Global Fund replenishment brings us one step closer to ending tuberculosis

In September, 2018, global leaders pledged their commitment to ending the tuberculosis epidemic at the first UN High-Level Meeting (UNHLM) on tuberculosis. They promised to invest resources to achieve a set of ambitious global targets, including treating an additional 40 million people with tuberculosis by 2022.1UN General AssemblyPolitical declaration of the high-level meeting of the General Assembly on the fight against tuberculosis.https://undocs.org/A/73/L.4Date accessed: December 12, 2018Google Scholar 12 months later, we are on the eve of the Global Fund to Fight AIDS, Tuberculosis and Malaria Sixth Replenishment conference, to be held in Lyon, France, on Oct 10. If this conference is successful in reaching its US$14 billion target, the Global Fund estimates it will be able to treat 33 million people with tuberculosis over the next 3 years, including 1 million people with drug-resistant disease.2The Global FundStep up the fight investment case, sixth replenishment.https://www.theglobalfund.org/media/8279/publication_sixthreplenishmentinvestmentcase_report_en.pdf?u=636898877700000000Date accessed: August 29, 2019Google Scholar However, the success of Global Fund replenishment goes beyond simply funding tuberculosis programmes. A fully funded Global Fund is necessary to tackle the epidemic in many of the highest burden countries, build strong domestically financed and managed programmes (especially in middle-income countries), and ensure that all countries have the resources and capacities needed to carry forward sustainable, equitable, and effective programmes to fight tuberculosis. The Global Plan to End TB 2016–20 charted an ambitious but feasible path to end the tuberculosis epidemic by 2030.3Stop TB PartnershipGlobal Plan to End TB: the paradigm shift.http://www.stoptb.org/global/plan/plan2/Date: 2016–2020Date accessed: October 6, 2019Google Scholar Unfortunately, globally, we are way off course towards that goal4Reid MJA Arinaminpathy N Bloom A et al.Building a tuberculosis-free world: The Lancet Commission on tuberculosis.Lancet. 2019; 393: 1331-1384Summary Full Text Full Text PDF PubMed Scopus (178) Google Scholar in large part because of severely under-resourced programmes. Donors and national governments need to step up their investments if we are to get back on track to end tuberculosis, and a successful Global Fund replenishment is the first step. Donor investments in tuberculosis fall far short of the annual $2·6 billion in donor assistance called for in the Global Plan.5WHOGlobal tuberculosis report.http://www.who.int/tb/publications/global_report/en/Date: 2018Date accessed: October 6, 2019Google Scholar Donor financing, especially targeted at the highest tuberculosis burden, low-income countries, needs to increase substantially to make up for funding shortfalls over the past few years. These donor funds not only provide essential support to low-income countries, but also are key to leveraging additional co-financing from national governments. The 2019 replenishment alone is anticipated to spur an additional US$13 billion of domestic investment for tuberculosis programmes by 2023.2The Global FundStep up the fight investment case, sixth replenishment.https://www.theglobalfund.org/media/8279/publication_sixthreplenishmentinvestmentcase_report_en.pdf?u=636898877700000000Date accessed: August 29, 2019Google Scholar Many current recipients of tuberculosis financing are middle-income countries that, based on their disease burden and economic growth, will soon become ineligible for Global Fund investment. Over half of country-specific tuberculosis financing is directed towards these countries4Reid MJA Arinaminpathy N Bloom A et al.Building a tuberculosis-free world: The Lancet Commission on tuberculosis.Lancet. 2019; 393: 1331-1384Summary Full Text Full Text PDF PubMed Scopus (178) Google Scholar that are rapidly becoming too wealthy to qualify for donor support.6Silverman R Projected health financing transitions: timeline and magnitude–working paper 488. Center for Global Development, Washington, DC2018Google Scholar Donor funds can play an essential role in ensuring that transition does not threaten progress towards elimination in middle-income countries. First, transitional finance can be leveraged to support the development and implementation of robust domestic financing strategies crucial for tuberculosis programme sustainability, including resource mobilisation plans; budget prioritisation and management; efficiency and targeting measures; and the implementation of health insurance, social contracting, and other systems strengthening initiatives. Second, donor funds are crucial sources of finance for programmes targeting vulnerable and marginalised communities, including people with HIV, immigrants, and prisoners. Often, countries do not have sufficient political will to invest in programmes for these communities, and donors step in to close the gap. A fully replenished Global Fund will enable investments directed to social insurance schemes that protect these groups during those crucial transitionary periods when neither domestic political will nor financial resources are readily available. Although there is no denying that greater domestic resource mobilisation is essential to end the tuberculosis epidemic, the Global Fund and other donors continue to have a major role to play. The process of transitioning from donor to domestic financing must be done judiciously. Many transitioning countries face challenges, such as indebtedness, weak governance and public institutions, and high inequality.7Yamey G GD Bharali I Flanagan K Hecht R Transitioning from foreign aid: is the next cohort of graduating countries ready?.http://centerforpolicyimpact.org/wp-content/uploads/sites/18/2018/03/Transition-from-foreign-aid_DukeCPIGH-Working-Paper-final.pdfDate accessed: October 6, 2019Google Scholar In this context, transition might have crucial effects on the quality and coverage of services, especially for vulnerable populations. There is a pressing need for rigorous research to determine metrics and best practices for when and how donor transition should occur. This transition must be accompanied by a new technical and implementation agenda, supported by the Global Fund, civil society, and academia, but led by countries. This agenda should focus on building sustainable donor-independent country programmes. A successful sixth replenishment will enable to the Global Fund to act as a powerful driver of effective transition, while also securing achievement of the UNHLM targets between now and 2022. The UNHLM showed that there is substantial political will to end the tuberculosis epidemic; a fully funded Global Fund can translate that political will into sustainable action. We declare no competing interests.