The LifeTrust Initiative

Health, equity and globalization

Prof. Michel D. Kazatchkine

Executive DirectorThe Global Fund to Fight AIDS, Tuberculosis and Malaria

Lancet Lecture, University College, London November 24, 2008

Outline (1) • Globalization has contributed to poverty

reduction in developing countries; however there are also growing inequities

• Health has become a key focus of international action to address such inequities between the global north and south

• The Global Fund is an innovative instrument for helping to reduce global health inequities

• Significant challenges remain to sustain global health efforts

Globalization: more wealth, but also more inequity

• Unprecedented global economic growth in the past decade (BRIC bloc)

• Increased inequities within countries and between the richest and poorest countries

• Financial crisis could further exacerbate such inequities

• The proportion of people living in extreme poverty (<$1 a day) in developing countries has declined from 32% to 19% between 1990 and 2004

• But this has been accompanied by rising inequality within developing countries overall

Poverty reduction has been accompanied by rising inequality

MDG Report 2007 (UN)

Increasing income inequality between richest and poorest countries

Gross National Income per capita in nominal US dollars

YearRichest

countriesPoorest

countries Ratio

1980 $ 11 840 $ 196 60

2000 $ 31 522 $ 274 115

2005 $ 40 730 $ 334 122

WHO Commission on Social Determinants of Health 2008

Unstable relationship between economic growth and progress in life expectancy

Global economic downturn could increase inequities

• Developing country economy growth projection marked down from 6.4% to 4.5% in 2009

• An additional 40 million people in poverty in 2009

• 90% of the burden of infectious disease is concentrated in developing countries, whereas those countries account for only 20% of the world’s wealth and only 12% of global expenditure on health

• AIDS, TB and malaria are the major infectious diseases and still kill over 4 million people a year

The inequitable burden of infectious disease

Why health funding can no longer be so “soft”

• Health is a key investment for development

• Investments in health are showing results and impact

• AIDS treatment and health systems challenges highlight need for long-term effort and lifetime commitments

• Sustainability is a responsibility shared by countries and the international community

• Convergence of donor political and economic interests with global health outcomes

Breaking the silence

“I exist as a living embodiment of the inequity of drug availability and access in Africa …

... I stand before you because I am able to purchase health and vigour. I am here because I can pay for life itself.”

- Justice Edwin Cameron

International AIDS Conference, Durban, 2000

Outline (2)

• Globalization has contributed to poverty reduction in developing countries; however there are also growing inequities

• Health has become a key focus of international action to address such inequities between the global north and south

• The Global Fund is an innovative instrument for helping to reduce global health inequities

• Significant challenges remain to sustain global health efforts

Key developments

• Millennium Development Goals

• Social mobilization

• Political commitment

• New resources

• New instruments

Buenos Aires

Millennium Development Goals (2000)

MDG 1: Eradicate extreme poverty and hunger

MDG 2: Achieve universal primary education

MDG 3: Promote gender equality and empower women

MDG 4: Reduce child mortality

MDG 5: Improve maternal health

MDG 6: Combat HIV/AIDS, malaria and other diseases

MDG 7: Ensure environmental sustainability

MDG 8: Build a partnership for development

Social mobilization and political commitment

Total health ODA commitments, 2001-2006

$7.2 $7.6

$11.2$13.3

$16.5

$20.1

2001 2002 2003 2004 2005 2006

US$ Billions

UNAIDS

New instruments in global health

• World Bank Multi-country AIDS Program (2000)• Global Alliance for Vaccines and Immunization (2000)

- International Finance Facility for Immunization

• Global Fund to Fight AIDS, TB and Malaria (2002)• US President’s initiatives

- AIDS (2003), Malaria (2005), Neglected Tropical Diseases (2008)

• Unitaid (2005)• (PRODUCT) Red (2005)• World Bank Malaria Booster Program (2005)• Debt2Health (2007)• Advanced Market Commitments (2008)• Affordable Medicines Facility for Malaria (2009)

Outline (3)

• Globalization has contributed to poverty reduction in developing countries; however there are also growing inequities

• Health has become a key focus of international action to address such inequities between the global north and south

• The Global Fund is an innovative instrument for helping to reduce global health inequities

