Foreign Affairs Committee on March 20th, 2018

[The Chair (Hon. Robert Nault (Kenora, Lib.)), Liberal, Bob Nault]

I call this meeting to order. Pursuant to Standing Order 108(2), briefing on the Global Fund to fight AIDS, tuberculosis, and malaria. Presenting today are Christoph Benn, Scott Boule, and Svend Robinson.

I think the bells are going to ring at 5:15 pm for a vote. I'm assuming that it's a half-hour bell, but I'll have that confirmed shortly. We'll try to wrap up and give you 15 to 20 minutes to wander down the street. I expect it will be tight today, so let's try to keep it that way.

I will turn the floor over to Mr. Benn to provide opening comments. As you all know, the Global Fund is a very important matter. As Canadians, we're all very proud to be part of it. We want to continue to grow the knowledge of Canadians regarding the importance of the Global Fund, not only to those who receive the help, but also for Canadians who believe that's a part of our role as Canadians and Canadian parliamentarians.

We're proud to have Christoph here with his colleagues and I want to turn the floor over to him.

[Dr. Christoph Benn, Director, External Relations, Global Fund to Fight AIDS, Tuberculosis and Malaria]

Thank you so much, Mr. Chair, Vice-Chairs O'Toole and Laverdière, and honourable members of the committee. I'm pleased to meet you. It is indeed a distinct honour and privilege for me to be here, particularly today.

I have a couple of personal words before I start my comments.

I know that all of you know my colleague Svend Robinson. Some of you will also have heard that he retired recently from the Global Fund, but he kindly joined us for this trip today. I'm also here with his successor in the Global Fund, responsible for parliamentary affairs, and that is Mr. Scott Boule, who will be more the counterpart in the future. I hope you will work as well with Scott as you have with Svend while he was at the Global Fund.

I also have other information to share with you. This will be my last trip in this function as director of external relations of the Global Fund. I've decided, after more than 15 years with the Global Fund, to transition out during the course of this year. I have to say that I've been in this position testifying to this committee many times over the last 15 years, and it has always been a particular pleasure and really a privilege to engage with you and to have this interaction. I want to thank you at the beginning for these many years of very good interactions. I hope you will extend the same kind of support and hospitality to my successor, once that person has been appointed. This is not the case yet, but it will happen in due course. I just wanted to inform you about that at the beginning of my statement.

I have a couple of points to share with you.

The first one is really one of deep gratitude to Canada. You were one of the founders of the Global Fund when we were created in 2002. You have been one of the most important donors to the Global Fund. Canada, to date, cumulatively, has contributed more than $2.3 billion Canadian, and I would like to thank you for that.

It's not just the financial support; it's also the strong political commitment that we always receive from Canada. That was expressed very much in our last replenishment that was hosted by Prime MinisterTrudeau and the Canadian government, in Montreal, in 2016.

It was really a collective effort. It was the most successful replenishment in the history of the Global Fund. In fact, it was the largest replenishment for any global health issue ever in history. It was a collective success for the Prime Minister and the government, but also for parliamentarians. You were present, and I am always very conscious of the fact that no government in the world can commit these amounts of monies without strong multi-party support in Parliament. This is as much your success as it is ours.

We also had very strong support from Canadian civil society, from many community groups from around the world. They made it possible, at that time, to mobilize almost $13 billion for the years 2017 to 2019. We are extremely grateful to Canada and to all of you for that great success.

Now, you are also entitled to learn what the Global Fund is doing with these resources, because that's the key. You have to be in a position to also report back to your constituencies about how this money is invested and what kinds of results are being achieved.

Very briefly, these are the headlines of the results.

The Global Fund is now supporting 11 million people with life-saving antiretroviral treatment every day. This is a lifelong treatment, and we are able to provide 11 million people with this treatment, particularly in the poorest countries in Africa, where we have our major investment. Actually, about 70% of the Global Fund investment goes to Africa because that's where you have the highest disease burden and also the poorest countries.

