Transcript Evolution of Context (1/3)

Impact and
implications of
the GFATM crisis
Sharonann Lynch
Médecins Sans Frontières (MSF)
Context
• In November 2011 at its 25th meeting the Board of the GFATM took the
unprecedented decision to cancel Round 11 (which was opened August
2011).
• Round 11 was replaced with a Transitional Funding Mechanism to help
countries that otherwise face disruption of existing services (no new ART
or DR-TB treatment slots)
• Grants from the next funding window to be available only in 2014.
• At its 26th meeting in May2012 the Board agreed on "opening new
funding opportunities starting in late September 2012 to allow for Board
funding decisions to be made no later than the end of April 2013."
International funding context
International AIDS Assistance from Donor
Governments: Commitments, 2002-2011
GFATM 2010 3-year replenishment
(2011-2013) conference:
• Called for USD 20 bn needed to
scale-up programs
• Failed to reach even the minimum
scenario of USD 13 bn
• Pledges amounted to USD 11.7 bn
Source: Kaiser/UNAIDS July 2012
GFATM context: Contributions, Commitments and
Disbursements (2002-2012)
25,000
3.6 million people currently on antiretroviral therapy
260 million people treated for malaria
9.3 million people treated for TB
64,000 people treated for DR-TB
20,000
Contributions: $22.2b
In USD millions
Contributions
15,000
Commitments
Disbursements
10,000
Annual Contributions
Annual Commitments
5,000
Annual Disbursements
0
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
Q1-2012
Source:
Trustee, May 2012
Source: GFATM
GFATM context: rationing and new reform
• The blunt rationing tools of the GFATM
– 10% efficiency cuts across all grants
– Funding history rule: recent grants make countries Ineligible to apply for
another round
– Cuts to phase 2 renewal grants of middle-income countries
• Policy reform: from bottom up to a top down model?
– Allocating country resource ‘envelopes’?
– Countries applying by invitation only for specific interventions
• Reform could jeopardize core principles
– Demand-driven and focused on people in need
– Interventions that match country demands and country contexts
The costs of inaction
3
2.5
0
People (millions)
3-year delay =
3 million AIDS deaths
People (millions)
3-year delay =
5 million new HIV infections
2011
2020
0
Sources: Schwartländer B et al. Lancet, 2011, 377:2031–2041;
John Stover, Futures Institute, personal communication, May 2012.
2011
2020
Thousands
Accelerated treatment
Modeled for Kenya an additional 323,000 on
ART including:
•
CD4 <500 cells/µl already on waiting
lists for ART or in pre-ART care
•
Pregnant and breastfeeding women
•
Active tuberculosis (TB)
•
HIV+ partners in serodiscordant
couples regardless of CD4 count
1,000
900
800
700
600
500
400
300
Base Case
200
Accelerated Scale-Up
100
2010
2011
2012
2013
2014
2015
New Annual Infections, base
case and accelerated scale-up
140,000
120,000
100,000
31% reduction in HIV incidence within 5 years
80,000
60,000
Accelerated Scale-up
40,000
Base Case
20,000
0
2010
2011
2012
2013
2014
2015
The size of the Rounds has been shrinking over time
• Round 8
– launched March 2008, board approved November 2008
– $2.8 billion
• Round 9
– launched October 2008, board approved November 2009
– $2.4 billion
• Round 10
– launched May 2010, board approved December 2010
– $1.7 billion
• New funding window
– 2011 was effectively a gap year
– September 2012: 2 years and 3 months since the last successful Round was
launched
– April 2013: 16 months since the last approval of scale-up applications
Implications: country perception
UNAIDS survey findings
Intention to apply
Of the 78 reporting countries:
• 55 countries (71%) intended to apply
for Round 11.
–
–
•
•
•
51% ART focus
45% PMTCT coverage focus
9 (12%) would not apply.
10 (13%) were not eligible
4 countries (5%) were undecided
Perceived risk
• Nearly 71%: moderate to high risk of
ARV treatment service disruption.
• Almost 60% concerned about
PMTCT service disruptions.
• Over 68% anticipated a disruption in
TB related services for people living
with HIV.
Source: UNAIDS
Malawi
• Threats/risks
– GFATM
• 100% of ARVs from GFATM (would represent 2/3 of health budget if had to be
absorbed nationally)
• Last approved GF funding was Round 7
– SWAp fund & PEPFAR: no ART support
– UNITAID/CHAI: funding for pediatric HIV commodities ending in 2013
• Programmatic ambitions: what is at stake?
–
–
–
–
–
–
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ART initiation at CD4 < 350
TDF-based first-line (full rollout deferred)
VL monitoring (rollout deferred)
PMTCT Option B+ (full implementation delayed)
Scale up of diagnosis and ART for children (under threat)
Facility coverage 600 sites (full implementation delayed)
52% salary top-ups ended
Mozambique
• Threats/risks
– GFATM
• Round 9 funding not released on time (emergency request of $16M in Sept => only
$10M arrived to date)
• Round 10 proposal rejected
• Not eligible for Round 11 or TFM
– World Bank: funding ending 2013
– UNITAID/CHAI: funds for pediatric HIV commodities ending 2013
• Programmatic ambitions: what is at stake?
