Foreign Affairs Committee on April 4th, 2019

[The Chair, Liberal, Michael Levitt]

Good morning, everyone. I'm going to call to order the 135th meeting of the Standing Committee on Foreign Affairs and International Development.

We are privileged to be joined this morning by representatives from the Global Fund as they head into their sixth replenishment cycle, which will be happening later on this year in Lyon.

This is our annual update, because I think it's clear to members around this table—and to everybody following this hearing this morning—how important and what a priority the Global Fund is for Canada.

As background, the Global Fund was established as a public-private partnership in 2002. It brings together governments, communities, international development organizations, civil society organizations, the private sector and people affected by the three diseases to accelerate the end of AIDS, tuberculosis and malaria as epidemics.

The Global Fund has certainly been a priority for successive Canadian governments. We're looking forward to hearing the update this morning. I want to introduce our three representatives from the Global Fund. We're going to have Françoise Vanni, director of external relations. We're going to have Loyce Maturu, and we're going to have Scott Boule, senior specialist of parliamentary affairs. Ms. Maturu is the network speaker and advocacy officer.

It's my understanding, Ms. Vanni, that you will be presenting opening remarks. Can I ask you to take about 10 minutes? I know there are going to be many questions from members who are very interested in hearing from you directly.

[Françoise Vanni, Director of External Relations, Global Fund To Fight AIDS, Tuberculosis and Malaria]

Thank you very much, Chairman Levitt, Vice-Chair O'Toole, Vice-Chair Caron—he's not here yet—and honourable members of the committee for the opportunity to address you today.

My name is Françoise Vanni. I'm the new director of external relations for the Global Fund. I assumed the role last September. I know many of you worked with my predecessor Christoph Benn, who had been working in that position for many years and has testified in front of this committee many times. He has conveyed to me the strong support the committee has consistently provided to the Global Fund. I look forward to getting to know all of you in the many years to come.

On behalf of the Global Fund and our partners, I would like to begin by expressing our profound gratitude to Canada for your long-standing support for our work and the leadership in the fight against HIV, TB and malaria. Canada is a founding donor of the Global Fund and has always played a crucial role in our success. Our fifth replenishment, hosted by Canada in September 2016, was the most successful ever, with pledge commitments increasing substantially for the three-year cycle that began in 2017. Support from the Canadian government, including our allies in Parliament, was essential to producing this great result.

Canada was a leader in pledge increases as well, providing a 24% increase over your previous pledge and our seventh-largest pledge commitment overall. We take very seriously the responsibility to report back to you regularly regarding the returns of those investments and the need to work with you to ensure Canadian citizens know the immense value of contributions to the Global Fund, as well as the major role such investments are playing in achieving the 2030 sustainable development goals.

The Global Fund is the world's largest global health financier, investing nearly $4 billion U.S. a year. Since our creation in 2002, Global Fund-supported programs have saved over 27 million lives. This accomplishment includes helping to cut AIDS-related deaths in half since the epidemic's peak in 2005, contributing to a 25% decline in TB deaths and a 45% decline in malaria deaths since 2000. In 2017 alone, in the over 100 countries where we operate, 17.5 million people received antiretroviral HIV therapy, five million people were treated for TB and 197 million insecticide-treated bed nets were distributed to prevent malaria. In total, we provide the majority of the international funding to combat these three diseases: 20% for HIV/AIDS, 65% for TB and 57% for malaria. Two-thirds of our funds go to countries in sub-Saharan Africa where HIV and malaria are most geographically concentrated, along with nearly half the global TB burden.

Ultimately ending these epidemics will only be achieved with sustainable health systems that are fully funded by the countries themselves. Through our co-financing policy, the Global Fund requires recipient countries to consistently increase domestic investments in their national health systems. This effectively leverages budget increases in domestic financing for health. In the 2015-17 funding cycle such commitments increased by 33% compared with 2012-14. During the current 2018-20 cycle a further 41% increase is projected. The Global Fund has achieved these results while consistently receiving strong reviews for performance, efficiency and transparency.

