A Question of Will
LAST WEEK President Bush hosted a White House summit on malaria. "We know exactly what it takes to treat and prevent the disease," Mr. Bush said, referring to insecticide-treated bed nets and other simple measures. "The only question is whether we have the will to act." The day before the malaria summit, the question of will was raised again by the announcement of an AIDS breakthrough. According to clinical trials conducted in South Africa, Kenya and Uganda, male circumcision can cut the chances of HIV infection by perhaps 60 percent; on one estimate, making circumcision widely available could avert 3 million deaths over 20 years in sub-Saharan Africa. The question is whether health systems in poor countries will be boosted so that circumcision is an option for those who want it.
Action on such issues requires institutions; unfortunately the Global Fund for AIDS, Tuberculosis and Malaria is in disarray. The fund provides one-fifth of all donor funding for AIDS, nearly half for TB and two-thirds for malaria; it is central to the battle against all three diseases. But five years after its creation, the fund's first leader, Richard G.A. Feachem, is stepping down; last month, donors and recipient countries on the organization's board deadlocked over the choice of a successor.
The uncertainty over the Global Fund's leadership is compounded by uncertainty over its business model. The fund started out as an institutional experiment in the aid world: It kept overheads low by resolving not to design programs, instead collecting and evaluating funding requests prepared by agencies in poor countries. The principle here is attractive: If donors cede control over the design of programs to recipient countries, the recipients will feel a greater stake in their success and will implement them better. But in practice, poor countries often need technical assistance, both to design programs and to deal with implementation headaches such as negotiating the procurement of medicines.
Until the fund's leadership question is resolved and until the new leader finds the right balance between hands-off and hands-on, there will also be uncertainty about the fund's finances. Over the past five years, the fund has disbursed just over $3 billion to 136 countries -- a quick start for a new agency. But the fund needs to grow, perhaps providing half of the $8 billion-plus per year that's reckoned to be needed to meet the challenge of these three diseases. Without this sort of boost, there won't be enough money to deploy the medical tools that already exist, let alone to make use of new discoveries such as last week's on circumcision.