Honourable Board Members,

Colleagues,

Ladies and Gentlemen,

All of us are committed to a comprehensive response to challenges presented by HIV, TB and Malaria. In doing so we will address the needs and concerns of the people who live with these conditions, as well as those at risk. We will do so within the context of a comprehensive strategy that includes multi-sectoral action - to prevent, to treat, to care, to empower people who are affected and at risk.

Only a month ago, the Commission on Macroeconomics and Health delivered its Report on health's role in development. The Commissioners' work showed how hard it is for nations to undergo sustained economic growth if their people do not enjoy good health. Simply put, the good health of the people is an essential pre-requisite for national prosperity.

The Commissioners argued that if the world's leaders are serious about reducing poverty and fostering development, they have to invest more in enabling all people to be healthier. And, in its Report, the Commission showed how health investments can be managed in order to achieve the best results. The Commission proposed a scale-up of effective action to yield tangible results by spreading best health and development practices widely into all the societies where they are needed.

Several hundred experienced experts worked closely with the Commissioners during their two year project - bringing together skills in public health, development, medical research, economics, political science and management. They drew on the accumulated expertise within WHO, the World Bank, UNAIDS and other UN organizations. The Report – with its sensible mix of analysis, advocacy and detailed prescription – represents a turning point.

Let me take you through some of the argument.

We now measure the impact of ill-health on individuals, and on their societies, by estimating the number of years of healthy life they lose as a result of each illness. Added up, the total number of healthy life years lost as a result of the illness can be described as the "disease burden " that it causes. The total disease burden in a society represents the gap between the actual health of the population and an ideal situation where everyone lives into old age in full health.

Together, the three diseases are responsible for more than one third of all deaths in Africa. Moreover, malaria is the largest killer of children in Africa. Malaria and AIDS are responsible for one third of all deaths of children below five years of age. Fulfilment of the Millennium Goals to halve TB and malaria mortality, and significantly reduce new HIV infections within the next 15 years will make a massive difference to the prospects of poor populations, particularly in Africa. It is fair to say that unless this happens, Africa will face unprecedented economic and social devastation.

Of the burden caused by the three diseases, HIV/AIDS makes up just over half, both in terms of healthy life years lost, and mortality. Malaria and TB share the rest on a roughly equal basis. It means that more than 90 million healthy life years are lost to HIV each year, 40 million to malaria and nearly 36 million to TB. More than five and a half million lives are lost every year to the three diseases.

Africa stands out both in absolute and proportional figures and an overwhelming share of the global burden of these three diseases. More than three quarters of AIDS deaths are found in Sub-Saharan Africa, 90 per cent of malaria deaths and 22 per cent of TB deaths. This is the case despite the fact that Sub-Saharan Africa contains just over 10 per cent of the global population. South and South-East Asia is the second largest area of disease, although here, as we remember, the three diseases make up a smaller part of the total disease picture. Seen in relation to its large population, East Asia's burden is less extreme, although still significant, especially when we break the region into individual countries. The Caribbean's AIDS situation compares with that of Africa's, which means it needs special attention within the American Region.

The situation becomes even more worrisome if we look at the ways these diseases have developed over the past decades and where they are headed.

The result was a worsening of the malaria situation in Africa – both in terms of number of victims as well as less effective treatment being delivered to those ill with malaria. This failure of treatment has been due to the emergence and rapid spread of resistance to the low cost drugs commonly used for malaria treatment as well as to the deterioration of the health care infrastructure.

In many parts of Africa, the prevalence of malaria infection in children is over 80 per cent during times of peak transmission, and by the age of one year most children will have already experienced 3-4 life-threatening infections. The prevalence of infection simply could not get much higher, but unless rapid steps are taken to change failing drugs, child death rates from malaria in these areas will increase dramatically.

In Africa, the drastic increase in TB is closely linked to the AIDS pandemic. With a weakened immune system, people living with HIV are much more vulnerable to succumbing to a TB infection than other people. In Kenya, for example, HIV prevalence in adults more than doubled between 1990 and 1996. So did TB incidence.

In many of these areas, the increase comes from a small base. That is in particular the case in Russia and its neighbours, where HIV was largely unknown until the mid 90s. But with the fact that there is no cure for AIDS and that access to effective treatment still is extremely limited, early action and emphasis on prevention is crucial. The trends may therefore be as important as the current burden in determining action on HIV/AIDS.

I would also like to mention that industrialized countries (Western Europe and North America) have no reason for complacency. The increase in people living with HIV is for a large part due to effective treatment which reduces mortality. But despite the resources these regions possess, they have seen no substantial progress in reducing new HIV infections over the past decade.

