Submission from the Global Fund to Fight AIDS, Tuberculosis and Malaria for the

Foreign Affairs Select Committee Call for Evidence on Global Health Security (GHS0009)

Introduction and Description of Organization

The Global Fund to Fight AIDS, Tuberculosis and Malaria was created in the midst of the last major pandemic to hit humanity: HIV and AIDS. We mobilize and invest US$4 billion a year to support programs run by local experts to fight HIV, TB and malaria and build resilient and sustainable systems for health in more than 120 low and middle-income countries, including the most challenging operating environments. This makes us the largest multinational funder of prevention, diagnostics and treatment for infectious diseases. The programs we fund have saved an estimated 38 million lives since our creation in 2002, and during that time deaths from AIDS, tuberculosis and malaria have declined by about half. In partnership with governments, civil society, technical agencies, communities, the private sector and people affected by the diseases, we are a proven multisectoral model to drive infectious diseases into retreat and save lives. We have also proven our ability to allocate significant sums rapidly, with transparency and accountability.

Steadfast support from the British people and from Parliament has made the United Kingdom one of our strongest partners, and your support has made these results possible. The 1.4 billion GBP pledge commitment made during last year’s sixth replenishment, which represents a 17 percent increase, was essential for successfully achieving our fundraising target of US$14 billion for the next three-year grant cycle. As a result of this success, country allocations have increased by 23 percent. The Global Fund counts on continued support from the UK, especially as we all confront new challenges due to the COVID-19 pandemic, in order to maximize impact against the three diseases and stay on track to achieve the Sustainable Development Goals.

UK Investments in the Global Fund are Directly Supporting Global Health Security

Infectious diseases do not respect borders, and the COVID-19 pandemic makes clear that our global health security is only as strong as the world’s weakest health system. As a result, investments in global systems for health have always been critical to keep citizens safe from infectious diseases including HIV, TB and malaria, and to help fight new health threats like COVID-19.

The Global Fund through its investments to fight the three diseases already contributes significantly to health security and pandemic preparedness. For example, we make large, sustained investments in surveillance and data systems, laboratory strengthening, health workforce training, diagnostics and therapeutics, along with a strong focus on, and support for, vulnerable and marginalized communities, including through removing human rights and gender related barriers to accessing health services.

A recent study conducted by the Georgetown University Center for Global Health Science & Security quantified the extent to which Global Fund expenditures support health security. Researchers examined Global Fund expenditures in 10 countries from 2014 to 2020. They found that just over 19 percent of funds went to activities that directly support health security according to the WHO’s International Health Regulations Joint External Evaluation (JEE) Tool. Such activities include funding for laboratory systems, workforce development and antimicrobial resistance. Another 18 percent of our funds went to activities that indirectly support these efforts, meaning that in total 37 percent of Global Fund investments either directly or indirectly advance global health security.

This finding is not surprising because the Global Fund is the largest multilateral investor in systems for health, investing approximately one-quarter of our funding or more than US$1 billion a year to support community health systems and to build stronger health systems. These strong health systems that we are building to fight HIV, TB and malaria are also urgently needed to fight COVID-19. For example, the Global Fund has played a major role in scaling up access to Cepheid’s GeneXpert instruments for TB, which are faster and more accurate, delivering results in hours rather than days with fewer “false-negative” results. They can also detect resistance to first-line drugs, so appropriate treatment can be started immediately after diagnosis, and they do not require specialized labs or technicians. We have installed over 10,000 of these devices in laboratories across low and middle-income countries and have trained technicians to operate them. Since COVID-19 struck, we have been at the forefront of enabling use of GeneXpert machines to also conduct fast, reliable and accurate COVID-19 tests.

Support for community systems and responses is a key component of the Global Fund’s mission to accelerate the end of epidemics and it is critical for health security. Communities are not just users of services. They offer valuable experience, expertise and leadership in governance, implementation and oversight over health programs. Communities expand the reach and uptake of services far beyond formal health facilities and empower people to advocate for their rights while holding governments accountable. Community organizations and networks have an indispensable role to play in improving equitable access to quality services, in building community understanding and knowledge of public health approaches, and in contributing to comprehensive health care. Community responses should be an essential component of health security investments.

Investments in health systems and community responses are critical for health security and pandemic response because if health systems collapse under the additional strain of COVID-19, the additional deaths from HIV, TB, malaria and other illnesses will likely be far greater than deaths from COVID-19 itself. Modelling from UNAIDS and WHO suggests that a six month disruption of antiretroviral HIV therapy could trigger more than 500,000 extra deaths from AIDS-related illnesses, bringing the mortality rate back up to levels last seen in 2008. In addition, indirect pandemic health impacts may be as large or greater than direct impacts. For example, antimicrobial resistance – when organisms develop resistance to antimicrobial drugs – is one of the biggest threats to our future global health and economic security. This threat is being compounded by the pandemic through the disruption of TB, HIV and malaria services, which threatens to reduce treatment adherence and therefore lead to increased drug resistance.