Also, tuberculosis is a very important disease and one of the priority areas for the Global Fund. In fact, the Global Fund provides about two-thirds of all international funding for tuberculosis worldwide. With that, we have been able to support 17 million people with tuberculosis treatment. That is a global public good. This disease is affecting all countries around the world, including Canada. We are also addressing the increasing challenge of multidrug-resistant tuberculosis, which is a very serious global public health threat. We will have this year a high-level summit hosted by the UN General Assembly that will look at this in more detail. You can assume that the Global Fund, as a major funder of tuberculosis programs around the world, will play an important role in that.

The third disease is malaria. With your support, we've been able to purchase and distribute about 800 million mosquito nets around the world so that families, and particularly children, who are most affected by malaria, are protected from this disease.

All of that has led to quite dramatic and very welcome decreases in the disease burden from AIDS, tuberculosis, and malaria. On average, globally, the number of cases of AIDS, tuberculosis, and malaria has gone down by about one third, but also the mortality, the number of people dying from these diseases. In certain countries you can see much more improvement than that, and in many countries we can move towards the elimination of malaria, particularly in Southeast Asian countries such Vietnam. Also many African countries, such as Tanzania, have seen decreases in malaria mortality of 70% or more.

These are, by all historic standards, huge achievements over a relatively short period of time. They have been achieved also with the generosity of Canada and your citizens, and I want to thank you for that.

We are part of the movement to achieve the sustainable development goals. That is our focus. That is the new framework in which we operate. We're working towards providing universal health coverage for people around the world. The mandate that has been mentioned in the SDGs is specifically to end AIDS, tuberculosis, and malaria as epidemics by the year 2030. We have very concrete plans in terms of how we work towards these goals. That can only be done collectively, because these are very ambitious targets, and we have to be aware of that.

We need many partners: governments such as yours, but also the private sector. Again, I'm pleased to report that at the replenishment here in Montreal we had the highest level of contributions from the private sector ever. The Global Fund has mobilized altogether more than $2.2 billion from the private sector, and at the recent replenishment held here in Canada, the private sector doubled its contribution to the Global Fund. It's an important topic, because we will not solve the development issues through only one sector alone.

A very important aspect of our work is also to increase the domestic funding. We are aware that we are talking a lot about how all of this can be sustainable. It cannot only be sustainable by donor money. We are leveraging the resources provided by you and other donors so that countries increase their domestic health budgets, and we use our policies to make part of our disbursements dependent on evidence that they're increasing their domestic budget.

That has worked quite well. Just in the last period, countries that we support have increased their health budgets by $6 billion. That is another very important component, and we will continue to push and work on that.

The Global Fund has been repeatedly evaluated by many international bodies. There are multilateral aid reviews, particularly by the United Kingdom, but also by Australia, and we always score very highly. We come out as an organization that gets the highest scores for these investments.

We've also recently been evaluated by MOPAN, the Multilateral Organization Performance Assessment Network, of which Canada is a member. It regularly evaluates and assesses multilateral organizations. That was concluded, and again we came out as very strongly recommended. I was able to report to our board on that. Thus, I think you should be reassured that not only are there measurable results, but it's also the question of how effectively and efficiently we work, and that's evaluated by these bodies.

We also usually come out among the top organizations in terms of transparency, which is another very important aspect for the oversight that you also conduct. In the aid transparency index, we always score very highly because we make all our disbursements, all evaluations, and all audits and investigations done by our office of the inspector general public on our website, which is a remarkable sign that we believe transparency is one of the best ways to achieve accountability. Without transparency, it's difficult to really make sure that the money is always used to the best possible effect.

I'll say a couple of words on gender. We applaud the Canadian government for the initiative of the feminist policy agenda in development, which will also play a significant role in Canada's upcoming G7 presidency. The Global Fund is very much supportive of that, not just because we believe in gender equality but also because we are aware that we will not be able to be effective and to really overcome these diseases unless we overcome gender inequality. That applies, particularly in Africa, to young women and girls, who are still disproportionately affected by HIV. They often have an HIV infection rate eight times higher than the rate among young men. Therefore we've made that a particular focus of the Global Fund. In fact, we are focusing on 13 priority countries in southern and eastern Africa, where we have these special programs looking at how to address more effectively young girls and women. That is quite in line with Canada's policy.

