Founder, Taufiqur Rahman
Innovative financing for Global Health
HIV/AIDS: A shared responsibility
World Bank: Rethink Strategy
HIV/AIDS financing: Insufficient?
Global Fund and Health Systems:
Global Fund and global cooperation with UNITAID, GHIT, and Gates Foundation
US Global Assistance: Saving lives through efficient health procurement (December 2012)
2013 will be a year of tough economic choices and austerity. US and other International assistance will not grow because major donors are busy putting their own house together. US international assistance will need to be more efficiently used. This is the reality and we must accept that. Whether we like it or not, we will have to do more with less and be smarter about use of our existing resources. This brings me to a discussion which donors and recipient countries must have. How can we work together for effective use our comparative advantages and make some tough choices about smart investments? Its’not easy but it has to be done.
Let us talk about health financing which is a large part of US government assistance to developing countries. We talk about partnership and collaboration, and then we continue to fund organizations for their individual mandates and do not set any incentives for serious collaborations to focus on core competencies and more efficient use of resources.
Procurement of drugs and diagnostics are a major part of any health budget. Inefficient procurement arrangements continue to add to unnecessary costs and inefficient delivery systems. Inefficient supply and distribution arrangements result in waste and inefficient use. Poor quality drugs are procured by corrupt procurement officers. Many country systems result in huge delays in procurement, loosing months in the process. Donor funded quality drugs are left to expire without redistribution system. We have serious problems which can be solved through coordinated efforts in strengthening distribution and storage systems at the country level. PEPFAR, USAID, and World Bank are now increasingly talking about strengthening health systems as a key focus. Others should join this discussion and partnership.
PEPFAR indicated that they have saved millions of dollars by procuring generics to fund HIV treatment. A major part of Global Fund procurement is also for generics, thus making much better use of resources. President’s Malaria Initiative and TB programs are also buying generics to make more efficient use of resources. Results for Development Institute, a think tank, study indicates that procurement streamlining of bed nets for Malaria program will save $600 million over 5 years which can fund additional bednet procurement to benefit another 300 million people. The Procurement funding by various donors have one common problem. Each agency funds procurement with its associated costs. Millions of dollars are lost through overhead, inefficient procurement at the country level, and variance in quality of procured drugs by many country systems. Would it not be easier if we funded one agency to manage the procurement process while countries can access quality assured cheaper products with uniform prices? One such agency is UNITAID, a drug purchasing facility set up with airline levy by France, Brazil, and other countries. UNITAID uses market dynamics and its purchasing power facility to negotiate lower prices for quality assured drugs and diagnostics for HIV/AIDS, TB, and Malaria. These negotiated prices are then available to countries to fund their programs. Two thirds of UNITAID funding comes from airline levy. It has been successful in reducing costs of drugs and diagnostics between 10% to 40% while making sure the drugs have approval from stringent authority like US FDA or WHO. That is a saving of millions of dollars. Imagine if major donors would divert their health product procurement funds to this agency to use its purchasing power to push for even lower prices of drugs and diagnostics. The negotiated prices will be offered to all developing countries, allow more generic drug producers to produce quality assured drugs, contribute to local drug production in developing countries, and allow the markets to grow. It will also allow countries to increasingly use own resources to fund their procurement as opposed to request international assistance. We will see major collaboration between large pharmaceutical companies with drug companies in the developing countries. If we are focusing on country ownership of health programs and use of internal resources, does it not make sense to push for lower drug costs so that poorer countries can afford them from own sources? The resources freed up from efficient procurement can be invested in other priority areas and accelerate our work toward universal access to treatment and saving million more lives. In August 2012, UNITAID, Gates Foundation, and PEPFAR announced an agreement that will reduce TB diagnostic test kits (Xpert MTB/RIF cartridges) prices by 40% which will remain in effect until 2022. Think for a moment, how can we all help put more people on treatment with existing resources when such resources are pooled and multiple overheads are eliminated? Isn’t it time for a global discussion on efficient use of resources for health product procurement and serious collaboration to make a difference in the health of poor people? Should we not invest to strengthen health systems for better storage and distribution? It is also time for US Government to join this procurement partnership with UNITAID and help more efficient use of its investment in the health sector. For the last two decades, we have talked about poor quality drugs. We should not have the same discussion over next 10 years. Let us aim for universal quality products for developing countries and focus on universal access to treatment with urgency.
