Yearly Archives: 2012

Commission des Nations Unies sur les drogues.. encore beaucoup de travail…

Vienne, où je participais récemment à la 55ème session de la commission des Nations Unies sur les narcotiques et les drogues (CND). J’y retrouve la cohue affairée des diplomates venus débattre de “résolutions” et que j’ai souvent côtoyée ces dernières années aux Nations Unies à New York. A la différence, cependant, des réunions des Nations Unies sur les objectifs du Millénaire, les débats me sont apparus ici englués et stériles.

Pas de résultats. Ou plutôt,  le constat que, malgré des investissements colossaux dans la”guerre contre la drogue” déclarée par le Président Nixon, la production et la mise en circulation d’opiacés se sont accrues dramatiquement dans le monde, de près de 400 pour cent depuis les années 80. Le constat également, que la “guerre contre la drogue” aura été un facteur important de l’expansion de l’épidémie du VIH/Sida. Les pays dans lesquels l’épidémie est largement dépendante de l’usage de drogues illicites injectées et dont les politiques publiques s’appuient sur les concepts prônés par la “guerre contre la drogue” , restent confrontes a une croissance épidémique, alors que le nombre des nouvelles épidémies diminue dans le reste du monde, en particulier en Afrique. Cinq des sept pays du monde ou l’incidence de l’infection par le VIH a cru de plus de 25 pour cent dans les dix dernières années, se trouvent en Europe de l’Est et en Asie centrale avoisinante. Le constat, enfin, que la “guerre contre la drogue” aura été associée à une augmentation de la mortalité liée à l’usage de drogues et de la violence.

Et pourtant, les politiques publiques restent bien lentes à changer ou ne changent pas. Les conventions internationales dont débat la CND datent des années soixante, vingt ans avant l’irruption de l’épidémie. Dans de nombreux pays, en dehors de l’Europe occidentale et de l’Australie, ces politiques publiques affirment clairement une priorité à la répression aux dépens de la santé publique.

« Rien ne doit bouger » aura été le leitmotiv de cette session de la CND. A la différence de ce de ce que j’avais vu à New York, la participation des ONG m’a semblé ici tolérée plutôt que souhaitée.

Un épisode de la CND aura réveillé les participants et les débats,  l’intervention du Président Evo Morales demandant que la consommation de feuilles de coca en Bolivie soit considérée comme faisant partie du patrimoine historique et culturel du pays et que la culture de la coca soit reconnue, à condition que le pays démontre qu’elle n’est pas détournée vers la production de la cocaïne dérivée…

Heureusement, la salle était pleine pour le déjeuner organisé par l‘International drug policy consortium ou Ruth Dreifuss, ancienne Présidente de la confédération Helvétique et pionnière des politiques de réduction des risques, et moi-même, intervenions au nom de la Commission Cardoso dont nous faisons partie. Cette commission avait publié il y a un peu moins d’un an un rapport sur la faillite des politiques répressives en matière de lutte contre la drogue. Elle prépare un nouveau rapport centré sur les liens entre politiques publiques de lutte contre la drogue et sida.

A  peine deux-trois heures pour marcher dans ces belles rues anciennes proches du Hofburg ou du Stefansdom. Arrêt indispensable, cependant, pour déguster un Cafe “crème” (au sens propre du terme) au Cafe Diglas, banquettes rouges, journaux suspendus et serveurs en complet. Ici, décidément, le temps prend son temps.

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6eme conférence contre le sida à Genève: il est temps de se remobiliser

 

“Partager pour vaincre” jamais peut-être le thème de la 6eme conférence francophone contre le sida n’aura été autant d’actualité. Deux ans après Casablanca, c’est Genève qui accueille cette année des centaines de participants, militants d’ associations, médecins, chercheurs, acteurs francophones  de la lutte contre le sida. Ces grandes conférences sont importantes pour se rassembler, faire le point être ensemble. Cette année plus encore peut être.
Si je regarde en arrière, je vois des progrès extraordinaires accomplis dans la lutte contre l’épidémie mais, en même temps, je perçois maintenant un climat de désengagement de l’opinion, je vois le poids des contraintes budgétaires, je vois beaucoup d’instrumentalisation, j’entends ce que les associations nous ont dit, je perçois la possibilité de remise en question de certains de nos acquis, un climat que nous ne pouvons laisser prévaloir.
Si je regarde en arrière, les dix années qui se sont écoulées depuis l’assemblée générale des Nations Unies de 2001, depuis les conclusions de la commission macro économie et santé, depuis Abuja, depuis la création du Fonds Mondial,

