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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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