Ten Questions Shaping the Global Fund’s Future

Introduction

The Global Fund to Fight AIDS, Tuberculosis and Malaria has achieved results that few global institutions can point to.( 1 ) The Global Fund's 2026 Results Report estimates that the partnership has helped save 72 million lives since 2002. In 2025 alone, programs in countries where the Fund invests supported 26.9 million people on antiretroviral therapy, treated 7.4 million people for tuberculosis and distributed 196 million insecticide-treated mosquito nets.

But the institution faces significant headwinds. In the wake of funding cuts, countries supported by the Global Fund largely protected HIV treatment, but prevention absorbed serious losses: the number of people receiving PrEP in Global Fund-supported countries fell from 1.4 million in 2024 to 1.1 million in 2025. TB programs faced disruptions to case finding, diagnosis and treatment. Malaria programs reported stock-outs and delays to time-sensitive prevention campaigns.

The Global Fund has faced defining tests before, and every leader has inherited an institution at an inflection point. Created in 2002 amid the global AIDS emergency, it was deliberately built as a different kind of institution: a financing role rather than an implementing role, independent technical review, shared governance and country-led implementation.( 2 )

The incoming leader will be its fifth permanent Executive Director. Its founding administration had to turn an ambitious idea into a functioning financing mechanism while moving money quickly, raising resources and building credible safeguards almost at the same time. The second leadership era collided with the 2008 financial crisis and then a more damaging institutional crisis.( 3 ) By 2011, donor shortfalls, investigations into misuse of grant funds and concerns about oversight had contributed to the cancellation of a new funding round and a fundamental transformation of the institution between 2011 and 2013.( 4 ) Transitional leadership reorganized the Secretariat and strengthened grant management and risk controls.( 5 )

The third Executive Director inherited that redesign, implemented a new funding model and then had to navigate the 2014-2016 West Africa Ebola epidemic, which exposed how quickly disease programs can falter when underlying health systems collapse.( 6 ) ( 7 ) The fourth Executive Director took office in 2018 and soon confronted COVID-19. The Global Fund protected HIV, TB and malaria programs while mobilizing more than US$5 billion through its COVID-19 Response Mechanism to support tests, protective equipment, oxygen, laboratories and surveillance.( 8 ) The pandemic was followed by war, displacement, climate shocks and the sharp contraction in international financing.

The new Executive Director will take charge as development assistance for health contracts. The US-led PEPFAR program and UNAIDS are undergoing radical transformation. Governments face debt, limited fiscal space and competing demands. New technologies could transform HIV prevention, TB diagnosis and malaria control, but countries may lack the financing or delivery systems to use them at scale. Meanwhile, the Accra Reset and wider demands for sovereignty are challenging a longstanding model in which Geneva and Washington set priorities and countries implement them.

Countries face these changes from very different positions. Some are assuming more of the cost of their disease responses, while conflict, poverty and renewed health threats like Ebola leave others dependent on sustained external financing. In either case, greater government responsibility offers no guarantee that national budgets will cover community organizations or services for people at greatest risk. What happens as donor support declines will depend on who makes decisions, which services receive funding and whether people affected by those decisions have a say.

The Fund brings more than money to this task. Its purchasing power helps countries secure affordable health products, and its investments support laboratories, supply chains, health workers and community services. But tighter budgets, growing demand for integrated care and pressure to shift authority toward countries are testing the boundaries of that role. The incoming Executive Director will have to decide how these relationships should evolve and where the Fund can contribute most.

The Executive Director will also inherit a record of achievement built by countries, communities, donors, and staff over more than two decades. The Global Fund has navigated major challenges while helping sustain and expand access to lifesaving services. Some of the priorities discussed here are already underway. The incoming leader’s task is to build on these strengths, accelerate progress, and determine how the Fund must adapt to a changing global health landscape.

1. Should the Global Fund deepen its existing role or broaden it?

The Global Fund needs to define what it should achieve by 2035 and how it should measure success. Rising malaria cases, the persistent burden of TB and increasing numbers of people acquiring HIV in Eastern Europe, Central Asia and Latin America make this task more urgent. Saving lives, accelerating progress toward ending HIV, TB and malaria, strengthening national health systems, and helping countries sustain results with less external support are connected ambitions. The choice is how the Fund should define its role in advancing them: deepen its work as a financier of the three diseases or take on a broader health financing role.