1. Les traitements antirétroviraux qui transformaient déjà la vie des patients dans les pays riches, n’étaient à ce moment là, vous le savez bien,  pratiquement accessibles à personne dans les pays pauvres où vivent 90 pourcent des malades du sida. Aujourd’hui, c’est 7 millions de personnes qui ont accès au traitement ; 45 pourcent de couverture des besoins les plus immédiats en Afrique; des progrès considérables dans la prévention, une mortalité et une morbidité du sida qui reculent en Afrique et dans la plupart des régions du monde ;Le paludisme était une maladie négligée. Aujourd’hui la mortalité du paludisme en Afrique a reculé de 30 à 50 pourcent et près de 80 pourcent des foyers dans les pays endémiques ont accès à des moustiquaires imprégnées d’insecticide pour se protéger de l’infection ;Et, pour la première fois depuis longtemps, le nombre absolu de cas incidents de tuberculose a diminué, alors que la population mondiale continue de croître, et la mortalité de la tuberculose continue de diminuer.
2. La science a fait des progrès remarquables en matière de traitement et de prévention, souvenez vous du sentiment d’optimisme que nous ressentions à Rome il y a quelques mois.
3. L’échelle à laquelle nous sommes passés est pour moi, par moments, presque incroyable  ainsi, les seuls financements du Fonds Mondial permettent chaque jour, à 800 personnes dans le monde en développement de débuter un traitement antiretroviral, à 800 femmes enceintes seropositives d’accéder à la PTME, à 2500 malades de la tuberculose d’être dépistés et traités, et la distribution de 200.000 moustiquaires.
4. Et ainsi, les premiers signes d’impact que l’on voyait sur le terrain il y a quelques années ont maintenant laissé place à des données solides sur la diminution de la progression et sur l’impact humain, économique et social de l’épidémie. Et c’est pourquoi, nous disions, encore l’an dernier, que si les ressources étaient disponibles, nous pourrions d’ici 2015, faire que pratiquement aucun enfant ne naisse infecté par le VIH, que des millions de vies soient encore sauvées par l’accès large au traitement et à la prévention, que le paludisme ne soit plus un fléau de santé publique et que l’on atteigne les objectifs du millénaire en matière de lutte contre la tuberculose.

Mais, voilà :
Aujourd’hui, nous voyons :
La crise économique et financière et son impact sur les budgets publics des donateurs publics et privés, son impact sur ce que les pays en voie de développement peuvent financer dans les secteurs sociaux. L’annulation du Round 11 du Fonds mondial, que l’impact de la crise soit réel ou instrumentalisé dans cette décision, en est la meilleure illustration ;
Une moindre mobilisation ou un désengagement de l’opinion et des politiques dans de nombreux pays, au Nord comme au Sud et une instrumentalisation de la crise par un certain nombre de politiques, de leaders d’opinion pour attaquer l’aide au développement alors que, en période de crise,  l’aide au développement est plus nécessaire encore.
Une tendance pour chacun de nous à travailler « dans son coin » sur son sujet, protégeant son secteur, et portant, que de grandes choses nous pouvons faire si nous sommes ensemble.
Un certain fatalisme, une certaine résignation devant un contexte politique et économique plus difficile ;
Une tendance à méconnaître les autres acquis, au delà du traitement et de la prévention, considérables, de la lutte contre le sida de ces dernières années : la structuration et le renforcement des systèmes de santé, la participation et la démocratisation dans les prises de décision en santé publique, l’accent sur les plus vulnérables, la prise de conscience de la fragilité épidémique des populations les plus vulnérables pratiquement partout dans le monde, l’innovation en matière d’accès au traitement, notamment au travers de l’engagement du secteur privé, un partenariat institutionnel plus fort et bien meilleur, quoiqu’on en dise ;
Je vois aussi la fin, la mort des négociations de Doha, la place très insuffisante du  débat sur les biens publics mondiaux dans les discours sur la mondialisation et la “régulation” et les faibles progrès de la mondialisation à faire accéder aux marchés des pays riches les produits en provenance des pays pauvres (quota, exonérations de taxe) ;
Enfin, me semble t il, nous n’avons pas trouvé ensemble le bon langage, le nouveau langage qu’il nous faut tenir ensemble dans le contexte où nous nous trouvons.
Alors, dès lors, il nous faut retrouver le langage que dicte l’éthique à laquelle le juge Cameron nous appelait ; retrouver le langage de la science et rejeter le langage de l’opinion du moment. Bachelard disait : «  la science, dans son besoin d’achèvement, comme dans son principe, s’oppose absolument à l’opinion . S’il lui arrive, sur un point particulier de légitimer l’opinion, c’est pour d’autres raisons que celles qui fondent l’opinion. L’opinion pense mal, elle ne pense pas, elle traduit des besoins en connaissance ».
Il nous faut nous re-mobiliser :
Pour les ressources, pour un Round 11 du Fonds mondial, pour des ressources prévisibles
Pour restaurer la confiance des pays et des communautés récipiendaires dans la volonté collective du monde de mettre fin à l’épidémie,
Pour le maintien de certains acquis fondamentaux des dernières années dans le financement international de l’aide, je pense en particulier au rôle décisionnel plein des pays, à ce que l’on traduit par « l’appropriation delà décision par les pays » ou  »country ownership », menacés en temps de crise ;
Pour que la communauté internationale se tienne aux objectifs qu’elle s’est fixés,
Pour que l’effort redevienne pleinement collectifVoilà ce sur quoi je crois que nous devons nous interroger au cours de cette conférence, ici à Genève, ville qui accueille les institutions multilatérales clefs pour la santé publique mondiale.
Le cynisme n’est pas acceptable. La résignation et l’apathie sont nos ennemies.
Il y a tant de raisons de poursuivre la dynamique de ce que nous avons pu réaliser dans les dix dernières années, tant de raisons d’optimisme, d’espoir.
Nous savons ce que nous pouvons réaliser si nous nous mobilisons tous ensemble dans un même mouvement, dans le même effort, si nous restons confiants.

