Health Aid Governance in Fragile States: The Global Fund Experience Olga Bornemisza, Jamie Bridge, Michael Olszak-Olszewski, George Sakvarelidze, and Jeffrey V Lazarus Fragile states represent key challenges for global health governance. This study analyzes Global Fund grant data from 122 recipient countries as an initial exploration into how well these grants are performing in fragile states as compared to other countries. Since 2002, the Global Fund has invested nearly US$ 5 billion in 41 fragile states, and most grants have been assessed as performing well. Nonetheless, statistically significant differences in performance exist between fragile states and other countries, which were further pronounced in states with humanitarian crises. This indicates that further investigation of this issue is warranted: variations in performance may be unavoidable given the complexities of health governance in fragile states, but may also have implications for how the Global Fund and others provide aid. For example, faster aid disbursements might allow for a better response to rapidly changing contexts, and there may need to be more of a focus on building capacity and strengthening health governance in these countries. INTRODUCTION State fragility remains one of the most significant challenges for the well-being of affected populations, progress towards the Millennium Development Goals, and health and development donors. Fragile states–broadly definable as a state that “cannot or will not deliver core functions to the majority of its people, including the poor” 1 –are home to one-sixth of the world’s population, but one-third of those living on less than US$ 1 per day. 2 These states often face the double challenges of fractured health systems and reduced capacity to absorb external funding. Violence, conflict, corruption, exclusion or discrimination of certain groups, and gender inequalities are also common characteristics. 3 These states carry a disproportionate burden of many health problems including HIV/AIDS, tuberculosis and malaria. For example, four fragile states (Democratic Republic of Congo, Nigeria, Sudan and Uganda) together account for 45% of the estimated malaria deaths among children in the world. 4 The greatest burdens in terms of maternal and child health are also found within fragile states. 5 Health aid in these countries is increasing, but is often fragmented between different donors and their programs. 6 This underlines the importance of effective health governance in these contexts. Health governance is defined by the World Health Organization (WHO) in terms of various key health- related state functions such as policy guidance, intelligence and oversight, collaboration and coalition building, regulation and incentives, system design, and accountability to the public. 7 The Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund) was established in 2002 to raise and disburse substantial funding in order to achieve sustained impacts on the three diseases. By mid-2010, it had approved proposals worth US$ 19.3 billion: supporting tuberculosis treatment for seven million people, the distribution of 122 million insecticide-treated nets to prevent malaria, the
Health Aid Governance in Fragile States: The Global Fund Experience
Jul 09, 2023
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