Non Communicable Diseases: Inaction means increased poverty , (November 2012)
Non communicable diseases (NCD) are heart disease and stroke, cancer, diabetes, and chronic lung disease and they kill nearly 36 million people each year, over 80% of these are in low and middle income countries. NCDs account for 63% of global deaths from diseases. According to Center for Global Development reports, less than 3% of global health assistance in developing countries have been spent on NCDs between 2001-2008. NCDs are increasing in the poorer countries due to rapid urbanization, lack of knowledge for prevention, poor dietary habits, and tobacco use. These four diseases kill more people globally than infectious diseases. Common risk factors for these are tobacco use, unhealthy diets, physical inactivity, and harmful use of alcohol, as well as high blood pressure and cholesterol. A year ago, global community made a huge commitment in a UN conference to fight NCDs. In May 2012, WHO sponsored international conference led to a global commitment to reduce NCDs by 25% by 2025. Yet, we see very little action for large scale interventions and resource allocation. NCDs cost US economy billions of dollars and kills thousands of Americans each year. Between now and 2030, developing countries face $14 trillion in NCD-related health-care costs and lost productivity. Professor Moodie of Melbourne University contends that “"Seven trillion dollars of lost output in developed countries is attributable to NCDs". According to World Health Organisation (WHO), Cardiovascular diseases (CVD) are costing governments nearly $863billion globally. Overall CVD is estimated to cost the EU economy €195 billion a year. According to a 2011 report by Harvard University for World Economic Forum, “Over the next 20 years, NCDs will cost more than US$ 30 trillion, representing 48% of global GDP in 2010, and pushing millions of people below the poverty line”. The report also indicate that “with respect to cardiovascular disease, chronic respiratory disease, cancer, diabetes and mental health, the macroeconomic simulations suggest a cumulative output loss of US$ 47 trillion over the next two decades. This loss represents 75% of global GDP in 2010 (US$ 63 trillion).” The estimated cost of new cancer cases in 2009 was US$ 286 billion globally. All these evidences point to staggering costs of NCDs. The solution is not another global fund for NCD nor separate allocation of resources, rather a commitment for integration of preventive services within existing health systems, scaled up education to improve lifestyle changes, put more resources on health systems strengthening, and major political commitment for immediate actions.
In 2008, over 17 million people died from CVDs. WHO estimates that over 23 million people will die from CVDs by 2030. Each year cardiovascular disease (CVD) causes over 4 million deaths in Europe and over 1.9 million deaths in the European Union (EU).As for diabetes, approximately 350 million people have diabetes. The deaths from diabetes are expected to double between 2005 and 2030. Diabetes can damage the heart, blood vessels, eyes, kidneys, and nerves. 50% of people with diabetes die of cardiovascular diseases. Diabetes is the leading cause of kidney failure. Each year, according to Center for Disease Control(CDC), 7.6 million people die from Cancer and quarter of a million women die from cervical cancer. Over 85% of these deaths are in developing countries with. Tobacco use kills nearly six million people every year and is expected to increase to 7.5 million by 2020.
Why are we failing to tackle NCDs? Health investments are fragmented, unstructured treatment and poor quality of services, poor collaboration between private and public sectors, fragmented and inefficient resource allocation, and inadequate political commitment and focus to improve the health systems for integrated service delivery. Global communities including donors are allocating too much funds for vertical programs and are not pooling their investments for a more effective health service delivery. Technical partners are not strongly advocating for more coordinated efforts to tackle health problems, resource pooling, and strengthening health systems. Partnership is weak on efficient resource management and investment. Tough decisions are not made on what programs do not add value and what duplications must be avoided for more efficient business model.
Solutions are simple. Technologies and treatment are available and cost effective. Yet we have not taken major steps to tackle NCDs. For reducing incidence of CVD and Diabetes, we need to promote physical activity, reduction in tobacco and salt consumption, and healthy diet. This requires large scale health education and incentives for behavior change which can be initiated by any government in partnership with civil society and private sector. It can be an integral part of national education system, media, and health education. Governments need to initiate good policies and effective compliance monitoring. For CVD, widespread adoption of multidrug therapies could save nearly 18 million lives over a 10-year period and this is low cost. NGOs and government health departments can integrate NCD education in their existing health programs without major increase in resource allocation. Millions of poor people can not afford drugs for treatment of NCDs. Private sector can contribute to more research and cheaper drugs. Global community can jointly push for lower prices of drugs. This has been done for HIV/AIDS and TB, and it can now be done for NCDs.