 

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La tuberculose, Puccini et .. Isango

Je tenais beaucoup à me rendre au Cap, pour la première de la Bohème produite et chantée par la compagnie Isango. Un vieux théâtre en bois, appelé le “German center”, au cœur de la partie ancienne de la ville. Salle pleine. Depuis un peu plus de six ans, Isango monte certains des grands opéras de Mozart à Puccini, en langue locale et avec un orchestre d’instruments locaux. La production, il y a deux ans, de la “flute enchantée” avait reçu de nombreuses récompenses, dont le globe de cristal à Paris pour le meilleur opéra. Les instrumentistes font appel à des xylophones et des percussions. Les musiciens ne cessent de se balancer, ou de danser, au rythme qu’ils impriment à la musique, plutôt qu’ils n’obéissent à la baguette d’un chef. Avec un résultat étonnant : les crescendos qui précèdent ou accompagnent les grands airs apportent la même émotion que ceux dévolus aux cordes dans la partition de Puccini. Les chanteurs sont tous issus de townships à Soweto. Un spectacle magnifique, alternant l’émotion des grands airs chantés en anglais et l’énergie, proche de celle de la comédie musicale, des scènes “de contexte” chantées en langue locale (ainsi, la scène ou le propriétaire mafieux vient réclamer son loyer). Pauline Malefane  qui chantait Mimi a une voix d’une grande beauté, assurée et pure. Elle est entourée d’une troupe remarquable. Pour ce spectacle, Rodolphe est devenu Lungelo et Marcello est Mandisi.

Le Fonds mondial a subventionné cette production de la Bohème.  Le spectacle sera donné dans plusieurs villes d’Afrique du Sud, à Londres en mai, en Europe et aux Etats Unis. La brochure de présentation parle de l’action du Fonds dans la lutte contre la tuberculose, et du partenariat mené, pour cette production, avec la fondation Desmond Tutu.

Desmond Tutu était présent à cette première, avec ce sourire généreux et radieux qu’il arbore si souvent, un sourire presque déroutant, mais que je lis comme un sourire d’espoir de l’Afrique.

Le message s’imprime dans nos esprits en même temps que l’émotion de la musique. Nous ne sommes plus à Montparnasse en 1830, mais la tuberculose reste la maladie des pauvres, des plus pauvres de ce monde. Je me souvenais de malades rencontrés au Malawi dans un Hôpital General submergé par les malades du sida, des malades en haillons couchés sur des brancards en bois dans un hôpital de district du Nord de l’Inde, ou d’autres, dans une prison Ukrainienne. Le traitement de la tuberculose coute 20 dollars US pour six mois. Un traitement bien suivi a maintenant plus de 85 pour cent de chances d’amener la guérison dans le monde en développement. Mais la tuberculose tue encore 1,7 million de personnes chaque année dans le monde. Elle reste la première cause de mortalité des malades du sida.

 

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Reflections on the Global Fund, An open letter from Michel Kazatchkine

March 2012

Today, March 16, I will step down after five years as Executive Director of the Global Fund, having also contributed to the mission of the Global Fund as a member of the Transitional Working Group, Chair of the Technical Review Panel, and member and Vice-Chair of the Board.

As I leave the Global Fund, I wish in this open letter to share a number of reflections based on the unique perspective that is afforded the Executive Director.  My hope is that these observations will contribute to ongoing discussions about the Fund’s future direction as it marks its tenth anniversary and undergoes a challenging process of transition under new leadership.

The main aim of this letter, however, is to emphasize a number of the themes that I have frequently addressed during my term as Executive Director, including the remarkable progress that has been made in the fight against AIDS, TB and malaria in the last decade, the major contribution to this progress made by the Global Fund and the absolute imperative of continuing the Fund’s vital work.  In an era where discourses of austerity and risk mitigation are becoming dominant, I wish to entreat  the global health community not to abandon the ambitious approach that has brought us to where we are today, in which we set and strive to reach bold targets, jointly identify challenges along the way, and collectively resolve to overcome those challenges. In this regard, I wish to highlight why I believe it is critical that the international community strongly reaffirms its commitment to the Global Fund as the primary vehicle for achieving global health goals in the years ahead and an instrument that is uniquely capable of translating public health and human rights principles into action.

