 Welcome, everyone. I'm going to ask if we can get started in the next few minutes here. So if you've not had a chance yet to grab a sandwich and a drink, please go ahead and do so and find your seat. My name is Lisa Cardi. I'm the Deputy Director of the Global Health Policy Center here at CSIS. I'd like to thank our co-sponsors for this event, the Kaiser Family Foundation, and the friends of the Global Fight. We're very happy to have with us here this afternoon Michelle Kosikstein, a longtime friend of CSIS and a leader in the global health movement. I'm newly arrived here. In fact, this is the first of these events that I've been able to moderate, but I already feel quite at home. I think that's in part because CSIS is a very hospitable institution. I think it's in part because we serve very tasty box lunches. It's a bit of a bonus. But it's also because, particularly for this event, the Global Fund is an institution that I feel a very close association with. Over the last eight years I've followed its development with great interest from a number of different perspectives. And I was one of the group of people back in late 2001, early 2002, that was involved with thinking about how to put together the Global Fund's original architecture. And I have to admit at that point in time, I think few of us could have ever anticipated the impact and the success that the Fund has enjoyed. The results truly speak for themselves. HIV at this point in time, more than three million people on ARVs, up from a number that was probably less than three or four hundred thousand, I think in early 2001, if that. TB, a 50% increase in detected cases, simply over the last five years. And I think even more remarkably malaria. I believe in 12 African countries, 70% decrease in newly reported cases over the last several years attributable to the Fund's efforts. However, these remarkable achievements have only come as the result of the collective efforts of many, of governments, both donor governments and governments that have hosted the Fund's programs, of civil society, of communities of people living with HIV, and of the multilateral institutions that have supported the Fund's efforts. It's truly been a remarkable alliance. However, sustaining the current momentum, achieving even greater efficiency and impact, and indeed expanding the Fund's programs to the stated goal of $8 billion worth of both ongoing and new efforts by 2010 is going to be a major challenge, particularly in the face of today's economic crises. Fortunately, the Fund has many friends here in Washington. And I think the turnout today tells us this is going to be a very important and timely discussion. So Michelle, you're really very welcome here today. But before I give you the floor, I'm going to invite one of our co-hosts, the Kaiser Family Foundation, Alicia Carby, to please come and offer a few words. Well, thank you very much, Lisa. And also thank you to Steve Morrison and Karen Meacham and their team here at CSIS. The Kaiser Family Foundation has a very longstanding productive relationship with CSIS, and it's a partnership that we're particularly proud of. We're also very happy to be co-sponsoring this event today with CSIS and Friends of the Global Fight. On behalf of myself, Jennifer Cates, who unfortunately could not be with us today and the Kaiser Family Foundation, I'd like to welcome you to this very, very timely discussion. We are very pleased to have with us Dr. Kazak Shkin to share his thoughts on the successes and challenges of the Global Fund and the current issues facing the Fund, especially in light of the global financial crisis and issues that may be facing the Global Fund in the near future. Yesterday, he touched upon some of his thoughts on these issues. He participated in Kaiser's inaugural edition of our new live webcast series, U.S. Global Health Policy in Focus, which is devoted to discussing current and critical issues facing the U.S. government's role in global health. Each session will include leaders in their fields talking about their, oh, I'm very sorry. I already started the presentation. I'm very sorry. Each session will feature leaders in their field talking about their experiences, some of the challenges they faced in addressing global health challenges around the world. Our first session surpassed our expectations, so for that, we are eternally grateful for your participation. And while today's focus, the focus of today's discussion will be a bit different than yesterday's webcast, I know that the conversation will be no less rich and enlightening. So with that, I know we are eager to hear from our guest. So thank you, and again, welcome. So I don't think Michelle needs much of a further introduction, but just a word or two. I think he's well-known to everyone in this room, but Michelle has worn many different hats over the course of his very distinguished health career as a very accomplished scientist, a researcher, a clinician, an advocate. He's been associated with the fund in many different ways as the inaugural chairman of the fund's technical review panel as a member of the board and then as vice-chair. And immediately before becoming the executive director of the fund, he served as France's global AIDS ambassador. And actually, Michelle, I think this month marks your two-year anniversary as executive director of the fund. So congratulations to you and welcome. We're really very glad to have you here today. Thank you very much, Lisa. Thank you, Alicia, Alice. And thank you, Steve, and good afternoon, everyone. Thank you very much to CSIS, Kaiser, and friends of the fight for this opportunity. It's a pleasure to be here in Washington and to have this opportunity to address you and have a discussion with this particular audience here. In times where we have to talk about global health, where we have to advocate for development. So let me just say that I'd like to touch briefly on four areas here. One is remind how seriously a downturn in the globalizing economy can affect the poorest and the most vulnerable, and risks widening even further the gap between the richest and the poorest countries. And second, I'd like to recall how the international community now eight years from the Geneva G8 meeting in 2001, which is an important meeting for us at the Global Fund. It's the meeting where the first pledges came through the Global Fund. How the world has so successfully taken on health as a key means of reducing inequities between the richest and the poorest. I'll then touch on the Global Fund's portfolio and about some of the innovations in development that the Global Fund has brought. And finally, I'll discuss some of the challenges that we presently face at the Global Fund. And of course, the overarching theme of this presentation and of our discussion has to be that we need to find altogether the means to ensure that development and particularly health in development remains a global priority and that the gains, the extraordinary gains that were made in the last decade are not lost. So first on growing inequities in our globalizing world. As everyone knows well here, I guess, the overall number of people living in extreme poverty has quite significantly decreased in the last 20 years. And as you can see on the slide, the proportion of people living in extreme poverty in the last one dollar a day has declined from 32% to 19% between 1990 and 2004. And that decrease in poverty has largely been fueled by the unprecedented participation in the world economy of what's called the BRIC countries, Brazil, Russia, India, China. But, and there is no doubt that globalization has improved the lives of millions of