Health, equity and globalization
Prof. Michel D. Kazatchkine
Executive Director
The 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
Poverty reduction has been accompanied by
rising inequality
MDG Report 2007 (UN)
•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
Increasing income inequality between richest
and poorest countries
Gross National Income per capita
in nominal US dollars
Year
Richest
countries
Poorest
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
The inequitable burden of infectious disease
•
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
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
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
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
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
Global Fund portfolio: AIDS
Global Fund
portfolio: malaria
! " #
%
Global Fund
portfolio: TB
$
! " #
!
$
&'
& ( &
140 countries with Global Fund grants
1
2 (new)
3 (new)
4 (new)
5 (new)
6 (new)
7 (new)
0
2,500
5,000
Kilometers
BG/261107/6
Targeting the poorest countries:
Global Fund approved amounts by country per capita income,
September 2008
3500
3000
2500
2000
1500
1000
500
$m 0
US$ 0-1000
US$1000-2000
US$2000-5000
US$5000-10000
Other
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
Reaching the vulnerable
e.g. Global Fund support to harm reduction programmes
No Global Fund grants
0
1,100
Kilometers
2,200
Global Fund grant, with financing of harm reduction
´
Number of people receiving ARV therapy in
low- and middle-income countries, 2002—2007
People receiving ARV therapy (in Millions)
3.0
North Africa and the Middle East
Europe and Central Asia
East, South and South-East Asia
Latin America and the Caribbean
2.8
2.6
2.4
Sub-Saharan Africa
Global Fund supported programs
2.2
2.0
1.8
1.6
1.4
1.2
1.0
0.8
0.6
0.4
0.2
0.0
end 2002
end 2003
end 2004
end 2005
end 2006
end 2007
Global Fund results: June 2008
)((
*+ &
&
4.5
4
60
DOTS
ARVs
3.5
ITNs
50
45
40
35
2.5
30
2
25
1.5
/.0 &
) +,&
$- .
3
55
20
15
1
10
0.5
5
0
-
Dec-04 Jun-05 Dec-05 Jun-06 Dec-06 Jun-07 Dec-07 Jun-08
GP/110608/9
AIDS impact: Malawi
Initial decline in workplace mortality at Escom (national electricity company)
after roll-out of antiretroviral treatment
Source: Global Fund
Decline in adult mortality with introduction of
ART: Botswana
5
50
on ARV
Deaths aged 25-54
40
4
30
3
20
2
10
1
0
0
1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005
Persons on ARV (Thousands)
Registered Deaths (Thousands)
6
Increase in TB financing and new sputum positive
cases detected and treated
New SS+ cases treated under DOTS
300,000,000
1.9M
250,000,000
276M
1,500,000
1.4M
200,000,000
2,000,000
196M
150,000,000
107M
1,000,000
127M
100,000,000
41M
50,000,000
-
0.38M
0.6M
500,000
0.5M
2002
2003
2004
2005
2006
2007
New SS+ cases treated under
DOTS (annual)
Annual amount disbursed
(in US$)
Amount disbursed (US$)
Malaria in-patient and out-patient laboratory-confirmed
4,500
4,000
3,500
3,000
2,500
2,000
1,500
1,000
500
0
Mar-01
Apr-01
2001
May-01
Jun-01
Apr-02
May-02
Jun-02
Jul-02
Aug-02
Sep-02
Oct-02
Nov-02
Dec-02
Jan-03
Feb-03
Malaria in-patient cases
Feb-02
Mar-02
Out-patient confirmed cases
Oct-01
Nov-01
Dec-01
Jan-02
Non-malaria in-patient cases
Jul-01
Aug-01
Sep-01
2002
WHO national database
Jan-01
Feb-01
2003
Mar-03
Apr-03
May-03
Jun-03
Jul-03
Aug-03
Sep-03
Oct-03
Nov-03
Dec-03
Jan-04
2004
Month
Feb-04
Mar-04
Apr-04
May-04
Jun-04
Jul-04
Aug-04
Sep-04
Oct-04
Nov-04
Dec-04
Jan-05
Feb-05
2005
Mar-05
Apr-05
May-05
Jun-05
Jul-05
Aug-05
Sep-05
Oct-05
Nov-05
Dec-05
Jan-06
Jun-06
Jul-06
Aug-06
Sep-06
Oct-06
Nov-06
Dec-06
Jan-07
Feb-07
2007
Mar-07
Apr-07
May-07
Jun-07
Jul-07
Aug-07
Sep-07
Interventions
2006
Apr-06
May-06
Incidence ~64%
Feb-06
Mar-06
Oct-07
Nov-07
7,000
6,000
5,000
4,000
3,000
2,000
1,000
0
Non-malaria in-patient cases
Declining malaria in health facilities after scale-up
of bed nets and anti-malaria treatment:
Rwanda, 2001-2007
cases
Impact: malaria
Tanzania accelerating reduction of child mortality (MDG 4 & 6)
Interventions: ITNs and malaria treatment with integrated
management of childhood illness
MDG targets
Masanja et al, Lancet, 2008
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
Other
10%
Administration
10%
Monitoring and
Evaluation 3%
Health
Systems
35%
Commodities,
Products, Drugs
45%
! "
Infrastructure
and Equipment
9%
Human
Resources
23%
The Global Fund and health systems strengthening
• 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
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
Infrastructure: Support for renovation of existing
health centres
Mukoma Health Centre, Rwanda (Source: PEPFAR)
*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)
Sources:
UNAIDS,
STB, RBM
Estimated
resource
needs
60
50
US$bn
40
HIV/AIDS
TB
30
Malaria
20
10
0
2009
2010
2011
2012
2013
2014
2015
Total ODA commitments, all sectors, 2001-2006
!
"
#
$!
"$ #
!
%
&'(&)*+,,-
Resources: increasing both availability and demand
Estimated Need
Estimated
Need
Demand
Available resources
$ US billion
Available
resources
and
demand
Global Fund requested and approved 2-year
funding (Rounds 2 – 8)
7000
53%
5791
6000
Approval rate
Millions, US$
5000
40%
34%
39%
22%
34%
47%
4000
3298
3000
2512
2137
2000
1000
3059
2519
2398
1853
620
860
968
726
1119
847
0
Round 2
Round 3
Phase 1 request, million US$
Round 4
Round 5
Round 6
Round 7
Round 8
Phase 1 upper ceiling request for TRP recommended proposals, million US$
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
Scaling up Health Insurance
80%
7,000,000
Number of beneficiaries
6,000,000
5,000,000
4,000,000
3,000,000
Improving Access to Health Care
Global Fund
subsidy
2 m illion
72%
2005
60%
Global Fund cofinance subsidy
44%
Out-of-pocket and/or
Government subsidy
1,3 m illion
2,000,000
3 million
40%
2006
49%
40%
43%
35%
20%
1,000,000
0
7,800
300,000
900,000
P rivate health
Civil
Geno cide Co mmunity
insurance servants/M ilitary survivo rs, health insurance
priso ners (398 mutuelles)
0%
P o pulatio n co verage
with health insurance
P o pulatio n with at
least o ne
co nsultatio n in health
center
Utilizatio n rate o f
district ho spitals
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
Study areas of the 5-year evaluation of the
Global Fund (2008)
• Organizational efficiency
• Effectiveness of the Global Fund as a
partnership
• Impact studies in 16 countries