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 2016, Venezuelans living with HIV asked the Global Fund to Fight AIDS, Tuberculosis and Malaria for emergency aid. But despite an economic catastrophe, Venezuela’s high national income made it ineligible. Data on HIV that might have helped was censored or had never been gathered. The public debate around this case highlighted the growing use of indicators and data in global health finance. Mathematical models had shown that ending HIV was achievable through rapid scale-up of testing and treatment to meet the Sustainable Development Goal of “ending AIDS” by 2030. But funding for the global HIV response has leveled off, and was not enough to meet the goals everywhere. Bilateral and multilateral donors were targeting funds where they could have the greatest impact, especially in Sub-Saharan African countries where HIV prevalence is high and national incomes low. Donors also needed to show progress to the politicians who approve their budgets. Yet how progress is measured through indicators and data is contested, including by civil society. As an example of how indicators can become sites of contest and levers of political power, the chapter examines Global Fund corporate Key Performance Indicators (KPIs) on lives saved, service coverage, and health systems strengthening.