Action for Global Health

1. Action for Global Health Policy Conference, London, 28 June 2010 Session 4: The Changing Global Health Architecture and Implications for the MDGs Presentation by Richard Manning, Vice-Chair of the Replenishment of the Global Fund

2. Health Financing Architecture • Health Aid a laboratory for aid architecture • Major scaling-up • Major results • Major controversy

3. In Theory..... • Could envisage a pure ‘horizontal’ aid delivery model, leaving recipients entirely free to allocate according to their own priorities • Meets ‘ownership’ and ‘alignment’ goals of Paris/Accra • Poses problems of enabling governments to be held to account • Risks major problems when decisions appear arbitrary or wrong • Hard to maintain donor public support

4. Also in theory..... • Aid could be entirely ‘pre-packaged’ in favour of one objective or another, by sector, sub-sector, type of recipient etc • Some attractions in terms of results focus: eg results being achieved by GAVI and GF • But poses serious issues around local ownership, sustainability, arbitrary donor decisions

5. In practice..... • Mix of aid instruments is appropriate • Differences of donor and recipient priorities need to be tackled • Donors should be consistent in bilateral and multilateral fora • A portfolio approach, involving considered priority-setting, should be adopted • This should recognise the inter-relationships among MDG outcomes • Advantages of multilateral approaches need to be highlighted, not least for scaling up actions known to be highly-effective • Special-purpose funds need to apply aid effectiveness criteria, notably on alignment; but equally have much to teach, eg on results focus • Locally-led decision-making the best means to rationalisation: the overall package has to ‘make sense’ at country level (and, for health, at patient level) • Think twice before adding new special purpose funds

6. So.... • “Global funds are an important, legitimate, and growing part of our assistance portfolio. They have strengths and weaknesses – weaknesses that are in part the unintended consequences of our own decisions. We need to help them increase their effectiveness. We need also to strike a better balance between global funds and “horizontal” assistance, and between bilateral and multilateral aid, if we are to increase the impact of our development portfolio as a whole. To do so, we will need to develop and implement, with the involvement of our political authorities, a clearer strategy that takes account of the incentives facing key stakeholders.” (Donor Schizophrenia and Aid Effectiveness: The Role of Global Funds Paul Isenman and Alexander Shakow – IDS 2010)

7. Global Fund’s added value? • The Global Fund has become the main vehicle through which donors have channeled massive new resources to address the three diseases. • By the end of 2009, the Global Fund had approved proposals totaling US$ 19.2 billion, making it the largest multilateral contributor to the health-related MDGs. • The Global Fund has created a development financing model that works.

8. Global Fund’s role in contributing to MDGs by 2015 (1) • The Global Fund is well-positioned to continue to make a major contribution to progress toward the health-related MDGs. • The Global Fund is making by the far the largest multilateral contribution to MDG 6 (combat HIV/AIDS, malaria and other diseases). • It provides about two thirds of international funding for malaria and TB and about one fifth of international funding for the response to HIV.

9. Global Fund’s role in contributing to MDGs by 2015 (2) • Global Fund supported programs are reducing under-5 mortality by: • Preventing and controlling malaria • increasing access to pediatric HIV treatment • supporting more comprehensive care, support and treatment for infants and children exposed to and infected with HIV • funding PMTCT programs.

10. Global Fund’s role in contributing to MDGs by 2015 (3) • The GF is also contributing to improved maternal health through programs scaling up prevention and treatment of HIV, TB and malaria. • reducing the largest causes of mortality among women of childbearing age, as well as reducing major causes of maternal deaths. • Almost all Global Fund-supported HIV programs provide sexual and reproductive health-related services, thereby contributing to universal access to reproductive health – the second target under MDG 5. • Global Fund investments are also contributing to maternal and child health by strengthening health and community systems, which has enabled countries to expand the delivery of primary health care services.

