United States and other donors, the Fund is establishing an Office of the Inspector General that will further strengthen financial management practices. The United States believes strongly that this unit should have an independent and direct reporting line to the Board. Additional evidence for this answer can be found in the Report of the Executive Director, GFATM 10th Board meeting, April 2005. "

Does the program have oversight practices that provide sufficient knowledge of grantee activities?

Explanation: The Global Fund has the potential for considerable oversight of grantee activities, from initial audits and reviews of Principal Recipients before grant signing, independent reviews by the LFAs before each disbursement, oversight by the CCM, and formal review of all grantee activities at month 20, in advance of making recommendations to the Board on Phase II funding. The Fund's performance-based funding policy defines oversight practices for each financial disbursement based on extensive and independently reviewed programmatic and financial data. Nevertheless, the Secretariat has not made full use of these available data sources in its grant decision-making process, neither for disbursement decisions nor for Phase II renewals. The U.S. Government, via an interagency team, holds a seat on the Board of Directors of the Global Fund, and sits on various technical committees of the Board. Policy decisions and funding recommendations for project grants are presented to the Board by the Secretariat and the U.S. casts its vote on these decisions. The U.S. has also been able to use its authority as a Board member to request and obtain extensive information from the Global Fund Secretariat on virtually all aspects of their operations.

Evidence: "Evidence for this answer can be found in the following documents: 1) Framework document of the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM), December 2001. 2) GFATM Fiduciary Arrangements for Grant Recipients, July 2003. 3) GFATM Guidelines for Performance Based Funding, July 2003. "

Does the program collect grantee performance data on an annual basis and make it available to the public in a transparent and meaningful manner?

Explanation: The Global Fund is a leader in pushing the frontiers of transparency in international governance because of the wealth of grantee performance data it makes available to the public. The Global Fund Secretariat collects grantee performance data on an annual and sub-annual basis, and makes it available on its website including the actual, signed grant agreement with associated targets and quarterly or semi-annual disbursement requests and progress updates. Also, grant performance reports exist for all grants that are undergoing evaluation for continued funding under Phase II, which make available a wide range of performance and contextual information together with independent reviews. Finally, the Secretariat produces a scorecard that shows the continued funding decisions and their rationale based on this data. Examples of the grantee performance data are presented in the 2005 progress report, and grant-by-grant information is available on the Fund's website. Nevertheless, some have questioned the reliability and timeliness of the data gathered, and its relevance for the public as well as the Secretariat in evaluating grant performance.

Evidence: 1) "www.theglobalfund.org/en/1) Framework document of the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM), December 2001. 2) GFATM Fiduciary Arrangements for Grant Recipients, July 2003. 3) GFATM Guidelines for Performance Based Funding, July 2003. 4) Annual Report of the Global Fund, 2003. 5) A Force for Change: The Global Fund at 30 months, June 2004. 6) Investing in the Future: The Global Fund at Three Years, March 2005. 7) GFATM has advanced in key areas, but difficult challenges remain, GAO report, May 2003. "

Has the program demonstrated adequate progress in achieving its long-term performance goals?

Explanation: The Global Fund reports reaching calendar year 2004 targets for two of the three long-term goals, antiretroviral treatment and TB cases treated under the DOTS strategy. The Global Fund did not report meeting the malaria prevention target.

Evidence: Investing in the Future: The Global Fund at Three Years, March 2005, p. 38.

Does the program (including program partners) achieve its annual performance goals?

Explanation: The Global Fund has established standard baselines and targets and reported on aggregated results data for three of their top ten annual indicators. In a move towards standardization, the USG is participating with other donor countries to develop annual performance measures to capture both impact and process data for the Fund. These efforts are not yet complete and, therefore, have not been used for evaluation.

Evidence: The USG (and other donor countries) are in the process of completing development of the seven remaining annual performance measures, and have stated that these measures will be available by the end of December 2005.