people. But let's also be clear, globalization has not been without its victims and the hundreds of millions of people left in illiteracy, hunger, disease and poverty. What this slide shows in the arrow and the red bar below is that actually the share of the poorest quintile in national consumption in 2004 was 3.9% as compared with 4.6% in 1990. And that means that inequities have been increasing in the developing countries, whereas the mean overall poverty level in the world has increased. And if inequities had increased within countries they have also increased in between the richest and the poorest countries. According to the WHO commission on social determinants in health the gross national income of the richest countries in 2005 was as you can see on this slide 120 times the GNI of the poorest countries as compared to 60 times the GNI of the poorest countries 15 years ago. So growing inequities. And finally one more slide and this comes from the World Bank. And this slide shows that developing countries are anticipated to expect a significant for in GDP growth in the next two years with the crisis. We talk a lot about the crisis in our countries in our rich countries, but the crisis will impact severely on the developing world. And the World Bank as you can see here projects a markdown from 6.4 to 4.5% in 2009 for economic growth and this would translate in an additional 40 million people in poverty. So the ripples of this crisis are likely to be enormous. My point here is that inequities in health are of course among the most immediate, the most evident and the first priority people talk about when we travel to and when you travel to countries and when it comes to infectious disease and the data on this slide are familiar to all of you of course 90% of the burden of infectious diseases is concentrated in the developing world whereas as you know those countries would account for only 20% of the world's wealth and only 12% of global expenditure on health and AIDS, TB and malaria although treatable and preventable continue to kill over 4 million people every year. This is a picture of Genoa. I already discussed why Genoa is so important to us at the Global Fund. But for the reasons I just said I'd like to come back to Genoa and I'd like to restate that equity should I believe in difficult times, economic times that we're facing features centrally in the debate about development aid including inequities in access to healthcare. The rich cannot forget in times of economic downturn their responsibility to help minimize those inequities. And if I go back to the Genoa G8 communique it spoke of, quote, breaking the vicious circle of poverty and disease. Genoa was the meeting where the first pledges to the Global Fund were made with the promise that the fund should be operational before the end of the year and Lisa and some of you in the audience were in Brussels in 2001 where when we gathered together to design what would be a Global Fund and yes it was operational before the end of the year actually December 31, 2001 and we saw I think an extraordinary example of what the world can do when it comes together with a common purpose. Since 2001, oops something wrong here I'm missing a slide but that slide was to show that since 2001 we've seen an extraordinary increase in resources in international resources for AIDS that went exceeded actually 10 billion per year 10 billion last year 2008 and this slide now shows that a similar extraordinary increase in funding for AIDS did occur in this country in the U.S. with a U.S. contribution that went from less than half a billion dollars in 2000 to nearly 6 billion dollars in 2008. With new resources we've also seen a lot of creativity around new instruments to fundraise and also to deliver health. Gavi and the World Bank Map or Multi-Country AIDS Program in 2000 Gavi has now been raising resources as you know in international capital markets through what's called the IFIM the International Finance Facility for Immunization the Global Fund made its first grants in 2002 the U.S. committed to three significant initiatives by far 2003 then the Presidential Malaria Initiative and a specific effort on neglected tropical diseases more recently. Unitate was established in 2005 and a number of other new means of financing global health were generated. Two of those I'll just mention relate directly to the work of the Global Fund one is the Product Red Initiative that all of you would know here in the U.S. which is a branding and consumer-led initiative that brought around 140 million U.S. dollars into the Global Fund in a year and a half or less than two years of existence and then depth to health which from 2007 allowed me now to sign two agreements one with Pakistan and Germany and the government of Germany the other with Indonesia and the government in Germany whereby depth which is a totally inert thing can really be transformed into a creative finance for health because it's being converted into resources for the Global Fund that is a country such as Indonesia I mean Germany sorry agreed to go into that arrangement with let's say Indonesia and so Germany would take 50 million out of what Indonesia is indebted to towards Germany and erase 25 million provided that the remaining 25 million are actually invested by Indonesia into the Global Fund programs in Indonesia so it's really turning that money into productive money going to health and other initiatives let me here acknowledge the initiative taken by Russia that decided to ultimately reimburse the Global Fund their grants and thus shift from being a beneficiary country to being a donor country so as a result of these efforts and of these new means of delivering health we've seen dramatic changes and one you did mention is a dramatic increase in the number of people accessing antiretroviral treatment in the developing world and that came from as you said less than 300,000 let's say in 2001 2002 to now actually 4 million people on antiretroviral treatment of which more than 2 million are supported by Global Fund funded programs and when it comes to the population level now in Malawi or as shown here in Botswana on this slide we're seeing signs of impact that is a decrease in mortality in addition to the decrease in morbidity at the population scale and you clearly see here the correlation between decrease in mortality and increase in access to antiretroviral drugs as you also said Lisa when it comes to TB major progress and what this slide shows is a sort of direct correlation between increased global resources for TB and the Global Fund is currently provided an overall two thirds of the available international funding for tuberculosis a correlation between that increasing increased global resources and the number of new spirit and positive cases detected and then as seen in the purple line the number of people eventually receiving dots treatment and we estimate that Global Fund programs have now allowed for an additional 5 million people to access anti-tuberculosis treatment in the last six years and when it comes to malaria and you talked about the spectacular results I'd like to show this particular map showing how in just four years the coverage in with long lasting impregnated bed nets has increased in the African continent and we're now able to really think of achieving universal coverage I believe in the next two to three years and hopefully reach the MDG when it comes to malaria perhaps earlier than 2015 this is another slide on malaria and what it shows is the declining cases in malaria and declines in child mortality here in Rwanda health facilities but we have evidence from a number of