As I reflect on my years as head of the Global Fund, five things clearly stand out:

1. The Global Fund has been highly effective in its primary role as a financing institution

Around $33 (30.6 pledged end-2011) billion has been mobilized through the Global Fund since 2002, more than $20 billion of this in the two replenishment processes that I was involved in as Executive Director. Since 2002, more than $15 billion has been disbursed, 80% of this in just the last five years.  Grants have now been made in 150 countries.  I am convinced that without the Global Fund, nothing like these sums would have been committed to global health. The fact that they have been is a tremendous vindication of Kofi Annan and G8 leaders who recognized ten years ago that a new mechanism was essential.

The distribution of Global Fund financing to date – achieved with a demand-driven model and independent technical review of proposals closely corresponds with epidemiological trends and country needs.  Overall, the funds have been invested in a way that is consistent with the Fund’s mandate to accelerate progress on MDG 6, while at the same time contributing strongly to the other health MDGs and health system strengthening, and mobilizing the capacities of both government and non-governmental entities.  For example:

  • More than half of the $22 billion approved by the Board so far has gone to countries in sub-Saharan Africa, which have the greatest health needs;
  • 90 per cent of approved funding has gone to low or lower-middle income countries, which are least able to finance their own health programs;
  • The portfolio is broadly balanced between treatment and prevention interventions, with around 40 per cent of funding spent on drugs and other health commodities;
  • Around a third of approved financing has supported health and community systems strengthening, including salaries and training, infrastructure development and monitoring and evaluation;
  • Around half of Global Fund financing is estimated to benefit women and children directly or indirectly, and
  • Around 40 per cent of reported expenditure is by non-government entities.

These achievements and factors have been verified in a number of international publications, the independent, five-year evaluation of the Global Fund performed in 2007 and subsequent reviews undertaken by donors in 2009 and 2010.

In addition to being well-targeted, Global Fund resources have been managed with minimal overheads.  Operating expenses (including Local Fund Agents costs) have ranged from 3 per cent to 7.7 per cent of total expenditure (operating expenditures plus commitments),  and until 2010 were covered entirely through interest earned on the Global Fund trust account held at the World Bank.

Despite the media and political furore that surrounded misappropriation of Global Fund resources last year, the reality is that the Fund has a strong track record of appropriately targeting and efficiently managing its resources that should provide a sound basis for continued donor confidence and support. The Global Fund has exhibited an unprecedented level of transparency with regard to these losses, responding vigorously to them both in the affected countries and by increasing vigilance and strengthening controls across the portfolio.

The new risk management approach that is now being introduced should enhance that confidence and will earn the strong support of implementers as well if it focuses on strengthening their own capacities and systems, rather than adding another layer of compliance requirements at the Secretariat level.

* * *

2.     Global Fund financing has allowed countries to achieve unprecedented results and impact in the fight against the three diseases

When the Transitional Working Group that established the founding framework of the Global Fund met in Brussels in 2001, it did so in the context of a global health emergency and an almost Utopian dream that the three diseases might one day be defeated.

Five years later, in 2006, the feasibility of scaling up on a global scale to confront the three diseases had been demonstrated, even in the most resource-constrained settings. And today we are able to say that the world has reached a point where the early signs of impact reported in the first few years of the Global Fund have now given way to sustained, positive trends in the fight against the three diseases.

In the fight against AIDS:  The estimated number of new HIV infections has fallen by 20 per cent, from 3.1 million to 2.6 million[1], in the last ten years.  Twenty-two of the 33 countries where HIV incidence has fallen by more than 25 per cent in that period are in sub-Saharan Africa.  The global number of AIDS-related deaths has fallen nearly 20 per cent from the peak of 2.1 million in 2004 to an estimated 1.8 million in 2009, due mainly to increased coverage of antiretroviral therapy and improved care and support for people living with HIV in low and middle-income countries.  AIDS-related deaths among children younger than 15 years of age have also declined by 20 per cent, from 320,000 to 260,000.   With the steady scale-up of PMTCT programs, the world is now striving to realize the vision of an AIDS-free generation in the next few years.

In the fight against TB: The absolute number of incident TB cases per year has been falling since 2006[2]. The annual incidence rate has also been falling steadily since 2002, making it likely that the MDG target of reversing TB incidence by 2015 will be achieved.  TB mortality is also declining globally.  However, MDR-TB remains a major challenge.

