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Africa: Global Fund as Legacy of Innovation

AfricaFocus Bulletin
Nov 15, 2006 (061115)
(Reposted from sources cited below)

Editor's Note

After more than 20 hours of deliberations early this month, the board of the Global Fund to Fight AIDS, Tuberculosis and Malaria was unable to agree on a new executive director. Despite the resulting delay, some observers say the failure actually indicates how seriously the Fund is taking its mandate to build a consensus between developed and developing countries.

The voting system requires a two-thirds majority within each voting group of "donors" and "recipients." According to the Global Fund Observer, in the board's discussions, it quickly became evident that the top two candidates were Michel Kazatchkine (France's HIV/AIDS Ambassador and former Vice-Chair of the Global Fund) and Michel Sidibe (a citizen of Mali who is a top UNAIDS official). In numerous votes, Kazatchkine received the support of all or almost all of the "donor group" together with about half of the "recipient group", and Sidibe received the support of all or almost all of the recipient group together with about half the donor group. (Board members could support one or both candidates.) Thus, even though each received the support of more than two thirds of all board members, neither received the support of two thirds of both groups.

[For more background and discussion of the selection process, see the Global Fund Observer at http://www.aidspan.org/gfo]

The Global Fund, launched 5 years ago at the initiative of UN Secretary-General Kofi Annan, has fallen short of its initial goals, with donor funding falling far short of the $10 billion a year originally intended. But it has achieved significant results in prevention and treatment, and, argues its head of Global Partnerships, pioneered new forms of international collaboration.

This AfricaFocus Bulletin contains excerpts from a speech by Dr. Kingley Moghalu at the International Conference on the Legacy of Kofi Annan, Georgetown University, Washington, D.C., 30-31 October 2006.

For previous AfricaFocus Bulletin's on the Global Fund and other health issues, visit http://www.africafocus.org/healthexp.php

++++++++++++++++++++++end editor's note+++++++++++++++++++++++

The Global Fund as a Metaphor of War

Paper presented by Dr. Kingsley Chiedu Moghalu
Head of Global Partnerships
The Global Fund to Fight AIDS, Tuberculosis and Malaria

At the International Conference on the Legacy of Kofi Annan
Georgetown University, Washington D.C., USA

30-31 October 2006

[Excerpts only. Full text available in archive at http://health.groups.yahoo.com/group/Global-AIDS-Alliance]

... in a full view of Kofi Annan as the seventh Secretary-General of the United Nations, the HIV/AIDS pandemic and the fight against it will have a pride of place. So, here we are - at a legacy conference discussing HIV/AIDS in the context not of the legacy of a leading figure in public health, but that of a diplomat and statesman.

The question is: why? Because HIV/AIDS is far more than a public health crisis, though that in itself would have been reason enough to act. HIV/AIDS attained its destructive height in the last decade of the 20th century and the beginning of the 21st. The worst pandemic in recorded history, it confronted the world with a political imperative - 22 million deaths since the disease was first clearly identified 25 years ago, 40 million infected by the virus and counting, five million infections and three million deaths annually.

The pandemic reached its crescendo at a time when the world was organized differently from the past. We had shifted from the equidistant empires and nation states that made up the international system of centuries past and whose interactions with one another were not intimate, to the reality of an international society of states with organized, multilateral forums of cooperation such as the United Nations and regional organizations.

Moreover, a tentative shift was also taking place as context for the phenomenon of HIV/AIDS - that of a struggle between the idea of self-interested sovereign states not much concerned about the localized problems of "others" and that of an "international community" in which people mattered as much as states and interactions across borders are as frequent, diverse and intimate as never before.

... Kofi Annan saw the pandemic for what it truly was - a crisis of human existence, especially in Africa, the most affected continent, which happened to be the one from which he hailed. The dimensions of HIV/AIDS and the response it called for were not necessarily self-evident, for the pandemic was closely - but not exclusively - associated with modes of transmission that invited stigma and silence. It was not surprising, then, that many people including some leaders, like ostriches, buried their heads in the sand and hoped the problem would go away.

