Strengthening and Leveraging Key Multilateral Institutions


H.E Hifikepunye Pohamba, President of the Republic of Namibia, opened the 2009 HIV/AIDS Implementers? Meeting in Windhoek, Namibia on June 10, 2009. The meeting was hosted by the Government of Namibia and co-sponsored by PEPFAR; the Global Fund to Fight AIDS, Tuberculosis and Malaria; UNAIDS; UNICEF; the World Bank; the World Health Organization; and the Global Network of People Living with HIV. The conference focused on three major themes: sustainability, efficiency and effectiveness, and prevention. Photo by Lukas Amakali

Strengthening and Leveraging Key Multilateral Institutions

Key Points:

  • PEPFAR's success is linked to the success of its multilateral partners, particularly the Global Fund.
  • Through the GHI, the USG will expand engagement with key multilateral institutions and global health partnerships in support of a comprehensive approach to achieving the Millennium Development Goals (MDG) and other core objectives.
  • In order to ensure the long-term sustainability of the Global Fund, PEPFAR will support reforms that create conditions for eventual transition of some PEPFAR programs to Global Fund mechanisms.
  • PEPFAR will support efforts by UNAIDS to mobilize global action and facilitate adoption of country-level changes that allow for rapid scale-up of key interventions.
  • Given the important role of WHO as the key normative global health institution, PEPFAR is working to expand collaboration and promote best practices with this organization.
  • PEPFAR will expand efforts to coordinate with multilateral development banks and support their health systems investments.



Since the inception of PEPFAR, the USG has considered both bilateral and multilateral efforts essential in achieving durable success in the fight against AIDS. PEPFAR needs to work with and through others to build political will, establish international norms, ensure a broad-based multisectoral response, and support service delivery. In addition, through its work with multilateral partners, PEPFAR is able to leverage its investments, mobilize resources, and provide stable external financing.

The need for a coordinated multilateral response is even greater today than it was five years ago. As PEPFAR shifts from an emergency response, it is expanding work with multilateral organizations and bilateral partners, and increasing country-level and international commitment to financing and implementation.

The Obama administration is committed to a collaborative, transparent, and integrated approach to international health and development challenges. PEPFAR's success is linked to the success of multilateral mechanisms like the Global Fund and multilateral partners like the UN system.

Over the next phase of PEPFAR, the program is working toward an international consensus on the scale of the global HIV/AIDS need, as well as the increased political and financial commitments necessary to meet it.

Global Fund to Fight AIDS, Tuberculosis, and Malaria

The Global Fund is a unique global public-private partnership dedicated to attracting and disbursing resources to prevent and treat AIDS, tuberculosis, and malaria. As a partnership among governments, civil society, the private sector and affected communities, the Global Fund represents a new approach to international health financing.

Since its creation in 2002 and with strong financial support from the USG, the Global Fund has become the main external financing mechanism for programs to fight AIDS, tuberculosis, and malaria. It has approved funding of $18.7 billion for more than 600 grant programs in 144 countries. Worldwide, of all international financing, the Global Fund provides approximately one quarter for AIDS, two-thirds for tuberculosis, and three quarters for malaria.

PEPFAR strongly supports the Global Fund. The United States made the founding contribution to the Global Fund, and remains its largest donor. The USG has contributed more than $4.3 billion to the Global Fund to date, with additional pledges that bring the total USG commitment through fiscal year 2009 to $4.5 billion. In addition to these direct contributions, PEPFAR provides specific technical assistance funding for grant implementation and oversight. By working through the Global Fund, the USG can catalyze contributions from other donors, expand the geographic reach of USG bilateral programs, promote country ownership, and increase the sustainability of national health programs.

The Global Fund model represents an inherently country- owned approach, which fits well with PEPFAR's goal of supporting increased country ownership of national HIV/AIDS programs. This goal is critical to the long-term sustainability of AIDS responses and can be supported through a robust and coordinated multilateral response. PEPFAR is working with both the Global Fund and the UN system to support increased country ownership in a coordinated manner. The Global Fund can provide countries with predictable, performance-based financing, and the UN system has the mandate, country presence, and expertise to build country-level capacity and leadership. Nevertheless, continued USG engagement and support at the country level will be essential in supporting a full transition to country ownership. Consequently, PEPFAR will expand the engagement of its country teams with its country-level Global Fund counterparts and processes.

PEPFAR is also supporting a shift in Global Fund grant architecture. This shift would move it from a project-based approach to a program-based approach supporting comprehensive national responses to AIDS, tuberculosis, and malaria. These reforms are intended to consolidate and rationalize country programs and reporting requirements, harmonize Global Fund financing with country-level fiscal and planning cycles, and reduce transaction costs. By reducing duplication of effort at the country level, both PEPFAR and the Global Fund will enable countries to identify gaps in services, and achieve better value for money.

