Journal Article

It is time to increase Africa’s governmental representation on the governing board of the global fund to fight AIDS, tuberculosis and malaria

Kakoma, Josephat, Bridge, Gemma, von Agris, Jean Merlin, Brown, Garrett Wallace, Hayes Badenhorst, Robyn, Fransen, Lieve, Nalugala, Reginald Maudlin

2025

Overview

In terms of GFATM, lasting critiques include claims that conditional funding often distorts country health priorities, undermining health system strengthening,2 while imposing external agendas resulting from asymmetrical power between global health funders on the GFATM Board and country implementors.3 4 This can result in policies that are misaligned with national priorities, creating duplicated human resources, disjointed monitoring and evaluation systems, with increased transactional, opportunity and direct costs to implementors.5 Regarding sustainability, the GFATM has been accused of inadvertently creating an overreliance on foreign aid, with an associated shifting of responsibility for health to funders and non-governmental organisations (NGOs).6 The lack of self-reliance is compounded in Africa by a lack of government direction and weak regional governance, diluted power and financial uncertainty,1 escalated by limited GFATM support to improve local financial management or capacity building within implementing countries. [...]a reliance on external expertise rather than leading from within impacts on sustainability. In terms of disease burden and ‘most affected’, the two African constituencies account for 81% of Global Fund allocations for malaria, 76% for HIV/AIDS and 39% for tuberculos. [...]the mortality statistics for the two African constituencies demonstrate that they combine to embody 95% of all deaths associated with global malaria, 60% of global HIV and 33% of global tuberculosis, which are each accompanied by high social and economic impacts. National ownership and aid effectiveness Evidence suggests that nationally owned programmes result in greater aid effectiveness.10 Moreover, enhanced local and national ownership improves needs-based indicator selection and performance, as well as better system alignment and health prioritisation,11 which also reduces fragmentation.12 Well-designed local programmes with high levels of national ownership improve country capacities and resiliency in addition to improved accountability and leadership.13 14 In terms of the effectiveness of financial results, programmes that have high perceptions of national ownership result in improved additionality toward national health and financial targets,5 15 increased value for money and return on investment, while also improving partnership and perceptions of legitimacy.16 Finally, national ownership supports a decolonisation agenda,17 while improving the sustainability of programmes.6 18 What this indicates is that national ownership is crucial to aid effectiveness, which GHIs must advance.

• Publisher: BMJ Publishing Group Ltd,BMJ Publishing Group LTD,BMJ Publishing Group
• Subject: Accountability / Acquired immune deficiency syndrome / AIDS / Capacity development / Civil society / Commentary / Decision Making / Economic impact / Financial management / Funding / Global Health / Health policy / HIV / Human immunodeficiency virus / Legitimacy / Malaria / Return on investment / Sustainability / Tuberculosis / Vector-borne diseases