However, after years of remarkable progress in the fight against the three diseases, new threats have pushed us off the trajectory needed to reach the SDG targets. For example, as I am sure you are aware, gender inequality is a major driver of disease, particularly HIV. An estimated 1,000 adolescent girls and young women are being infected with HIV every day. Canada's commitment to a foreign policy focused on gender equality is therefore the right approach and essential for progress against HIV, and it's very well aligned with the Global Fund's mission.

The Global Fund partnership is scaling up investments to meet this challenge, including by strengthening linkages with education and supporting interventions to reduce gender-related barriers to HIV services. For example, in South Africa we support a program run by peer group trainers that provides counselling, HIV prevention education and academic support to over 61,000 girls to help them stay healthy and stay in school. Together with partners, the Global Fund has set targets to reduce the number of new infections among young women by 58% in 13 African countries over the next five years, which is rather ambitious.

Other obstacles that threaten continued progress include the growing threat of drug-resistant TB and the 3.6 million “missing” TB cases that are not being diagnosed every year. Also, more than one-third of people living with HIV are still not accessing treatment, and marginalized populations are 28 times more likely to contract HIV. We are also seeing a recent increase in malaria cases, especially in the highest burden countries.

I can go into many more details regarding our investments that respond to these challenges during today's discussion, but fundamental to addressing them all is building resilient and sustainable systems for health. As a result, 27% of our investments, or about $1 billion U.S. annually, goes toward fundamentals such as improving procurement and supply chains, strengthening data systems, training the health workforce, building stronger community responses and promoting more integrated service delivery. Building stronger health systems is the foundation for progress toward universal health coverage, and this annual investment makes the Global Fund the largest multilateral grant funder worldwide for these vital needs.

In February, we launched our sixth replenishment campaign at a preparatory meeting hosted by the Government of India in New Delhi. This event brought together governments, donors, technical partners, civil society groups and people living with the diseases in a demonstration of global solidarity. Pledge commitments for this replenishment will cover the three-year cycle from 2020 to 2022. I'm grateful to have the opportunity to discuss the investment case that was released at that meeting.

Our message during this replenishment campaign is that we need to step up the fight. We need to step up the fight to get back on track if we are to end HIV, TB and malaria and achieve SDG number three: health and well-being for all.

To get back on track to reach the SDG target of ending the epidemics by 2030, the investment case identifies a fundraising target of at least $14 billion U.S. to fund programs to fight the three diseases and build stronger health systems in the next three-year cycle. This level of funding will build on the success of the Montreal replenishment by saving an additional 16 million lives and averting an estimated 234 million infections by 2023, reducing both mortality and incidence rates by approximately one half.

Canada has consistently increased its contribution to the Global Fund each replenishment cycle. Thank you for that. I hope that our strong partnership will translate into another increased pledge in the sixth replenishment. The ongoing multi-party support we receive has been essential for achieving the remarkable progress of the last 17 years, and it will be indispensable to step up the fight this year and get back on track.

I'm very pleased to be joined today by Loyce Maturu, who was a featured speaker during the fifth replenishment conference in Montreal. I'd like to invite her to say a few words about her experiences living with HIV and her work with the Global Fund.

[Loyce Maturu, Network Speaker and Advocacy Officer, Africaid Zvandiri, Global Fund Advocates Network]

Thank you.

I'm truly humbled and honoured to be here today, being in a room with so many respected people. I would like to see all protocols observed.

My name is Loyce and I live in Zimbabwe. In 2000 I lost both my mother and my younger brother in the same week due to AIDS-related illnesses, and it was one of the most devastating moments for me, losing the people who were close to my heart.

In 2004 I started getting severely sick. I was coughing a lot and I lost weight. By that time, I was only 12 years old. That's when I was sent to the clinic and it was found that I had tuberculosis and HIV. Knowing about it was one of the scariest things, because back then people knew that if you had HIV you were going to die anytime soon.

When I found out about it, I cried. I lost all of my confidence and I thought I was going to die, just like how my mother and my younger brother passed away due to AIDS, but I am very lucky that I was one of the fortunate in 2004. I managed to get access to tuberculosis treatment from a Global Fund-supported clinic. If it were not for the Global Fund support in Zimbabwe, I would not be here today.