In the fight against malaria: The number of malaria deaths has fallen by nearly 20 per cent globally in the last decade[3].  Three countries have eliminated malaria since 2007, with 10 more expected to do so in the next five years, including the entire WHO EURO region.  Huge progress has been made in sub-Saharan Africa where at least 11 countries have recorded a greater than 50 per cent reduction in malaria cases and related deaths in the last five years. Overall child mortality in sub-Saharan Africa has dropped by approximately 20 per cent in the last decade.   According to WHO, between 2008 and 2010 alone, more than 250 million insecticide-treated bed nets were delivered to sub-Saharan Africa with support from a variety of donors (mainly the Global Fund), enough to cover nearly three-quarters of the population at risk of malaria and providing a sound basis for efforts to reach universal access.[4]

With a determined effort, we may now think of eliminating malaria as a public health threat in most endemic countries in the coming years.

As a principal financier of antiretroviral treatment and the majority of HIV prevention globally, and the provider of two-thirds of international financing for TB and malaria, the Global Fund has made a major contribution to this progress.   By the end of 2011, the Fund was supporting 3.3 million people on antiretroviral treatment, or about half of those receiving it globally.  The cumulative number of people to receive DOTS for TB had reached 8.6 million and the cumulative total of insecticide treated bed nets distributed with Global Fund support had reached a remarkable 230 million by the end of 2011.

I am, of course, not suggesting that all of this can or should be attributed to the Global Fund. Ultimately, it is the countries to which we should attribute results, but it is clear that without the Global Fund, we would not have achieved anything like the progress made globally against the three diseases in the last decade.

Crucially, it is not the Global Fund that has determined overall global strategy for tackling the diseases; rather, the Fund has served as an effective instrument for resourcing national plans and advancing the global plans developed by the Roll Back Malaria and Stop TB partnerships, WHO and UNAIDS. 

* * * 

3.     The Global Fund has shown that it is a highly effective mechanism for translating public health and human rights principles into action

To me one of the most exciting things about the Global Fund and something that strongly distinguishes it from most other financing bodies is its capacity to move concepts and principles into action. Let me touch on six areas.

In the last five years:

The Global Fund has increased global attention on human rights and expanded access to services for the most vulnerable and at-risk

A major strategic effort has been made by the Global Fund to increase gender-based interventions and programming that addresses sexual orientation and gender identity, including for men who have sex with men.   As a result, between Rounds 8 and 10, the number of proposals that contained interventions targeting women increased by around 30 per cent, while the proportion of funded proposals that included care and support for sexual minorities increased from around 30 per cent to nearly 50 per cent.

The Global Fund has been at the forefront of financing interventions for other at-risk populations, for example, through the first multi-country proposal for HIV prevention among sex workers that was approved for the LAC region in 2011.  The fact that the Fund is by far the largest funder of harm reduction among injecting drug users is a unique achievement that must be sustained in contexts where relatively small investments have enabled HIV prevention programs to be introduced in difficult environments and have helped to support remarkably effective community-based networks.  In 2010, a specific MARPS (Most-at-Risk Populations) channel was introduced.

As Executive Director, I was pleased to lend my voice to a number of important advocacy issues, including on global illicit drug policy and the persecution of men who have sex with men in Africa, and I was thrilled when, in November 2011, the new Global Fund strategy approved by the Board included a specific strategic objective on human rights for the first time.

The Global Fund has pioneered democratic planning and decision-making processes through Country Coordinating Mechanisms (CCMs)

At the time of the Global Fund’s creation, the Country Coordinating Mechanism was seen as quite a revolutionary concept for national decision-making in health.  As Executive Director I have consistently met with CCMs during country visits and I have seen great diversity among them in terms of their ways of working, their inclusiveness and how closely Global Fund proposals reflect national plans and needs.

While nearly all CCMs are a work in progress, I believe that significant advances have been made in the last five years to increase participation and inclusiveness, ensure core funding for CCM operations, leverage additional support from bilaterals and other donors and achieve consensus on new CCM guidelines that were approved by the Board in 2011.

The Global Fund has created instruments that are helping to leverage lower prices for pharmaceuticals and other health commodities.

These include:

The Price and Quality Reporting (PQR) mechanism: Established in 2004, the PQR now contains reliable data covering more than $2 billion of procurement transactions and has become an important tool to help the Global Fund ensure value for money and to provide countries with transparent data that assist in making procurement decisions.  The PQR shows a continuing downward trend in the average cost of the most common ARV regimens from around $125 in 2008 to $100 in 2011.

Voluntary Pooled Procurement (VPP): VPP was introduced in 2008 and by late 2011 had procured health products in 45 countries valued at around $700 million. The mechanism has expedited the average time from first procurement request to delivery in most countries.  In 2011, average prices for ARVs procured through VPP were 8 per cent lower than the levels negotiated by the Clinton Foundation. Likewise prices for Long Lasting Impregnated Nets (LLINs) procured through VPP were on average 6.5 per cent below the prices reported in the PQR.

Market Shaping Strategy: I was very pleased when the Board approved this strategy in 2011, with the initial objectives of increasing value for money of pediatric antiretroviral formulations, expediting the transition to single dose ACTs and ensuring product optimization for first and second line ARVs.