–
–
–
–
–
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ART initiation at CD4<350
TDF-based first line (under review, funding-dependent)
PMTCT Option B+ (under review, funding-dependent)
Scale up of diagnosis and ART for children (under threat)
VL monitoring (in current guidelines, but implementation deferred)
80% coverage target, compared with 53% today (full rollout delayed)
DRC
• Threats/risks
– GFATM: main source of funding for ARVs but major disbursement and
management problems
– PEPFAR, World Bank, UNITAID/CHAI: limiting or phasing funding for ARVs
– EU, Sweden, UK: no concrete plans in coming years to invest in HIV/AIDS
treatment
• What we’re seeing
– ART scale-up (now at 12%, not expected to reach 25% by 2015)
– Further rationing of ART (treatment slots already limited, patients’ waiting
time has increased)
– Implementation of WHO guidelines (350, TDF) (full implementation delayed)
– PMTCT Option B or B+ (full implementation delayed)
– Further decline in operational capacity (govt and NGOs)
– Decreased HTC (less than 10% the target)
– Facilities are charging patients for ART
Guinea
• Threats/risks
– GFATM
• Heavy reliance on the GF: funded 50% of ARVs in 2011
• Current GF grant (Round 6, phase II) ends Dec 2012 => purchase of ARVs foreseen
under Round 10 but major disbursement delays
• Ineligible for Round 11 and TFM: earlier ART proposals too modest in terms of
treatment slots (Round 6 for 11k patients, Round 10 for less than 2k)
• What are we seeing?
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–
–
–
–
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Initiation rates halved from the previous year
Potential gap for continuity of ART for 11K patients due to late disbursements
Patients presenting late stage
Treatment slots (already capped) would need to be cut further
Patients being turned away/added to waiting lists
Patients pay for OI treatment since September 2011
Spotlight on TB
•
Malawi
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–
•
Mozambique
–
–
•
–
Planned to use Round 11 to expand MDR-TB detection and treatment
(ambition was to use Round 11 to start 10,000 new patients on
treatment over 5 years)
No other known donor prospects for TB/DR TB
Uzbekistan
–
•
Planned to use Round 11 for TB drugs and reagents (World Bank has
since covered) and DR TB drugs
Dependent on R7 for 1s/2nd line drugs
Myanmar
–
•
Planned to expand TB treatment to 15,000 children over 5 years (on
hold until more funding becomes available
Planned to use Round 11 to purchase 16 GeneXpert
Planned to scale-up MDR-TB testing and treatment with Round 11
Zambia:
–
Planned to use Round 11 to help improve case finding, scale up TB
diagnosis using mobile technology in remote areas, and increase the
number of people on IPT
GFATM and TB
• 79% of donor funding
• 11% of total funding
• Largest DR-TB funder
Implications: HIV and TB services, TB, civil society and
health systems support
GFAN: Impacts of the Global Fund’s Round 11 cancellation and funding shortfalls
Wednesday 25 July. 3:3opm-6:30pm
VENUE: Booth #820, Opposite Global Village Session Room 2
MSF – Losing Ground: How funding shortfalls and the cancellation of the Global Fund's
Round 11 are jeopardising the fight against HIV & TB
RESULTS – The Global Fund: Progress at risk - Opportunities and obstacles in the fight
against TB and TB-HIV
HIV/AIDS Alliance – Don’t Stop Now – How underfunding the Global Fund to fight AIDS,
Tuberculosis and Malaria impacts on the HIV response
Eurasian Harm Reduction Network – Global Fund’s retrenchment and the looming crisis
for harm reduction in Eastern Europe and Central Asia
Open Society Foundations – The First to Go: How Communities are being affected by the
Global Fund Crisis
What's next: treading water or gaining ground?
• Model of the GFATM: the September Board meeting will
make a decision
• New funding window: opened by end of September and the
decision on applications by the end of April 2013
• Funding the GFATM
• In September 2012 UN General Assembly Fundraising event hosted
by UN SG
• 3-year replenishment cycle (2014-2016) - a pledging conference in
September or October 2013 to raise an estimated USD 20 billion
needed
• Financial transaction tax
State of ART: tools,
strategies, & policies
dashboard
Conclusion
• To reach with HIV treatment and help
retain as many people as possible as
quickly as possible and as early in their
disease progression as possible…
…we need a fully funded and
functioning Global Fund
• We need governments to pick up the
pace of scale-up and funding levels.
Report & survey results in 23 countries:
www.msfaccess.org
• We can’t beat this plague with the same
funding levels we’ve had for the past 4
years.