endemic countries now be it Rwanda, Zanzibar, Eritrea Ethiopia, Burundi, also Kenya Mozambique, Swaziland, South Africa where substantial reductions in somewhere between 14 up to 70 or 95% in Zanzibar reductions in malaria related deaths have been observed in the last two to three years what this particular slide shows is to the right of the slide the dramatic decline in outpatients and in inpatient cases relating to malaria in health facilities in Rwanda as the incidence decreased of malaria case by 64% in these years 2006 and 2007 and as you may see with the dotted line an increase in the case of non-malaria related illnesses taken care of by those hospital health facilities so this is a direct evidence of one of the means by which what people call vertical funds directly impact on positively impact on health systems because with a greatly relieved malaria burden hospitals are actually capable to manage other health related conditions more effectively and these results in malaria I really think are among the strongest the strongest signs ever seen that the world is actually able to act and to halt and to reverse major infectious diseases as we all aim at in MDG6 and this has led to the transformation in the lives of millions of people I shan't go into detail into the story of Marceline here for reasons of time but I can't prevent myself from just bringing one very briefly one story here Marceline is one of the people that were photographed in a project that Global Fund has run with Magnum and some of you may have seen the exhibition at the Corcoran's Museum this summer but Marceline when she was diagnosed with AIDS had already lost two of her sisters and her husband two AIDS and you see here Marceline pictured as her brother takes her on his bicycle for a 15 km ride to the clinic to get her antiretroviral drugs and Marceline has regained much of her lost weight and she has regained life and she says that if it wasn't to take her medicines every day morning and evening she would actually quote forget that she has AIDS and this is something we do have to keep in mind so a few words about the Global Fund itself and looking at the audience I know that many of you are familiar with what the Global Fund is it is a partnership as we call it an innovative public-private partnership and I like us to be called a public-private partnership although I think this doesn't quite capture enough the key role that the civil society is playing and has been playing in our activities it supports programs that reflect country ownership and it is a response to country demand to the requests formulated by local stakeholders in an inclusive national process that goes through what we call the country-coordinated mechanism or CCM it only supports interventions that are evidence-based with all proposals being reviewed by an independent technical review panel and it is performance-based that is we go with disbursements disbursements that are dependent upon implementing countries achieving the targets that we have been negotiating with them that they have set and that we have been negotiating with them at the time of the grant agreements our portfolio now approved grants of which more than 7 billion have now been disbursed through over 600 grants in 140 countries that is in all all eligible countries be them the poorest countries of the world or some of the lower middle and middle income countries as you see here based on demand about 60% of the funding goes to HIV AIDS 25 to malaria 15 to TB and this is showing the global funds contribution to the increase in the number of people receiving anti-retroviral treatment I'll skip this slide we discussed it earlier this shows you the portfolio in malaria and TB and as I said the fund now contributes about 2 thirds of the international funding that is available for both TB and malaria and this shows you the 140 countries with global funds grants that is again all eligible low and middle income countries receiving at least one grant in one of the diseases the point on this slide is that the poorest countries are specifically targeted by global funds so that the global fund resources overwhelmingly reach the poorest countries as you can see here from the left two bars that correspond to the countries with the lowest per capita income here is a little more about reaching those who are in need for example 60% of the funding so far approved by the global fund are for Sub-Saharan Africa 65% of the overall funding that we have committed to support orphans just go to the southern Africa region which is of course the epicenter of the epidemic and of the orphan issue when it comes to diseases 35% of our funding going on anti-retroviral treatment goes to southern Africa and when it goes to malaria and TB as you can see on the slide we're strongly targeting the countries with the highest burden of both diseases that is 19 African countries that account for about 90% of malaria burden on the continent and the 22 so-called high burden countries when it comes to TB and still on reaching those in need and the vulnerable this is a slide showing that the global fund when it comes to harm reduction programs that are so important to prevent the spread of HIV among drug users we are funding actually harm reduction programs in all countries that are eligible to the global fund Europe and Central Asia before the fund prevention in injecting drug users in that region and was basically and virtually ignored the fund is now the largest support of these programs in the world with an investment of close to 900 million dollars I'll skip this slide and I shan't go into the detail of the calculation I'm sure we'll come back to this in the discussion because that's the most pressing issue of course is about the resources in our resources in 2010 but let me put it in a very simple way and not go into the scenarios here in 2007 our board looked at three potential scenarios of growth of the global fund a low, middle and high scenario and we're exactly when it comes to the demand that we have seen and the extraordinary increase in demand that we have seen in 2008 we're actually exactly following the middle scenario and we expect and we anticipate to reach the 8 billion figure in 2010 that Euliza or Alicia I don't remember mentioned in the introductory remarks and so this is why I'm coming here to Washington with a very clear and simple request that I realize will be a challenge a request for funding of 2.7 billion in 2004 in 2010 from the US that is 30% of that 8 billion figure now I'm putting forward this 8 billion figure as something we anticipate something we foresee something that I of course do not know whether it will be the real figure because again by definition we respond to the demand and I will only know by June and July that it will come to the global fund let me say that obviously the resources are the driving force to sustainability and new resources and sustainable resources will be needed in our fight for health for global health but sustainability is not only about resources sustainability is also about addressing the weaknesses of the systems and I'll come back to that resources also about ensuring that we're using the most effective interventions that are evidence based sustainability is also as said on the slide promoting human rights that is making sure that stigma and discrimination do not prevent those who are most in need to actually access preventive and treatment services and it's also progressively and as we do in Rwanda using the opportunities afforded by scaling up in global health to strengthen the social safety net in poor countries that is having health insurance and social