In fact only two countries have shown a real reduction in the number of people who live with HIV. Those are Uganda and Thailand, and both can credit high-level political commitments which have translated in effective national prevention campaigns for their success. There are also indications that Cambodia is joining this very exclusive group of success stories. These three countries' success is extremely important. Not only do they show that prevention can work. They also give us an indication of what works under varying circumstances in very different countries. Then there is Brazil, which has shown us how it is possible to use treatment to considerably extend the life-span for those living with HIV, even in populations with incomes well below those in Europe and North America.

While many of the treatments for so called opportunistic infections have been available at just a few cents for many years, recent advances in research, simplification in treatment schemes and drastic price reductions now make it possible for the millions of poor people who need antiretroviral therapies to start accessing them – and thus have a chance of living a full life.

For malaria, we have seen that, for example, the child mortality rate in Malawi has declined over the last decade, compared to an increase in all other countries in the region. The change of antimalarial drug in the early 80’s seems to have been a major factor in this decline, illustrating the potential impact of improved malaria treatment policies.

In several countries, but perhaps most graphically in Peru, we have seen that nation-wide commitments to the Directly Observed Treatment – or DOTS – strategy has succeeded in reversing a increasing trend of TB prevalence and setting the country on track of halving the TB incidence every 10 years.

Now, I would like to share with you our knowledge of the needs in concrete financial terms.

If we were to reach the targets, the world community has set itself, for these three diseases, what would it cost? The most conservative estimate from the Commission on Macroeconomics and Health stipulates that we would need an additional US$400 million for TB treatment. We would need US$1.5 billion for malaria, of which prevention would take four fifths of that sum. For HIV/AIDS, the total amount needed is US$6.2 billion. Of this, US$3.6 billion would go to prevention and US$2.6 would be spent on care and treatment.

This is a minimum estimate for an investment which limits itself to investments in immediately possible levels of delivery with an emphasis on expanding the lower levels of district health system, such as health posts and outreach services. If we include substantial investments of existing systems of all levels of service delivery, the estimates would be substantially higher. They would be higher still if we counted in the needs of other countries with a higher GNP – like Brazil, Mexico, and Russia.

Interestingly, for TB, we are not so far away from getting the job done. As you can see from this slide which compares levels of current expenditures with resources needs for scaling up, the funding gap for TB is relatively small. For malaria and for HIV/AIDS, we are facing an enormous challenge, however.

Let me end by showing what the difference in funding means. I will use the example of TB, although similar, and even more dramatic changes could be shown for malaria and HIV/AIDS. We have seen a steady increase in the percentage of TB patients which receive DOTS. The target is to reach a 70 per cent coverage rate by 2005. With current funding levels, the target will only be reached by 2013. With an accelerated progress based on meeting the funding requirements for existing plans, we could reach that target within three years, on schedule. The additional funding needed, although relatively modest, means the difference between success and relative failure.

Let me now give the podium to Peter, who will enlarge on the readiness of countries to react to these immense challenges.

Distinguished Delegates,

Colleagues,

This Fund exists, and this Board is meeting, because all of us in this room believe that it is both necessary and possible to make major advances against AIDS, TB and malaria, and that the major factor holding back progress is the lack of resources.

The financial resources equation has two sides. One side is the need for funds, for which Dr Brundtland has presented compelling evidence. The other side of the equation, the basic question I will address, is how prepared countries are to utilize new funds and make a real and rapid difference to the global burden of these diseases. Of course, our response must not only go to those countries which are the best prepared: some countries are in the greatest need precisely because they are ill prepared to meet the challenges of AIDS, TB and malaria.

SLIDE 14

In order to indicate the extent to which there are currently existing programmes with immediate capacity to utilize new funds in responding to these three diseases, the UNAIDS Secretariat and WHO have conducted a world-wide assessment of programme preparedness in affected countries.

This assessment provides us with a region-by-region "snapshot" of current programme status, based on country-level review and estimates.

Given the global distribution of HIV, 113 countries have been assessed across all regions and representing 95 per cent of the global burden of AIDS. Malaria is more concentrated, with 81 countries in 5 regions representing 95 per cent of the global disease burden. And in the case of TB planning, 22 countries which represent 80 per cent of the burden have been assessed.

Working closely together across national, institutional and programme "boundaries", we have sought to harmonize approaches and speak a common language. To address the state of efforts in each country, summary profiles of national efforts were compiled for each disease area, as 16 parameters drawn from the proceedings of the Transitional Working Group were assessed. Five of those parameters most emphasized by the TWG were used to make up a summary "checklist" to enable a simple indicative "scoring" with respect to:

1. The existence of a national strategic framework to address the disease;

2. The existence of an operational plan;

3. That this plan is costed;

4. That there is a monitoring and evaluation plan in place; and

5. That there is coordination mechanism in place – across different government sectors and between government, NGO, civil society and donors.

For all three diseases, the core criterion for readiness is the existence of a national strategic planning process. Experience has shown that the existence of a well-planned national strategy with political buy-in is an essential element for programme success.

