Governance and Health Aid from the Global Fund: Effects Beyond Fighting Disease

A review and analysis of accountability in global health funding, research collaborations and training: towards conceptual clarity and better practice

INTRODUCTION

Accountability is a complex idea to unpack and involves different processes in global health practice. Calls for accountability in global health would be better translated to action through a better understanding of the concept and practice of accountability in global health. We sought to analyse accountability processes in practice in global health funding, research collaborations and training.

METHODS

This study is a literature review that systematically searched PubMed and Scopus for articles on formal accountability processes in global health. We charted information on processes based on accountability lines ('who is accountable to whom') and the outcomes the processes were intended for ('accountability for what'). We visualised the representation of accountability in the articles by mapping the processes according to their intended outcomes and the levels where processes were implemented.

RESULTS

We included 53 articles representing a wide range of contexts and identified 19 specific accountability processes for various outcomes in global health funding, research collaborations and training. Target setting and monitoring were the most common accountability processes. Other processes included interinstitutional networks for peer checking, litigation strategies to enforce health-related rights, special bodies that bring actors to account for commitments, self-accountability through internal organisational processes and multipolar accountability involving different types of institutional actors. Our mapping identified gaps at the institutional, interinstitutional and broader system levels where accountability processes could be enhanced.

CONCLUSION

To rebalance power in global health, our review has shown that analysing information on existing accountability processes regarding 'who is accountable to whom' and 'accountability for what' would be useful to characterise existing lines of accountability and create lines where there are gaps. However, we also suggest that institutional and systems processes for accountability must be accompanied by political engagement to mobilise collective action and create conditions where a culture of accountability thrives in global health.

The Global Fund: why anti-corruption, transparency and accountability matter

Background

The creation of the Global Fund to Fight AIDS, Tuberculosis and Malaria, also known as the Global Fund, was prompted by the lack of a timely and effective global response, and the need for financing to fight against three devastating diseases: HIV/AIDS, tuberculosis, and malaria. During the formation of the Global Fund, necessary anti-corruption, transparency, and accountability (ACTA) structures were not put in place to prevent fraud and corruption in its grants, which resulted in the misuse of funds by grant recipients and an eventual loss of donor confidence in 2011. The Global Fund has instituted various ACTA mechanisms to address this misuse of funding and the subsequent loss of donor confidence, and this paper seeks to understand these implementations and their impacts over the past decade, in an effort to probe ACTA more deeply.

Results

By restructuring the governing committees in 2011, and the Audit and Finance; Ethics and Governance; and Strategy Committees in 2016, the Global Fund has delineated committee mandates and strengthened the Board’s oversight of operations. Additionally, the Global Fund has adopted a rigorous risk management framework which it has worked into all aspects of its functioning. An Ethics and Integrity Framework was adopted in 2014 and an Ethics Office was established in 2016, resulting in increased conflict of interest disclosures and greater considerations of ethics within the organization. The Global Fund’s Office of the Inspector General (OIG) has effectively performed internal and external audits and investigations on fraud and corruption, highlighted potential risks for mitigation, and has implemented ACTA initiatives, such as the I Speak Out Now! campaign to encourage whistleblowing and educate on fraud and corruption.

Conclusions

From 2011 onwards, the Global Fund has developed a number of ACTA mechanisms which, in particular, resulted in reduced grant-related risks and procurement fraud as demonstrated by the decreased classification from high to moderate in 2017, and the reduction of investigations in 2018 respectively. However, it is crucial that the Global Fund continues to evaluate the effectiveness of these mechanisms; monitor for potential perverse impacts; and make necessary changes, when and where they are needed.