It didn't. Kofi Annan, giving voice to the age of globalization, was quick to identify HIV/AIDS as one of those "problems without passports" and a fundamental challenge to Africa's development. Making HIV/AIDS his personal priority, he responded with all the political influence he could command as the Secretary-General of the United Nations. ...

Kofi Annan believed, correctly, in hindsight, that an unprecedented global mobilization of resources - political, financial, technical - was the only hope against AIDS as he saw Africa wracked by the disease, its development stunted by a pandemic that wasted the promise and productivity of its able-bodied young men and women and threatened -- still threatens, lest we forget - the very survival of several African countries as states in the sense we understand the term.

So Kofi Annan responded with the metaphor of war. He envisioned, championed and eventually birthed a global fund to serve as a "war chest" to finance a counter-attack on multiple fronts against the AIDS pandemic.

The Creation of the Global Fund

It was fitting that the road to the creation of such a fund began in Africa. And here we cannot give credit to Annan alone. I should note the strong support and shared vision the Secretary-General had in the fight against AIDS with one of Africa's leaders, President Olusegun Obasanjo of Nigeria. That partnership was to set the stage for the mobilization of a concrete political response from Africa toward the establishment of a global fund. This response was carefully and successfully orchestrated, for it was at a continent-wide summit of African leaders on HIV/AIDS, tuberculosis and other infectious diseases hosted by President Obasanjo at Abuja in April 2001 that Annan first publicly and formally proposed a global fund for the fight against AIDS.

... it is important to mention some salient points about this conference. First, it was held in Africa, at the initiative of an African leader, and involved the highest level of political leadership on the continent. ...

Second, Annan opened his speech to the African leaders with the momentous - and accurate - declaration: "This is a conference about Africa's future". HIV/AIDS is a global phenomenon - indeed, the pandemic is spreading at its fastest rates in Eastern Europe and the Caribbean and is on a steep rise in Asia. But, with Africa having 10 per cent of the world's population and 60 percent of all HIV infections, with the disease the primary cause of death of African adults, the actual and potential impact on Africa's development prospects and its security is a fundamental and negative one.

Third, the Secretary-General spoke in strategic terms of an existential war and how to win it. He set out in very clear terms what the objectives of Africa and the world should be in this war and precisely how to achieve them. These objectives were: prevention - halting and reversing the spread of HIV by sexual transmission, stemming transmission from mother to child, making care and treatment available to all, delivering scientific breakthroughs, and protecting children orphaned by AIDS.

Annan then proposed to African leaders how he believed these objectives were to be met. The first thing that was needed was political leadership through which the citizenry could be mobilized and the fight against AIDS prioritized in national budgets. Second there was a need to involve local communities. Third, Annan advocated a "deep social revolution" that would empower women and address the dynamics of gender relations that facilitate the spread of the virus. Fourth, he identified the necessity for cheaper antiretroviral drugs at a time when the prices of these medicines wee far beyond the reach of ordinary African citizens.

Finally, he spoke the "m-word": money. "We need money", Annan stressed. "The war on AIDS will not be won without a war chest, of a size far beyond what is available so far", he stated. "I propose the creation of a Global Fund, dedicated to the battle against HIV/AIDS and other infectious diseases. This fund must be structured in such a way as to ensure that it responds to the needs of the affected countries and people. And it must be able to count on the advice of the best experts in the world - whether they are found in the United Nations system, in governments, in civil society organizations, or among those living with HIV/AIDS or directly affected by it".

...

The next stage of mobilization toward the creation of this disease-fighting treasury was the United Nations General Assembly Special Session on HIV/AIDS (UNGASS), which took place in New York in June 2001. At the UNGASS, the member countries of the UN issued a Declaration of Commitment on HIV/AIDS and called for the establishment of a global fund (referred to at the time as a "global HIV/AIDS and health fund") for that purpose.