protection as part of the health system package but it's also sustainability building and strengthening our partnerships our partnerships on the ground with the bilateral and I'd like here to actually express my gratitude to the many people I have seen on the ground the PEPFAR staff, the USG staff the embassies in countries where I travel and where I find people who are extraordinarily familiar with the global fund jargon processes and are truly committed to support the global fund and to support countries in actually best implementing the programs that are funded with our resources I do think with the successes that I'm discussing with you today that we have to really think about what bilaterals can do best and where is the best added value of the two approaches in scaling up access to prevention and treatment on the multilaterals there's still work to do and I know Bill Steiger discussed that briefly when he was with you a few weeks ago I fully agree that we need more flexibility here when it comes to the work of the multilateral agencies on the ground and more joint accountability for results and including I think a better proximity of those agencies with the civil society on the ground this is a slide mentioning again what I just did on our activities and our relationship with PEPFAR with bilateral PEPFAR that I think has truly been very successful on the ground including joint procurement of drugs and commodities joint monitoring and evaluation support for strengthening CCMs the USG has put a number of specific grounds to help strengthening the CCMs that have been extremely useful but sure we can do better and we can do better with bilaterals in some countries I've seen in common basket funding 24 countries sitting around the table to decide on disbursements and I think that can result really in gridlock and that's not the best way we should go for let me finally address some of the challenges and of course the first challenge is that of health systems and let me again recuse this ridiculous damaging whatever vocabulary I could find here debate about vertical funding versus horizontal funds and Steve you did run this session on health systems in Mexico at the time of the AIDS conference I think we all agree AIDS to be in malaria as we scale up have revealed the profound weaknesses of health systems in countries that were existing of course before we would scale up but our ability to scale up in these diseases have revealed those weaknesses like never before and I would add Gavi and I would add bilateral PEPFAR have really changed the development paradigm here by supporting both access to preventive and therapeutic interventions and support to health systems I mean Gavi, Glomofan, PEPFAR and of course together with the IDA are the main funders of health systems it's the vertical funds that are the main international funders of health systems and when I talk about health systems I of course talk about the infrastructure the procurement system monitoring and evaluation but I also talk about human resources and about data collection and operational research what the slide shows here is that we are currently devoting approximately 35% and that again it's in response to the demand that comes from countries 35% of our resources go to what you would generically called health systems strengthening monitoring and evaluation a 2 small percentage, 3% infrastructure and equipment and human resources 3% and I was struck by how similar this figure is to PEPFAR which is actually devoting 32% of its resources so 35 and 32 very very similar we do have a health systems funding gap you know, Glomofan, PEPFAR, Gavi are as I said probably the biggest financiers of health systems in the world today but we cannot do it alone and here I'd like us all to be somehow honest with ourselves the commission on macroeconomics and health in 2001 you know said that we would need somewhere about 35 to 50 US dollars per capita, per annum in order to ensure that people access a basic health package and if we're serious about health systems strengthening we should realize that now as the world spends about 10 or 12 US dollars per capita per annum we will not be reaching full capacity in building health systems unless we have major additional resources so again, let's focus on the resources let's focus on plans with targets let's rather than spending time on sterile debates between vertical interventions and horizontal health systems strengthening which I really think is just a cruel distraction let me just dwell for a second on the role of the civil society and here is a trainer in malaria teaching a village on how to use bed nets currently as you can see on this slide about 50% of the funding from Global Fund goes to the civil society or to let's say non-government organizations at large including faith-based organizations, community groups the private sector and organizations of people living with diseases and I'm very pleased that in the last round, round 8 we could offer people the opportunity to apply for funds that would go specifically to community systems strengthening which is very much needed on the ground I want to remind those of you who are not so familiar with our Global Fund jargon that when countries apply to Global Fund they now can apply to what we call dual-track funding that is in the grant application have two principal recipients for the funds, one from the government and one from the non-governmental sector private sector is an important component of our partnership I talked briefly about product red but there are other efforts and very significant efforts from the private sector when it comes to resource mobilization the contribution of the foundations particularly of the Bill and Melinda Gates Foundation and Chevron that was the first large company to join in what we call a corporate champions program but there are many other ways by which the private sector also contributes to the funds through co-funding of programs on the ground and through pro bono services that are helping implementation when it comes to data quality again something that was actually I picked some of the points that Bill raised in his talk because I think it could be a good platform for the discussion here we do have a number of strengths I believe at the Global Fund and the major strength and that follows the principles of the Paris Declaration and of the Accra agenda for action is managing for results that is we promote the use of data for funding decisions and therefore we also commit or are ready to commit funding if countries request for it funding to be used for M&E strengthening we also have in-country data verification all data that come to us are verified in-country for each disbursement with also on-site clinic checks each year and periodic audits but we do also have challenges and weaknesses we have gaps in surveys and surveillance that's not specific to the Global Fund let's not forget that most of the countries where we're funding programs actually do not even have the basic demographic data we do have challenges with the partners to truly align and jointly support monitoring and evaluation and there are issues around incentives to use evidence and data to improve programs and you may have seen one of the articles on this topic in the Lancet from Chris Murray on some of the GAVI data recently finally procurement and here I'd like to acknowledge Bill's comment on the fact that the fund has largely supported procurement that creates no distortion in markets and respected intellectual property but Bill also raised the question of whether the fund can achieve the best value for money and it's probably true that