Despite these successes, not enough has been done to ensure that all countries are using optimal first line AIDS treatment and that second line ARVs are accessible at the scale needed.  The WHO/UNAIDS Treatment 2.0 plan promoted an important initiative in this regard.   The same is true for second line TB treatment, where continuing high prices threaten the future sustainability of TB programs and account in part for the inadequate progress made against MDR-TB.

The Global Fund has focused on expanding access to effective and affordable drugs beyond public sector programs

The best example here is for malaria.  By hosting the Affordable Medicines Facility for Malaria (AMFm) since it was established in 2007, the Global Fund has contributed to an innovative partnership for improving access to artemisinin-combination therapies (ACTs).  Since Phase 1 began in mid-2010, price negotiations with manufacturers and co-payments have together achieved impressive reductions in median retail prices of ACTs, from a range of around $5-12 before the AMFm to between 50 cents and $1.30 currently in eight pilot countries.  Total co-payments have been approved for around 175 million treatments, with two thirds of orders for sales in the private sector.

The AMFm has achieved remarkable results in its first phase.  If the evaluation of the AMFm scheduled for later this year is positive, the question for the international community should not be whether but how the mechanism can be expanded and offered to countries as part of a comprehensive malaria funding package from the Global Fund.

The Global Fund has been in the vanguard of efforts on innovative financing for health

In the public sector, the Debt2Health initiative, led by Germany, has pioneered the conversion of debt owed to international donors into new funds to fight disease through the Global Fund.

In the private sector, PRODUCT (RED), an outstanding, global, consumer-driven effort, has raised nearly $200 million for the Global Fund since it was established in 2006 and now includes more than 20 partner companies, among them iconic brands such as Apple, Coca-Cola and Nike.  More recently, Deutsche Bank has introduced Exchange Traded Funds that benefit Global Fund programs, while private sector investments in country programs by companies such as Accenture and Standard Bank have increased substantially in the last two years, highlighting the huge potential for these corporations to help countries leverage Global Fund investments more effectively.

I believe that it is vital for the Fund’s innovative financing work to continue and to be appropriately resourced, not only so that new funding streams can be tapped for the Fund itself but also as a way to inform the larger global policy agenda on innovative financing for development.

The Global Fund has been a leader in advancing and implementing the aid effectiveness agenda

On becoming Executive Director, I became concerned over efforts from some quarters to discredit so-called “vertical funds” and to pit disease interventions against “health systems strengthening”, as though we should choose between one or the other rather than do both.  The reality is that the Global Fund was built on aid effectiveness principles and has taken a leading role in their development in the Paris, Accra and Busan meetings. The Global Fund exercised early leadership in measuring  aid effectiveness across its full portfolio, and then implement measures to improve its performance, including introducing national strategy applications, reviewing grants for aid effectiveness as part of performance and working to better align reporting cycles.

* * * 

4.     Partnerships require a lot of attention and work but are the only way to ensure long-term success and sustainability

The Global Fund partnership model is based on the belief that everyone’s capacity must be harnessed if the major diseases are to be tackled effectively and their social and economic implications are to be addressed as well as their clinical and medical impact. It is a model that recognizes that, while governments may often lead, other organizations – such as businesses and community groups – have much to contribute in advocacy, planning, resource mobilization and program implementation.

But we know – and we learn this every day at the Global Fund – that partnerships, both in countries and at the global level, are very demanding and that they require careful work and perseverance in order to function well. They involve power asymmetries that need to be addressed constructively and with mutual respect. They require different parties to surrender some of their power, share information and knowledge, set aside differences, and work towards a common goal.

At the country level, I have seen many good examples of multi-stakeholder collaboration and shared responsibility for implementation of Global Fund financing. In some countries, such partnerships exist on paper but there is little true collective ownership of the funded programs or adequate effort to integrate them closely with the national health system.  There also remains a tendency for CCMs to be somewhat inward looking and disconnected from broader health system challenges.

The governance of the Global Fund was explicitly structured in 2001 as a unique and ambitious model of partnership in international development financing, giving voice to implementers, civil society and the private sector, in addition to donor governments.   But the results have been mixed. On the one hand, the multi-stakeholder composition of the Board has brought the rich benefits of diverse perspectives to Global Fund decision-making. Many Board members for example were impressively engaged in developing the new Global Fund strategy in 2011. On the other hand, the independent five year evaluation of 2009 found that although the inclusiveness of Global Fund governance was unprecedented, “little of this has yet translated into clearly defined, durable and formalized operational partnerships.” Possibly as a reflection of this, the very senior level political leadership from both implementing and donor countries that was a characteristic of the Global Fund Board in the early years has decreased markedly,  notwithstanding the fact that commitments to health and development are as much determined by political factors as they are by economic ones. Also, for a variety of reasons, implementing countries often remain relatively too passive on the Board, despite recent constituency-building efforts.