That decision should guide the Fund’s future structure and its relationships with other institutions. Deepening its existing role would mean modernizing how it finances disease responses and the systems that sustain them. A broader role could extend its financing or services to additional health priorities. Either path would require clarity about what the Fund should lead, what it should deliver jointly, and what other institutions are better placed to do. Each option should be judged by whether it helps countries achieve better health outcomes and gives them greater control over their health priorities.

Practical cooperation can advance while those longer-term decisions take shape. Procurement, technical assistance, back-office operations, market shaping and pandemic preparedness offer opportunities to reduce duplication and establish a clearer division of responsibilities with Gavi, Unitaid, the Pandemic Fund and others. Shared services, closer institutional relationships or eventual consolidation should follow from a clear purpose. The Fund should bring concrete proposals to these discussions and be willing to change its own practices.

2. How should the Fund balance different operating models?

The Fund will need to support countries taking on more of their own financing while sustaining long-term support in places where conflict, humanitarian crises and extreme poverty make that prospect distant. In its 2024–2026 grant cycle, the Fund is investing US$5.3 billion—38 percent of its total investments—in challenging operating environments.( 9 ) A substantial share of its work therefore takes place where sustained external financing and flexibility will remain essential. The incoming Executive Director must make both models work within one institution.

For countries moving toward greater domestic financing, support should increasingly emphasize market access, technical assistance and transition financing that allows national systems to assume responsibility without disrupting care. In fragile and conflict-affected settings, the Fund will need flexible financing, grant arrangements that can adapt quickly and reliable ways to deliver services when government systems cannot.

These models will require different staffing, partnerships, funding horizons and approaches to risk. The Fund must be able to adjust as country circumstances change, including when conflict or economic shocks reverse progress. Different ways of working should preserve the same commitment to service quality, community participation and accountability.

3. What should the Fund offer countries after grants end?

As countries take on the cost of their HIV, TB and malaria programs, many will still need help buying commodities at affordable prices, maintaining data systems and reaching people whom government services often miss. This question has become more urgent since the Fund published transition timelines in April 2026, with final grants for one group of country disease components scheduled to end by December 2030 and another group receiving their final allocations in the 2029–2031 cycle.( 10 )

The Fund will have to decide how much responsibility it should retain after a country’s grants end. Continuing support could help countries sustain services, but it would require money and staff time when resources for the poorest countries are already stretched. The choice is how far that continuing role should extend and which countries and services should qualify.

The Fund could offer procurement and technical services to a broad group of former recipients while reserving financing for specific needs. That would preserve some benefits of the partnership as governments assume more responsibility. It would also require the Board to agree on how to pay for these services and how much funding to reserve for countries whose grants have ended.

A further choice is whether countries should have a route back to financing when conditions deteriorate. The World Bank’s International Development Association offers a precedent through transitional support and renewed eligibility after graduation. For the Fund, such an approach would require monitoring what happens after grants close and agreeing on when treatment interruptions, rising patient costs or declining prevention coverage warrant renewed support. Countries should know those terms before their final grants end.

4. Should procurement become the Fund's enduring global public good?

Procurement is one of the Fund's clearest strategic opportunities. In 2025, US$1.02 billion in health products were ordered through the Global Fund's Pooled Procurement Mechanism, which aggregates demand from more than 80 countries.( 11 ) Since 2018, countries have also used US$128 million in non-Global Fund resources to procure products through the platform. The U.S. government has also turned to Wambo to finance procurement and distribution of lenacapavir for PrEP for people in PEPFAR-supported countries, offering a concrete example of the platform’s role beyond Global Fund grants. ( 12 ) Those figures point toward a larger role in price transparency, regional demand aggregation, access negotiations and risk-sharing. Procurement can also contribute to a broader market-shaping strategy that addresses product development, supplier diversity and barriers to uptake.