PEPFAR's long-term goal is to see more management and operation of bilateral programs conducted by the countries themselves, with financial support through the Global Fund. In order to promote this goal, PEPFAR is working to improve grant performance, quality, and consistency of services, and transparent and accountable financial management. PEPFAR is continuing efforts with the Global Fund Secretariat, its Inspector General, and its Board to improve the impact, oversight, and cost-effectiveness of Global Fund grants. Financial and program accountability is paramount to ensuring that PEPFAR funds are effectively leveraged and that, ultimately, programs are successfully implemented.

Joint United Nations Programme on HIV/AIDS

UNAIDS is an innovative venture of the United Nations family, comprising a Geneva-based Secretariat and 10 cosponsoring bodies: the World Health Organization, the UN Development Programme, the UN Office on Drugs and Crime, the UN Children's Fund, the UN Population Fund, the International Labor Organization, the World Food Program, the UN High Commissioner for Refugees, the World Bank, and the UN Educational, Scientific, and Cultural Organization.

UNAIDS is guided by a Programme Coordinating Board (PCB) with representatives from 22 governments from all geographic regions, the UNAIDS Cosponsors, and ten representatives of nongovernmental organizations, including associations of people living with HIV. UNAIDS is widely viewed as UN reform in action.

UNAIDS has field-based staff and works directly in 70 countries, addressing HIV/AIDS primarily through country- coordination theme groups that seek to mobilize all sectors to address AIDS. The UN system is an important partner because of its power to convene. UNAIDS also provides technical support for country-led strategies, provides robust global-level strategic information, and ensures the meaningful involvement of civil society in efforts to combat the epidemic.

The gains made to date in the fight against AIDS are largely due to a multisectoral approach that recognizes both the clinical needs and structural contributors to the epidemic. The UN system is an essential part of this multisectoral and rights-based approach, and UNAIDS has been an effective mechanism within that system to mobilize and coordinate Member States. Increasingly, UNAIDS is at the forefront of global efforts to mobilize additional resources and forge coalitions to leverage the AIDS response in achieving broad-based health and development objectives.

In this next phase of PEPFAR, the USG will, as a board member and major funder of UNAIDS, continue to be a strong supporter of the organization. UNAIDS serves as the mechanism through which to organize and maintain momentum in the UN system's response to the epidemic. PEPFAR will partner with UNAIDS as a convener and norm-setter to facilitate increased action and attention in certain areas of the epidemic. In particular, PEPFAR views the UN system as able to contribute effectively to rapid scale-up of cross-cutting gender interventions, PMTCT, male circumcision, and prevention among injecting drug users (IDUs).

While most parts of the Joint Programme are not programmatic implementers, UNAIDS can establish and disseminate international norms, build political will, and provide technical support at the country level around these interventions. PEPFAR will also collaborate with UNAIDS to strengthen national ownership of the response to HIV and support a multilateral process to build upon country-level processes through which global need and global resources for the fight against HIV are identified.

World Health Organization

As the global norm-setting body for public health, WHO builds support for best practices, including PMTCT, and disseminating promising new interventions like male circumcision. The WHO provides technical support to governments, helping them develop National Strategies that include guidelines for minimum packages of services. In addition, the WHO is a global leader in the area of health systems strengthening. PEPFAR and WHO are discussing a four-year strategic framework that emphasizes, among other areas, collaboration in health systems strengthening, strategic information, antiretroviral treatment, prevention, and the challenges posed by HIV/TB coinfection. PEPFAR and WHO are continuing collaboration to promote best practices and make progress on a number of specific challenges related to the epidemic.

Multilateral Development Banks

Multilateral development banks like the World Bank and the International Monetary Fund play important roles in financing and economic and policy analysis that inform both HIV/AIDS work and broader development policy. In its next phase, PEPFAR will expand efforts to coordinate with these organizations to improve the performance of their health systems investments. It will also work to better integrate PEPFAR services with their broader economic development efforts.


Moving Forward with Strengthening and Leveraging Key Multilateral Institutions

Years 1-2 -

  • Expand work with multilateral organizations and bilateral partners, increasing country-level and international commitment to financing and implementation.
  • Support Global Fund efforts to shift grant architecture to program-based approach.
  • Expand engagement with UNAIDS around gender, male circumcision, PMTCT, and comprehensive packages of care for IDUs.
  • Complete development of PEPFAR/WHO strategic framework.
  • Engage with multilateral development banks around health system investments.

Years 3-5 -

  • Increase alignment of PEPFAR and Global Fund funding with national plans based upon new grant architecture.
  • Harmonize PEPFAR, UNAIDS, and Global Fund indicators in support of country-level objectives.
  • Continue efforts with multilateral partners in building country capacity to deliver services and manage distribution programs.




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