The Global Health Security Challenges Ahead

Health security is not just about preventing pandemics. It is about preventing pandemics from increasing mortality from all other causes. From our experience combatting AIDS, TB and malaria – health crises with profound economic, social and political consequences – the Global Fund has the potential to be a thought leader bridging divides in thinking between universal health coverage and health security.

The Global Fund responded quickly and at scale to the COVID-19 pandemic and is playing a critical role in the global response to COVID-19 in the poorest and most vulnerable countries. To date, the Global Fund has approved a total of US$814.9 million to support the COVID-19 response across 106 countries. Requests for funding have been approved within five to ten days in the majority of cases. The Global Fund is also working with private sector partners to identify pro-bono, pragmatic solutions to help low-income countries quickly strengthen their capacities to fight COVID-19, for example in terms of connectivity and technology.

But the fight is not over, and significant needs remain. The latest survey results of Global Fund-supported programs across 106 countries show widespread disruptions to service delivery as a result of the COVID-19 pandemic, impacting approximately three-quarters of HIV, TB and malaria programs.

At the current rate, COVID-19 is killing about the same number of people every month as HIV, TB and malaria combined. However, the death toll from these three diseases will have increased as a result of the knock-on impacts from the COVID-19 pandemic, due to lockdowns, resources diverted to the new virus, and interruptions to lifesaving services. Moreover, some of the countries that have so far been spared the worst of COVID-19 itself may be hardest hit by its economic consequences. No country is immune to the spiraling economic costs of the pandemic. Prolonged economic shocks leave deep scars, which will have profound effects on people’s health in the years to come.

Right now, global leaders are quick to say that in the fight against COVID-19 we must leave no one behind, that we are only safe when everyone is safe. However, the test of this commitment will be when access to vaccines takes away the sense of urgency and fear in wealthier nations. Will we then see continued commitment to finish the fight? Or will the flow of resources dwindle as attention shifts to other matters?

Once diseases no longer threaten those living in the wealthiest countries, they are reclassified as development or humanitarian issues, rather than being considered as global health security threats. That reclassification means they attract a fraction of the resources.

For example, TB was once the biggest killer in all the wealthiest countries in the world. Once we learned how to prevent and cure TB, wealthy countries were eventually able to ensure it was no longer a major public health threat. But it still kills about 1.4 million people a year, mainly the poorest and most marginalized. This year, COVID-19 and TB are likely to be neck and neck in the grim race to be the biggest infectious disease killer. Yet this is where the similarity ends.

Total global spending on TB prevention and treatment is US$6.5 billion, but the figure for COVID-19 is several hundred times as much. The pipeline for new TB medicines for next year contains a handful of promising advances, while the equivalent pipeline for COVID-19 contains hundreds of diagnostic, therapeutic and vaccine candidates. Perhaps most startling is the difference on data. On January 1, 2021, everyone with access to the internet will be able to get a reasonably accurate picture of how many people died from COVID-19 in 2020. To get the same figure for TB, we must wait until October 2021 when WHO finalizes the laborious consolidation of country data submissions.

This is not good enough. The idea that global health security only refers to prevention and protection against diseases that might kill people in rich countries is neither moral, sustainable nor practical. Will we allow COVID-19 to become, like we did with HIV, TB and malaria, another lingering “residual pandemic” we care much less about because it only kills the poor? Or will we take COVID-19 as the catalyst to rethink what we mean by global health security?

Even if you set aside the inequity of our current approach to global health security, creating this false distinction between diseases we care about and those we do not has not worked in the past and will not work in the future. Political leaders in the poorest countries will not invest in preparedness against potential infectious disease threats when actual diseases are already killing their people. The capabilities and infrastructure we need to prevent future threats are largely the same as those we need to defeat existing diseases. Most low and middle-income countries based their COVID-19 responses on the laboratories, disease surveillance, community networks and supply chains that were created to fight HIV, TB and malaria.

Investments in the Global Fund Produce Results

Strong support from the UK and other partners produced exceptional results in 2019. Our annual Results Report for 2020 shows that the Global Fund partnership has saved 38 million lives since 2002. In countries where the Global Fund invests, AIDS-related annual mortality has been reduced by 61 percent, while malaria-related annual mortality has been reduced by nearly 50 percent and TB-related annual mortality has been reduced by 25 percent since the Global Fund was founded. This is clear proof that global commitment and community leadership can force the world’s deadliest infectious diseases into retreat.

