Chapter 5 presents the book’s second comparative case study, which examines four major global health agencies: the World Health Organization (WHO); the Joint United Nations Programme on HIV/AIDS (UNAIDS); Gavi, the Vaccine Alliance; and the Global Fund to Fight Aids, Tuberculosis and Malaria (GFATM). The structure of the examination is analogous to Chapter 4’s. After enumerating the characteristics on which the four institutions are matched, I chronicle how differences in their de facto policy autonomy have given rise to disparate performance outcomes: The WHO and UNAIDS have been characterized by relentlessly declining autonomy and performance over their life cycles, Gavi and GFATM by the opposite trends. I then delve into the operational origins of these differences, which, once again, defy a purely design-based explanation. Like Chapter 4, the case study draws on extensive interviews and archival material.

In 2017, the Global Fund Board revised its Eligibility Policy, which sets out the criteria for which countries are eligible for financing. This chapter considers the impact of decisions made using those indicators, and explores debates over use of Gross National Income per capita (GNIpc) to determine aid eligibility. It also shows the role of civil society and community representatives in these high-level policy debates. Reviewing the Global Fund’s history, this chapter shows it was not the only donor wrestling with these problems of prioritization, and that in many countries the Fund was the last remaining external HIV donor to transition out. When some middle-income countries with concentrated epidemics among key populations saw multiple donors divest, programs for key populations, such as harm reduction, were at risk. In revising the Fund’s Eligibility Policy, the high-stakes contest was focused on a brief document of just a few pages, in which changing a single indicator could have sweeping consequences for countries such as Russia, where the Fund supported civil society advocacy for key populations. This chapter shows how three civil society delegations worked together to advance a shared position on the policy.