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All authors have completed the ICMJE uniform disclosure form at http://www.icmje.org/coi_disclosure.pdf.
We declare no financial or non-financial competing interests.
IY managed the research process, including model design, plot of figures, data management and analysis, interpretation of results, and co-wrote the first draft of the report. EK contributed to literature search, analysis design, plot of figures, data collection, analysis and interpretation, and the writing of the report. EB conceived the research idea, contributed to literature search, analysis design, data collection, analysis and interpretation, and co-wrote the first draft of the report. All authors read and approved the final manuscript.
Role of funding source
EB is supported by the National Institutes of Allergy and Infectious Diseases and by the Doris Duke Charitable Foundation. The funding organizations had no role in the conception or execution of this analysis.
Ethics committee approval
I, the lead author (the manuscript’s guarantor), affirm that the manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.
Since its founding in 2002, the Global Fund to Fight AIDS, Tuberculosis, and Malaria (Global Fund) has become the dominant multilateral health financier in low- and middle-income countries. The health impact of the Global Fund remains unknown because existing evaluations measure intermediate outcomes or do not account for preexisting and counterfactual trends.
We conducted an econometric analysis of data from all countries eligible to receive Global Fund grants from 1995 to 2010, prior to and during the Global Fund’s activities. We analyzed three outcomes: all-cause adult (15–59 years), all-cause under-five, and malaria-specific under-five mortality. Our main exposure was a continuous longitudinal measure of Global Fund disbursements per capita. We used panel fixed effect regressions, and analyzed mortality trends controlling for health spending, health worker density (a measure of health system capacity), gross domestic product, urbanization, and country fixed-effects.
Results and discussion
We find that following Global Fund disbursements, adult mortality rate declined by 1.4 % per year faster with every $10 per capita increase in disbursements (p = 0.005). Similarly, malaria-specific under-five mortality declined by 6.9 % per year faster (p = 0.033) with every $10 high per capita Global Fund disbursements. However, we find no association between Global Fund support and all-cause under-five mortality. These findings were consistent after subanalyses by baseline HIV prevalence, adjusting for effects of concurrent health aid from other donors, and varying time lags between funding and mortality changes.
Grants from the Global Fund are closely related to accelerated reductions in all-cause adult mortality and malaria-specific under-five mortality. However, up to 2010 the Global Fund has not measurably contributed to reducing all-cause under-five mortality.