By pooling orders across countries, the Global Fund can negotiate lower prices and give manufacturers clearer expectations of demand, helping bring new products to countries sooner. But securing the lowest prices today can create tension with incentives for manufacturers to invest in innovation and future supply. The incoming Executive Director will need to decide whether procurement remains primarily a service attached to grants or becomes a permanent global public good available to countries using domestic and other non-Global Fund financing. A broader model could expand access to affordable products, but it would also require new financing, governance and accountability arrangements. It could also compete with emerging regional mechanisms, such as the African Pooled Procurement Mechanism. The Fund would need to define how its purchasing power could support regional procurement ambitions, including through shared demand forecasting, coordinated negotiations and a clear division of responsibilities.

This also requires a more sophisticated approach to sovereignty. Country ownership does not mean every country must purchase every product independently. Some products can and should move to national or regional procurement. Others - especially low-volume commodities or products requiring global access agreements - will remain more efficient to procure globally.

The same discipline should apply to local manufacturing. Regional manufacturing can strengthen health security and economic development, but procurement decisions should still protect affordability and health outcomes. The Fund can use its purchasing power to help create viable regional markets rather than supporting dozens of uncompetitive national manufacturing projects.

The platform can also give countries a benchmark for price and quality when they buy elsewhere. Governments and national oversight bodies could use those terms to assess whether alternative purchases offer value for money. But access to lower prices will not solve every constraint. Pre-financing could help countries place orders when domestic budget releases arrive too late to avoid shortages.

5. How far should the Fund move into health systems?

Between 2024 and 2026, the Fund is investing approximately US$5.9 billion in health and community systems, 43 percent more than in the previous grant cycle and its largest investment in this area to date.( 13 ) Climate-related shifts in malaria transmission and disruptions to service delivery also make adaptation relevant to the Fund’s core mission. These connections provide a case for carefully extending its work, but additional responsibilities need financing and a clear link to better outcomes. The incoming leader will need to define the scope of that expansion while protecting resources for HIV, TB and malaria.

There are practical reasons to consider a wider role. Someone receiving HIV treatment may also need care for other STIs, diabetes or hypertension. The same laboratories, supply chains and health workers often serve several disease programs. Financing these services together could improve care and reduce duplication. But a broader mandate would bring new demands on a shrinking budget. Spending more on general health services could leave less for treatment, prevention and community organizations that already struggle for funding. Governments and other funders would need to agree on who pays for the additional work.

In this context, the Fund should also clarify who is responsible for integrating in-country private-sector delivery into country programs. Private providers, pharmacies, laboratories and supply chains can help expand access, but their role needs to be planned alongside public services, with clear expectations for data sharing, quality of care and accountability.

The Fund could pursue a middle course: finance integrated services where they improve HIV, TB and malaria outcomes, while leaving broader health financing to others. That would allow an HIV clinic to offer hypertension care or a laboratory to serve several programs, provided partners share the costs and responsibilities.

Each approach has consequences. A narrow mandate may preserve focus but limit opportunities to improve how patients receive care. A broader mandate could strengthen services while stretching the Fund’s resources and accountability. The incoming leader will need to establish how far the Fund can go, what others must contribute and how the Board will judge the results.

6. How much risk should the Fund take on innovation?

The Executive Director will have to decide how early the Fund should commit money and staff to promising innovations. Waiting for regulatory approval and strong evidence reduces the risk of backing products that fail. It can also leave countries waiting years for procurement and delivery arrangements after a product succeeds. The coming pipeline makes that choice consequential: long-acting HIV prevention products, long-acting TB prophylaxis, new diagnostics and rapidly improving digital and artificial intelligence (AI)-powered tools.

One option is to select a small number of potentially high-impact innovations and prepare countries for them before approval. The Fund could negotiate access early, plan procurement, prepare delivery platforms and align partners. Some of that work would inevitably support products that disappoint. The Board would need to agree on how much financial and institutional risk it will accept, what evidence justifies an early commitment and what further evidence is needed before wider adoption.

