THE GLOBAL FUND: WHICH COUNTRIES OWE HOW MUCH? By Tim France, Gorik Ooms and Bernard Rivers (21 April 2002) [excerpts only: for full article, including formatted table, see http://www.hdnet.org and http://www.aidspan.org] Nearly one year ago, the majority of the world's nations resolved at `UNGASS', a major UN conference on AIDS, to increase annual expenditure on the AIDS epidemic to $7-10 billion by 2005, with much of this money to be raised and disbursed by a new global fund. When the fund was eventually set up, its mandate was extended, and it was named the Global Fund to Fight AIDS, Tuberculosis and Malaria. AIDS, an unprecedented and accelerating emergency, is already having a devastating impact in Africa, with similar impacts unfolding on other continents. Every day, 8,000 die, and 13,000 more become infected. Experts agree that reasonable expenditures on prevention and treatment of AIDS, tuberculosis and malaria can be of dramatic benefit not only to human health, but also to economic development. Thus far, efforts have been made to raise the money needed by the Global Fund through ad hoc voluntary donations. These efforts have failed. Governments have pledged a mere $1.8 billion. Contributions from the private sector have been even more disappointing, with not a single meaningful pledge since the Bill & Melinda Gates Foundation offered $100 million ten months ago. It's time for a new approach. The Global Fund needs to grow rapidly to the point where it raises $10 billion a year. Contributions to the Global Fund should be equitably shared among the countries whose citizens live the most comfortable and unthreatened lives. This means that the wealthiest countries, such as the US, should contribute considerably more than they currently do. But it also means that contributions should come from the likes of Australia, Singapore, and the United Arab Emirates - relatively wealthy countries that have not yet contributed a penny. Part of the problem is that to date, nobody has proposed which countries should give how much. The following table therefore offers an `Equitable Contributions Framework' that can be used as a starting point for working out an appropriate contribution level for each country, and for measuring how well each country is doing against that level. The Framework suggests that $1 billion a year should come from the private sector, as a minimum to justify the label `public/private partnership' and the two seats it has out of the 18 voting seats on the Fund board. The remaining $9 billion a year should come, in proportion to Gross Domestic Product (GDP), from the 48 countries that have a `high' Human Development Index, or HDI. (The UN's HDI measures the overall quality of life based on standard of living, life expectancy, and literacy plus school-enrolment.) The proposed contribution comes to 0.035% of GDP for each country. Not one country has yet given at this level. ... It is to the credit of countries like Uganda and Nigeria that, poor as they are on a per capita basis, they have made multi-million-dollar contributions to the Fund. And it is to the shame of many of the 48 relatively wealthy countries that they have contributed little or nothing, without even stating why. The Global Fund represents a bold new approach. The Fund's leaders say that it will be more fast-moving, participatory, transparent and accountable than traditional channels. The Fund needs a chance to prove itself. It would be a shame if it were to fail simply because it did not receive the funding it needs to get properly established and to respond to the most urgent and obvious needs. The authors are: * Dr. Tim France, Health & Development Networks (US EST +11 hours) Thailand: Tel: +66 9 950 0685; Email: tfran@hdnet.org; Web: http://www.hdnet.org * Gorik Ooms, M,decins Sans FrontiSres (MSF) Luxembourg (US EST +7 hours) Mozambique: Tel: +258 82 311 075; Email: msflmoz@teledata.mz; Web: http://www.msf.lu * Bernard Rivers, Aidspan (US EST) USA (New York): Tel: +1 212 662 6800; Email: Rivers@aidspan.org; Web: http://www.aidspan.org ================================ [display table in courier font to line up columns; better formatted versions available on web sites indicated.] Table: Equitable Contributions Framework for the Global Fund, based on GDP (21 April 2002) a) G7 "high Human Development Index" countries: I | Suggested | Total pledge | Estimated | I | "equitable | to GF thus far| portion of | I | annual | ($m., and | total pledge | I |contribution"| as % of Col 2)| that applies | I | (US$m) | | to 2002 | I--------------|-------------| ------ | -----| ---- |------ | I United States: | 3,479 | 450 | (13%)| 250 | (7%) | I Japan: | 1,646 | 200 | (12%)| 68 | (4%) | I Germany: | 658 | 158 | (24%)| 35 | (5%) | I United Kingdom:| 498 | 219 | (44%)| 67 | (13%) | I France: | 453 | 151 | (33%)| 51 | (11%) | I Italy: | 376 | 215 | (57%)| 73 | (19%) | I Canada: | 243 | 100 | (41%)| 38 | (15%) | I--------------|-------------| ------ | -----| ---- |------ | I G7 total: | 