The Global Fund to Fight AIDS, Tuberculosis and Malaria has spent the last five years test-driving a new approach to global health financing.

Guided by the principles that the broad participation of local stakeholders, combined with high levels of transparency and accountability, lead to improved results from aid money, the approach has so far produced encouraging returns: the Global Fund estimates it has saved 1.46 million lives by its grants to 450 programmes in 136 countries.

But as the Global Fund's founding executive director, Sir Richard Feachem, reaches the end of his term and prepares to hand over to Prof Michel Kazatchkine on 1 April 2007, the agency is faced with the challenge of moving smoothly from start-up to being an efficient, well-established organisation.

Feachem spoke to IRIN/PlusNews about the Fund's journey from its beginnings in global health financing to one of the leading forces in efforts to combat TB (tuberculosis), malaria and HIV/AIDS.

One of the most controversial elements in the Fund's policy is its "hands-off" approach, which aims to make the processes of grant application, implementation and reporting as country-driven as possible. Feachem explained that basing disbursements on performance places the responsibility for keeping the money flowing on grant recipients.

"I think it's the first truly post-colonial approach to development finance and it's long overdue," he said.

The downside has been the potential for corruption and mismanagement: the Global Fund has already terminated grants to Uganda and Chad over such concerns.

Country Coordinating Mechanisms (CCMs), made up of representatives from the government, civil society, the private sector and donors, submit grant proposals to the Fund and oversee implementation, with the goal of encouraging local ownership of programmes supported by the Global Fund, but Feachem is the first to admit that the CCMs have worked "very well in some countries, very badly in a few countries and so-so in others."

In some cases, CCMs have been appropriated by one sector, typically the government, and voices from other sectors have not been heard; in others they have been plagued by conflict of interest on the part of members.

A criticism often levelled at international donor agencies is that they have poured huge sums of money into HIV/AIDS programmes without considering either the weak capacity of developing countries to absorb the funds or the need to strengthen health systems more broadly.

"When the Global Fund started, critics and sceptics said that the absorption capacity [of developing countries] was too weak, and that they would not be able to use this money. This has been shown to be absolutely wrong," he said. "Global Fund money has been effectively used by NGOs [nongovernmental organisations], churches and governments to scale up their programmes."

According to Feachem, half of all Global Fund grants are spent on activities to improve health systems, such as recruiting, training and retaining health workers, and purchasing equipment. "But the overall task of strengthening health systems is a large one, and it is beyond the scope of the Global Fund's mandate," he added.

He shares concerns about the predictability and sustainability of donor funding for HIV/AIDS programmes that will need to be financed for many years to come. Despite the Global Fund's best efforts, he admitted, "we can't guarantee that; we live in an uncertain world, and our recipients live in an uncertain world."

While there is an urgent need for the international community to agree on long-term, binding commitments, Feachem feels that decisions about what the money is spent on should be less influenced by "trendiness" and "volatility of opinion".

"If we believe fighting HIV/AIDS is a very high priority and will take three more decades, then we should put money behind that belief, and we should stop inventing new priorities," he said.

Despite its achievements, Feachem wished the Global Fund had been able to do more under his stewardship. "I think we can see the light at the end of the tunnel, I think we can see the corner, but we haven't turned the corner yet and that's a disappointment."

He described the Global Fund's work of raising money and distributing it in a transparent and accountable way as "easy" in comparison to the work being done in recipient countries by thousands of men and women, who are responsible for delivering the programmes and translating the money into infections averted and deaths prevented.

Feachem's message to his successor is simple: "remain very ambitious, remain very innovative, remain very bold and keep taking risks."