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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
1.6
1.8
2.0
2.2
2.4
2.6
2.8
3.0
end 2002 end 2003 end 2004 end 2005 end 2006 end 2007
Pe
op
le r
ece
ivin
g A
RV
th
era
py (
in M
illio
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
2
2.5
3
3.5
4
4.5
Dec-04 Jun-05 Dec-05 Jun-06 Dec-06 Jun-07 Dec-07 Jun-08
ARV
s an
d D
OTS
(milli
ons)
-
5
10
15
20
25
30
35
40
45
50
55
60
ITN
s (m
illion
s)
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
tere
d D
ea
ths (
Th
ou
sa
nd
s)
0
10
20
30
40
50
Pe
rso
ns o
n A
RV
(T
ho
usa
nd
s)
on ARV
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
nu
al a
mo
un
t d
isb
urs
ed
(in
US
$)
-
500,000
1,000,000
1,500,000
2,000,000
New
SS
+ c
ases
tre
ated
un
der
D
OT
S (
ann
ual
)
Amount disbursed (US$) New SS+ cases treated under DOTS
0
500
1,000
1,500
2,000
2,500
3,000
3,500
4,000
4,500
Jan
-01
Fe
b-0
1
Ma
r-0
1
Apr-
01
Ma
y-0
1
Jun
-01
Jul-
01
Aug
-01
Sep
-01
Oct-
01
Nov-0
1
Dec-0
1
Jan
-02
Fe
b-0
2
Ma
r-0
2
Apr-
02
Ma
y-0
2
Jun
-02
Jul-
02
Aug
-02
Sep
-02
Oct-
02
Nov-0
2
Dec-0
2
Jan
-03
Fe
b-0
3
Ma
r-0
3
Apr-
03
Ma
y-0
3
Jun
-03
Jul-
03
Aug
-03
Sep
-03
Oct-
03
Nov-0
3
Dec-0
3
Jan
-04
Fe
b-0
4
Ma
r-0
4
Apr-
04
Ma
y-0
4
Jun
-04
Jul-
04
Aug
-04
Sep
-04
Oct-
04
Nov-0
4
Dec-0
4
Jan
-05
Fe
b-0
5
Ma
r-0
5
Apr-
05
Ma
y-0
5
Jun
-05
Jul-
05
Aug
-05
Sep
-05
Oct-
05
Nov-0
5
Dec-0
5
Jan
-06
Fe
b-0
6
Ma
r-0
6
Apr-
06
Ma
y-0
6
Jun
-06
Jul-
06
Aug
-06
Sep
-06
Oct-
06
Nov-0
6
Dec-0
6
Jan
-07
Fe
b-0
7
Ma
r-0
7
Apr-
07
Ma
y-0
7
Jun
-07
Jul-
07
Aug
-07
Sep
-07
Oct-
07
Nov-0
7
Month
Mala
ria i
n-p
ati
en
t an
d o
ut-
pati
en
t la
bo
rato
ry-c
on
firm
ed
cases
0
1,000
2,000
3,000
4,000
5,000
6,000
7,000
No
n-m
ala
ria i
n-p
ati
en
t cases
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)