As Executive Director of a major global partnership I have always been conscious of the need to devote time to interacting with partners and ensuring that they are paid due credit. Partnerships require work, time, attention and regular communication. They involve finding consensus among different points of view. Sometimes they are frustrating. But, especially in the current environment, it has never been more important than it is today for us to make partnerships work in global health. The continued success of the programs that the Global Fund supports depends on this.

* * *  

5.     The leadership of the Global Fund needs to carefully assess and strike a balance between competing tensions that are inherent to the Fund’s model

A number of tensions are intrinsic to the Global Fund model and to an extent are exacerbated by the current climate of economic austerity. These include:

  • The tension between a Fund that decides “from the top down” what is the most pertinent to fund in countries and the Global Fund’s core principle of country ownership.  This includes the key question of how best to prioritize the needs of the most vulnerable populations even where there is a lack of political will in the country to do so.   If the Fund determines that the costs and risks of full country ownership may in some cases be too high, it should nevertheless be wary of shifting to a funding model that is based explicitly or implicitly on a system of pre-allocation of funding at the expense of the results- and performance-based funding model that has served it so well.
  • The tension between a Secretariat that confines itself simply to grant management functions and leaves everything else to partners versus a Secretariat which – due to the complexity of issues or for strategic reasons – also has the capacity to assess the epidemiological context, measures the Fund’s contribution to overall targets and results, evaluates its own performance and harmonizes data with other sources.
  • The tension between the need to strengthen national systems, such as for procurement, and the need to ensure that commodities are delivered in a timely and efficient manner, e.g. by setting up parallel systems.
  • The tension between being a constantly learning and evolving institution, and the toll that relentless change and reform are beginning to take on staff.
  • The extreme tension found at the nexus of five of the foundation principles of the Global Fund: country ownership, the Global Fund as principally a financing mechanism, a very small (lean) Secretariat relative to that of most international development agencies and with no field representation, full transparency and effective risk management.  This combination has created a dynamic tension that has defined the operations of the Global Fund from its inception. Audit findings last year of a $13 million financial misappropriation led to a suspension of contributions by some donors. Fraud at any level is, of course, unacceptable and the Fund has an appropriate zero tolerance of fraud policy. But great care must be exercised to prevent zero tolerance of fraud from becoming zero tolerance for risk and zero tolerance of error. Moreover, as I mentioned in section 1, the reality is that the Fund has a strong track record of appropriately targeting and efficiently managing its resources that should provide a sound basis for continued confidence and support.

* * *

I am proud of the remarkable achievements of the Global Fund and of the efforts and initiatives we have taken over the last five years to improve it.  For example, on becoming Executive Director in 2007, I introduced a new organizational structure that I believe succeeded in its primary objective of accommodating the organization’s rapid growth, namely, the doubling between 2007 and 2011 of both funds disbursed annually and the number of staff.  I also strengthened the Secretariat’s capacity to track expenditure, measure results and grant performance, implement the Board’s numerous policy and strategy initiatives, undertake evaluations (such as the large Five Year Evaluation in 2007/08), respond to the increasing demands for the Fund to participate in the global health policy arena, interact more effectively with partners and develop a basic level of technical expertise about the three diseases. Under my leadership, the Fund established entirely new administrative systems when it left the WHO umbrella in 20o9.  And in response to the increasing complexity of managing rapid, linear growth in the number of grants, in 2009 I introduced a new grant architecture based on single streams of funding, among other grant management reforms.

In 2012, the new management of the Global Fund is introducing further significant change based on recommendations made by the High Level Panel last August, the Comprehensive Transformation Plan and the five-year strategy approved by the Board last November, as well as its own assessment of current needs and political considerations.  As it does so, it will be crucial to clearly recognize and manage the tensions in the Global Fund model that I have outlined in such a way that they are a creative rather than a destructive force.  The agenda for change at the Global Fund needs to strike a balance between the prevalent notions of austerity, efficiency and risk management and the core principles that have distinguished the Global Fund from other funding bodies and that have been so instrumental in its decade of success.

* * *  

Despite the impressive gains made in global health in the last decade, the war against the three diseases is not yet won.   If the Global Fund is to continue making a major contribution to achieving global health goals in the coming years, it will be important for the Board to clearly communicate how the current focus on “transformation” at the Fund will lead to better results and increased impact.  Failure to do so could jeopardize the confidence of implementing countries in the Fund as an institution that has their interests primarily in mind and would sorely test the commitment of staff.  My hope is that the Fund will emerge from this period of change having retained and strengthened its unique qualities of inclusive governance, dynamic partnership, unparalleled transparency, commitment to be truly global and firm commitment to country ownership.

I extend my sincere thanks to everyone who has supported me and the Global Fund for the last five years. There are far too many people to thank them individually in this letter. I have been honored and privileged to have been central to such a magnificent, mission driven organization, and wish it and all associated with it, every possible success in the future.

Michel D. Kazatchkine
Geneva, March 16, 2012

 


[1] AIDS at 30, Nations at the Crossroads. UNAIDS 2011.