Recently the world celebrated International Women's Day. A report was launched on that day, the “Global Health 50/50 Report”. The Global Fund was mentioned as one of the organizations with the highest score among all global health organizations, based on seven criteria related to gender equality. I can assure you that this is a high priority for us, and I think we are aligned with the Canadian government on this priority.

However, I also want to leave you with some of the challenges. With all these kinds of results and decreases in incidence and in mortality, we know that we still have huge challenges ahead of us. If we really want to reach our sustainable development goals, if we want to end these epidemics, there is a lot of work that still needs to be done. The biggest risk in international politics is that support for various organizations often comes in waves and that while riding on the back of success the attention might turn somewhere else. The world has many different challenges and problems—there's no question about that—but I think we are at a critical point in time when we cannot afford to relax and move on to other issues. We've been driving these diseases down to a certain level, but unless we really eliminate them to a level where they can't come back, we will pay a very high price. Really, it's a monetary price if we are not driving the epidemics down now, because they often come back with a vengeance, and it will be much more costly and difficult to then resume these programs. Therefore I appeal to you and to others to maintain your support so that we can maintain our progress.

This refers also to Canada's G7 presidency. The G7 has been instrumental in the Global Fund in many different ways. In fact, it was created with the help of the G7. We have been regularly in the leaders' declarations and leaders' summits. I would ask for your support, as Canada has this year's presidency, to maintain this tradition. Even a political statement without any financial commitment helps tremendously to keep the political momentum going. I would ask for your support this year in order to continue with Canada's leadership in global health and on the Global Fund, as you were our last host for our replenishment.

Also, I have a final word on the role of parliamentarians. Certainly from our perspective, we cannot overestimate how important bipartisan and multi-party support around the world is for the Global Fund. I think Canada is an excellent example of that. Global health and the Global Fund traditionally have been above party politics in almost all donor countries—and I visit all of them regularly. That is a very good sign. It is about saving lives, providing services to people, and these things are usually not controversial in terms of party politics. That's very important to maintain. Also, where you have the opportunity to interact with your colleagues, with parliamentarians from other countries, it would be great if you could reinforce this message based on the excellent experience we have in working together.

With that, Mr. Chairman, thank you so much for your support, for all the very good years of collaboration with you.

I trust this will continue in the future and you will extend your support as well to my new colleagues and future colleagues so the relations between Canada and the Global Fund will remain as strong as ever.

Thank you so much.

[The Chair, Liberal, Bob Nault]

Thank you very much.

In case I forget, at the end of the meeting I want to thank both you and Mr. Robinson for your years of service. The Global Fund would never be nearly as successful if it wasn't for the quality of the people who are running it. If it wasn't for Mr. Robinson, I probably wouldn't know half of what I know about the Global Fund. He's always very active in pursuing and making sure we new chairs of committees like ours are aware of the importance.

Thank you to both of you. Good luck to Scott in his new job.

With that, I'll turn the floor over to Mr. Aboultaif to start the questions to the Global Fund.

[Ziad Aboultaif, Conservative, Edmonton Manning, AB]

I will share my time with Mr. O'Toole. I'll probably use a few minutes of my five minutes.

Welcome aboard and thank you. We met this afternoon.

I came back from Africa with Minister Bibeau. We went to Senegal and the GPE conference, and there is quite a bit of attention, at all levels, on education. That's part of the solution to what's happening. Africa remains the focal point because of its demographic growth. That is unprecedented and moving forward, it is going to be scary, in a way. That's going to demand more money from our world and the contributors to support all the programs and all the missions moving forward.

Most of the countries out there, including France and Canada, have announced doubling their contribution to education, committing 20%. How is this going to affect your budget?

[Dr. Christoph Benn]

I'm very glad you're raising that question because health and education go hand in hand. I was at the GPE replenishment; I was invited to the GPE as a close partner because that's how we understand that. We work together as partners because often you cannot achieve the full impact of education without better health. The health status of young people matters a lot for their educational attainments and the other way around as well. Without good education you cannot achieve health. I was pleased to see that many countries there pledged the 20%; how many countries spoke up was quite impressive. We do that similarly on the health side. We push them to maximize their spending on health. The target for health is 15% of public expenditure, which some countries meet; many do not, but they are moving toward it.

We implement joint programs with GPE on health and education, particularly again referring to what I said, the programs focusing on young girls and women, where health and education are particularly important.