Those commitments could also narrow countries’ choices. Separate financing streams for vaccines, preventive treatment and diagnostics can determine spending before countries assess which combination would have the greatest impact. This matters particularly for TB, where future vaccines could complement existing prevention options. The Fund will need to decide how much flexibility countries have to allocate its financing across eligible interventions, while coordinating with Gavi and other partners so that separate funding streams support a mix suited to countries’ epidemiology and delivery capacity.

Delivery innovation raises a similar question about who carries the risk. Individual countries cannot reasonably test every drone company, digital platform or AI model. The Fund could pool evaluations across countries and vendors, set standards for investment and adoption, and catalyze successful interventions into country approaches. That would require accepting some failed investments and setting clear conditions for stopping them.

The Fund’s own operations belong in this discussion. Donors increasingly expect multilateral organizations to demonstrate efficiency, and AI and process redesign could reduce administrative work. The Fund must decide which tasks to automate, how much to invest and what oversight remains necessary. The case for taking those risks should rest on evidence that the changes save time and money while preserving the quality of grant decisions and oversight.

7. Should the Fund build technical capacity or buy it?

PEPFAR, WHO and UNAIDS historically supplied much of the technical expertise that helped countries decide which interventions to prioritize and how to implement them.

That ecosystem is changing. The Global Fund therefore needs to answer a basic question: what technical capability must exist inside the Secretariat, and what should be financed through WHO, Africa CDC or other partners?

Countries could lose access to essential technical support as partner institutions cut staff and programs. The Fund will need to identify those gaps and finance a reliable response, drawing on expertise within countries and regional institutions as well as global partners.

The choice is not simply institutional expansion versus outsourcing. Building expertise inside the Secretariat could improve accountability but duplicate other organizations and further centralize power. Relying on external partners may be more efficient but leaves the Fund dependent on institutions that are themselves under financial pressure. The answer should begin with functions: identify the capabilities countries require, decide where each is best housed, and attach financing and accountability to those arrangements.

8. How should the Fund support communities as countries assume greater control?

The incoming Executive Director will have to decide how far the Fund should go to protect community participation and services as governments assume more control over financing. Governments may resist conditions on how they spend their own resources. But transferring authority without safeguards could leave communities with less influence and services for marginalized populations without funding.

The Fund’s relationship with civil society is one of its most important strengths. In countries with few formal channels for participation, the Country Coordinating Mechanism (CCM) may be the only regular forum where communities and government shape the health response together. Civil society also scrutinizes budgets, tracks whether services reach people and holds governments accountable. As UNAIDS’ mandate and resources contract, and as PEPFAR also disengages from civil society, the Fund may face greater pressure to sustain this work.

Country ownership cannot simply become government ownership. Some governments will not prioritize marginalized populations even when they can afford to do so. Continued external financing can protect essential services, but it can also allow governments to avoid responsibility and sustain parallel arrangements. The Fund must decide when to finance community organizations and human rights work directly, what commitments to seek from governments and whether some support should continue after other grants end.

These decisions also raise questions about the future of CCMs. Their quality and legitimacy vary widely, and their role after transition remains unresolved. The Fund could strengthen CCMs as lasting forums for participation and oversight, or support other national institutions that can perform those functions. Either approach will require judging whether community representatives have real influence over budgets, services and decisions—and deciding what to do where governments deny them that influence.

9. How should power be balanced in Global Fund governance?

The Global Fund gives governments, civil society, communities, foundations and the private sector a shared role in decisions about its work. The incoming Executive Director will face pressure to change how that power is distributed, both from countries receiving grants and from potential new funders. Any formal changes will require Board agreement.

As the grant portfolio becomes increasingly concentrated in Africa, the case for greater African influence grows. That could mean changing Board representation, committee membership or leadership roles. Adding seats alone may achieve little if the same actors continue to shape funding policies and negotiate decisions. Giving implementing countries more authority would require others to share power, while preserving an independent voice for communities and civil society.

New funders could press for influence of their own. Gulf states, emerging economies, large philanthropies and technology fortunes may bring substantial resources, along with preferences about where and how the Fund spends them. The proposed Malaria Impact Accelerator, reportedly linked to a potential GiveWell partnership, could bring US$2–3 billion in additional malaria financing, raising questions about how targeted contributions would shape priorities across the Fund’s mandate.( 14 ) Offering a greater role in governance could help attract that financing, but could also make the Fund’s priorities more responsive to a small number of wealthy contributors.

