Financing HIV and AIDS Programs in Africa: Hopes and Challenges Dr Debrework Zewdie Deputy Executive Director The Global Fund to Fight AIDS, Tuberculosis and Malaria Talk in three parts: Where we were: looking backwards to move forwards Where we are now: the achievements we have made Where we are going and how we can get there Addis Ababa 04 December 2011

Outline Where we have come from Global economic situation and implications for HIV resources Global Fund financial situation and implications The way forward Addis Ababa 04 December 2011

AIDS at 30: Where We Have Come From 30 years since the first publications describing AIDS Since then, very noticeable achievements made include: 1. Billions of dollars committed, and 5-6 million people receiving ART 2. Community action: Mobilization of communities and affected groups to respond to AIDS 3. International leadership and commitments secured 4. Solidarity and partnerships at all levels to execute the response The last decade has been a historic one for global health 1996: International AIDS Conference in Vancouver: triple therapy shown to work 2000: United Nations launched the Millennium Development Goals 2000: G8 met in Okinawa and vowed to tackle communicable diseases 2000: International AIDS Conference in Durban placed access to antiretroviral treatment on global political agenda 2002: Creation of the Global Fund, and first grants started 2003: 3 by 5 launched by UNAIDS and WHO 2005: Paris Declaration on Aid Effectiveness endorsed, calling on the world to be as effective as possible in pursuing global health goals 2010: United Nations summit to assess progress toward Millennium Development Goals: more work needed Addis Ababa 04 December 2011

Total Resources Available 1987–2007 1000 2000 3000 4000 5000 6000 7000 8000 9000 US$ million US$ 1.6b UNGASS Declaration of Commitment on HIV/AIDS 1996 1997 1998 1999 2001 2002 2003 2004 2005 1986 1987 1990 1991 1992 1993 US$ 59m World Bank MAP Global Fund PEPFAR UNAIDS Gates Foundation 2006 2007 10 000 US$ 10b Source: UNAIDS & WHO unpublished estimates, 2007 1988 1989 1994 1995 WHO GPA International mobilization resulted in significant increases in resources for the AIDS response Global Health Initiatives (such as Global Fund) followed by unprecedented increases in commitments While still short of the estimated annual needs, current resources have allowed programs to extend coverage of services and achieve results considered not feasible just a few years ago Global Fund , PEPFAR and others have effective mobilized finances, political leadership and other resources Broad approach to investment: Quote: “on the results of the consultations, UNAIDS called on the international community to ensure that no credible, costed, evidence-informed, inclusive and sustainable national AIDS plan should go unfunded”. Addis Ababa 04 December 2011

Economic Challenges: Maintaining Existing Commitments People receiving ART through Global Fund supported programs: Number of patients surviving if ART was discontinued: Coverage of ART needs to increase globally to reverse the epidemic, but who is going to pick up the bill? According to the Investment Framework, $ 22 billion will be needed in 2015 to meet demand and impact upon HIV epidemics, and this annual need will then fall to under $ 20 billion by 2020 However, these graphs show the impact of continuing existing levels of ART through the Global Fund (from a paper co-published by the Global Fund) The panel on the left shows the rapid scale up of treatment in recent years and the future projections for this cohort of patients. This incorporates R10 grants as well. Of the 3.5 million people receiving ART with Global Fund support in 2011, we estimate that 2.3 million will still be alive and receiving treatment in 2020 The proportion of these patients receiving second-line regimens will rise from 2.5% in 2009 to 24% by 2020 The full annual cost of supporting these patients will decline by 10% from about US$ 1.9 billion in 2011 to US$ 1.7 billion in 2020. This is just for treatment, and not including HIV prevention. The panel on the right shows the estimated number of patients who will survive if they remain on ART (orange line), and the number of surviving patients if their ART was to be discontinued from 2011. Note the initial rapid mortality trend in the first couple of years This is modeled on assumptions but highlights the crucial need to ensure that ART is a priority to be continued to prevention the reverse of the gains achieved so far. Addis Ababa 04 December 2011