7,352 | 1,493 | (20%)| 580 | (8%) | b) Non-G7 "high Human Development Index" countries: I | Suggested | Total pledge | Estimated | I | "equitable | to GF thus far| portion of | I | annual | ($m., and | total pledge | I |contribution"| as % of Col 2)| that applies | I | (US$m) | | to 2002 | I--------------|-------------| ------ | -----| ---- |------ | I Spain: | 195 | 58 | (29%)| 19 | (10%) | I Netherlands: | 128 | 125 | (97%)| 42 | (32%) | I Switzerland: | 85 | 10 | (12%)| 3 | (4%) | I Belgium: | 81 | 19 | (24%)| 6 | (8%) | I Sweden: | 80 | 58 | (73%)| 20 | (25%) | I Austria: | 67 | 4 | (5%)| 1 | (2%) | I Denmark: | 57 | 2 | (4%)| 1 | (1%) | I Finland: | 42 | 2 | (4%)| 1 | (1%) | I Greece: | 39 | 2 | (4%)| 1 | (1%) | I Portugal: | 37 | 1 | (4%)| 0 | (1%) | I Ireland: | 33 | 10 | (31%)| 3 | (10%) | I Kuwait: | 10 | 1 | (10%)| 0 | (3%) | I Luxembourg: | 7 | 3 | (41%)| 1 | (14%) | I Others: | 1 to 161 | 0 | (0%) | 0 | (0%) | I--------------|-------------| ------ | -----| ---- |------ | I Non-G7 total: | 1,648 | 294 | (18%)| 99 | (6%) | c) Totals from the above table (i) Total for all 48 high HDI countries: * Suggested "equitable annual contribution" to Global Fund: US$9,000 million * Total pledge to Global Fund thus far: US$1,788 million * Estimated portion of total pledge that applies to 2002: US$679 million (ii) Total for all non-'high HDI' countries that have donated**: * Suggested "equitable annual contribution" to Global Fund: $0 * Total pledge to Global Fund thus far: US$33 million * Estimated portion of total pledge that applies to 2002: US$11 million (iii) Total for private sector (foundations and corporations) ***: * Suggested "equitable annual contribution" to Global Fund: US$1,000 million * Total pledge to Global Fund thus far: US$101 million * Estimated portion of total pledge that applies to 2002: US$34 million (iv) Grand total * Suggested "equitable annual contribution" to Global Fund: US$10,000 million * Total pledge to Global Fund thus far: US$1,922 million * Estimated portion of total pledge that applies to 2002: US$725 million The final column is based on private sources plus our own estimates, because the information is not published. We understand that total pledges are: 2002=$725m., 2003=$487m., 2004=$132m., 2005=$67m., 2006=$27m., plus $484m. for which the year(s) are not specified. ... ================================ Accompanying note to readers and editors The above article was written by three people who work with non-governmental organizations (NGOs) in three different continents. They `met' electronically through their active involvement in the Break-the-Silence (BTS) dedicated e-mail discussion forum, which has over 3,000 members worldwide. BTS serves to support civil society participation in international debates on HIV/AIDS and other health-related issues. Since October 2001, BTS discussions have mainly focused on the Global Fund. Financial contributions to the Fund have decreased significantly in recent months, and are far below the originally intended level. The first funding requests for grants from the Fund, in March 2002, were already for far more money than the Fund can currently provide in any sustained way. ... The article, written in response to that frustration, proposes the establishment of an `Equitable Contributions Framework' to serve as a guide to appropriate contribution levels to the Fund. If you or your organization are encouraging contributions to the Fund from your own country, you can use the Framework to highlight your country's appropriate contribution, its total pledges already made, its apparent pledge for 2002, and the consequent shortfall. To join the BTS forum, send an e-mail message to: join-break-the-silence@hdnet.org To read previous BTS postings on the Global Fund process, go to: http://archives.healthdev.net/bts ***************************************************************** Health GAP (Global Access Project), Philadelphia, USA Act Up-Paris, France African Services Committee New York City, USA 18 April 2002 [excerpts only: full text will be available on web archive of this posting at http://www.africaaction.org/docs02/gf0204.htm] To all Members, Board of Directors, the Global Fund to fight AIDS, Tuberculosis, and Malaria (GFATM): ... Summary: We insist on a concerted effort on the part of this Board to correct and redress the devastating cumulative impact of years of indifference to untreated HIV/AIDS in developing countries, where 95% of people with HIV/AIDS live. The Board must emerge with a clear statement prioritizing massive scale-up and implementation of antiretroviral treatment programs in developing countries. The acute need for more money for the GFATM must not be reserved for internal, hushed Board discussion. On the contrary, the desperate need for more resources must be publicly emphasized by the Board. Bona fide demand for funding-especially funding for programs that include antiretroviral treatment, on the scale necessary for substantial impact-tremendously outpaces the funds available to the Board for spending for the first and subsequent tranches of 2002. ... 