Cost-effective screening that can detect cervical cancer and pre-cancerous cervical lesions, thus allowing early treatment and reduce deaths from cervical cancer. A simple but effective technique, visual inspection with acetic acid (VIA), is easily available in poorer countries and doctors and nurses can be quickly trained. This requires minimal technology, thus is low cost.
CDC’s Global Tobacco Surveillance System (GTSS) can enhance a country’s capability to design, implement, and evaluate tobacco use control interventions. This is available for countries to collect relevant information for good policies and prevention initiatives.
So, what should the global community do? First, we must have political commitment for actions against NCDs. UN declaration is not enough. We need real actions. If we have learned anything from advocacy by HIV/AIDS activists and implementation of HIV/AIDS programs, it is political commitment that generates political actions for resource allocation and galvanizing the global players to come together on common agenda. Second, we must focus on strengthening existing health systems for integrated services. It is integrated service delivery that is efficient, effective, and provides value for money. We need to reduce funding for vertical programs and rethink our strategic focus. We need to look at efficient use of resources and help countries to rethink their health interventions and reprioritize investments. If our goal is poverty reduction, then we need urgent actions and reallocation of resources to reduce the deaths and disability from NCDs. Third, innovation and technology must be the driving force for efficient and low cost service delivery. More investments must be made to reduce and simplify technology, drugs, and test kits. More research must be funded to improve existing technology and service delivery. More work needs to be done for improving public/private innovative partnerships. Innovation must be encouraged for efficient service delivery and lowering management costs. Finally, we must allow countries to be in the driving seat. Donors should not develop strategies and solutions for the countries, rather provide them the knowhow and technology to fund their own solutions. Each country is different and appropriate interventions must be country specific and culturally sensitive. What may work in India, may not work in Nigeria or China. Each country should be helped to provide universal access to health services for prevention, care, and treatment. It is time for global solidarity, global action, pooling of resources, and global political movement. Painful decisions on efficient arrangements, technical and financing, at international level must be made. Some consolidation are essential for better use of resources. We need to have integrated health interventions as key to sustainable development and reduce allocation for vertical programs to free up resources. Elimination of certain programs or institutions may need to be made to free up resources for strategic investment for quicker impact. Inaction on NCDs will increase poverty. If we do not act now, we will loose whatever gains we achieved in poverty reduction over last two decades. It is that simple.
Global Health Financing: US interest needs consolidation (October 2012)
As the US and European governments struggle with economic challenges, there are pressures to reduce development assistance financing. Global economic crisis has increased poverty and poor health. Our investment must continue to improve health of poor people of the world. Healthy people can contribute to economic development. US Government contributes approximately $10billion per year in international health through multiple channels and the time has come for consolidation and more focused strategy for efficiency, impact, and sustainability. There are too many agencies, here in the US and overseas, resulting in duplication and large management costs. There was a time when many vertical investments made good sense and our investments achieved excellent results. However, our resources are spreaded out thin. We now need to respond to new realities of country ownership, economic development of many countries, and consolidate our resources for more effective investment. Our work must help countries to reduce dependency on external resources for their national health services. Technology, bold political commitment, and innovation are key to new investment strategies for impact. Here are few ideas for policy makers and politicians to consider.
First, the time has come to consolidate health financing so that pooling of resources and focused strategy can make the most difference. Billions of dollars invested inefficiently mean less money available for other priorities. We cannot afford to support institutions where resources are inefficiently allocated to support individual strategies. There was a time for special Presidential initiatives but are they needed now? US government needs to relook at their investments and consider developing one global strategy so that resources can be more efficiently allocated and managed. One department should not advocate for maternal health resources while others want money for communicable diseases. Multiple advocacy for resources and political positioning in DC are common. At the same time, we see millions of deaths from non communicable diseases such as cardio vascular disease or diabetes. The solution is simple. Consolidate health financing for integrated service delivery by strengthening health systems so that services can be offered more efficiently. We do not need to fund three clinics in one village, each delivering one service as per donor funding. We see that too often and then we complain that we do not have enough resources nor trained manpower. Bring services under one roof and management/financial structure. Look at why Ethopia, Brazil, and China are successful in delivering a strong health system.