Within four weeks after the UN summit, Annan kicked off the process of creating a concrete financing institution by appointing Dr. Chrispus Kiyonga, a former Ugandan minister of health, as chair of the Transitional Working Group that was to design this institution and its mechanisms. Annan instructed that efforts be made to establish the Global Fund within six months from the start of the work of the TWG.

A noteworthy fact was that, although he was Secretary-General of the United Nations, Annan was quick to realize that, given the unique kind of governance and operational structure envisaged for the nascent fund, such an organization could not comfortably be a UN agency, or even be optimally effective if it was one. So he took the position that it should not be a UN organization, though it enjoyed the backing of the UN and its Secretary-General. Thus was Global Fund to Fight AIDS, Tuberculosis and Malaria established as an international public-private partnership organization, registered as a Swiss foundation, in January 2001.

...

The Global Fund: Innovation

In order to understand the Global Fund and its place as a major legacy of Kofi Annan, it is necessary to understand the scope of innovation it represents in international development and in international organization. ...

What Annan described to the delegates of the World Health Assembly was a public-private partnership. It would have a board made up of both developing and developed donor countries, the private sector and foundations, non-governmental organizations, and UN agencies, and the board would set "broad policies" that would support national health plans approved by an independent advisory body of health experts.

And so indeed it was. The Board of the Global Fund has 23 members - equal numbers of representatives of developing and donor countries, a seat for NGOs of developing countries and another for those of developed countries. The private sector and philanthropic foundations have a seat, as, uniquely, do representatives of communities of persons living with AIDS, TB and malaria. The World Bank, WHO and the United Nations Joint Program on HIV/AIDS (UNAIDS) each have a non-voting seat on the Board.

A second pillar in the architecture of the Global Fund is the Technical Review Panel (TRP), the panel of health experts Annan foreshadowed. This independent body reviews proposals submitted to the Fund on the basis of their technical soundness and potential to save lives, and recommends successful proposals to the Board for funding approval. The third architectural pillar is the Secretariat, led by the Fund's Executive Director, while the fourth arm is a Partnership Forum of stakeholders that meets every two years.

The very institutional design of the Fund was thus unprecedented - a public-private partnership governance structure to address a global challenge, with sovereign governments and NGOs and private corporations seating at the same decision making table with the same voting rights, and developing and donor countries have identical voting powers (and no vetoes!), a far cry from the weighted voting rights in accordance with economic strength that governs the Bretton Woods institutions. ...

In addition to the public-private nature of the Global Fund, it has contributed to wider development goals through several other innovative approaches. Two of these are of cardinal importance. The first is local ownership of the programs the Fund finances, while the second is the Fund's practice (not just rhetoric) of performance based funding.

"Local ownership" is one of the buzzwords of international development. But it is easier said than done. What the Global Fund has done is to make this a concrete reality of its work by replicating the public-private governance model at national levels. Country Coordinating Mechanisms (CCMs) in recipient countries bring together governments, civil society and private sector organizations, and persons living with the three diseases, to formulate program proposals that are submitted to the Global Fund for funding. The Fund does not entertain proposals that have not gone through this process at the national level except in very rare circumstances. While this principle encourages multi-sectoral collaboration in the fight against the pandemics in developing countries, in practice it is not without difficulties that trail most innovations. For example, how truly representative of various stakeholders CCMs are in reality varies from country to country as does how well they are actually function even when there is the required representation of different sectors. Nevertheless, courtesy of this Global Fund innovation, governments and civil society and private sector in several countries have been made to collaborate for the first time to achieve development goals. ...