a number of countries we are again a system of country ownership so it's probably true that some countries can do better when it comes to value for money in buying drugs and there is a tension between the principle of country ownership and how much value for money you can actually get when it comes to buy drugs this is why we have now introduced what we call a voluntary procurement so countries that wish so can actually adhere to a central procurement by the Global Fund but let me also say that there are limits to what we can hope and here I'll just show you and these are my last slides two examples first the example of ACTs and as you can see in the last three years 05 to 7 when it comes to ACTs we have witnessed both a decline in the median price of ACTs as well as a decrease in the range of price in between countries that are purchasing ACTs with Global Fund money when it comes however here with second line ARVs which as you know is and will be a major challenge in terms of cost we've seen a decrease in the range of prices in between countries that buy the ARVs but basically no change in the median price of the drugs so let me just finish with a few summary points I've been discussing the fact that health is a key investment for development and for reducing the inequities between the Global North and the Global South that more important than ever in the financial crisis we should focus on the poorest and the most vulnerable that investments in health are showing the results and the impact and I think that is the strongest piece that we can bring to our advocacy to the new administration on the hill and to decision makers at large to the G8 in La Magdalena in July I've talked about the increased convergence of donor political, economic and security interests something that you are discussing at CSIS with global health outcomes again I think a strong piece of our advocacy and the fact that AIDS Malaria TB treatment and health systems challenges highlight the need for a long term effort and lifetime commitments but in fact as I discussed the fact that sustainability is not just about resources so 2009 and 2010 to me are absolutely key years it's years where we will either fail or succeed after building these successes that I discussed in my presentation in the last six years I truly feel these are mission critical years 2010 we'll see the replenishment of the IDA at the World Bank and the replenishment of the Global Fund for 2011 to 2013 that will take us to January 1st 2014 one year prior to the deadline of the MDGs and it's also a critical year for GAVI so in the next two years the poor of the world will really be watching to see whether we keep our financing commitments for global health in difficult times a second opportunity I see in these two years is for us all to focus more than ever on results as I said I think results and impact are our strength and at the time you know when the world devotes so much effort to rescuing institutions that have failed I think I hope it will also spend equal effort on institutions that actually work and this means of course targeting resources in an efficient and cost effective manner as we discussed building the partnership with the civil society and rewarding good performance the third opportunity and I've said that two or three times in this presentation already is and that's an imperative of course is acting to ensure that inequities between the rich and the poor are not further exacerbated by the financial crisis and now it's the time to ensure that the gains we have made since Genova 2001 are not lost and so let me just finish on some quotes again from Genova and I really invite you to reread that that communique I find it extraordinary Genova was really a time with a vision and in times of crisis of course we tend to lose that vision we tend to be somehow in fear in defensiveness in bureaucracy somehow limiting ourselves to what might be feasible rather than actually reaching to fulfill ambitious commitments the Genova G8 communique spoke of taking quote a quantum leap in the fight against infectious diseases it said breaking the vicious circle of poverty and disease once for all end of quote it spoke of the G8's quote determination to quote make globalization work for all our citizens and especially the world's poor end of quotes so it is that spirit of determination and commitment to equity in global health that should guide us in our advocacy effort and should guide us to the next G8 and beyond so thank you for your attention Michelle thank you very much for that comprehensive overview and for your willingness to be honest about what the accomplishments have been and also honest about what the remaining challenges are and I like very much the note that you ended on because I think it is actually very important to look back before we can really look forward about where it is that we need to try to be going between now and 2015 or whatever deadline we want to set for ourselves so we have probably about 20-25 minutes for some questions now and what I'd like to suggest we do is that we maybe group them in three or four questions at a time just for time efficiency sake and I'm going to ask my colleagues here who have microphones if they will help get around the room and actually particularly if you could keep an eye on this corner over here because it's hard to see beyond the podium so we have a question right here in the front row I think Hi, I'm Matt Kavanaugh from the Results Educational Fund Michelle thanks for being here it's a key moment for you to be here and kind of sharing these messages with DC and so on that note I have two questions for you specifically about what those in this room can do it seems like we have an incredible opportunity right now in that for all of the success of the last administration on HIV and AIDS one of the things that administration asked last year about in half of the U.S. contribution to the Global Fund Congress was able to get it up to level funding but that's a real challenge right we now have an administration that ran all of the people in major places set on the campaign trail that they wanted to fully fund the Global Fund so what do you need from folks in this room to help make that clear bold case that this is exactly what this new administration's kind of vision for foreign policy is and then on the other side funding available but also demand right I think we all have a massive worry that countries will get a very clear message from the last round of funding in which for the first time we weren't able to fund at the full levels requested all of the funds requested because of because there hadn't been enough donations that countries will pull back right that they'll stop expanding and that we'll have a problem of demand and that we won't have demand to reach this 8 billion even though we know that it's needed from past years so what can we do to kind of solve that problem as well thank you Is there another question we can take please in the third row there let's take both questions together Hi good afternoon my name is Jennifer Redner I'm with the International Women's Health Coalition thank you for being here today my question is related to the Global Fund Gender Equality Strategy could you speak a little bit about the plans for implementation of the strategy thank you Perfect follow up my name is Janet Fleischman I'm going to talk about the interesting new development of this gender strategy both about women and girls and about men who have sex with men and the piece on the women and girls side that is focusing on integrating sexual and reproductive health and HIV services why don't we go ahead