Study Details

A Trickle or A Flood: Commitments and Disbursements for HIV/AIDS from the GFATM, PEPFAR and MAP


Bernstein M.  Sessions M. 


March 2007



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Center for Global Development (CGD)


Governance, funding

Study Type

A review and analysis of the disbursement policies and practices of three global health initiatives.


The aim is to provide an overview of resources committed and disbursed by three global health initiatives: the Global Fund (GF), PEPFAR, and the World Bank's MAP. The review provides an analytical framework for understanding the three initiatives: disbursement policies and practices. In addition, the study provides brief case studies of Ethiopia and Uganda.


The review analyses primary and secondary material, supplemented by interviews with former and current officials of the three global health initiatives.


This review of three GHIs’ commitment to and disbursement of funds in Uganda and Ethiopia identifies a number of challenges facing governments as they attempt to utilise large increases in external funding. Harmonisation and alignment with government systems remains a key challenge.

In 2004, the GF, PEPFAR, and MAP contributed 57% of the $3.6 billion in resources for HIV/AIDS programmes to low and middle-income countries. By 2005, they were disbursing more than $3 billion per year, with over 70% of this total coming from PEPFAR. The new resources represent a huge increase in funds at the country-level. In Uganda and Ethiopia, by 2005, total resources from these initiatives had exceeded the two governments' entire health sector budgets for 2003. The large scale of the new resources provided, and the differences in funders' disbursement procedures, meant that money was difficult to manage in Ethiopia and Uganda. Both Governments encountered challenges when utilising the money: spending was delayed, and accelerating progress in implementing the Global Fund grant required turning to actors outside the government. Disbursements also lagged behind commitments - possibly because of absorption challenges.

The three initiatives have different fiscal years, different disbursement mechanisms, and different time horizons which makes it very difficult for governments to integrate these resources into coordinated national plans and then monitor and report on how they are used.

Data availability varies between funders: the GF makes its information publicly available but MAP and PEPFAR do not. PEPFAR does not disaggregate its data by country. This makes analysis of fund disbursement very difficult.

Conclusions /

The main conclusion of the study is that funders need to work harder with governments to help ensure that external funds are harmonised and aligned with government systems, so that they can be used more effectively.


Further information can be obtained from Aisling Walsh or from Neil Spicer, or from any of the individual country researchers.

Last Updated: Friday 16th November 2007