On that note, I would really like to thank Canada for investing in the Global Fund over the past years, because it also contributed to my being alive and healthy today—and not only me, but millions of people across the world who are being supported through the Global Fund.

With your leadership here, we're really looking forward to your supporting us and pushing this agenda to make sure Canada continues investing in the Global Fund so that no babies will be born with HIV, just the way I was. No child should stop school because they're sick, because we know what needs to be done. We must make sure that no one feels they cannot access treatment, because we know what can be done for someone who accesses antiretroviral therapy or tuberculosis medicine, and this can only be done if Canada continues investing in the Global Fund.

With those words, I would like to say thank you very much.

[The Chair, Liberal, Michael Levitt]

Let me say, Ms. Maturu and Ms. Vanni, thank you for your opening remarks.

Ms. Maturu, thank you for making the journey here to share your story with us. It's certainly inspirational and so important that we hear the real consequences of the actions being taken by the Global Fund. I know that is something that's going to stick with all members around this table and everybody listening this morning.

With that, and without delay, MP Aboultaif, the floor is yours.

[Ziad Aboultaif, Conservative, Edmonton Manning, AB]

Good morning.

Thanks for being here this morning.

You've listed an increase in problems out there, and the challenges are just growing. You've put 2030 as a target year for ending the epidemic of TB, AIDS and HIV. We know that money is always needed, and the population growth is also.... It's hard to catch up at some point. How optimistic are you that you will achieve ending these problems by 2030 if the funds are available?

[Françoise Vanni]

The objective of ending the epidemics by 2030 was set up by the international community in 2015. This is the promise that, in some way, the world has made to itself and to future generations based on global plans that obviously include technical partners: WHO, UNAIDS, Stop TB, and Roll Back Malaria. We have robust plans to get there. We have some tools that we know work, exactly as Loyce was referring to, so it is possible.

We have a good track record of achieving results. We do have the recipe. We know what works. We know the challenges ahead. We have the plans. We have the promise, but we need to step up.

At the moment, we are at this juncture where either we step up and we will be able, indeed, to achieve the 2030 target of ending the three diseases as worldwide epidemics, or we don't and then we will go backwards and we will see the number of deaths and the number of new infections and cases increase again. We are not going to stand still.

We are optimistic, provided that the world keeps its promise and steps up the fight. From our end, we are also very motivated to work better, to accelerate the way we work, to accelerate our partnership, to accelerate innovation and to make sure we execute the programs in the best possible way. This is also our promise.

[Ziad Aboultaif, Conservative, Edmonton Manning, AB]

Perhaps I could ask you to highlight, in a specific way, the most significant steps in the plan that are really going to achieve the result that is being looked for. We could reach 2030 with all the money requested and still be standing, looking back and saying that we still have a problem: “How do we move forward? What can be done? We need more money.” Maybe other problems might show up, and then we would still have to deal with those.

I would really like it if you could be specific about one or two highlights of the plan that we could list and make note of to at least be able to understand as a contributor, as Canada, and be confident that you're going to achieve your goal at the end of the day.

[Françoise Vanni]

I will highlight two or three things that are very important.

One is the focus on health system strengthening, meaning that we are not only working towards the three specific diseases, but we know from experience that we need to build health systems in order to end the epidemics. Therefore, the systems are supposed to be sustainable to deliver other health outcomes and development outcomes for the country.

Health system strengthening is key to the sustainability of our efforts. We are investing about a fourth of our current investment in that area—about $1 billion U.S. a year, which is very significant.

The second element towards sustainability and towards ensuring that there is a future is the fact that we are catalyzing domestic resources for help through our co-funding requirements. This means that each time we allocate a grant to a county to fight the three diseases, we also require them to step up their own efforts, and their own funding for the fight against these three diseases and for building their own health systems. We've been very successful in doing that.

In the current investment case, we are projecting an increase of 48% of domestic resources for health. We expect implementing countries to actually invest most of the resources that are needed to step up the fight and end the epidemics by 2030. If we are requesting at least $14 billion for the Global Fund, we are in fact expecting the implementing countries to invest $46 billion, which is much more.

