Transitioning in Thailand
Increased domestic spending on health is essential for the sustainability of health programs. It is also smart economics. When a government invests more in health, it translates into bigger growth and development, and leads to transition of funding from external to domestic resources. An excellent case in point is Thailand, an upper middle-income country that has opted to transition from Global Fund support ahead of schedule. In the next two years, Thailand plans to use Global Fund resources as a “front-loading” strategic approach in its response to HIV and TB and transition to fully government-supported programs as of 2017. Mark Dybul, Executive Director of the Global Fund, singled out Thailand as an example of shared responsibility and country ownership. “We are looking to learn from Thailand,” Dr. Dybul said at a Board meeting of the Global Fund on 20-21 November.
Government health spending in Thailand has doubled from US$5 billion in 2006 to nearly US$11 billion in 2012, and now accounts for 14 percent of total government spending – the highest in Southeast Asia. In 2013, about 90 percent of the actual spending on HIV in Thailand was financed from public resources. External funding for HIV has focused on prevention in programs for key populations, such as men who have sex with men, sex workers and people who inject drugs, and treatment for uninsured migrants. In terms of TB, external funding has centered on the diagnosis and treatment of migrants and prisoners in conventional TB, multidrug-resistant TB and combined TB-HIV services.
The Global Fund’s country team for Thailand is working closely with the Coordinating Country Mechanism on a roadmap for the transition. The aim is to avoid shortfalls, and to ultimately achieve the national target of ending AIDS by 2030, by stressing prevention services among key populations and by promoting an environment where community services can thrive. Partners, and particularly WHO, UNAIDS and USAID, are also actively involved in supporting the transition. The country team believes Thailand has the financial capability, the health systems and the political will to gradually take over funding for HIV and TB services by 2017. However, the transition will be a complex process and two years will be a challenging timeframe. Participation of civil society and non-government community groups is vital to sustain the work.
In a new initiative aimed at fostering a higher degree of transparency and ethical conduct, the Global Fund met this month with partners and major international suppliers of mosquito nets to develop and sign an industry-led initiative to combat fraud. The Integrity Pact for Global LLIN Procurement, which was agreed upon by all invited manufacturers of insecticide-treated nets during a forum held at the Secretariat’s headquarters in Geneva, contains a list of practical and effective mechanisms for self-regulation to minimize the risk of wrongdoing and corruption during the procurement of these essential commodities. To strive for a global accord, external donor partners the President’s Malaria Initiative, the UK’s Department for International Development and UNICEF were invited to join as co-sponsors of the initiative.
Mark Dybul, Executive Director of the Global Fund, celebrated the Integrity Pact as a landmark agreement that strengthens the partnership between the Global Fund, partners and the manufacturing industry in combatting fraud and abuse. “This pact speaks volumes of the spirit of public service and accountability we all share in the fight against these diseases,” Dr. Dybul said. “By joining our forces, we will deliver more nets to more people who need them and will have a bigger impact, both in value for money and in lives saved.” Dr. Dybul particularly acknowledged the strong commitment shown by participating manufacturers to minimize risks posed to public funds.
The Integrity Pact includes elements to advance more transparency of bids, greater conformity in compliance of anti-corruption systems across the industry, additional consistency to increase fairness, more transparency in product registrations and awareness of the Inspector General’s whistleblowing process to flag potential procurement irregularities. As part of the agreement, the suppliers will contribute US$ 15,000 each for the creation of an independent integrity monitor.
Last year, the Global Fund suspended contracts with two international suppliers of mosquito nets after uncovering evidence that they had committed serious financial wrongdoing in Cambodia. Together with partners, the Global Fund has established a framework for procurement aimed at making large-scale purchases of commodities take place in a fair, transparent and lawful manner. Gülen Newton, Head of the Global Fund’s Legal and Compliance Department, said the Integrity Pact is an important tool for increasing transparency and accountability in procurement processes, and for mobilizing industry towards joint action to minimize corruption risks.