with those okay thank you I mean already two key questions although very different Matt on your question um let me on the first point say that what people in this room can do I mean this room is filled with some of the strongest um groupings of people um in when it comes to advocacy in global health so the message is in times of financial crisis in times where where budgets are a danger and um although somehow many of us feel that perhaps when it comes to funding development development funding may not be as quote soft funding as it would have been in the 80s or the 90s clearly there is there is a source of major concern for all of us the message is that is all together advocate for development um and development aid to be a priority of the foreign policy of the new administration and let's advocate health uh health in addition to education but health as being one of the priorities in development because um because health is the most immediate and evident of the inequities because by fighting AIDS, TB and malaria we're directly fighting the erosion of human capital that these epidemics are generating in the developing world because also we have shown the world what we can achieve we can be fully accountable in the money we have invested and we can show results and impact and progress in global health as never seen before in the history of public health so we do have I think very strong arguments in advocacy and this is the first thing I'd like to ask from the audience whether people here are in government or non-governmental organizations I agree with you when it comes to the risk that the trust that countries have built in the fund and in general in aid maybe may suffer if we are not keeping to our commitments um looking back at the history of the fund and I can't prevent myself from looking at the second row here in the audience but Scott Marguerite-Judy you remember it 2002-2003 the requests coming to the global fund were sort of very shy projects like the type of project that would be funded like the bilaterals used to do in the 80s you know a pilot project of 300 people on anti-retroviral treatment in district 121 part of Kenya nothing to do with the scale at which we need to address the diseases because countries were still looking into what's this new instrument and will that be sustainable will that be expanding and then progressively that trust came I think the trust from the donors and we saw that in the 2007 very significant replenishment of the global fund and the trust from the countries and to me the unprecedented demand that we saw in 2008 is really a very strong sign of that trust so yes if we are there is a risk of losing that trust with I think which is of course a major risk for the people who are in need of services and would not access those services but let me also say it bluntly I think it's a political risk as well and this is where it comes to the discussions you are having so often here at CSIS about health is politics and health is global health is foreign policy I wouldn't necessarily say that in round 8 that's more of a technical discussion for that wasn't able to fund I think in times of crisis it is also not unreasonable that we try and find as much efficiency gains as we have as we can and the 10% as you know is not a 10% decrease in funding that was arbitrarily is being arbitrarily applied to each grant it's our effort to try and find those 10% efficiency gains as we negotiate grants it will be easy in some cases more difficult in others and it's also efficiency gains that we have to apply to ourselves in the functioning of the secretariat now thank you both of you for your questions on gender we will be presenting the paper on the presentation to our policy and strategy committee around March 15 so I don't want to expand too much here on that but let me say that fighting the inequities relating to gender as a driving factor for the AIDS epidemic in the world addressing gender inequities fighting violence against women paying supporting more strongly sexual and reproductive health are clearly in our priorities let's also be clear Global Fund is not a top-down organization we are not deciding for countries what they want to do so I'll follow Matthew's math score it's also your responsibility our joint responsibility to make sure that countries when they send us their requests our strategy is to show that we give a high priority to these issues but we will not fund something that the countries do not request us to fund so it is our common responsibility to actually have all of these issues very high on the agenda when they submit their requests to us further questions my name is Ahmed Meir I used to be dealing with science policy at the State Department for many years the question that I'm asking is maybe tangential I don't know so much about the Global Fund but what are you doing in terms of long-term leadership in these countries in terms of both research collaboration and building up expertise because at some time you want to see both facilities for drugs being manufactured in these countries and leaders in these countries also something that I found very difficult and I imagine it's involved here was the IPR issue for example there was a vaccine institute in Korea when I was there and we couldn't get support all the way from the US and many countries to develop vaccines vaccines really that are important to the developing countries thank you my name is Charlotte Calvin and I work for PAF and I had a somewhat related question I noticed in your presentation the importance of M&E and health systems strengthening and specific mention of operations research as an important part of that yet only 3% of Global Fund monies are going to M&E to academic institutions and as someone who's responsible for supporting a lot of these activities we often find that the first thing cut out of the budget is the impact evaluation of operations research or that when it's funded there's very weak capacity so I'm curious to know your thoughts on through the future especially in the context of the financial crisis for building up the local research on institutions and capacities in country let's go over to the front row Michelle thank you for joining us today a question about health systems strengthening my name is Eric Williams and I work with physicians for human rights but specifically on the health workforce advocacy initiative which is a civil society initiative affiliated with Gua in reviewing the TRP review for health systems strengthening there were about 45 requests for grants funding only of which 25 were recommended for funding there seems to be a little bit of a gap in terms of how do we encourage more countries to make specific requests for health systems strengthening there seems to be clear bottlenecks to where we might or where the fund might be able to kind of clear up the law gym in terms of making it more clear as to how to strengthen those how to put in those requests for funding and I'm wondering what are your thoughts about raising the level of interest in countries so that there are more requests for health systems strengthening because I think that we would all agree that at the end of the day you really can't address any of the three diseases unless you have a strong system for health let's take one last question right in the front row here my question fits in nicely with what you have just said about health systems strengthening I know the global fund and PEPFAR both under the leadership of Mark Dible and you they have really done excellent work for health systems strengthening and I'm just wondering how we could accelerate this in any given country