1. Prioritizing antiretroviral treatment-redressing the crisis in HIV medicines access HIV treatment access is a human rights and public health necessity. As a new, non-duplicative mechanism that includes funding HIV treatment programs among its objectives, the GFATM at its launch was seen as the best hope for sustainable, accelerated scale-up and implementation of antiretroviral treatment programs in developing countries. However, applicants and potential applicants have received mixed messages from the board and from bilateral donors regarding proposals that include funding requests for antiretroviral treatment. When the historical exclusion of treatment was coupled with donor pressure to scale back the size and scope of proposals at the Country Coordinating Mechanism (CCM) level, many countries chose to submit proposals with very modest treatment components, that under-represented the capacity of a country to deliver medicines for AIDS, tuberculosis, and malaria treatment. ... If the GFATM is to take up its task of remedying the disparity in HIV treatment access, the Board must clarify through a public communication that viable antiretroviral treatment programs are feasible, fundable, are a required aspect of a comprehensive, effective response to the AIDS pandemic. Funding requests containing components for AIDS treatment must not be downgraded in consideration because of relative higher cost. The direct and measurable impact of treatment access on morbidity and mortality, as well as its spillover benefits to HIV prevention efforts, are outcomes necessary to demonstrate for donors the value and impact of GFATM funded interventions. The most dramatic outcomes possible with the scarce resources available will be produced by funding discrete sectors with antiretroviral treatment, effectively delivered. The Board should encourage exactly such applications, and commit all available resources on hand. 2. Patents and the procurement of medicines by the GFATM Commitment to the procurement of lowest possible cost, quality medicines-including quality generic drugs-must be communicated by Board members. Generic competition has been shown to be the most powerful tool in exerting downward pressure on drug prices. The procurement of quality generic versions of HIV medicines will increase life-extending treatment access by extending finite resources as efficiently as possible. In most developing countries, there is little viable market for pharmaceuticals. Given the decimation of adult populations in some countries due to untreated HIV disease, the interest of brand name pharmaceutical companies in guarding patent monopolies and concomitant high prices must not determine the policy of the Board regarding health commodities procurement. ... ***************************************************************** Medecins Sans Frontieres (MSF) OPEN LETTER TO MEMBERS OF THE BOARD OF DIRECTORS AND TECHNICAL REVIEW PANEL OF THE GLOBAL FUND TO FIGHT ADS, TUBERCULOSIS AND MALARIA 18 April 2002 Original version with footnotes and malaria report referenced available upon request from: rachel_cohen@newyork.msf.org [excerpts only: full text will be available on web archive of this posting at http://www.africaaction.org/docs02/gf0204.htm] ... Treatment: a medical and ethical imperative As a medical humanitarian organization, MSF believes that the Global Fund must provide financing for treatment programmes for HIV/AIDS, TB, and malaria. This is an ethical imperative. It is now widely accepted that treatment and prevention are mutually dependent and synergistic; that one reinforces and strengthens the other, and that prevention-whether through condom distribution, bednets, or general health education-has failed to control these three diseases alone. We know this firsthand from our experience in the field. We are therefore encouraged by the news that proposals that include well-designed treatment interventions will be eligible for funding. However, the Fund has failed to clearly spell out the critical need for addressing treatment as part of a comprehensive approach to controlling HIV/AIDS, TB or malaria ...We are deeply concerned that patients already living with HIV/AIDS, TB, or malaria will be written off despite pronouncements of support for treatment programmes that would extend or save their lives because donors and some in the international health community traditionally favour prevention at the expense of treatment ... It is vital to improve treatment interventions, not expand use of ineffective treatments It is of vital importance that the Global Fund be used to support improvement of treatment interventions, and that it does not inadvertently facilitate the expanded use of ineffective treatments. Yet the Fund has not taken a clear stand on the need to make ARVs, second line TB treatments, or new, more effective anti-malarials available (at the lowest possible cost). For