GDP Growth Rates for 2009 The world economic recession Brown shows countries in recession … i.e the traditional donors therefor more funding is required from newer economies Note WHO Abuja report Addis Ababa 04 December 2011

Financing trend in Recent Years Slide shows international commitments for HIV on the left, and international disbursements on the right Shows the leveling off of funds that has occurred in recent years to $7.6 billion in 2009 (on the right) The decrease primarily reflects reductions in direct bilateral funding by several governments as well as currency fluctuations The drop in funding for the AIDS response between 2009 and 2010 comes after years of significant increases: disbursements rose by more than six-fold between 2002 and 2008 In 2010, the Global Fund’s disbursements reached US$ 3 billion for the first time, compared to US$ 1 billion in 2005 Source: UNAIDS, Kaiser Foundation, 2011 Addis Ababa 04 December 2011

What does this mean? 2011 – 2013: 10 Billion USD to be disbursed 2008 – 2010: 8 Billion USD disbursed Donors will honour their pledge For all signed grants, including Round 10, the resources are available for the life of the project Everyone who is on treatment funded by the Global Fund will stay on treatment We are introducing a transitional funding mechanism to bridge any treatment gaps Addis Ababa 04 December 2011

Progress Being Made: Changes in HIV Incidence 2001-2009 What have been the results of these investments: According to UNAIDS in 2009 there were 22.5 million people living with HIV in Sub-Saharan Africa There were 1.8 million new HIV infections in the region in 2009, compared to 2.2 million in 2001 33 countries were highlighted by UNAIDS as reducing incidence by more than 25% between 2001 and 2009 (see slide) There were 1.3 million HIV-related deaths in the region in 2009, compared to 1.4 million in 2001 There have been notable successes in starting and maintaining people on ART 3.9 million people receiving ART in the region at the end of 2009 – 37% of the estimated need NEW UNAIDS DATA TO BE ADDED Source: UNAIDS 2010

Annual HIV Domestic and International Spending Annual HIV domestic public and international spending in current US dollars, total and per person living with HIV, among the 15 low- and middle-income countries with the highest spending, 2009 or last available year, international dollars (purchasing power parity). We don’t have the slide but when we present this slide can mention that although many countries do provide substantial amounts of funding internally and externally very often the MoF have ‘ not a clue’ how much money is going to AIDS – hence the need for better communication Source: Country Progress Reports 2010 Addis Ababa 04 December 2011

Moving from Emergency to Sustainability Group I: Longer-term reliance on external funding Group II: Can move toward self-sufficiency Later to make the point that in spite of context, some countries will contiue to need intrernational support Build upon the gains but the current AIDS financing is not sustainable Weak health systems, fiduciary control and absorptive capacities Aid effectiveness and co-ordination Optimizing programmatic and donor synergies Global economic downturn affecting donors Ensuring sustainable domestic contributions to HIV responses and health budgets This slide is from the results from the R4D group It shows the calculated spending requirements up to 2015 for selected countries, as a % of their Gross Domestic Product Countries in Africa are already making some contributions to their AIDS budgets from domestic sources However, external support will need to continue for the longer term in order to maintain HIV responses The group I countries all in Africa will continue to require external investments in order to maintain their HIV response , however there is a second group of countries who , based on their emerging economies could move toward more sustainable self financing Some African countries – such as South Africa – could move toward greater sustainability in the foreseeable future Source: Spending Requirements in 2015, R4D Addis Ababa 04 December 2011

Private Sector and Innovative Financing Could be an easy slide with some photos from product red and private sector partnerships in Africa Addis Ababa 04 December 2011

Effective Interventions/Value for Money Could be an easy slide with some photos from product red and private sector partnerships in Africa Addis Ababa 04 December 2011

Accountability This slide could show photo’s of the HLP report; the white report from last year (results with accountability) and the lessons learned report of the OIG – although these are all GF things. There could also be photo’s of Transparency International or Mo Ibrahim Foundation logos/events Addis Ababa 04 December 2011

Note: There are animations in this slide – click to reveal further text. ‘The choices we make today will define who we are as people and as a global community’ 1 Acknowledgements: Tarek Elshimi, Ade Fakoye, James Bridge, Natalie Cartwright