• Significant challenges remain to sustain global health efforts

The Global Fund: an innovative instrument in health and development

• A financial instrument, not an implementing entity

• Supports programs that reflect country ownership

• Evidence-based

• Performance-based

A unique partnership

MultilateralsBilaterals

Civil SocietyPrivate Sector

Patients

Affected Communities

Countries

The Global Fund: an innovative instrument in health and development

• A financial instrument, not an implementing entity

• Supports programs that reflect country ownership

• Evidence-based

• Performance-based

Global Fund portfolio

• $14 billion in approved financing

• $7 billion disbursed

• 600+ grants in 140 countries

Malaria25%

HIV/AIDS61%TB

14%

Global Fund portfolio: AIDS

Global Fund portfolio: malaria

Private/Other US$ 4.4 million (1%)

MultilateralUS$ 62.7 million (13%)

BilateralUS$ 106.7 million (22%)

Global Fund US$ 308 million (64%)

Global Fund portfolio: TB

Grants from other sources

US$ 66 million (33%)

Global Fund US$ 133 million (67%)

140 countries with Global Fund grants

BG/261107/6

1

2 (new)

3 (new)

4 (new)

5 (new)

6 (new)

7 (new)

0 5,0002,500

Kilometers ´

Targeting the poorest countries: Global Fund approved amounts by country per capita income, September 2008

0

500

1000

1500

2000

2500

3000

3500

US$ 0-1000 US$1000-2000 US$2000-5000 US$5000-10000 Other

$m

Resources go where they are needed

• Regions

– 60% of approved funds in Rounds 1-8 are for sub-Saharan Africa

– 65% of funding for orphan support is for southern Africa

• Diseases

AIDS: 35% of Global Fund financing for ART is for southern Africa

Malaria: $1.5 billion approved for 19 African countries that account for 90% of malaria burden in Africa

TB: More than $1 billion approved for 22 high burden countries that account for 80% of global TB incidence

0 2,2001,100

Kilometers ´No Global Fund grants

Global Fund grant, with financing of harm reduction

e.g. Global Fund support to harm reduction programmes

Reaching the vulnerable

0.0

0.2

0.4

0.6

0.8

1.0

1.2

1.4

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end 2002 end 2003 end 2004 end 2005 end 2006 end 2007

Pe

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py (

in M

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ns)

North Africa and the Middle East

Europe and Central Asia

East, South and South-East Asia

Latin America and the Caribbean

Sub-Saharan Africa

Global Fund supported programs

Number of people receiving ARV therapy in low- and middle-income countries, 2002—2007

Global Fund results: June 2008

GP/110608/9

Accelerating Results

0

0.5

1

1.5

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2.5

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Dec-04 Jun-05 Dec-05 Jun-06 Dec-06 Jun-07 Dec-07 Jun-08

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(milli

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15

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25

30

35

40

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ITN

s (m

illion

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DOTS

ARVs

ITNs

AIDS impact: Malawi Initial decline in workplace mortality at Escom (national electricity company) after roll-out of antiretroviral treatment

Source: Global Fund

Decline in adult mortality with introduction of ART: Botswana

0

1

2

3

4

5

6

1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

Re

gis

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Pe

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Deaths aged 25-54

Increase in TB financing and new sputum positive cases detected and treated

0.5M

41M

107M 127M

196M

276M

1.4M

0.6M 0.38M

1.9M

-

50,000,000

100,000,000

150,000,000

200,000,000

250,000,000

300,000,000

2002 2003 2004 2005 2006 2007

An

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(in

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New

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Amount disbursed (US$) New SS+ cases treated under DOTS

0

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3,500

4,000

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Jan

-01

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-05

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5

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Apr-

05

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Malaria in-patient cases

Out-patient confirmed cases

Non-malaria in-patient cases

Interventions

Incidence↓~64%

20042001 2002 2003 2005 20072006

Declining malaria in health facilities after scale-up of bed nets and anti-malaria treatment: Rwanda, 2001-2007

WHO national database

Impact: malariaTanzania accelerating reduction of child mortality (MDG 4 & 6)

Masanja et al, Lancet, 2008

Interventions: ITNs and malaria treatment with integrated

management of childhood illness

MDG targets

Addressing health systems challenges

• Human resources

• Procurement systems for drugs and health commodities

• Infrastructure

• Laboratory equipment

• Monitoring and evaluation systems

Direct funding of health systems through Global Fund grants

Health Systems

35%

Administration10%Other

10%

Commodities, Products, Drugs

45%

Infrastructure and Equipment

9%

Monitoring and Evaluation 3%

Human Resources

23%

Direct Funding of Health Systems through GFGrants (2007)

