When the Global Fund began, its many creators — including United Nations Secretary- General Kofi Annan — envisioned it raising and spending at least $8 billion a year. But the launch in 2002 was overshadowed by the Sept. 11, 2001 attacks, and some donors cut back after the 2008 recession, so the fund has struggled to raise even half that much annually.
The United States is by far the largest donor but has its own parallel efforts, the President’s Emergency Plan for AIDS Relief and the President’s Malaria Initiative.
Nonetheless, largely because generic drug prices have plummeted, the Global Fund now claims to have saved 22 million lives in the developing world. By its count, it has helped about 11 million people get H.I.V. drugs and 17 million get tuberculosis treatment, and has paid for about 800 million mosquito nets.
In 2011, the fund struggled after accusations that it had become a swollen bureaucracy and was letting aid recipients pilfer funds. Dr. Mark R. Dybul, who was appointed in 2012, has been credited with making it more efficient and effective.
Last year, the fund was one of only three multilateral agencies to earn top grades on the “value for money” report card issued by Britain’s foreign aid department.
Mr. Sands said it would be “premature” for him to describe any changes he contemplated. He could not name any countries he thought of as model aid recipients for others to emulate.
As some aid-receiving countries become wealthier, it has been suggested that the Global Fund offer them a blend of grants and loans. Mr. Sands said he was “not particularly convinced of the logic of loans,” but wanted to trim grants in ways that do not cause local epidemics to rebound.
Selecting a replacement for Dr. Dybul has been a struggle for the fund’s board. In February, the process was halted after a report that one candidate had retweeted harsh criticisms of President Trump and that another had a potential conflict of interest as a former executive of a drug company benefiting from the Global Fund’s spending.
During his career, Mr. Sands has been credited with helping rescue Britain’s banks during the 2008 fiscal crisis and harshly criticized after Standard Chartered paid New York State $340 million to settle claims it laundered money for Iran.
He dropped out of the race for executive director on Nov. 10, and then on Nov. 12 asked to be reinstated. He said on Tuesday that he initially decided a move to Geneva would be too hard on his wife’s London-based business.
“Then I very quickly realized I’d made the wrong call,” he said.
The other candidates were Simon Bland, a former British aid official who ran the New York office of the U.N.’s AIDS-fighting agency; Frannie Leautier, an executive at the African Development Bank and World Bank; and Anil Soni, a drug-company executive who was chief adviser to the Global Fund’s first executive director.