The Board will need to decide what should determine influence: financial contributions, responsibility for delivering programs, the burden of disease or the experience of affected communities. Those principles should guide both greater African representation and the terms offered to new funders. Agreeing on them before negotiating individual seats would give the Fund a stronger basis for managing competing demands.

At the same time, the Board should also decide how much more of its deliberations to open to public scrutiny, including future leadership selections. Publishing selection criteria, giving candidates a public forum and explaining major decisions would help countries and communities hold the institution’s leaders accountable.

10. Can the Fund finance its next decade without diluting its model?

Successful replenishments will remain essential, and securing them will remain a central responsibility of the Executive Director. But the Fund needs a longer view than the next three-year fundraising cycle. The choice is how much effort to devote to developing new financing sources, and what conditions it is willing to accept to secure them.

A parallel ten-year financing strategy could combine traditional development assistance and new philanthropy with support for domestic financing, health insurance and blended finance. These sources serve different purposes: some would finance the Fund directly; others would help countries cover costs that grants now support. Most will take years to reach scale, so they offer little immediate relief from declining aid. Developing them now would require investment without any guarantee of substantial returns.

New philanthropy presents a particular tradeoff. Some donors will contribute through the existing allocation model; others will want to choose countries, products or programs. Accepting those conditions could bring in money that would otherwise go elsewhere. It could also leave country priorities underfunded while favored initiatives attract resources. The Fund will need to decide how much earmarking it can accommodate and when to decline an offer.

At the same time, the Fund needs continued American financing and political support, while Washington’s bilateral health MOUs place greater emphasis on direct agreements with governments. The Executive Director will need to find practical ways for the Fund’s pooled financing and country partnerships to work alongside those agreements.

The strategy should also recognize what countries contribute outside Global Fund grants. Health taxes, expanded insurance coverage and government purchases of medicines can help sustain services. The Fund could give these efforts greater weight in financing and transition decisions, while examining whether the money is actually released and reaches the people and services concerned.

The Executive Director will be judged on resources raised. The Board should also judge whether those resources help countries assume more of the cost over time. A ten-year strategy would need to reconcile both goals: keeping programs funded now while reducing their dependence on external assistance.

The questions cannot be avoided

The Executive Director will make these decisions while raising money, keeping grants moving and responding to crises. Reform will take staff time and resources already under pressure. Taking on new responsibilities will mean stopping some activities, deferring others and asking partners to do more.

Several questions will be especially difficult. Countries want greater control, but benefit from the Fund’s global purchasing power. Broader health systems investments may improve care, but make accountability for disease outcomes harder to establish. Transition can increase national responsibility while leaving marginalized populations without services. New donors can bring resources and conditions that conflict with country priorities. The Fund will also enter debates about global health reform with its own practices open to scrutiny.

There is room for disagreement about how to resolve these questions. The Board, countries, communities and donors will have to negotiate the answers. Delaying those discussions carries consequences: funding cuts, grant deadlines and individual donor agreements can determine the Fund’s direction before the partnership has agreed on it.

The incoming Executive Director’s record will include the money raised and the grants delivered. It should also include whether countries can sustain services, whether communities retain influence and whether the Fund concentrates its resources where it can achieve the most. Those are the tests that should guide its next decade.

Dr. Jirair Ratevosian is a ONE Data Fellow, a public health practitioner and global health policy expert based at the Duke Global Health Institute. His work sits at the intersection of data analysis, policy synthesis, and identifying pathways to expand equitable access to new health innovations. Previously, Dr. Ratevosian served as Chief of Staff at the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), where he led major initiatives on health equity, global health security, and multilateral financing, including U.S. engagement with the Global Fund.

Disclaimer: Publications as part of the ONE Data Fellowship Series represent independent thought on the part of the fellows and do not necessarily represent policy positions of ONE Data or The ONE Campaign, its Board members or employees.