instance, in the case of malaria treatment, it would be wrong to support programmes that continue to use treatments in areas where they have lost their effectiveness due to resistance on the basis that they are inexpensive. Where resistance to traditional first-line treatments-especially chloroquine and sulfadoxine-pyrimethamine (SP)-is high, malaria treatment must include not only traditional antimalarials, but also artemisinin-based combination therapy (ACT), as per the recommendations of the world's leading malaria experts convened by WHO in April 2001, and the February 2002 statement of Roll Back Malaria on Malaria and Resistance. ... ... MSF recently released a report about changing malaria treatment protocols in Africa where resistance to first-line drugs is high (please see the enclosed report entitled "Changing National Malaria Treatment Protocols: What Is the Cost and Who Will Pay?"). The central concern of the paper is with the growing rates of resistance to chloroquine and SP in Africa, namely in Kenya, Rwanda, Tanzania, Uganda, and Burundi, and the possibility that these countries, which are ready to change their national malaria treatment protocols, will, possibly for financial reasons, settle on a sub-optimal "mid-term" protocol (e.g. amodiaquine + SP) rather than the clearly more effective choice of ACT. ... Purchasing drugs at the lowest possible cost is essential We are deeply concerned about the sort of technical advice being given to potential recipient countries-by donor governments, the World Health Organisation, and others-in relation to purchases of medicines. Specifically, we are outraged that countries have apparently been advised that they will only be able to purchase patented drugs for their programmes. In the proposal to the Global Fund from Malawi, for example, it clearly states the following: "At present, we are assuming that the Global Fund will only finance patented drugs. This is in line with consultations with WHO and the donor community and initial documents from the Technical Support Secretariat. If however, Global Fund rules permit the use of generic drugs, the proposal and programme budget will be amended to reflect this." To ensure that international funding mechanisms, including the Global Fund, offer treatment to the highest number of people possible, it is essential that funds be available for bulk purchases of medicines and medical technologies at the lowest possible cost, through international tender. ... We therefore call on all members of the Board, whether individually and/or collectively, to issue a clearly articulated public statement during the Board meeting indicating that the Global Fund explicitly supports purchases of lowest cost drugs, whether generic or brand-name, and the use of TRIPS-legal safeguards to override patents when they constitute a barrier to access. The Global Fund should also clearly specify that these measures are fully compliant with TRIPS and in keeping with the spirit and letter of the Doha Declaration. ... These principles related to procurement of drugs and diagnostics are crucial because prices of medicines and other essential health care goods will have a profound impact on the reach and effectiveness of the Global Fund. Antiretroviral drugs for the treatment of HIV/AIDS provide a good illustration: ...Using the lowest cost suppliers will increase by as much as three times the number of patients who can be treated with the same amount of money, and will allow for greater investments in other important components of care and prevention. We know this firsthand from our experience in the field in our ARV demonstration projects. ... More funds desperately needed ... To date, the Fund has received funding requests totaling US$5 billion over five years, and yet the total amount of multi-year financing pledged is merely US$1.9 billion and the amount of funding available for disbursement in the first funding cycle is approximately US$200 million. This falls drastically short of the needs and will be a major disappointment for all of those who have placed great hope in the ability of the Fund to reduce the death rates from these three treatable diseases. We call on you as members of the Board to take whatever steps necessary to ensure that donors immediately allocate additional resources to the Global Fund and other financing mechanisms to fight these three diseases. ... Sincerely, Bernard P,coul, MD, MPH Director, MSF Access to Essential Medicines Campaign ************************************************************ This material is being reposted for wider distribution by Africa Action (incorporating the Africa Policy Information Center, The Africa Fund, and the American Committee on Africa). Africa Action's information services provide accessible information and analysis in order to promote U.S. and international policies toward Africa that advance economic, political and social justice and the full spectrum of human rights. 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