Does the program demonstrate improved efficiencies or cost effectiveness in achieving program goals each year?

Explanation: A Large Extent is given because the program has maintained relatively small operating expense at the Secretariat, but there are limited data on the efficiency of the Fund in achieving performance objectives in the field. Considerable weight is given to the administrative costs in this question due to the design and purpose of the Global Fund as a financing instrument. As described in section I, the Fund's design relies on local direction and implementation and has not staffed up to directly implement programs but rather serves as a financing and monitoring entity. The Fund restructured the operations unit in 2004, in part, to improve program efficiency. The USG maintains an efficiency measure for the Fund of the operational support costs as a percentage of total costs, and the Fund Board established an efficiency measure of operating expenses in the 2005 operating budget for the Secretariat.

Evidence: The 2003 baseline for the Board's efficiency measure is 13% of grant disbursements and 3% of grants under management. The objective is to maintain administrative expenses at or below 10% of total expenditures. In 2004, administrative expenses declined to 6.8% of grant disbursements and 2.2 % of grants under management. Administrative expenses increased from $32 million in 2003 to $51 million in 2004, but disbursements grew at a greater rate over the same time period. In 2004, on average each Global Fund staff member disbursed $5 million with projections of $16.4 million compared to $2 million per staff at the World Bank and $4.5 at the Inter-American Development Bank.

Does the performance of this program compare favorably to other programs, including government, private, etc., with similar purpose and goals?

Explanation: A Small Extent is given because the Global Fund compares favorably in its establishment and rapid scale-up but has only limited data and independent evaluations of results on the ground to date. The Fund has maintained a low rate of operating costs per dollars disbursed relative to the World Bank and other comparable organizations and programs. The Fund rapidly established the organization and identified its procedures and financing mechanisms, country coordinating mechanisms, recipient countries and grantees.

Evidence: Since it's inception, the Fund has contributed to putting 130,000 people on antiretroviral treatment. The Fund accounted for roughly 20% of global spending on HIV/AIDS, 50% on TB and 45% on malaria in 2004 with nearly $6 billion in total pledges and over $3 billion committed to 310 grants in 127 countries by that time. There is some evidence that the financing strategy is overly reliant on state donors. Of the first 27 grants awarded, 70% are on track, 22% are underperforming but show promise and 8% are lagging (Liden, Low-Beer, 2005). The Fund's Board first met in January 2002, six months after the G-8 pledged to create it.

Do independent evaluations of sufficient scope and quality indicate that the program is effective and achieving results?

Explanation: The independent studies that have evaluated the Global Fund have for the most part come to similar conclusions: That while the Fund has made progress in establishing key governing structures on the ground and in bringing new partners together to address the HIV/AIDS pandemic (as well as TB and malaria), the program has not, after three years, demonstrated consistently its use of performance data to guide the distribution of its funds. Much of the Fund's limitations in this regard stem from its difficulties in obtaining accurate information that it requires from countries to make performance-based funding decisions. In addition, it is clear that grantees have, generally, not been held accountable when they fail to achieve their goals. Finally, none of the studies conducted looked at the overall effectiveness and/or impact of the Global Fund up to this point, which also limited the amount of credit the program could receive for this question. If new studies (of sufficient scope, quality and independence) become available by the time the PART is revisited in November 2005, and their results indicate or report positively on the Fund's impact and/or overall effectiveness, more credit can be given for this question.

Evidence: "Evidence for this answer can be found in the following reports: 1) GFATM has advanced in key areas, but difficult challenges remain, GAO report, May 2003. 2) Global Fund Country Case Studies Report, Britain's Department for International Development (DFID), January 2003. 3) Kaiser Family Foundation's Center for Strategic and International Studies (CSIS) Task Force on HIV/AIDS, and UNAIDS. 4) Tracking the Global Fund in 4 countries: an interim report, London School of Hygiene and Tropical Medicine, Oct. 2003. "