High Net-Worth Individuals
As an innovative partnership, the Global Fund constantly seeks to broaden the base of stakeholders to defeat AIDS, TB and malaria. The private sector and high net-worth individuals are key partners in galvanizing resources. Together with foundations like the Bill & Melinda Gates Foundation, the private sector and high-net worth individuals are taking a prominent role in the effort to end the three diseases as epidemics.
The Global Fund and the Gates Foundation are mobilizing individuals, with initiatives in Viet Nam and India, where philanthropy is gaining pace. In Vietnam, one family has already made a commitment of $5 million to the Global Fund.
“It is great to see a growing number of individuals in low and middle income countries investing to turn the tide against these diseases,” said Christoph Benn, Director of External Relations at the Global Fund. “I recently met with some of the wealthiest families in Hanoi and Ho Chi Minh City in Viet Nam, and they are interested in participating in an initiative that mirrors the recently established Indonesia Health Fund.”
In October last year, Dr. Tahir, Chairman of the Tahir Foundation in Indonesia, announced an investment of US$65 million to the Global Fund, matched by the Gates Foundation for a total investment of US$130 million. The contribution was followed by the introduction of an innovative financing initiative, led by Dr. Tahir, creating the Indonesia Health Fund. The fund was established with an initial investment of US$40 million from eight Indonesian business leaders. Dr. Tahir is recruiting additional business leaders to participate.
Moving Forward in Cuba
Cuba has a record of successful national efforts on HIV prevention, treatment and care. It has one of the world’s smallest HIV epidemics, with a prevalence rate in the general population estimated at 0.2 percent, on par with Denmark. It is also one of a handful of countries in the world that is in the process of WHO certification for mother-to-child transmission elimination, a major achievement for a relatively isolated country with serious economic constraints.
Cuba’s free universal health system, with universal access to HIV-related services, has contributed to this success. But another factor that sets Cuba apart is the active engagement of key populations and people living with HIV in the design and implementation of its health response. Open, inclusive and participatory discussion during all stages of the grant cycle among all relevant stakeholders, known as country dialogue, is the best strategy to identify health interventions and achieve high impact.
Lucrecia Palacios, Program Officer at the Global Fund, says Cuba’s effective investment and multi-stakeholder response has led to strong community and health programs that foster service integration. “There is great collaboration in Cuba between community groups such as men who have sex with men, people living with HIV, transgender people and the government,” said Palacios.
Gülen Newton, who heads the Legal and Compliance Department at the Global Fund, was impressed by the country dialogue and engagement of key populations she saw on a recent visit to Havana. “Everyone had a voice. No voice had more value than others,” Newton said.
Cuba was the first country in Latin America and the Caribbean whose concept note for HIV was approved for grant-making. Silvio Martinelli, the Regional Manager for Latin America and the Caribbean at the Global Fund, recently met Cuban partners, including Mariela Castro, who heads Cuba's National Centre for Sex Education. Castro, the daughter of President Raul Castro and niece of Fidel Castro, is a strong advocate for the rights of LGBT people. As director of CENESEX, she advices and coordinates Cuban policy on sexual education and sexual rights and on integral attention to transgender people. “CENESEX has done impressive work fighting stigma and discrimination,” Martinelli said. Until 1993, people who received a positive HIV test result were placed under forced quarantine.
As countries in Latin America and the Caribbean experience economic growth and national budgets take a larger portion of the health response, long-term sustainability of programs is a special focus, Martinelli said. “Elimination is becoming more and more common in Latin America when talking about the three diseases,” Martinelli said. “Increasingly, governments are taking on the costs of medicines, reducing their dependency on Global Fund funding. This is in turn drawing more attention to key populations, which are often the politically unattractive and un-funded part of the response,” he said. “In this sense, Latin America and the Caribbean is an example of where we want other countries to go.”