Office of the Inspector General

Message from the Executive Director: Global Fund Grants in India

09 May 2023

According to the United Nations, India has now become the world’s most populous country and is projected to be the fastest growing economy in 2023 and 2024. India has long been an effective strategic partner of the Global Fund, both as a grant implementer and as a donor, and continues to demonstrate strong leadership in global health – by leading on the digital health agenda during its G20 presidency, and also notably by setting the ambitious and inspiring goal of ending tuberculosis (TB) in India by 2025, five years ahead of the targets set by the UN Sustainable Development Goals.

India is the largest economy of all countries supported by the Global Fund. Because of this economic position, the Indian government provides the main bulk of funding for its HIV, TB and malaria programs through domestic financing, with Global Fund investments performing more of an innovative and catalytic supporting role, with funding amounting to US$155 million for HIV, US$280 million for TB, and US$65 million for malaria for both government and nongovernmental organization grants. As India is governed under a federal structure, health care financing and services are shared between the central government, its states, and union territories. All implementers in the country work together, including communities, to implement strong programs.

For India’s sixth grant cycle, 60% of the total Global Fund country allocation (US$300 million) was implemented under a Payments for Results model, with its targets aligned to India’s national strategic plan objectives. This model directly links the disbursement of Global Fund investment to the achievement of specific programmatic results. Essentially, it is a modality in which the Global Fund makes payments based on the verification of results being achieved. It also provides both strategic and operational benefits that support increased flexibility, agility, and innovation in grant implementation. India is only the second country to receive the majority of its Global Fund investment through a Payments for Results modality, and the first at this scale.

A 2023 Office of the Inspector General (OIG) audit report on India notes the unique role that the Global Fund and its grants play in combating HIV, TB and malaria in India. The audit report also contains observations regarding the sustainability and transitioning of Global Fund-supported TB and HIV activities and investments to domestic financing and management. While the Secretariat acknowledges the OIG’s observation of challenges regarding sustainability and transitioning, it declined the need for a management action to respond to these concerns. In a country as complex and sophisticated as India, there are a multitude of factors that constitute transitional arrangements at the scale and capacities of different states. The Global Fund Secretariat believes there is already substantive evidence of planning and achievements in this regard. The Global Fund Secretariat is committed to working in collaboration with the government of India in the spirit of its strong partnership to continue to advance sustainability.

When considering the achievements and challenges associated with India’s fight against HIV, TB and malaria, the devastating impact of COVID-19 on the country, its health care system, and its people must be recognized. During this period under review for the OIG audit, the operating capacity of all Global Fund implementing partners and stakeholders in India was greatly hindered by COVID-19. Pandemic-related population movement restrictions and the redirection of human and financial resources severely impacted the delivery of health services.

Despite these obvious challenges, the OIG audit report recognized that Global Fund-supported interventions contributed to strong TB programmatic results, including reductions in missing cases and increases in treatment coverage. India’s health systems demonstrated resilience in recovering from the impact of COVID-19; TB case notification and treatment coverage were not only brought back on track but also surpassed pre-pandemic levels. The OIG audit report correctly notes that the government’s strong political commitment to the ownership of the TB program was (and continues to be) critical to this success.

This commitment, along with India’s new and innovative approaches to TB detection and treatment, is vital to the country’s continued success in combating TB. These elements are also instrumental in the global fight against TB given that India accounts for 26% of the global TB burden. We cannot move the needle globally on TB without the leadership of India, and the example India sets for other countries to eliminate TB is bold and inspiring. The OIG audit report also recognized that Global Fund investments have supported solid programmatic results in India for HIV. India’s national strategic plans and objectives have resulted in a reduction in AIDS-related deaths since 2010, and its innovative approaches have improved HIV treatment, care and support.

Looking forward, the Payment for Results model will continue to offer an innovative approach to support the government of India’s ambitious disease elimination agenda. As noted in the OIG audit report, there are some areas for improvement in the design, operationalization, risk assessment, mitigation and assurance mechanisms which would enable the Payments for Results model to be implemented more effectively, particularly in the context of future grants. The Secretariat is already working to establish a framework and guiding principles to aid the design and delivery of the Payment for Results model in India and in countries where it may be used in the future.

Importantly, the Global Fund is looking beyond grant implementation to find new ways to elevate our relationship with the government of India. Together, we must create more opportunities to further India’s leading role in global health. We look forward to developing and enhancing that relationship with the government of India as well as Indian NGOs, communities, the generic pharmaceutical industry and digital health innovators. India is leading the way in advancing new technologies such as molecular diagnostic tools for TB and TrueNat TB detection, as well as new vaccine and treatment manufacturing and development, and we welcome the benefits these innovations will deliver for global health.

We thank the OIG for this audit report. The work of the OIG continues to complement the active grant management and risk oversight and controls put in place by the Secretariat and upholds our proactive approach of full transparency and accountability of grant performance. The report highlights both the challenges and the successes on which we can build in the future. The Global Fund is committed to continuing our investments in India and working with the country as we seek to accelerate progress toward ending HIV, TB and malaria as public health threats.