[2] Global Tuberculosis Control Report. WHO 2011.

[3] Eliminating malaria: Learning from the past, looking ahead. WHO, RBM, PATH. October 2011.

[4] Global Malaria Report. WHO 2010

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10 ans du Fonds mondial… merci

Célébration à Paris des 10 ans du Fonds mondial, photo Fonds mondial /Gilles Bassignac

A Davos il y a une semaine, à Paris, mardi dernière, nous venons de célébrer les dix ans du Fonds mondial de lutte contre le sida, le paludisme et la tuberculose. Dix ans de progrès remarquables de la santé dans le monde.  Le Fonds a démontré tout au long de ces dix ans qu’il était l’instrument de choix, le bon modèle pour combattre ces maladies à l’échelle mondiale et combien nous pouvions collectivement être fiers de ses succès.

Il y a dix ans alors que nous voyions dans nos hôpitaux  la vie des malades transformées par les trithérapies antirétrovirales, pratiquement aucun malade n’y avait accès dans les pays en développementou vivent 90% des personnes infectées par le VIH. Aujourd’hui plus de 7 millions  de personnes ont accès  au traitement dans les pays pauvres. Aujourd’hui l’espérance de vie  d’une personne débutant le traitement est accrue d’au moins 25 ans.

Il y a dix ans le paludisme était une maladie négligée. En dix ans les progrès ont été considérables. En Afrique ou 80% des foyers dans les pays endémiques ont maintenant accès à des moustiquaires imprégnées d’insecticide  pour la protection de la maladie. La mortalité du paludisme a diminué de plus de 50% en Afrique et la carte des pays endémiques se rétrécit

Le nombre de nouveaux cas et la mortalité de la tuberculose sont en décroissance et nous sommes « dans les temps » pour atteindre les Objectifs du millénaire pour la tuberculose.

Nous pouvons être fiers de ces succès, fiers aussi du soutien fort et fidèle de la France et de l’Europe au Fonds mondial depuis dix ans.

Pour ma part je considère comme un privilège d’avoir été associé à cette aventure du Fonds mondial depuis 10 ans. A Bruxelles en 2001 dans la délégation française au ” Transitional Working Group“, comme premier président du comité technique de revue des propositions de 2002 à 2005, comme membre et vice-président du Conseil d’administration en 2005 et 2006 et enfin comme Directeur exécutif au cours des cinq dernières années.

Quelques semaines avant de quitter le Fonds mondial je souhaite adresser deux messages.

Le premier est un message de remerciements.
Si ces progrès sans précèdent en santé publique dans le monde ont pu être accomplis, c’est parce que nous nous sommes tous unis pour travailler ensemble
Alors merci aux pays qui luttent contre ces maladies. On parle des financements qu’apportent le Fonds mondial  mais il faut aussi se rendre compte que les pays eux-mêmes investissent dans des efforts humains, financiers et structurels considérables.


Merci à la France,  à l’Europe, aux pays donateurs d’avoir apporté les ressources qui ont permis l’accès à large échelle à la prévention et aux traitements.

Merci à la société civile aux ONG, aux communautés pour leur travail. J’ai voyagé partout dans le monde au cours de ces dernières années, en Chine, en Ukraine, en Afrique du sud, en Afrique de l’ouest, au Moyen-Orient, en Amérique latine et partout j’ai vu et vécu la force de leurs convictions et la détermination de leur engagement.

Merci aux  medias amis  qui ont soutenu ces batailles et ont par leur reportages contribué à la visibilité du travail du Fonds et des résultats accomplis aux cours de ces 10 années.

Merci aux fondations et au secteur privé qui soutiennent le Fonds avec passion Merci aux associations des« Amis du Fonds », en Europe, au Japon, aux Etats Unis, Asie Pacifique et en Afrique.

Mon second message est plutôt un appel. Ce n’est pas le moment de se désengager financièrement  Ce n’est pas non plus le moment  de se désengager sur les principes fondamentaux et les valeurs qui ont portés le Fonds et qui sont sa raison d’être : le principe d’appropriation par les pays ; le partenariat ; les financements liés aux résultats.

Faisons ensemble  que dans les dix prochaines années le Fonds mondial soit financé à la hauteur de ses besoins ; que le rêve de l’accès universel au traitement antirétroviral  devienne une réalité ; qu’aucun enfant  ne naisse infecté par le virus du sida d’une mère séropositive ; que le monde ait surmonté la menace  de la tuberculose multirésistante et que le paludisme ait cessé d’être  un problème de santé publique  une fois pour toute. Une bonne fois pour toutes.

Il y a dix ans tout cela était juste un espoir. Nous savons aujourd’hui que nous pouvons y parvenir. Il faut que dans les prochaines années l’engagement politique, les ressources  financières soient à la hauteur de cet espoir. Sinon nous aurons failli. Des millions de vie en dépendent.

 

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