This is increasing and making our efforts sustainable through this catalytic effect. As a testimony of that, we also have a sustainability and transition policy. Some countries transit through multi-year plans towards picking up the responsibility of taking care of the fight against these three diseases by themselves. This is a testimony of how countries become responsible and pick that up.

[Ziad Aboultaif, Conservative, Edmonton Manning, AB]

Thank you.

[The Chair, Liberal, Michael Levitt]

Thank you.

MP Saini is next, please.

[Raj Saini, Liberal, Kitchener Centre, ON]

Good morning and welcome.

Loyce, thank you very much for those very impactful and profound words.

I have two questions. The first question I have is on drug resistance, which I think is important to discuss. I know there are initiatives right now, with the Drugs for Neglected Diseases initiative that is working very hard, especially for those diseases that have been neglected. I think there are 12 or 13. I really like the model because it's an open science model.

More importantly, on going forward and hitting your SDGs, drug resistance will play a big role when you look at the parasitic resistance or the mosquito resistance. It's one thing to supply the drugs, but if the drugs aren't effective.... Have there been any discussions on dealing with that aspect of the problem?

[Françoise Vanni]

Yes. In the case of tuberculosis—to pick up the most worrying example among the three diseases—we face very significant global health security threats with multi-drug resistant TB. Multi-drug resistant TB represents a third of the antimicrobial resistance-related deaths in the world. One-third are related to TB. This is, indeed, a very important issue.

To give some sense of the scale, in 2017 there were 558,000 new cases with resistance. We see that as a threat for people living with TB, obviously, but also a global threat because it could easily spread.

We are investing in research in that area, together with Unitaid. We don't do research ourselves, but of course we work with partners. We are working very closely with Unitaid to come up with new solutions—new drugs—to improve the treatment for multi-drug resistant TB. The treatments so far are very long, not very successful and very painful for the patients, so a lot more definitely needs to be done in that area.

[Raj Saini, Liberal, Kitchener Centre, ON]

My second question relates to capacity building. One of the things that you have noted you want to do is to strengthen the health capacity and the delivery model, but to do that you need a functioning economy. You invest money locally in a health system, or in a country, but you can't continually invest in it. It has to be self-sustaining eventually.

Right now, I've looked at your top 10 donor list, and I don't see China on that list, yet I know that the greatest bilateral trade between sub-Saharan Africa and China is more than $120 billion. One thing is that the trade is one-sided because the trade is mostly extractive resources. You're creating this Dutch disease in many African countries, so the capacity to invest back into the system to keep it self-sustaining....

Has there been any attempt to engage China to say that this is a situation where we need their help? They have certain talents and skills. They are already in those affected countries. Sixty-five per cent of people who suffer from these three diseases live in sub-Saharan Africa, although China is the largest investor in their economy.

Has there been any attempt to engage China to help with this situation?

[Françoise Vanni]

Absolutely. Thank you very much for the question.

China stands at this stage as number 20 in terms of cumulative contributions to the Global Fund, since its inception in 2002. We are engaging with them very actively.

I think we are engaging with them probably more than before, exactly along the lines that you are indicating, meaning, how they can scale up their financial contribution, as a growing economy that is able to contribute more to the fight against the three diseases in the world but also leveraging their capacity and presence.

At the moment we're discussing a core funding modality focusing on malaria in west Africa, exactly building on what you indicated. They are building trade agreements and have a strong presence there, in some capacity. They are interested, indeed, in investing more in building health systems and fighting malaria.

[Raj Saini, Liberal, Kitchener Centre, ON]

My final question is this. I've noticed that at the last replenishment conference there was $12.9 billion, yet only $600 million of that was from private sponsorship, especially from one organization. You're looking at your sixth replenishment conference for the 2020-22 period. You're asking for $14 billion, but you want $1 billion of that to be private sponsorship.

I read somewhere that the amount of money available for private philanthropy around the world is more than $50 billion U.S. Has there been no attempt to garner more private sponsorship, or leverage more of that money?

[Françoise Vanni]

The Global Fund is a public-private partnership. I have to confess that I was surprised that we were not doing more in that space because we have a wonderful value proposition from the private sector to engage and contribute to the fight. This is definitely something that we are working on increasing. We have set up this target for the sixth replenishment to raise at least $1 billion from private sector sources.