[Ziad Aboultaif, Conservative, Edmonton Manning, AB]

Do you call that a change of direction or is it continuing in the same direction but with more money? I fear this is going to take away from the Global Fund in a way. Do you fear that, and have you thought about it? Can you look into solutions to it?

[Dr. Christoph Benn]

I see that as a partnership, not as a competition. I'm not naive; sometimes you might have budgetary competition, but particularly with GPE I've not felt that way. This was in addition to what countries often have pledged to the Global Fund. I think we need both and that's the spirit in which we work on education with GPE and other partners.

[Ziad Aboultaif, Conservative, Edmonton Manning, AB]

You mentioned Yemen during the lunch, and that's definitely something totally new to add to the extra work and extra challenges you have. How do you see the response of the international community to Yemen at all levels? Many women and children are dying of disease and so forth.

[Dr. Christoph Benn]

I think Yemen, first of all, is one of the huge international tragedies. I can't call it otherwise. What is going on there is a real tragedy.

The Global Fund has been providing programs for all these diseases—HIV, TB, and malaria—in Yemen for many years. When the civil war started, it obviously became more difficult to deliver drugs and commodities, yet we maintained that even through most of the early phase of the civil war, even when there was no kind of national government anymore with which we could co-operate. The disease program still continued, and we managed to bring supplies into Yemen until very recently. We also tried to work with the exiled government in Saudi Arabia, which provided some kind of protection for the areas that were under their control.

However, right now the situation has deteriorated so much that almost no humanitarian agency can still operate in Yemen, including the Global Fund. It is impossible for us at the moment to bring supplies and commodities to Yemen. It's extremely unfortunate, and we are constantly trying to find ways to do so.

To your question, I think that at the moment, the international community is failing Yemen. The situation of that civil war is such that almost no humanitarian agency can enter the different areas.

[The Chair, Liberal, Bob Nault]

Thank you.

Mr. Levitt, please.

[Michael Levitt, Liberal, York Centre, ON]

Thank you, gentlemen, for being here. I want to add my thoughts to the chair's comments about the contribution that certainly you two have made, and that I'm sure Scott will make, in this absolutely essential organization, and the good work that you do around the world.

I want to continue my colleague's line of questioning and focus on the human rights. I know that you have four strategic paths in the 2017-22 plan, and one of them is human rights and gender equality.

I'm looking at some of the larger recipients, countries such as Burundi, DRC, South Sudan, all three of which we've either studied or are going to be studying in our human rights subcommittee, and we know the challenges. We know the human rights challenges that are faced on the ground in those countries. We know the precariousness for civil society and human rights defenders operating in those environments.

It is such a tall order, where there is instability, to do what you do. How do you deal, in particular in countries such as Burundi, DRC, and South Sudan, with moving the plan forward and finding partners that can lend some protection and allow the work to be done?

Could you speak to that?

[Dr. Christoph Benn]

First of all, human rights are one of our key priorities in many different ways, not only because we believe deeply in human rights, but because by protecting human rights of people, particularly key affected populations, marginalized populations, men who have sex with men, commercial sex workers, migrants, many other groups that are sometimes criminalized.... If they don't have access to health services, we cannot achieve our goal. Human rights and public health go hand in hand, and that is our principle.

Then there's the particular challenge that you mentioned in countries that are either undergoing civil war or are in the post-civil war phase. Yemen is one extreme example of where we are beyond solutions, but that's rare; normally we do find solutions. We have the flexibility to work with partners who can still access, even in the most difficult situations.... Let's say we work closely with the Red Cross or others, and provide our grants to them. That enables us to work in those regions.

Quite an interesting example is the Democratic Republic of Congo. It's a huge country, by the way, with some of the highest disease burdens in the world, and our programs are working moderately or relatively well. We are working there mainly through faith-based organizations. It is the churches and faith-based organizations that run many of the clinics. The government hardly exists in many parts of DRC. That doesn't matter. As long as we find partners with which we can work, mainly the churches and the faith organizations in DRC, we achieve very good results. The coverage with bed nets and malaria as well as HIV interventions in DRC is surprisingly good. The audit by our AG has found very good results.