Performance based funding is also easier as an aspiration than as an active and practical principle. The principle of accountability is enshrined in the foundation of the Global Fund. Money should not be spent simply for its own sake, or just as a process, but to achieve concrete outcomes in prevention, treatment, and lives saved by the interventions funded. The Fund has monitored and evaluated each recipient of its grants, and this typically takes place after the first two years of a total life span of five years of Global Fund financing for country programs. This is particularly challenging, but is also possible, because the Global Fund is a financing mechanism, not an implementing entity. Good performance is encouraged. Weak performance in some countries has led the Fund to set up an early warning and response system that alerts implementing technical partners to provide the necessary support to support a fledgling program. Non-performance is penalized through grants suspensions, changes in the principle recipient of Global Fund resources, or through outright cancellations of programs - again, a particularly difficult decision when we are speaking of funding lifesaving programs. Examples of countries where the Global Fund has sanctioned non-performance include Myanmar, Nigeria, Uganda and Ukraine.

Moreover, in international development finance, a certain dynamic can easily develop between the funder and the funded, whereby political considerations lead to continued financing of non-performing programs or governments. But the Global Fund, no doubt helped by its nature as a public-private partnership, has remained remarkably insulated from political considerations in its own funding decisions, and thus better able to ensure performance based funding to fight AIDS, TB and malaria. ...

The War Chest and Its Impact

Created only five years ago, the Fund has grown significantly in the size of its resources, and its impact is increasingly apparent. As of October 2006 the Fund had total assets of 9.6 billion. These resources have been mostly contributed by sovereign governments who, despite the public private character of the organization, look set to remain its most important resource base. But the Bill Gates Foundation has contributed $650 of the Global Fund's assets, and efforts to generate more resources from private sector corporations are gradually gaining ground.

As of October 2006 the Fund had committed $4.9 billion to prevention, treatment and care programs in 132 countries in five funding rounds that take place roughly every nine months. Sub-Saharan Africa has received 60 percent of the Fund's resources so far, not by design or as policy but in a reflection of demand. Twenty percent has gone to Asia, 10 percent to Latin America and the Caribbean, while 9 percent has gone to Eastern Europe. Divided by disease categories, 56 percent of the Fund's resources have gone to anti-AIDS programs, 26 percent to malaria, and 14 percent to TB programs.

What's the "bang for the buck"? What has this money achieved? The war against the phenomenon of HIV/AIDS and the pandemics of malaria and TB has, in truth, only just begun ... As of this writing, 500,000 people are on antiretroviral treatment for HIV/AIDS as a direct result of resources provided by the Global Fund, while the Fund projects that 1.8 million people will receive such treatment at the five year term of all the programs it approved for funding in its first five funding rounds. 2 million have been successfully treated for TB while the projected five-year, five-round outcome is 5 million people successfully treated.

For malaria, Global Fund resources have put 12 million insecticide treated mosquito bed nets in the hands of poor families in Africa and Asia (with 109 million bed nets to be financed in the five year span of all five rounds). The Fund has financed a major shift from drug-resistant malaria medicines to effective, artemisinin based combination therapy treatments that cost 12 times as much and are thus out of reach of average families in Africa.

Global Fund-financed programs have had remarkable impact in particular areas, though grant performance of these programs has been impressive across the board and all things considered. In the Lubombo region of Southern Africa (encompassing parts of South Africa, Botswana and Mozambique), Global Fund financing has contributed to a 90 percent decline in the incidence of malaria. And the combined impact of Global Fund financing and that of United States bilateral aid programs and the World Bank has led to an 800 percent increase in ARV treatment HIV/AIDS in Africa between 2004 and 2006.

But, when we consider that nearly five million people are infected with HIV yearly and the disease kills three million annually, and when we remember that more than a million children die each year of malaria, mostly those under the age of five and 90 percent of them in Africa, the scale of the challenge before the Global Fund and its partners becomes clear. And, as we consider Kofi Annan's legacy, we must not wear rose-tinted lenses ... there are some other cold facts to consider as well.

The first is that, ironically, while the AIDS pandemic was the main motivation for the creation of the Global Fund, its impact on the fight against AIDS in terms of the resources it has or can bring to bear, is in fact modest. As a result, the Global Fund share of global financing for the war on AIDS is about 20 percent. By contrast, the Fund's role - and thus its likely impact - is far greater in the fight against malaria, where it provides over 50 per cent of international funding.

