Dr Gro Harlem Brundtland
It is a great privilege to meet with
you this evening and to have the opportunity to speak with
representatives of nations, of civil society, and of the private
sector at this historic time.
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
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.
A study of the global figures shows
why it is important to focus on the three diseases; HIV/AIDS,
tuberculosis and malaria. Any serious attempt to reduce the disease
burden faced by the world's poorest people must concentrate on them.
Any serious attempt to stimulate global economic and social
development, and so to promote human security, must be successful in
addressing the burdens caused by AIDS, TB and malaria.
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
If we break this down to regions, we
see there are substantial differences. The AIDS problem is
overwhelming in Africa , but malaria is also dominating. TB is
predominantly linked to the large prevalence of AIDS. In South-East
Asia, East Asia and the Pacific and the Americas, TB plays a much more
important part, while malaria is a much smaller problem, particularly
because high malaria incidence is concentrated in certain well defined
areas and in marginalized groups. AIDS, of course, is a considerable
factor in all regions.
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.
Malaria saw a marked decline between
1950 and 1970, as many countries carried out large-scale eradication
efforts, focusing primarily on vector control. As it became
increasingly clear that eradication of malaria carrying mosquitoes was
an unrealistic prospect and as social and economic changes reduced the
funding available for such programmes, the effort floundered and
malaria became a relatively neglected disease.
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.
We see a similar trend with TB, in
particular in Africa and in Eastern Europe, Russia and the Newly
Independent States. After decades when TB was brought under control in
large parts of the world and had a stable trend in other areas, we saw
a marked shift for the worse in 1990. The fundamental political,
social and economic changes in the former Eastern Bloc countries over
the past fourteen years brought about a resurgence of TB as a result
of a decline in health services, worsening economic conditions and
growing drug resistance.
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.
For HIV/AIDS, the trends are
dramatic. I would like you to take a good look at the map on the
screen. The colours represent prevalence. You can see the striking
dark colours in much of Africa, the Caribbean, and parts of South-East
Asia. But even more startling are the rate of the spread of the
disease. The columns you see represent the increase in people living
with HIV. We are seeing a spectacular increase in Russia and its
neighbours – the column doesn’t even fit on the screen – and an
alarming increase in both China, the Middle East and South and
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.
In the last two years, Heads of
State have met to agree how to best tackle HIV, tuberculosis and
malaria. They are aware of the burden caused by these diseases, and
how it will develop if we do not scale up our efforts to fight them.
The new political momentum has encouraged the careful analysis of
available evidence and resulted in unprecedented international
agreement on the interventions that make the greatest difference. I
just mentioned HIV/AIDS prevention work that has proven to be so
successful even in some of the poorest countries. There is also a
growing body of evidence that shows it will be possible to deliver
care and treatment for people living with AIDS in resource-poor
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.
Of course, there are a number of
factors involved in succeeding this fight. Resources would have to be
spent both in the health sector and in other sectors. How much of the
funds would be needed outside the health sector varies between the
diseases, as you will see from this slide.
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
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.
Regionally, the needs would differ, with of course
the highest amount for Africa, and gradually lower levels of resources
needed in South and South-East Asia, East Asia and the Pacific, Latin
America and the Caribbean, Europe and Central Asia. The relative
weighting of the needs for the different diseases would also vary
among the regions, as you can see from the screen.
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
Let me now give the podium to Peter, who will
enlarge on the readiness of countries to react to these immense
Dr Peter Piot
you, Dr Brundtland,
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.
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:
- The existence of a national strategic framework to address the
The existence of an operational plan;
That this plan is costed;
That there is a monitoring and evaluation
plan in place; and
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
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.
The following slide illustrates the
distribution of national programmes in Africa by "level of
readiness" based on the "five-point checklist". I
should emphasize that these "indicative scores" are not a
judgement on the quality of country level programming. Rather, they
serve as a rapid assessment of where the essential elements are in
place that are required to build investor confidence, to enable
programme accountability, and to promote the partnerships required to
ensure quality programming.