Burundi is another example of where we continue to work, and one very important aspect is that we have these constant migration flows now.

[Michael Levitt, Liberal, York Centre, ON]

That was my next question.

[Dr. Christoph Benn]

There are not only the international migrations where migrants reach Canada or Europe, but in Africa there are a lot of migrants from Burundi and Rwanda now, a lot of migrants in Ethiopia and Kenya, and many other countries. We actually have an emergency fund. We created that so we can also respond to those situations. For example, Rwanda alerted us and said they had so many refugees from Burundi, who were receiving antiretroviral drugs because they are living with HIV and other things. Who is paying for that? Then we can step in and ensure that there is continuation.

We have a Middle East response under which we provide funding mainly for tuberculosis in migrants coming from Syria and Iraq going to Jordan and Lebanon. We provide the funding so that their health programs can continue. We call that a people-centred approach, because there are no countries, if you like, no national programs, no ministries of health. You follow the people and make sure that they can receive treatment and services, even if they migrate internally or across borders. That's a special program we started a few years ago, and it becomes more and more important that we do that because the old kind of model of a country with a national program works in many places, but in many places it doesn't anymore.

[Michael Levitt, Liberal, York Centre, ON]

I was going to raise two newer developing situations. One would be migrant flows from Myanmar into Bangladesh, and the other one would be from Venezuela into Colombia, which is something we've been studying lately as well. There's a massive shift going on there of a very, very vulnerable population, but I think you already answered the question before I asked it.

[Dr. Christoph Benn]

Yes. This kind of migration is a key issue.

[The Chair, Liberal, Bob Nault]

Thank you, Mr. Benn.

We'll go to Madam Laverdière, s'il vous plaît.

[Hélène Laverdière, NDP, Laurier—Sainte-Marie, QC]

Thank you very much to all of you.

Welcome, Mr. Boule.

I will not repeat everything that has been said about the extraordinary work done by the Global Fund. You know what I think about it, and you know that we have always wanted Canada to continue to support your absolutely essential work.

I will simply make a personal comment. I have been sitting on this committee for close to seven years. When we have good news about topics that are not easy, these become the high points of our year. We can see that progress has been achieved. It's good to see that an institution like yours works well, shows transparency and respects the major issues. Despite all that, I hope our paths cross again in the future.

I also would have a question to ask you about migrations and refugees. If you want to add something, do not hesitate. I also have a question for you about heritage, and the challenges you anticipate over the coming years. Are you concerned about potential funding challenges? There is, of course, a risk that attention will be drawn away before certain thresholds are reached.

I expect that the matter of migrations and refugees is one of those challenges, but aside from that, what are the major challenges the fund is going to have to meet over the next five, six or seven years?

[Dr. Christoph Benn]

Thank you. It's always a pleasure to see you, and thanks for your support over the years.

Of course we see a lot of challenges and also certainly some risks, no question. I mentioned earlier some particular challenges for the three diseases. You know, there is the kind of gender dimension, and I could mention TB and the challenge of identifying people with TB. We're talking here about millions of missing cases that are not diagnosed and therefore cannot be treated. We have a number of challenges.

With regard to malaria, by the way, while we have seen significant decreases over time, we are seeing now that it's stabilizing more for a number of reasons. Climate change is beginning to make a difference here. Growing resistance to the most common diseases is a challenge for all three diseases. Yes, we have these challenges, and we have certainly, as I think you alluded to, what you might call a challenging political environment among some of the donors—

[Hélène Laverdière, NDP, Laurier—Sainte-Marie, QC]

There are the big donors.

[Dr. Christoph Benn]

There are some big donors, like some neighbours of Canada, that cause some concerns. We're watching that very carefully. I would say that, yes, it's probably a difficult environment. Although the advantage of having done this job for 15 years is that I've seen many crises—political, financial—and the Global Fund has always survived that because there has been this strong commitment and the belief that we are achieving results, so we maintain the confidence and trust, even when the external environment has not been conducive.

The same applies, so far—let's be very open—with the current U.S. administration. I mentioned before that the reason is due to the very strong bipartisan support in the U.S. Congress. We have very strong support from Democrats and Republicans and so far, they have not allowed a single cut to the Global Fund. That is a very important factor.