We now have different work streams to engage with the private sector. One is with corporations themselves, where we expect them to contribute with money, but also with expertise and capacities, which is very important—innovation, in particular. We are also working with philanthropists, foundations and high net-worth individuals. Those are the two streams.

It does take some time, of course.

[Raj Saini, Liberal, Kitchener Centre, ON]

Thank you.

[The Chair, Liberal, Michael Levitt]

MP Duncan is next, please.

[Linda Duncan, NDP, Edmonton Strathcona, AB]

Thank you very much.

Thank you for appearing before us.

Loyce, thank you for coming all the way from Zimbabwe. I visited your beautiful country in 1986, when the country was in I'd say a much more positive and different situation. Thank heavens we've been able to keep you healthy.

You have reported that Canada is the seventh and I understand that's in the G7. What's the differential between the top donors in the G7 and what Canada's giving?

[Françoise Vanni]

The top donor in cumulative terms is the U.S., providing $1.3 billion.

[Scott Boule, Senior Specialist, Parliamentary Affairs, Global Fund To Fight AIDS, Tuberculosis and Malaria]

That's right. It's $1.35 billion a year, or $4.3 billion over the three-year replenishment cycle.

[Françoise Vanni]

Yes.

Canada in last place was $804 million Canadian. I cannot do the math just off the top of my head.

[Linda Duncan, NDP, Edmonton Strathcona, AB]

It's encouraging that Canada is giving a 24% increase, but of course we're still only at one-third of what we should be donating globally. We'll just keep the pressure up, because Canada can afford to give more, not just to the Global Fund, but obviously the Global Fund is in need.

I'm curious to follow up a bit more and Loyce may be able to speak to this. You spoke a bit to the significant blockages and barriers to being able to reach everyone. Obviously money would be one. I wonder if you can speak to whether some of the problems are simply the denial of the problem.

When I travelled at the same time to Malawi, the Government of Malawi was denying that they even had HIV. I'm wondering if there's still some vestige of that, of the government not admitting to the scale of the problem, particularly in diseases like HIV. Is it also a problem that we're simply not addressing poverty or education?

I'd love to hear from Loyce.

[Loyce Maturu]

Thank you so much for the question. For Zimbabwe, it's very different. The government is really not denying that there is a huge problem. I would like to highlight that over the years, a lot of people were dying because there wasn't so much support in terms of people accessing tuberculosis or HIV or malaria treatment. But because the Global Fund intervened, a lot of people are now surviving. When my mother and my younger brother passed away, the Global Fund wasn't in the country at that time. I witnessed so many deaths including my mother's and my younger brother's.

I was very fortunate to be among the thousands in Zimbabwe who managed to get access to tuberculosis treatment, which is all contributed by Canada and other donors around the world. I would like to reflect that in Zimbabwe, there are about 1.4 million people who are living with HIV, and because of the Global Fund, we are now at 1.1 million people who are on antiretroviral therapy. We can see the gap in that there's so much that needs to be done in terms of investment so that we can be able to reach those who are remaining.

Coming back to an issue as well, when you look at adolescent girls and young women, we are the ones who are disproportionately affected by the epidemic, and it's so sad that a lot of girls have to drop out of school for economic reasons, cultural reasons or child marriages that are happening especially in sub-Saharan Africa. This also puts us at risk. If you look at Zimbabwe as a country, an estimated 16,000 adolescent girls and young women are affected every year.

We know where the problems are. We know where the challenges are and we know how they're addressed but it really needs countries to really invest in the Global Fund so that it can help build strong health systems to make sure that we decrease the rate of infection among the people who are most affected.

Really there is so much that we need to step up the fight.

[Linda Duncan, NDP, Edmonton Strathcona, AB]

My understanding is that the Global Fund not only helps to provide medicines to people who have contracted these diseases, but do you also work in the area of trying to prevent the spread, for example, of TB or prevent people contracting malaria? Is there more that could be done about that? Again I go to the issue that, even in our country, they say that one of the main causes of illness is simply poverty. I would like to hear more about that, about the bigger analysis of why it is that we haven't been able to address these problems yet.