This situation owes itself to two main factors. The first is the rise in bilateral AIDS spending by donors such as the U.S. government through its Presidential Emergency Program on AIDS Relief (PEPFAR). ...

But, although multiple funding sources can put a strain on coordination by donors and recipients, individual institutional ambitions are ultimately less important than the overall outcome of the war on AIDS. That is why the partnership between the Global Fund and PEPFAR has increased and improved in order to ensure better coordination of support to countries highly affected by the AIDS pandemic. This relationship is especially important for Africa because, although the Global Fund finances programs in 132 countries in four continents, PEPFAR programs focus on 13 African countries especially burdened by the impact of AIDS. Moreover, the U.S. remains the highest single country contributor to the Global Fund, and it should be said that increased bilateral spending need not mean an inability or unwillingness to fund the Fund at the level of its resource needs. This brings us to the second point.

The most important factor is that when it comes to scaling up resources available to prosecute this war, the promise of the Global Fund has not been realized. There are many reasons for this, some of which may possibly include limitations imposed by the financial and funding model of the Global Fund (e.g. funding rounds as opposed to being a revolving grant-credit mechanism), but the most important is that donors have simply not lived up to their promise to fund the Fund at the level of its need and potential impact. The Fund can absorb and deploy far more resources even in its current form.

Kofi Annan envisioned a Global Fund of $10 billion in 2001, but today, five years later, the Fund is yet to hit that figure in its resource mobilization, and its funding rounds in recent years have been at an average of $1 billion a year. Of course, there has been significant growth in its resources, and the Fund has proved itself, at least in a preliminary sense, as a viable instrument to fight the fight. ...

But this is not the Global Fund of Kofi Annan's vision in 2001. Why have donors not provided more resources to the Fund, and why, in a world of 200 countries, has the Fund not attracted larger numbers of donors? ...we gloss over these questions at the peril of countries and societies shattered by the AIDS pandemic.

The Future of the War against AIDS: The Central Challenges

...
What, then, are the greatest challenges that face the fight against AIDS as we look to the future? There are two sets of overriding challenges one sees. One is the challenge that faces the Global Fund. Another is the challenge that faces the fight as a whole, in which there are multiple actors.

For the Global Fund, the most important challenges are two. The first is to mobilize resources that will equip it to become a real war chest, a veritable treasury in the war against AIDS, for this is its core mandate and is what will ultimately determine its success or failure. ...

The second main challenge facing the Fund is the challenge of its partnership structure, especially its partnership with the developing countries of the Global South. Deepening these partnerships at the level of reality, especially at the political and community levels, will influence the outcome of the Fund's resource mobilization drive in its next phase, for there can be no more authentic voices on behalf of the Fund than those whose suffering it was created to help assuage. ... This is a process, not an event, and is one that has already begun. In 2006, Friends of the Global Fund - Africa, -- part of a global network of independent advocacy organizations support the Global Fund and the fight against AIDS, TB and malaria more broadly, was established by private sector and civil society constituencies in African countries. ...

For the overall fight against AIDS, the challenge is to make prevention, recognized as the mainstay of the response to the scourge of AIDS a reality. The back of the pandemic cannot be broken without meeting this challenge, which, again, is easier said than done. Prevention is not easy because to do it effectively calls for an onslaught on several socio-cultural factors that drive the spread of the pandemic in many developing countries, especially in Africa, and which the fight against AIDS has barely begun to address seriously. It also points to the importance of new preventive technologies, such as microbicides for women.

All of this need not be at the expense of treatment, which remains essential as well, especially to stem the economic impact of deaths from AIDS. ...


AfricaFocus Bulletin is an independent electronic publication providing reposted commentary and analysis on African issues, with a particular focus on U.S. and international policies. AfricaFocus Bulletin is edited by William Minter.

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