•Estimates from Global Fund Rounds 2-7 proposals•100% = $5.2 billion USD

• Direct funding of health systems through disease interventions (approximately $945 million for Round 8; more than $4 billion overall)

• Health systems support across more than one disease– $186 million approved in Round 7– $ 290 million approved in Round 8 (health workforce, information systems,

supply chain management, community service delivery)

• Expanding health system capacity- Non-government actors (NGOs, FBOs, communities, private

sector, people living with the diseases) are recipients of 50% of Global Fund funding

- Dual track financing

• Majority of Round 8 proposals included community systems strengthening

The Global Fund and health systems strengthening

Human resources

• Increasing the number of health workers– Salaries for health workers & community health workers– Salary top-up

• Training (96% of grants have a training component)

• Saving lives of health workers to return to work

• Reducing AIDS, TB and malaria burden so that health workers can focus on other health needs

Mukoma Health Centre, Rwanda (Source: PEPFAR)

Infrastructure: Support for renovation of existing health centres

*Photo courtesy of FHI

Laboratory strengthening

• 67% of TB grants included laboratory strengthening

Examples: • Chad: Newly equipped

laboratories • Philippines: Training in sputum

microscopy (public and private) • Yemen, Sri Lanka: New

laboratories established

Outline (4) • Globalization has contributed to poverty

reduction in developing countries; however there are also growing inequities

• Health has become a key focus of international action to address such inequities between the global north and south

• The Global Fund is an innovative instrument for helping to reduce global health inequities

• Significant challenges remain to sustain global health efforts

Resource needs for AIDS, TB and malaria (2009 to 2015)

Estimated resource needs

0

10

20

30

40

50

60

2009 2010 2011 2012 2013 2014 2015

US

$b

n HIV/AIDS

TB

Malaria

Sources: UNAIDS, STB, RBM

Total ODA commitments, all sectors, 2001-2006

$90.6$98.3

$121.8 $120.9

$55.4 $64.8

2001 2002 2003 2004 2005 2006

Note: Amounts in gross US$ commitments. Source: Analysis of data obtained via online query of the OECD Development Assistance Committee (DAC) Database and Creditor Reporting System (CRS) during the period June 13-17, 2008.

US$ Billions

Resources: increasing both availability and demand

$ US billion

Available resources

Demand

EstimatedNeed Available

resources and

demand

Estimated Need

21371853

2512

3298

2519 2398

5791

860 968 847726

1119

3059

620

0

1000

2000

3000

4000

5000

6000

7000

Round 2 Round 3 Round 4 Round 5 Round 6 Round 7 Round 8

Mil

lio

ns

, U

S$

Phase 1 request, million US$ Phase 1 upper ceiling request for TRP recommended proposals, million US$

Global Fund requested and approved 2-year funding (Rounds 2 – 8)

40% 34% 39% 22% 34% 47%

53%

Approval rate

Sustainability: more than resources alone• Increased and more predictable resources

(domestic, external, further innovation)• Build demand for resources• Address health systems challenges• Promote evidence-based interventions effectively

targeted to those in need• Promote human rights• Strengthen social protection • Strengthen global and local partnerships• Learn and apply lessons: research and evaluation

Increasing Coverage of Health Care in Rwanda

300,0007,800900,000

3 million

1,3 million

2 million

0

1,000,000

2,000,000

3,000,000

4,000,000

5,000,000

6,000,000

7,000,000

P rivate healthinsurance

Civilservants/Military

Genocidesurvivors,prisoners

Communityhealth insurance(398 mutuelles)

Num

ber

of b

enef

icia

ries

Global Fundsubsidy

Global Fund co-finance subsidy

Out-of-pocket and/orGovernment subsidy

44%40%

35%

72%

49%

43%

0%

20%

40%

60%

80%

P opulation coveragewith health insurance

P opulation with atleast one

consultation in healthcenter

Utilization rate ofdistrict hospitals

2005 2006

Improving Access to Health CareScaling up Health Insurance

Strengthening partnership

• Global and local

• Harmonization and alignment Paris, Accra, IHP

• UNAIDS• WHO• World Bank• UNICEF• Stop TB• Roll Back Malaria• Bilaterals • GAVI• Civil society• Private sector

• Organizational efficiency

• Effectiveness of the Global Fund as a partnership

• Impact studies in 16 countries

Study areas of the 5-year evaluation of the Global Fund (2008)