Second, Maternal health contributes to women’s empowerment, better child health, and good family health. A healthy woman is a productive woman who can participate in economic development and help in poverty reduction. A woman should never die giving birth. A child should not die due to diarrohea or lack of vaccines. We need to invest our resources to improve women’s health. Women’s empowerment can happen with healthy women. Women must have choices about contraception, access to quality care, and ability to protect their children. 200 million women do not have access to family planning services. This is an unacceptable situation. Access to family planning saves lives and improves children’s health. If the global community truly believes in making sustainable contribution to health improvement of populations, it must start with women’s health. An empowered mother will not allow her daughter to get married at 15 or be taken out of school.
Third, we must invest in health systems so that quality services can be provided for years to come. Investing our resources in poor health systems mean loss of resources, inefficient services, disempowered clients, corruption, and never ending need for additional resources. Each country, middle or low income, must start the process of reducing dependency on external resources. Countries must enhance their capacity on internal resource allocation, efficient management, integrated services, information management, and procurement. Vertical programs should be discontinued. World Bank has made a commitment to invest in health systems. Other financing organizations should be asked to join this initiative. Combining loan and grant funds to make strategic investment in health systems is needed now. Health systems strengthening puts the countries in the lead. Low and middle income countries are contributing more resources to national health programs. This is a good development and we need to help these countries with technical assistance to make better use of their resources.
Fourth, innovative partnerships with private sector is urgently needed. In each country private sector plays critical role in service delivery. However, in most developing countries, private sector operates in unstructured manner, thus increasing costs and inefficient service delivery. We need to help countries to reduce costs of medicines so that poor people can afford them. We have to help local production of medicines. In a number of countries, the generic drug producers are major contributors to sustainable health services. When drug costs are low, national programs and citizens can use own resources to buy them. This is a much better approach than using tax payers money to subsidize drug procurement.
Finally, make smart decisions. Fund organizations for what they are good at. Make collaboration a key requirement. G-8 countries need to start a new dialogue with BRICS to pool resources and common investment strategy. We all have a stake in reducing poverty for a better world. In the private sector, they say “collaboration is the new competition’. Because they realized that efficiency comes from collaboration. Use of each others’ expertise and resources make good investment sense. Promote technology use to improve efficiency. $40 tablet will probably revolutionalize eduation in India and other places. Khan Academy has used internet to increase access to education materials to millions of people free of charge. M-health programs use mobile technology to reach clients quickly and record data efficiently. Mobile technology is also improving accountability and strengthening monitoring systems. There are many such applications. We must promote technology that are cheap but can contribute to accountability and efficiency. And we must make transparency a key element of resource allocation. We all need to know where the money is invested.
It is time for a more focused strategy and fund that strategy by pooling resources and reducing multiple institutional arrangements. It is time for consolidation and possible mergers. Mergers of organizations happen in the private sector, it can also happen in the development sector. It is time for new thinking under Obama’s second term.
Human Rights and HIV/AIDS: Time for USA to lead again (September 2012)
When the world faced a catastrophic disease like HIV/AIDS, the United States stepped in and created PEPFAR. In 2003, President Bush took the boldest step to allocate $15 billion over five years. It was the largest commitment ever by one single country for an international health initiative dedicated to a single disease. Many of us do not know but that one step made a huge difference and saved many countries from a major disaster. President Obama continued that commitment and allocated even more funds. UN took the lead and US supported the creation of the Global Fund to fight AIDS, TB, and Malaria in 2002. USA made the largest commitment to the Global Fund and agreed to contribute upto 33% of the budget which encouraged European donors, Japan , and Australia to join the fight. Even today US remains the largest donor to the Global Fund. Global Fund and PEPFAR achieved tremenduous results and now over 8 million HIV infected people are receiving treatment. Millions more received services to protect their health through counselling, testing, and behavior change programs. Hundreds and thousands of health clinics now offer prevention and treatment services for HIV infected people all over the world. It is a success story, a collective effort led by USA . Many countries now contribute a lot from own resources to cover costs of HIV/AIDS programs. We are now optimistic about an AIDS free generation if we can put another 7 million people on treatment by 2015. US leadership changed the course on HIV/AIDS. US-based Gates Foundation led the private foundation contribution for HIV fight and continues to put more resources for a vaccine. Money and technology made a huge difference but innovation in every intervention played a greater role for rapid scaling up and successes.
