Foreign Affairs Committee on May 31st, 2016

[Dr. Christoph Benn]

The simple answer is that over the last, I would say, 20 years, life-saving services have been made available to many of those populations and to many of them for the first time, because indeed tuberculosis and malaria are both diseases that have been there for a long time. I served as a medical doctor in Africa in the 1980s and 1990s when we didn't have even the simplest technology like bed nets, impregnated bed nets, or the means to diagnose and correctly treat tuberculosis and so on. That is certainly a factor, that it has been possible through a lot of international support, including from Canada, to make sure that these services can be provided even in poor countries and to marginalized populations. You're right. I think people should know that there are these huge successes internationally, because 40% reduction in TB and 48% in malaria are historical in terms of public health.

At the same time, and this leads me back to the event we're going to have here in Canada, we also want to make sure we address those whom we haven't reached yet, and often it's the more difficult to reach who are still to come. How do we make sure we get the remaining 50% or 60% of tuberculosis and malaria but also of HIV/AIDS?

You need to focus even more on the key affected populations, those Svend just talked about, those women and girls in the situations we talked about in southern Africa, and those in prisons, and you often also have to reach the remote communities in many countries. In a sense, we've reached the low-hanging fruit, if you like, with impressive results, but now we will go even further so that we can really reach the remaining 50% of those we haven't reached yet.

[Peter Fragiskatos, Liberal, London North Centre, ON]

Perhaps because we've been focusing on countries of focus, one of the issues that has arisen in that study is the debate between whether to support fragile states or whether to focus on middle-income countries. I note that in 2014, your new funding model called to support countries with high disease burdens and low resources. Typically, states with low resources are fragile states. Can you tell me more about how the global fund works with middle-income countries and how the new funding model of 2014 has impacts upon that?

[Dr. Christoph Benn]

We have actually a very interesting and important phenomenon worldwide. Most people suffering from HIV and tuberculosis are living in middle-income countries. Actually most poor people nowadays live in middle-income countries. It's a phenomenon. Therefore, yes we need to address the fragile states, the low-income states, and we do so. We focus most of our resources on low-income and fragile states; there's no question about that.

It's also important to say, without addressing those affected by these three diseases in middle-income countries, that we will not end those diseases either. Some fragile states are actually formally middle-income states. Look at Nigeria, for example. Because of the oil wells, Nigeria is a middle-income country, but at the same time, it's not only one of the most fragile, but it is also home, for example, to 25% of the global malaria burden. Therefore, you cannot be too rigid, if you like, in your approach and say that we will finance only the low-income.... We would miss many of the populations affected by these diseases.

However, we differentiate, of course. Proportionately low-income fragile states receive more resources from the Global Fund than middle-income countries do. We have a very progressive co-investment policy, by the way. The higher the per capita income of the country, the more we expect that they will co-finance. Actually, we encourage all countries to increase their domestic budgets to co-finance with the Global Fund, but if you're a middle-income country, the expectation is much higher.

Not only do we provide this international funding but we hold them accountable also for increasing their own health budget. Only in that way can we make the program sustainable.

[The Chair, Liberal, Bob Nault]

Thank you, colleagues.

The bells have rung. I'm going to, with your permission, allow one more question.

As long as we have a good 20 minutes to get over to the House, we'll be good. We'll wrap up in five minutes.

We'll go to one last question by Mr. Allison and Mr. Genuis.

[Dean Allison, Conservative, Niagara West, ON]

I want to finish off what Peter started, what I asked before.

My first question was about how you work with countries that are moving up. You started with the co-escalation, but also the fact that because of the way you guys would set up, you were able to buy cheaper. I'll pass all those things on.

Could you quickly hit that again in terms of the economies of scale you guys get, and how you also work with these countries as they continue to grow but still need help?

[Dr. Christoph Benn]

First of all, we do use our market share, which is pretty large, to reduce prices and make those prices available to the countries that we serve, if you like. We have been able through procurement to reduce global prices, for example, for HIV drugs, by 25% over the last two years. That has cut in half almost the price we pay as the Global Fund, and that's a direct benefit for the countries, not only if they are supported by the Global Fund.

Second, we are working with countries on transitional plans, particularly, of course, middle-income countries. That means you must have a transition plan in place, because they cannot expect the Global Fund will fund them forever. They have to take over increasingly the costs, but they also need some time so that their ministries of finance can prepare for that. That's happening. We've phased out of a number of countries that can then finance the programs themselves. But you shouldn't stop overnight. You have to give them the chance to take that over. There's a whole kind of transition policy now that the Global Fund board has approved, with Canada's support actually, that I think helped to prepare for that phase. Fortunately, there are more and more countries whose per capita income is rising, and therefore they will take more responsibility for that. That enables us to focus even more on the fragile states that for some time to come will still need this international support.

[Garnett Genuis, Conservative, Sherwood Park—Fort Saskatchewan, AB]

Thank you very much.

Mr. Robinson, I think you were a member of Parliament for almost as long as I've been alive.

I want to get your thoughts on the emerging strategies in terms of prevention of transmission of AIDS. What do you emphasize? What do you think is most effective? A lot of what I've read suggests that condoms are effective if used effectively, but there are significant issues with them actually being used effectively.

I'm curious about your thoughts on the prevention question.

[Dr. Christoph Benn]

Again, I think you're focusing mainly on HIV prevention. We'll leave the other two diseases aside for a minute.

[Garnett Genuis, Conservative, Sherwood Park—Fort Saskatchewan, AB]

Yes.

[Dr. Christoph Benn]

For HIV you have to look very much country by country. It's not kind of just one prevention strategy. In some countries condoms might be very important or still be important, but it always has to be complemented by a number of other strategies as well. That can be male circumcision in a number of countries, and we are promoting that. You might know that male circumcision alone reduces the transmission rate by about one-third or more. We talked about prevention in young women. It might be better education. There's not one answer. It depends very much on the situation.

Basically, what we say is there are very clear guidelines for prevention coming from our partners, WHO, UNAIDS, and others. That's what the countries put into their programs. We are not telling them how to do prevention. There are international standards. They need to be applied at the country level, and we follow basically the advice of the technical partners. They advise the countries, and we say we fund anything that is the international standard for prevention.

In most cases it will be a combination of different prevention approaches that will be successful.

[Garnett Genuis, Conservative, Sherwood Park—Fort Saskatchewan, AB]

I have a very short question in the remaining time. How do those international standards interact with what may be local cultures or may be some discordance between local cultural ideas and those international standards? How do you operate in the midst of, perhaps, that discordance?

[Dr. Christoph Benn]

I could talk for a long time about that, because I used to work in Africa when one of the main prevention methods was to kind of engage with the cultural perceptions, particularly around sexuality, and so on, which you know is a big topic.

I would say that by now, I think most countries are able and willing to apply the international standards to that. You often have to translate it into the global context—there's no question about that—and only the countries themselves can do that. But I don't see as much discrepancy between what is internationally recommended and what countries put into practice, certainly not as much as there was 20 or 25 years ago.

[The Chair, Liberal, Bob Nault]

I'm going to have to wrap it up there because we have a very important vote this afternoon.

I want to thank the representatives of the Global Fund. We very much appreciate the opportunity to dialogue, and we'll do this again. Thank you.

The meeting is adjourned.