With the next slide, we see how the "checklist" applies to programmes addressing AIDS, TB and malaria in Africa. I should emphasize that the fewer number of TB programmes assessed should not be taken as an indication that TB is somehow not a problem in many more African countries, or that TB programmes do not exist there. Rather, that the frame for analysis for the TB assessment focused on the 22 countries globally accounting for 80 per cent of the global burden, while the malaria and AIDS assessment was built on a broader base.

As we know, it is country-driven processes which are the basis for a sustainable and effective response.

Moving from left to right you can observe in the distribution of 44 countries assessed the progression achieved over the last several years towards more comprehensive national strategic planning and programming. There remain only a handful of countries where no AIDS response exists. But in many cases, plans are still in their early stages, and costing and monitoring elements have yet to be elaborated.

Despite Africa’s high TB burden, 3 of 9 countries in the region are in a high state of readiness.

In contrast, you can see that 27 of the 41 countries assessed with respect to their malaria programmes indicate that their planning and programme development is well developed, reflecting the increased priority that many countries have given to tackling malaria in the last few years. Many of the countries in which efforts have not progressed correspond to those in which armed conflicts continue to impede serious programme development, but it is notable that some have made good progress despite complex emergencies.

In Europe, malaria remains a problem in three countries, but burdens are low.

Three-quarters of the malaria programmes assessed in the region are at the top of the scale, in part as a consequence of inter-country Roll Back Malaria Initiatives. This includes a number of well prepared, but inadequately funded programmes in the Caribbean.

From across the 6 regions, there are a number of important summary points from this rapid assessment of which I will just touch on three:

• First, a great number of countries – in fact the majority of countries assessed – have already completed much of the planning and programme development work required to be confident of success in expanding their responses to AIDS, TB and malaria.

• Second, there remain considerable programme development challenges in roughly a third of the countries assessed – particularly in Africa and most particularly with respect to HIV/AIDS.

• And third – for this point I would like to return to the slide Dr Brundtland introduced earlier – there is a compelling need for effective responses in the education, social welfare, agriculture, and other sectors. Programme development in these sectors – particularly in relation to HIV/AIDS – has lagged considerably behind events within the health sector. The AIDS epidemic has reminded us that if responses to health emergencies are limited to the health sector, they are likely to fail. A multi-sectoral response cannot simply exist in rhetoric and not in action. Our rapid assessment suggests that we have a long way to go to ensure that there is an appropriate level of action, and resourcing, for the sectors other than health that have critical roles to play in addressing these challenges to sustainable development.

I will wrap up this presentation with a quick summary of comparing currently available financial resources with immediate programme needs.

Our resource tracking suggests that the US$800 million projected as available for 2002 from the Global Fund represents approximately one-third of the likely available international resources for AIDS, TB and malaria, one-fifth of the total resources available when we take national resources into account; and about 11 per cent of the "immediate programme need" of approximately US$7 billion.

Without taking into consideration new Global Fund resources, and assuming that current resource flow remain constant, this year’s US$3 billion gap will in just 2 years more than double. The implications are quite clear and represent a major challenge for the development of vigorous resource mobilization strategies both for the Global Fund, and for the other sources of funding, the international organizations, the private sector, and national governments.

SLIDE 27

Of course, it will be for the Board to consider what is the ideal proportion of total unmet needs in AIDS, TB and malaria that the Fund ought to try to meet. Eleven per cent is presumably a bare minimum in the Fund’s efforts: perhaps a more ambitious 15 or 20 per cent is the appropriate target to aim for. At the same time as the Fund keeps up its share of the bargain, it will of course be incumbent on all the players to make corresponding increases in their allocations to AIDS, TB and malaria.

AIDS, TB and malaria are massive global problems, but they are problems with solutions. The tools for effective responses exist. In the vast majority of countries around the world, there are detailed plans for dealing with AIDS, TB and malaria. There are countless communities ready to take action. And in order to build success, increased financial investment needs to be equally matched with investment in human resource and institutional capacities.

As part of our commitment to meet the challenge of scaling up responses to AIDS, TB and malaria, WHO and UNAIDS will continue to strengthen the analysis and monitoring across the three dimensions of the response:

1. Country implementation preparedness;

2. Costing a comprehensive response; and

3. Monitoring the gap between needs and available resources.

The analysis of the status of programme responses in countries is currently being incorporated into a Web-based information system to enable ready updating in countries. Together with Dr Brundtland on behalf of WHO and UNAIDS, let me assure you that this detailed survey and analysis work will be regularly updated and refined, and made available to the Board, the Technical Review Panel, and the Secretariat of the Global Fund in order to support the proposal review, monitoring and evaluation functions.

Finally, on behalf of Dr Brundtland and myself, let me thank you for your attention and the opportunity to share with you the work of our colleagues as background to the important proceedings of these next two days, on which so many hopes and lives will depend.