All these achievements will not be sustainable without ensuring basic human rights for any one infected with HIV. Stigma and discrimination continues on a large scale. We can not continue to invest large sums when countries are not serious about fundamental human rights. Recently USA took a bold step not to discriminate against HIV infected people and lifted the travel ban. It was the right decision, demonstrating a commitment to basic human rights. At the same time we see many countries still deny fundamental human rights such as right to treatment, equal access to other health services, gender equality, travel ban, etc.. These countries receive international funds for their HIV response which comes from USA and other donors. Approximately, 40 countries still ban travel by AIDS people. Many countries have discriminatory laws and policies that discriminate against HIV infected people. Some countries see them as criminals, some bar them from social agenda. We hear about HIV children denied education. We hear about HIV positive migrant workers denied continued employment. We hear about HIV girls socially ostracized. Many have to travel miles to secretly get medicine for fear of retaliation or discrimination. According to UNAIDS, “Nearly two thirds of countries reported policies or laws that impede access to HIV services by certain populations.” These same countries do not discriminate against people with cancer, cardio vascular disease, diabetes, or other deadly diseases.
UN Resolution 49/1999 (UN Commission on Human Rights) declared that “Discrimination on the basis of HIV or AIDS status, actual or presumed, is prohibited by existing international human rights standards”. All UN member countries have agreed to this but many rarely practice it.
We want an AIDS free generation. If one intervention that can make a difference in this fight, it would be for all countries to guarantee fundamental human rights for AIDS patients. We should have taken this bold step when first AIDS cases were identified. Parallel or vertical programs that separated AIDS patients contributed to discrimination and stigma. Political leaders in every country did not act fast enough to dispel miscommunication. Now we need to correct the course and insist that fundamental human rights is an integral part of all interventions on HIV/AIDS. That means, no discrimination, no stigma, access to medicine, treatment, and other health care through national health systems and financing. We need massive national education to educate about human rights of these people and strictly enforce rule of law against discrimination or stigma. We should fund programs that promotes and support human rigts of HIV infected people.
A number of organisations including UNAIDS is leading a world-wide advocacy with a global action plan on Zero discrimination and stigma. UN Secretary General and Hilary Clinton have also advocated about this in several meetings. More talk is not good enough, time for concrete actions. Millions live their lives being marginalised by society. They are pushed aside when it comes to basic rights to education and health. Millions do not have access to life saving medicines. It is time, once again, for the USA to lead the fight for fundamental human rights of HIV infected people. It is time for World Bank, Global Fund, PEPFAR, all UN and international agencies, and bilateral donors to speak with one voice. When a country guarantees basic human rights for HIV patients, they will make sure their national health budgets allocate resources for this treatment. They will take advantage of new technologies and innovation to focus on cost efficient services. They will take the much needed step to integrate HIV/AIDS services in existing health programs. They will send a clear political message to doctors, health care providers, local leaders, and communities that HIV patients are like any other patients. HIV positive people will have new hopes in every country. It is not Ok to discriminate against them. It is not acceptable to have stigma against HIV positive. It is not acceptable for HIV positive children to be denied proper schooling. The goal of an AIDS free generation can only happen if every country commit to protect the basic human rights of 36 million HIV positive people. US political leadership is needed once again to galvanize the world on this important human rights issue.
Less is more: Financing an AIDS free generation (August 2012)
US Government has promised to release a US government blueprint plan for an AIDS free generation on December 1, 2012.PEPFAR (US President’s AIDS initiative), the Global Fund, MAP (World Bank program), and UNAIDS remain the key players in the fight against HIV/AIDS. Global Fund was created as an emergency fund and after more than 10 years, it is not an emergency any more. In many countries we see declining infection and death rates, more internal resource mobilization, and better political commitment.
What we now need is a serious rethinking of how to use our financing and make commitment to sustainable development which translates into strengthened health systems, accountability, human rights, and transparency. We need innovative and bold thinking on financing for next five years and stop talking about funding gap. We need a more efficient financing arrangement so that less money can do more good. We need to incentivize key players to work together. A bold rethinking will be painful for existing players because it would mean reworking current responsibilities. Universal access implies putting at least 15 million HIV positive people on treatment and probably more, and do this efficiently.