take Africa or Asia or Latin America Caribbean nearly 40% of the health system is helped by paid based organizations often mission hospitals and clinics are in places where government dare not go if you concentrated on this sector as well which is so strong already maybe we could accelerate health systems strengthening and I'd like to know your views I saw that 5% of it goes to paid based and what can we do if we rely on CCMs there is a whole government bureaucracy and what else could we do I know you're innovative you're pioneer and you're very dynamic you'll do it thank you that was the answer to the question thank you shall I just take those few questions let me have the questions relating somehow to research together first I fully agree with you that without support to leadership to let's say governance at large we want to achieve sustainable results in global health but you know the global fund cannot do it or by itself and that is something I'd like to emphasize clear here our mandate and the mandate we receive from the international community when it came together in 2001 the public sector the governments from the north the governments from the south the private sector the civil society the communities affected by the diseases the multilateral agencies all coming together the mandate was we have to do something to bring to scale to real scale the interventions aimed at prevention and treatment so that's our basic mandate so you know I am I don't know I have been in my career one of I hope of the strongest advocates for investments in research and innovative technologies for prevention and treatment and vaccines but when it comes to global fund that is not the mandate of the global fund however the mandate of the global fund is to learn lessons as we implement from what we're doing so as to improve our means of implementing and that's a new science called operational research and operational research I truly believe is in the mandate of what we should fund operational research is a sort of real time assessment of what is being done and a multidisciplinary approach to that assessment from clinical science to social science to economics and to to geopolitics countries when they apply to global fund can request for up to 10% in the ground for operational research that I would agree with you both there is a bit of a vicious circle since there is so little research capacity actually being built in countries that's one of the reasons that for which operational research is not a priority and our request for funding operational research in the grounds that come to us are extremely actually extremely small yes the 3% figure for monitoring and evaluation I would agree with our colleague from PATH is too small again here we are responding to what countries decide to be their priorities and it's our as we all feel how the amount of data and the quality of data are important to all of us and to the success of the programs to programming the interventions we need to help countries to actually invest more into MNE and that advocacy is to me the role of our partnership and I keep saying that the global fund is not an institution talking to partners but the global fund is a partnership by itself we are made of partners sorry to be pedantic I say we are ontogenically a partnership yes so within that partnership we have WHO we have World Bank we have UNICEF we have the bilaterals the USG among others that on the ground have to help countries to actually have MNE higher on the priority agenda in the request and it's a bit of the same answer as I did to our colleagues on the gender strategy when it comes to health system strengthening again I would partly answer your question by saying it's in the partnership this is a very fragile model a model entirely relying on the partnership and all of us in the room know that that partnership is functioning you know in places very well with much strength and in other places it's just very weak it depends on institutions it depends on individuals it depends on a number of factors it cannot be controlled top down it can only live from our efforts to nurture that partnership and to have partners constantly feeling in countries partners the WHO representative the UNICEF the representative from the USG the embassy and or the PEPFAR that they own the global fund we all own the global fund on one of my slides I was saying I didn't read it actually that the global fund is truly a global public good it is our collective public good and we all own it so if the partners do not fulfill that role of actually helping countries to realize what you're saying with a more structured effort on health systems then those requests will not come to us or to Gavi but let's say there are difficulties there the first is that it's difficult to find the proper indicators so to have health systems strengthening enter into what all of us wish which is a performance based and for disbursements then there is an issue about resources I said in my talk that if it's to go from 11 dollars per annum per capita to 11.5 you know that's not the way we will truly move the health system issue but let's also be careful saying that you said something like how we scale up further without strengthening health systems I think the demand that we have been receiving from countries in round 8 and the demand that I somehow anticipate we will be receiving in round 9 is the very example that actually countries have understood how they can in parallel build demand for commodities delivery of preventive and treatment interventions and in parallel to that health system strengthening but health system strengthening for health system strengthening is I really believe something that won't work unless we have the 50 dollars per annum and per capita and then we would say ok we have that money how do we best allocate to strengthening health systems at this time what we have to do is to use every opportunity every most cost effective opportunity as we scale up interventions on the 3 diseases that the number one killer disease in the developing world to strengthen in parallel health systems not for the sake of strengthening health systems but for actually being better and better able to deliver prevention and treatment in these countries that is somehow answering the first hopefully the first part of your question the second part was about faith based organizations there's nothing that prevents that 5% figure to actually grow and a few months ago a year ago in Washington we had a meeting with faith based organizations and I was meeting with some of you earlier here and then you have the manual with you on how faith based organizations can access here's the manual thank you for the publicity how can faith based organizations access global fund funding so it is but I would take your point that sometimes it is difficult to find your way through the CCM the CCM is a very democratic concept it's built on what we see as an ideal world where where indeed all stakeholders come together the government the faith based organization the civil society the vulnerable groups the bilaterals the multilaterals the reality is that again in some places it works extremely well in some places it doesn't work at all but the reality check is also that let's be you know true to ourselves it needs a little time global fund is really operational somehow I think since maybe 2004 so it's a three and a half years old child you know those CCM require a little more support and a little more time to really be easily accessible as we as we would always and that tension between how urgent are the things we need to do and how slowly some of the means progress