Coordinating funds against HIV/AIDS is proving difficult.

The Global Fund to fight AIDS, Tuberculosis and Malaria has distributed significant amounts of money worldwide via Country Coordinating Mechanisms (CCM), whose role is to apply for grants from the fund, and principal recipients within each country who are legally responsible for local disbursement of funds and overseeing of sub-recipients. In the first rounds of grant funding the UN Development Programme was frequently the principal recipient, but in order to promote development of local capacity and ownership, national organisations, via CCMs, have more often become principal recipients.

Analysis of the early stages of the process in four African countries shows that the CCMs have often been ineffective in fulfilling their mandate. This has partly been due to delays in guidelines about their function, the limited capacity of recipients to meet Global Fund conditions for performance-based disbursement and delays in payment of funds. Many of the principal recipients are also often portrayed as unnecessarily slowing down the allocation of funds, but their problems often arise because they are small or young organisations without the networks and support required to achieve the tasks for which they are responsible. It is therefore time for the Global Fund secretariat to re-analyse the role of the principal recipients to further value and support them in their difficult role.

The Global Fund is one of several new global initiatives superimposed on existing country systems to finance the control of HIV/AIDS. WHO's "3 x 5" goal to have 3 million people in low and middle income countries on antiretroviral therapy by the end of 2005 is a particularly ambitious target, at an estimated cost of between US$5 and 6 billion. These initiatives require a higher level of coordination than is currently apparent. (1-3)

(1.) Hruska AJ. The Global Fund's principal recipients ... or neglected partners. Lancet 2004;364:918-20.

(2.) Gutierrez JP, Johns B, Adam R, et al. Achieving the WHO/UNAIDS antiretroviral treatment 3 by 5 goal: what will it cost? Lancet 2004;364:63-64.

(3.) Brugha R, Donoghue M, Starling M, et al. The Global Fund: managing great expectation. Lancet 2004: 364:95-100.