A 2010 report to Congress on PEPFAR’s cost of treatment indicated that mean costs of ARV treatment was $436 per patient and $489 per pediatric (Children) cases. For second-line treatment, cost per patient is $942. Cost of antiretroviral drug (ARV) was 39% of this cost. Non-ARV recurrent cost was 36% of this amount. This means antiretroviral(ARV) drug cost per patient would be $170. ARV costs are lower now. Cost of ARVs per patient is $100 for the least expensive WHO regimen. For 15 million people, taking $170 as per patient cost, the annual treatment cost would be $2.55 billion. For next five years, it would be $12.75billion. Assuming that countries collectively can contribute 35% to 40% to ARV treatment cost, then the international donors will need to put up $7.65 billion over five years which is approximately $1.53 billion per year. We can assume another $500 million for second line drugs and associated costs. Therefore, total drug and testing kits costs per year would be approximately $2billion. This is the simplistic calculation. BRICS countries make up for 31% of the global disease burden and they are committed to cover 100% of their costs. A new financing mechanism, UNITAID, was created in 2006 with French initiative and drug/research financing are done through airline levy. Britain, Brazil, Chile Norway, Gates Foundation, and others have joined the consortium. It has raised millions of dollars so far and can continue to raise funds through this innovative approach.
Here is the suggestion for a bold financing arrangement for next five years to meet global goal of an AIDS free generation within existing resource envelope or much less. We focus our energy on creating country capacity and sustainable financing for long term and predictable support to AIDS response. We need to agree with donors to focus on core competencies and efficient use of resources. In 2011, international donors have contributed $8.2 billion to AIDS programs. First step, continue to build political commitment at the country level for more local resource allocation and set a timeline for 100% internal financing for each country. Second, it is time to centralize drug financing and procurement. Let all drug and test kits procurement be managed by one entity which already has funds for drugs, test kits, and other items and allocate balance amount based on a projected costs. We should think of UNITAID for this. Its core competency is in drug procurement and distribution. UNITAID will be responsible for providing drugs and tests kits based on a co-fund strategy for any country needing this support. The key word is co-fund so that countries will have to come up with the other financing for full cost of treatment. Third, World Bank has promised to help with health systems strengthening for sustainability of AIDS response. The Global Fund, WHO, and the World Bank can work with national health and finance ministries to strengthen national health systems and integration of HIV in national health programs. HIV response must be an integral part of health service delivery to be cost efficient. Fourth, Bilateral donors such as PEPFAR, DFID, EU, CIDA and others focus on three areas: civil society capacity building, testing new schemes, and expanding private sector partnerships. Major financial support is now needed to scale up private sector providers to support national programs. If done right, this would contribute immensely to sustainable service delivery. Fifth, UNICEF, UNAIDS, WHO, CDC, and international research organizations could receive financing for their technical support, innovation in service delivery, and research work. Make no mistake, it will be innovation and technology that will continue to drive costs down and improve access to services.
It is time for bold new thinking. It is time to stop inefficient arrangements and allocative methods. Let us use the resources we have to make a lasting impact. And that means saving millions of lives quickly and efficiently.
HIV/AIDS: Transition Strategy (July 2012)
This week we have a major conference on HIV/AIDS in DC. Thousands of activists, managers, donors, government officials, civil society groups, and private sector representatives are attending this important meeting. Here are the facts. 8 million HIV patients are on treatment, another 7 million needs treatment soon. $16.8 billion have been invested in 2011, of which $8.6billion invested by low and middle income countries. Rest came from donors such as US, private foundations, Europeans, and others. Treatment costs for first line treatment have been reduced substantially, it is now $100 per year for the least expensive WHO regimen. However, treatment costs for drug resistant cases, which we call second line drugs, is still very high. AIDS free generation is a dream for many of us but it can be achieved with new thinking. We must do everything to get the additional 7 million people on treatment urgently. Universal access to treatment is absolutely critical to turn the tide and achieve our goal of zero infection. It is a fact that every HIV patients should receive treatment so that cycle of infection can be halted and reversed. US government generosity through PEPFAR and that of other donors will be remembered for saving so many lives in a short time. Global Fund was created, funded, and major scaling up took place in the first 10 years. UNAIDS, WHO, and other international players pulled their technical and financial resources to fight this deadly disease. We must sustain and enhance this achievement. And this can be done by seriously pursuing a Transition Strategy that will make much better use of all existing resources and bring back the focus on country ownership. Transition strategy would mean revising all individual strategies to come up with one common strategy, simple and implementable. The ‘Transition Strategy’ is what should be discussed by politicians, donors, technical gurus, civil society organisations, private sector, and activists.