Six million lives were saved in 2019 alone, which represents a 20 percent increase in the number of lives saved compared to the previous year – remarkable progress resulting from increased efficiencies in service delivery, success in finding and treating more people with lifesaving medicine, cost savings on health products enabling us to reach more people, and improved collaboration across the Global Fund partnership.

With 20 years’ experience fighting infectious disease, the Global Fund is working with health leaders, partners and governments to ensure the global response to COVID-19 includes lessons learned from the fights against HIV, TB and malaria: protect human rights and address stigma and discrimination, particularly among key and vulnerable populations; fight gender barriers to health; engage communities in the response; and fairly allocate limited COVID-19 resources and new tools so that no one is left behind.

In addition, we are playing a leading role in the Access to COVID-19 Tools - Accelerator (ACT-A) partnership as a co-convener of both the Diagnostics Partnership (with the Foundation for Innovative New Diagnostics) and the Health Systems Connector (with the World Bank), and we are a procurement and deployment partner in the Therapeutics Partnership. We also co-lead the WHO Diagnostics Consortium with UNICEF to negotiate pricing and procure diagnostic tests for COVID-19, and we have opened our innovative online sourcing portal, wambo.org, to all countries and organizations so they also can benefit from the Global Fund’s economies of scale for health products.

The Diagnostics Pillar has already negotiated the availability of 120 million antigen rapid diagnostic tests for low and middle-income countries at a guaranteed maximum price of US$5 per unit. These tests provide results in 15 to 30 minutes, rather than hours or days, and enable expansion of testing, particularly in countries that do not have extensive lab facilities or trained health workers to implement molecular tests. Expanded testing enables tracing and containing the virus now, and it prepares countries for the rollout of vaccines as soon as they are available.

The Global Fund has made an initial US$50 million available from our COVID-19 Response Mechanism (C19RM) to purchase at least 10 million of the new rapid tests at the guaranteed price. This will enable low and middle-income countries to begin to close the dramatic gap in testing between rich and poor countries. High income countries are currently conducting 292 tests daily per 100,000 people. For upper middle-income countries that number is 77, for lower middle-income countries 61, and for low income countries only 14. 

Continued Support from the United Kingdom is Essential

The UK’s G7 presidency in 2021 will be an important opportunity to highlight the importance of investments in global health. We hope all our allies in Parliament will be engaged in ensuring the G7 presidency is used to advance discussions of health security in a comprehensive way that includes the fights against HIV, TB and malaria, as well as health systems strengthening.

The resources we currently have available for the COVID-19 response are nearly fully allocated. The Global Fund is working with donors and partners to urgently mobilize an additional US$5 billion to help countries continue mounting a strong pandemic response that will also prepare them for future threats. More than US$230 million has been raised so far, but additional funds are urgently needed to avoid a critical funding gap in the world’s poorest countries. We urge the UK to join other donors and partners like Germany, Canada, Sweden and Denmark who have made additional contributions through the Global Fund’s C19RM to protect frontline health workers, shore up systems for health so they do not collapse under the weight of the pandemic, respond to COVID-19, and mitigate the impact on HIV, TB and malaria programs.

These funds will allow the Global Fund to continue playing a leading role in achieving the goals of the ACT-A partnership. The additional US$5 billion for the next 12 months is needed to ensure the over 120 countries where the Global Fund operates can effectively combat this pandemic, including US$1 billion  to adapt critical HIV, TB and malaria programs and US$4 billion to enable the Global Fund to implement core components of the ACT-A pillars on Therapeutics and Diagnostics, and to deliver critical enabling health systems interventions through proven Global Fund mechanisms.

As we enter the next phase of the fight against COVID-19, we must seize this moment to raise our ambition, to see this not just as the fight against one particular pathogen, but as the catalyst to finish the unfinished fights against HIV, TB and malaria, and to strengthen our defenses against future infectious disease threats. COVID-19 has taught us the massive costs of neglecting global health. Continuing a crisis and neglect cycle with existing ODA funding, or worse yet reduced ODA, will not work. New resources are needed to help communities build health infrastructure that is flexible enough to be repurposed when new emergencies arise.

Investing in the capacity and preparedness of other countries now will advance the future health security of the UK. Keeping everyone safe from the deadliest infectious diseases is not just the right thing to do to help the global COVID-19 response. It is essential for maintaining the global health gains we have all fought so hard to achieve, and for staying on track to achieve the Sustainable Development Goals.

December 2, 2020