Conversations from AIDS 2012: General Manager of the Global Fund

Gabriel Jaramillo, interim general manager of the Global Fund to Fight AIDS, Tuberculosis, and Malaria
John Donnelly
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WASHINGTON, DC — Gabriel Jaramillo is a newcomer at the International AIDS Conference in Washington, and yet he’s one of the most watched people here. He has been a highly successful financier and banker – he was the former chairman and CEO of Sovereign Bank – and took $1 in salary to become the general manager of the Global Fund to Fight AIDS, Tuberculosis and Malaria. The position is for one year only.

Six months into his term, he has done more than shift the chairs at the Global Fund, which in a decade has supported AIDS treatment for 3.6 million people, TB treatment for 9.3 million people, and paid for 270 million insecticide-treated nets to prevent malaria. Jaramillo wants to transform the Global Fund. This makes some people uneasy. He told John Donnelly the Fund needs to a complete management overhaul in order to be prepared for its second decade.

Q: Why did you take this job?

A: I was retired. I wanted to contribute, make a difference. I could have done many things, but I thought that introducing private sector practices into global health is something that would create value, and it would be a very good way to contribute. So last year I worked on malaria through the UN Special Envoy. I learned about the Global Fund through being part of the High-Level Global Panel (that looked at the Global Fund’s fiduciary controls and oversight). I became passionate about the Fund. The Fund is a fantastic idea, one that works and has provided phenomenal resources. So this year, I’ll do this, and next year I’ll see what I can do to contribute private sector practices to add value to global health. I think a common thread in global health is poor management, and I can contribute a lot.

Q: Why is there such poor management in global health?

A: Because it is very technical, very specialized, and today it is recognized that good business models and good management practices can give you better impact for your money. There is less passion and more interest in results.

Q: Less passion?

A: And more interest in results. I don’t like that phrase, though.

Q: What problems jumped out at you?

A: The first is that what works in this kind of venture is what is called the golden triangle, which has the right mix of civil society, the public sector, and the private sector. We were clearly short in private sector so we balanced that out. When you have the right combination of those three elements, you have the best environment for being innovative and for moving forward. We needed the right component of private sector in that triangle. We have brought very good private sector management in the Global Fund, and I think over time that will be the real transformation of the Fund, this combination of the golden triangle.

Q: What does that mean in terms of your daily work?

A: Well-understood strategies. Clear execution plans. Good oversight of the implementation. Those are all big words. At the end of the day, it’s being very nimble, and every day it’s reviewing the operation to get better. It’s never good enough, it can always get better. We save 100,000 lives a month. If we get 10 percent better, we save 10,000 more lives a month. Everything is susceptible to improving 10 percent. That is the obsession that has to be there. We can do it better every time. If you have that mentally, and that’s where the management mentality comes in, you will always be improving.

Q: So how will the outside world see these changes?

A: We have opened up the Fund to the partners. In our investment committee, if you can call it that, we have approved reprogramming – right now $7 billion in the next 18 months – and we are inviting our partners to the table. That means other bilateral institutions, such as PEPFAR (President’s Emergency Plan to Fund AIDS Relief), PMI (President’s Malaria Initiative), the technical agencies such as RBM (Rollback Malaria), Stop TB. We are inviting implementing countries, civil society, and the private sector to opine of the quality of the investment we are about to decide upon.
The other change is reform of the disease committees. Once a month, we have a malaria committee, a HIV/AIDS committee, a TB committee. We get together with our allies to see how we are doing against the war. We can establish if we are winning or losing and we correct the course. It makes so much sense. If you are in a war, you might as well get together with your allies once a month and review operations with them.

We work well with PEPFAR today, we will work better with PEPFAR tomorrow. We are complementary. We are both shooting at the same enemy. Being side by side is the way to go. We do this with the other bilateral agencies as well. This makes sure shooting at the right enemy, that there’s no friendly fire. It’s just so logical. Yes, we didn’t do that in the past. We are doing it now.

Q: What are you impatient about now?

A: What keeps me awake this week is that we need a very clear understanding of the demand in the countries so we can really shoot strategically where we get the best bang for the buck, where are the unserved opportunities, where is the burden hitting the hardest. If you find that in business, that is gold. That is where the opportunities are. That is where I am devoting a lot of my time right now.

Q: Are you saying that people in lead of this fight against the three diseases of AIDS, TB, and malaria don’t really know where demand is?

A: What I’m saying is, we want to know where the demand is. If we have the full picture, we know where the best place to use our scarce resources.

Q: Can you give me an example of what you don’t know?

A: One example of what we don’t know in some environments is who is providing AIDS services for men who have sex with men, and how big that population is, and what is the best way to cater to that demand.

You know at the beginning of the war you could shoot anywhere and you will hit the diseases. As we advance, we have to be more specific with the populations and the geographies and what is happening with the epidemiology. As we move on, that enemy has changed it face, and we have to be better.

Q: Is the Fund a reactive agency?

A: We are demand-based, I wouldn’t call it reactive. Once we know where the opportunities are, then we can talk to our partners to see who is going to take care of them. We can also motivate the countries to come to us for specific funds for very specific populations because we know they will be very effective. We will be geared to make that investment because the returns are so huge, and that is what my donors what to hear. They want to know from me that I know where we are putting that money and I understand what kind of impact we are going to get. I am very targeted at what I am doing, and that’s the name of the game now. Money is scarce, donors are more demanding. Rightly so.

Q: How much more time do you have left in your job?

A: Six months.

Q: And if you do not want to go?

A: I will leave.

Q: Even if you are not done?

A: Jobs are never finished. But we will have created a culture of profound change in terms of effectiveness at the Global Fund. The Global Fund has been a fantastic experience for the last 10 years. Now we are transforming the Fund for the next 10 years. We will do the ground work for that. From then on, it’s just the right culture, the right management. It doesn’t have to be me. My contribution is to help the Fund prepare itself for new times.

One part of that is that knowledge on the diseases is in the countries, it’s not in the Imperial College (in London). If you go to Nigeria today, you discuss the issues with sophistication, the best knowledge, the knowledge that works. A second is donors are more demanding, and third the countries have gotten good at this war. It’s a great moment. It is a sweet spot. It’s the moment you scale up investment. We are preparing this Fund to this new world. I see it as an opportunity. That’s my contribution.

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