What do we mean by a transition strategy? It is a business plan to include the following to happen over next five years. (1) each and every country to accelerate national resource allocation in their national health budgets for treatment, care, and prevention. Currently, 56 of the 99 low and middle income countries pay for over 50% for their HIV responses. We should aim for these 56 countries to cover 100% of the cost while helping the remaining 43 countries to reach at least 50% payment scheme by 2017. (2) All donors, UN partners, and international organisations must have one common strategy for universal access to treatment and care. Forget individual donor strategies. It is time for collaboration, coordination, and common sensical strategic approach to pooling of resources to make a difference in a short time frame. Support and fund private sector to initiate local production of drugs in developing countries so that prices come down much faster than what we have seen in the last two decades. Set an ambitious target of $50 per person per year cost for first line drugs and $100 for second line drugs by 2015 and achieve it. Clinton Foundation has already negotiated a reduced price of $475 for second line drugs. More reduction is a clear possibility. (3) Allocate resources for second line treatment, scale up treatment for universal coverage of second line treatment, and pursue political advocacy and other pressure to reduce the costs of second line treatment. (4) Integrate HIV/AIDS programs in existing health programs and discontinue the vertical arrangements; (5) make transparent reporting of all investments; (6) Continue to fund new technologies and more work toward a vaccine. (7) fund technical assistance to build and enhance capacity of health institutions and systems, and promote use of existing and new technologies; and (8) Ensure global support for zero tolerance for stigma and discrimination. A transition strategy must also include an improved financing arrangements which may eliminate certain existing arrangements that were essential at the beginning of this fight but are no longer relevant. It is time to ask hard questions and make hard nosed business decisions. There should be no room for putting scarce resources in unnecessary overheads and management arrangements that are burdensome on countries and duplicates efforts.
Open Letter to new Executive Director of the Global Fund January 19, 2013
Dear Mark Dybol,
Congratulations. We are delighted to have you lead the Fund.
As you embark on a tough new assignment to lead the Global Fund, I write this letter with utmost frankness. Your job will not be easy, the global environment is not easy, and the Fund is in a transition period where demand for resources outstrip what you will be given by all donors. And we need to save millions of lives much sooner.
We want The Global Fund to succeed because that would mean millions of life saved. While putting people on treatment is a priority, a bigger priority is sustainable treatment and shifting the treatment liability to national budgets. When the Fund started, it had very few but highly focused goals. Time to get back to that focus. My consultation reveals few priorities: universal access to treatment, reaching out to key populations such as MSMs, CSWs, etc., human rights, capacity building of civil society, and public sector health systems strengthening.
The Fund created hope, thus generating additional demands for treatment and services which now faces the resource crunch. The idea of universal access to treatment and AIDS free generation has gained momentum without the drum beat of additional funds. But you have friends and partners who are willing and able to fight this battle together. They do not want to be friends without responsibility or partners of conveniences, rather want to be true partners for a battle that can be won easily. We are at the tipping point of winning the war against the three diseases. It can be won or lost based on what you do next. The Fund is a fine concept, the true test of success lies in saving lives.
Gates Foundation’s innovative financing provides hope for new vaccines and technology. They make additional resources available for innovative programs that have promise and are scalable. It is a Foundation that has shown tremendous resolve, stamina, and professionalism in the health sector, some of which are worth learning. It is a Fund that truly believes in using existing technologies to their full potential and doing it efficiently. We can learn from their experiences.
Michel Sidibe of UNAIDS espouses sustainable AIDS response in Africa and elsewhere. He has pushed his troops in the field to support countries make the difficult transition from donor dependency to national dependency, protect human rights of all those infected, and increase national level sustainability. He advocates for basic human rights so that each and every person has access to treatment and care, and we will see a day when each baby is born AIDS free.
Margaret Chan of WHO has strengthened her technical teams to be much more supportive in all three diseases and health systems. HTM, STOP TB, and RBM are working hard to implement their new strategies.
Jim Young Kim and David Wilson of World Bank will support health systems strengthening for sustainable health services. They will bring resources and expertise.
Denis Broun of UNITAID facilitates lowering of prices of drugs and diagnostics through market dynamics so that low income countries can afford them and can plan a transition strategy to fund their procurement with internal funds or interim international funds.
UNICEF, UNFPA, UNODC, UNDP, and international NGOs are ready to provide core expertise where it matters most.