11. Broadening the role of the Fund to become ‘Global Fund for Health’? • The GF’s programs work across the continuum of health care and make a significant contribution to public health. • Its disease focused interventions, as well as its investments in public health are contributing to MDGs 4 and 5 and improving basic health services. • The Global Fund’s grant proposal guidelines are being sharpened to focus more explicitly on gender considerations and on the integration of maternal and child health. • At its April meeting the Global Fund Board asked the Secretariat to elaborate options for enhancing the Global Fund’s contribution to maternal and child health. • Papers on the issue will be provided to the Policy and Strategy Committee this autumn for a decision by the Board in December. • It is clear from the Board discussions that an expansion of the Global Fund’s mandate to incorporate maternal and child health can only happen if additional resources are made available. • one option could be the ring-fencing of funding provided for an MCH initiative.

12. The global fund Progress to date and likely progress under 3 funding scenarios ($13 bn, $17 bn, and $20 bn)

14. Results: Malaria in Rwanda • -By end 2007, more than 2.4 million Insecticide Treated Nets were distributed, achieving 60% coverage • -National ACT roll-out • Results: • 64% decline in child malaria cases • 66% decline in child malaria deaths (Facility data, 2005-2007) • Declining treatment demand

21. If we succeed... • By 2015, we can: • eliminate malaria as a public health problem in most malaria endemic countries; • prevent millions of new HIV infections; • dramatically reduce deaths from AIDS; • virtually eliminate transmission of HIV from mother to child; • substantially reduce child mortality and improve maternal health; • contain the threat of multi-drug resistant TB; • achieve significant declines in TB prevalence and mortality; • further strengthen health systems.

22. And if we fail.....? 1. Malaria • malaria morbidity and mortality would increase again and anti-malarial drug resistance would become a major problem; • the goal of eliminating malaria as a public health problem would become unattainable.

23. And if we fail....? 2. HIV/AIDS • millions of people in urgent need of HIV treatment would be denied such treatment, resulting in much increased morbidity and mortality, greater spread of HIV, and devastating impact on families (including orphans), communities and countries; • the yearly number of new HIV infections, which has decreased in recent years in every region with the exception of Eastern Europe and Central Asia, would rise again, resulting in millions of additional HIV infections; • hundreds of thousands of children would be born with HIV every year

24. And if we fail....? 3. TB • drug- and multidrug-resistant TB would become a major global public health problem, threatening the success of TB control efforts achieved to date and leading to substantial increases in TB prevalence and mortality

25. Progress of Replenishment • Pledging conference, New York, 4-5 October • The current economic situation – including austerity measures and funding cuts in many donor governments to address high levels of public debt – has increased the challenge • some encouraging signs (such as Japan’s recent announcement of a 27% increase for 2010 and the draft EC budget that includes an increase for the Global Fund) but the overall picture is mixed • In my view as Vice Chair, it will be a major challenge to get close to any of the three scenarios without some major and positive last-minute decisions by key donors.

26. Role of innovative Financing and FTT as potential source • Innovative Finance can play an important role. • For example, in GF: • the Debt2Health initiative, through which creditors forego repayments if part of funding spent through Global Fund approved programs • the development of exchange-traded funds (ETFs) through which the Global fund receives a portion of fees generated by the Funds. • Contributions from traditional public sector donors still provide about 95 per cent of funding for the Global Fund. • Need to be realistic about the scope for a financial transactions tax as a source of major new funding for the Global Fund or other development institutions in the near term. • But a tax of this nature, if structured appropriately, could provide the large-scale sustained funding in the orders of magnitude required to have a sustained impact on public health in developing countries.

27. So.... • civil society friends and allies of the Global Fund, and of public health generally, need to make their voices heard in donor capitals. • Particular importance of UK, as donor maintaining increases in aid and focused on results, to come to Replenishment meeting in October with a significantly increased pledge.

28. Postscript: G8 Muskoka Summit • We reaffirm our commitment to come as close as possible to universal access to prevention, treatment, care and support with respect to HIV/AIDS. We will support country-led efforts to achieve this objective by making the third voluntary replenishment conference of the Global Fundto Fight AIDS, TB and Malaria in October 2010 a success. We encourage other national and private sector donors to provide financial support for the Global Fund.