is the tension we live every day so I'm going to apologize in advance because we need to be out of here right at two o'clock but I think if we speak fast we have time maybe for a last question or two so if we the lady maybe with the pink turtleneck and the gentleman in the green shirt please and then let me just say Michelle will be around for a little bit afterwards we can adjourn to the back and there will certainly be some time if others of you have pressing questions that you can speak with him briefly when we're done please. Thank you my name is Kelly Curran from Japaigo Johns Hopkins University just a quick question I very much appreciate how field driven to what countries put in their proposals but I was wondering if you could speak a bit about the role of the technical review panel in particular in guiding maybe the balance of what interventions are funded under proposals I'm thinking particularly of balances between treatment and prevention in the area of HIV and some of the emerging prevention interventions such as male circumcision for example which countries have been so eager to take up or many countries in southern Africa have not been so eager to take it up does the Global Fund see a role in gently encouraging countries to pursue those interventions Well, sorry, okay Thank you very much Renan Rosimer from Pan American Health and Michelle thank you very much as usual very clear to the point two observations one I think that you've been a little shy I think one of the main impacts that the Global Fund will have in development is the CCM in the sense that you know it's forcing a cohabitation of the public and the private sector in the countries which sometimes ends up like but marriages but I think that learning how to do it is also part of the important thing but my question really has to do with something a little different the new window or the fund which has to do with the support of national strategies for those who are not familiar it's by imitation only some countries are being invited to apply for supporting their national strategies in a certain way that means that the fund is taking a more technical role of assessing the national strategies which is not what was in the beginning of the role of the other so how are you dealing with that subject in other words who decides whether the strategy Country X is worthy of support for both relatively complex questions so I might have some length but maybe Michelle at the highest level you can try and thank you for the questions they're important questions first the TRP is the TRP can take strong sense and it's never easy to speak about oneself but you know in the first session of the first TRP in 2002 we decided that we would just not consider an HIV request that would not have both treatment and prevention and if you remember those years 2001 and 2002 these were still years where people were discussing whether you know resources being scarce one shouldn't go for prevention quote rather than for treatment then it wasn't the sort of acquired dogma that one is complementary to the other and the two should go together so that was a decision of the TRP but the answer to your question is you know the board of the Global Fund having all the constituencies that I've been mentioning throughout the discussion all members of the partnership encourages a number of of things that's how we push the gender strategy the sexual minority strategy that you mentioned I hope an IVDU strategy in the coming months and encouraging countries to apply for health system strengthening that's what the Global Fund can do with a limit which is again that to me the principle of country ownership must be sacrosanct this is a key to the medium and long term success of our development efforts for too long the world or the rich world has been deciding for the others what they should do the but so when it comes to male circumcision I find it very difficult I would agree with you reading the papers and actually in the former life I was the first the sponsor of the first trial on circumcision in South Africa reading the evidence from the literature there's just no doubt about how effective that intervention may be but then when it comes to I don't think it's just countries not taking up male circumcision it's countries facing the many many challenges that scaling up such an intervention would represent and again it takes time it takes cultural time it takes political time it takes also technical support and maybe it's still a little too early and again there's a tension between how much the urgency and how much we would achieve and the time that is needed to do a number of things not a very good answer but that's the one I can provide you with and I say very important question let me just very briefly say that Global Fund in the very beginning has been funding projects then more comprehensive programs and now it's opening to funding national strategies although I see the continuum there of course the TB national a program on TB that we would have been funding in round seven or eight is very very close to actually funding a national TB strategy and of course one of the things that the TRP has been looking at from the beginning is how consistent is the program that is submitted to us for funding with a national strategy but here we would be presented with a national strategy that other donors could potentially also use as a basis for funding I fully agree with you it is not up to an external entity to validate a national strategy and I was quite firm on that in the recent intervention at the meeting of the international health partnership in Geneva to me a national strategy is validated by the country and owned by the country and I don't believe there is such a thing as a super national body that universally gives its blessing to national strategies however in order to for a donor to fund something it needs that the donor sort of approves the content of what has been validated by the country so for now that is for 2009 in the experimental first wave of national strategy applications by invitations on the as you said the TRP will be working in a totally different way from the usual way the TRP will first start with a desk review of all available documents documenting a national strategy in a given country it will not ask the country to write anything new just send in all the documents they have and if that desk review confirms that the country has indeed in its strategy all of the quote attributes of what a group currently chaired by the World Bank and WHO has considered to be the necessary minimal attributes in a strategy then the TRP would engage in a dialogue at the country level with the country going to the country to how to improve and fine tune that strategy and then the country would write and send to the global fund a financial request and only a financial request without the narrative of a proposal saying we've worked with you on a national strategy and we know that World Bank we know that US government we know that PEPFAR will fund this or that part and thus our financial request to you global fund is x% of that strategy and so as we move to that I think we'll move to funding comprehensive programs that are much more integrated harmonized and aligned as we all aim at by adhering to the Accra agenda for action and Paris declaration principles but it's it is work in progress so one of the less gratifying aspects of being the chair is to have to bring such an interesting discussion to a close but I'm afraid we do need to do that so actually I want to thank all of you for your participation as well for his candor and his insights in being with us today