Your friends at PEPFAR have some real good examples of private sector partnership, transition strategy (Botswana and South Africa), country partnerships, and integrated service delivery. US government focus on country ownership and AIDS free generation is what we espouse. None of these countries want to be in perpetual dependency but need technical and other help to fund their own programs.
GAVI provides good examples of co-investment, country ownership, and lean operation. We can learn a few things from them.
Then we have the countries, their experiences and expertise, and several local partners to implement programs more effectively and efficiently. But they want to be in the driving seat. CCM or no CCM, they want to make the decisions on investments and transition strategy. Health Ministers want to understand your transition strategy because it is not clear. Civil society want to know how they fit into the new strategy. The African Union, for example, has adopted a Roadmap on shared Responsibility and Global Solidarity for AIDS, TB and Malaria that outlines practical steps by which African countries, together with development partners, can deliver sustainable results. Shared responsibility and global solidarity move away from traditional donor– recipient relationships towards South–South and triangular cooperation.
Integrating HIV/AIDS, TB, and Malaria in existing health systems is efficient. The need for vertical programs are gone because sustainable health financing and service delivery demands integration. Without HIV/AIDS, maternal mortality will be 18% lower. Condom promotion and use reduces sexual transmission of HIV/AIDs, reduces unwanted pregnancies, and safer sex. More women are willing to accept testing and counseling if the HIV program is an integral part of ANC service delivery. Integrated platforms will reduce maternal and child mortality.
Many innovation exist, they are just under-utilized. Use of ICT can make monitoring efficient. Private sector partnership will promote co-investment with CSR funds. Co-investment examples of Neglected Tropical Disease program of USAID where private sector contribution resulted in reaching 250 million in six years. Such innovation is what we need to champion.
All these translate into need for highly focused investment strategy and serious roadmap for partnerships. The new funding model offers an opportunity provided it is managed by highly field experienced professionals. You need to take an uncompromising commitment to using comparative advantages of partners to make the best use of resources for greater impact.
You need to take full advantages of field presence of key partners. If needed, time to allocate some funds for this so that partners can also cover some of their costs. Money is not your problem, it is how you use the existing resources more efficiently to accelerate your work toward universal access to treatment. It is how you continue the public/private partnership and strategic engagement of civil society.
UN and other partners are key to your success. If a partner has procurement expertise, let Global Fund be open to using that to procure high quality drugs and diagnostics at the lowest possible prices. GAVI partnership with UNICEF is a good example. The power of pooling resources to influence the market is worth exploring. UNITAID partnership is a good example. And why not? We want sustainable financing through major reductions in prices for drugs, other health products, and diagnostics.
The technical assistance from US Government, French Government, and GTZ need to be used with strategic smartness. Utilizing key partners to fight the three diseases will require major change in mindset. It will require that the Fund become much more lean and reallocate certain amount of resources to buy the technical expertise and experiences that exists outside the Fund. You know how to do that. PEPFAR and USAID have been doing this for many years, that’s why US has so many strong partners among US international NGOs. Replicate such partnership. Be bold with outsourcing. Rethink efficiency and 'less is more'. Several hundred organizations have developed so much expertise and experiences that it would be a shame if we do not use them.
The time has come for the Fund to behave like a Venture Capitalist and be sharp with its investment strategy. The term I use is "venture social investment', investments for social good but with private sector rate of return concept and intense monitoring. VCs are highly trained in investment analysis and do not have too many people managing their business.
And the time has come for the Fund to showcase a new efficiency model that is innovative, sharp, and makes right investment decisions. It should not be a Fund that is still bogged down in processes to meet bureaucratic requirements, resulting in slow decision making. And you must set a new standard of transparency that is unmatched in the development assistance history. I firmly believe resources that donors pledged are sufficient provided innovative, cost efficient approaches and a focus on strategic partnership for collective actions are applied.
Simplicity has a sunny side, it gets the job done and it is efficient. Many countries already contribute a lot for the three diseases, we cannot ignore that nor can we ignore their plea for simplicity and much quicker investments to save million more lives. Country owned and sustainable health financing is what we should collectively aim for.
A final thought. It is time to mobilize Global Fund alumni to help you. They are a resource with experience which should not be overlooked. Let us also mobilise the Friends of the Funds with new strategy and a clear focus on universal access to treatment and human rights.
We wish you the very best of luck. We have much hope in your leadership. The world awaits the new Global Fund.
Founder, Center for Implementation Efficiency