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
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 the next slide, you can see that
with respect to the 5 key parameters for HIV/AIDS programming,
5 South-East Asian countries are distributed toward the higher
end of the scale, whereas 2 additional country assessments indicate a
need for more intensive programme planning and development effort. For
TB, the 6 priority countries distribute evenly in the mid-range.
Programme development for malaria in South-East Asia has a 50-year
history – as evidenced by all 9 country programmes assessed
clustering at the highest end of the scale.
The status of AIDS responses in East
Asia and the Pacific varies, in some cases reflecting relatively low
priority given to preparedness in countries which – at least for the
moment – have a lower prevalence of HIV. Assessments of the 3
priority countries for TB indicate that programme planning is well
established – it has the most coherent regional plan for TB control
– much more so for the 9 countries for which malaria programme
rapid assessments were prepared.
European responses to HIV are a very
mixed bag. In some cases the epidemic remains new, and programmes are
only now gearing up to deal with the explosive increase in HIV
incidence, which as Dr Brundtland just showed us has increased by 1300
per cent over the last 5 years.
In Europe, malaria remains a problem in three
countries, but burdens are low.
With respect to TB, though there is currently only
a single high priority country within the region –where DOTS
expansion has been piecemeal – we can reliably anticipate that with
rapidly rising HIV incidence – and the unfortunate synergies between
the two epidemics, that this picture is likely to change in the near
AIDS responses in the Americas are
in many cases long-standing and comprehensive. Still, the distribution
on this next slide demonstrates that there the there are a few
countries where that is still not the case. The concentration of the
epidemic among marginalized groups such as sex workers and men who
have sex with men, has in some cases been associated with HIV/AIDS
programme development being given relatively low priority. Only 1 of
the 22 TB high priority countries is in the American Region, and is
less well placed than it should be with respect to the 5 key rapid
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.
In North Africa and the Middle East,
recent evidence of the potential for the epidemic in this region ought
to shake some complacent assumptions that AIDS has passed the region
by. This next slide indicates that with respect to both HIV/AIDS and
malaria, programme development is patchy. The TB programme in the
single high priority country in the region exhibited only one of the 5
key parameters within the rapid assessment.
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:
- 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
I will wrap up this presentation with a quick
summary of comparing currently available financial resources with
immediate programme needs.
The next slide puts the resources of
the Global Fund for this year in context with other available
resources and immediate needs for AIDS, TB and malaria. The needs I am
talking about here are the immediate needs, on the assumption that in
AIDS in particular, the gap between what is needed for a comprehensive
response and the current level of activity is so large that we have to
envisage targets together with the relevant programme capacity,
ramping up over the next four years.
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.
Our projections of currently
available international resources for this year are further
disaggregated in the next slide, with roughly US$200 million each for
TB and malaria and approximately US$1.2 billion available for
HIV/AIDS, in addition to the Global Fund resources. Both the AIDS
resources and the Global Fund resources are attributed to G-7, other
DAC, UN organizations, foundations and corporate contributions as
illustrated. Roughly two-thirds of the UN system component is
attributable to the grant component of concessional IDA loans.
This slide combines our total
resource availability projections with our published estimates – and
I should add relatively conservative estimates – of the
"ramping up" of programming capacity addressing AIDS, TB and
malaria. We should be very clear what this slide represents: it is a
measure, viewed from a practical, programmatic and operational
perspective, of the currently existing resource gap. If this gap were
filled, countries would be able to scale up proven effective
approaches to significantly reduce the burden of AIDS, TB and malaria,
as spelt out earlier by Dr Brundtland.
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
Turning to the disbursement
of funds over the next four years, our survey of donors indicates that
many of the Global Fund pledges to date were made for the immediate
future, with promises of more to come later. For approximately US$500
million of the Fund pledges, it is not clear precisely when they will
become available for disbursement. This slide shows what is currently
available for 2002, together with actual amounts where they have been
promised for future years. It shows that over the next four years, the
resources available to the Fund will need to increase if the Fund is
to at least maintain its current position in meeting 11 per cent of
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:
- Country implementation preparedness;
Costing a comprehensive response; and
Monitoring the gap between needs and
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.