I'm not underestimating the pressure and I'm not saying that this will always remain the case, but so far, it has been because of this strong support. Scott is an expert on that because Scott is coming from the U.S. and has huge experience working with the U.S. Congress. He is working very hard to keep it that way, so that we maintain this bipartisan support.

We are watching all of that very carefully and we trust that, in the end, the confidence, the results, and the functioning of the Global Fund will prevail.

We talked a little bit about migration and the challenges for some countries. Of course, one other effect of migration, not so much in Canada...but we've seen in Europe where the wave of migration into a number of European countries put a lot of pressure on government budgets and, in some cases, also on development budgets. Fortunately, some of that has been reversed. There were major donor countries to the Global Fund that diverted some of the development aid money to refugees in their countries, but currently that trend has been reversed. We have to keep an eye on that as another effect of international migration. It sometimes puts development budgets under pressure and we have to defend that collectively, also because I deeply believe that, by improving the living conditions in these countries, we are also addressing some of the motivation for migration.

Health is a very tangible one. People do feel whether they have access to health care or whether their children have access to health care....if not, they will try to go somewhere that they might. I think this is a contribution to making sure that people have the right living conditions wherever they are born and where they normally want to live.

[The Chair, Liberal, Bob Nault]

Thank you.

We'll go to Mr. Saini, please.

[Raj Saini, Liberal, Kitchener Centre, ON]

Good afternoon, gentlemen. I also want to express my thanks to Dr. Benn and Mr. Robinson for your years of service and good luck to Mr. Boule on your new responsibilities.

I want to start with a medical question. As you know, with AIDS, there is always this opportunity for opportunistic infections. Right now in Africa, we know there is a huge preponderance of schistosomiasis, which will accelerate the progression of HIV. Let's set aside malaria and TB for a second. You have HIV, which you are fully focused on and you're dealing with HIV. You have the cocktail ready and you're giving the medication. There might be others. I just used one example because of its high rate of preponderance.

What are you doing to tackle that also, when you know it's connected to HIV? Not only that, but I'm sure there are other partners there working in unison. Is there isolation or are you working together? If that problem isn't solved, would that opportunistic parasite...? There may be others that will impact how you would deal with HIV.

[Dr. Christoph Benn]

Let me translate that. There is a group of diseases called neglected tropical diseases, and they are affecting hundreds of millions of people, often not with as high mortality as AIDS, tuberculosis, or malaria, but debilitating over the lifetime. These diseases usually get less attention and are less funded than AIDS, tuberculosis, and malaria.

Among them, schistosomiasis is the most prevalent one, and here there is a link, because having this disease increases the chance of HIV transmission. We can make that link, and in general the Global Fund can support the payment for opportunistic infections, whatever they might be, because, as you know, AIDS doesn't kill by itself. It impacts the immune system, and then other diseases basically kill the patient. We provide drugs that protect people from these opportunistic infections, and schistosomiasis is the one among the NTDs that is relevant here.

The answer is yes, we try to integrate as much as possible. To be honest, I would sometimes like to see it even more integrated, so we could expand that even a bit further. We have a clear mandate from the international community on AIDS, tuberculosis, and malaria, and we cannot move away from that, but where there is a clear link, we can also provide funding, provided the country applies for it.

[Raj Saini, Liberal, Kitchener Centre, ON]

The second question I have is in terms of financing. You mentioned in 2016 you had the fifth replenishment conference of the Global Fund to fight AIDS, tuberculosis, and malaria. One of the things I am sure you are very sensitive to is to make sure of the funds you receive and the programming you have for three years going forward.

The question is this: in the United States, the Mexico City policy—or the “global gag rule”—changes every time a new administration comes to power. Either it is enhanced or it is rescinded. That must affect your abilities going forward year to year or administration to administration, in how much money you receive for specific programming. It seems almost—if you start in 1984 with Ronald Reagan, Bill Clinton rescinded it in 1993, then George Bush in 2001, Obama in 2009, and Mr. Trump in 2017—that once the administration changes, that will be affected.

How do you deal with that? It is sizable—about $9 billion U.S., if I remember my numbers. It's around that much, maybe more. How does that affect your ability to do your programming?