Allocating scarce resources strategically--an evaluation and discussion of the Global Fund's pattern of disbursements.

BACKGROUND: The Global Fund is under pressure to improve its rationing of financial support. This study describes the GF's pattern of disbursements in relation to total health expenditure (THE), government health expenditure (GHE), income status and the burden of HIV/AIDS, TB and malaria. It also examines the potential for recipient countries to increase domestic public financing for health.

METHODS: This is a cross-sectional study of 104 countries that received Global Fund disbursements in 2009. It analyses data on Global Fund disbursements; health financing indicators; government revenue and expenditure; and burden of disease.

FINDINGS: Global Fund disbursements made up 0.37% of THE across all 104 countries; but with considerable country variation ranging from 0.002% to 53.4%. Global Fund disbursements to government amounted to 0.47% of GHE across the 104 countries, but again with considerable variation (in three countries more than half of GHE was based on Global Fund support). Although the Global Fund provides progressively more funding for lower income countries on average, there is much variation at the country such that here was no correlation between per capita GF disbursements and per capita THE, nor between per capita GF disbursement to government and per capita GHE. There was only a slight positive correlation between per capita GF disbursement and burden of disease. Several countries with a high degree of 'financial dependency' upon the Fund have the potential to increase levels of domestic financing for health.

DISCUSSION: The Global Fund can improve its targeting of resources so that it better matches the pattern of global need. To do this it needs to: a) reduce the extent to which funds are allocated on a demand-driven basis; and b) align its funding model to broader health systems financing and patterns of health expenditure beyond the three diseases.