While large parts of the world are trying to tackle the new coronavirus pandemic, the fight against other epidemics continues. Peter Sands, Executive Director of the Global Fund – the world’s leading partnership in the fight against malaria, HIV and TB – reflects on his recent visit to DR Congo and explains why we need to step up the fight against the most lethal epidemics.
(Kongo Central, February 2020. Peter Sands, fourth from the left, during his visit to DR Congo. © Cordaid)
The Global Fund is the world’s leading partnership in the fight against three of the most deadly and rampant epidemics in the world. Together, they continue to kill nearly 2.6 million people a year: HIV, TB and malaria. In February Global Fund Executive Director Peter Sands went to DR Congo, to gauge the impact of the efforts made by the Global Fund and partners such as Cordaid, in the fight against HIV and TB. And to convince all parties – including the government – to step up the fight. We asked him to look back on his visit and discuss some of the challenges ahead.
You visited Kinshasa and the province of Kongo Central. What struck you most?
“What struck me in DRC is the scale of the implementation challenges. The single biggest challenge is the severe gap in human resources for health. Then there’s the complicated way things work in DRC. Think of the vastness of the country, the logistics and the time it takes to distribute drugs and provide services across the country. And you have the complex and many-layered administrative structures, all the way from policy-making bodies in Kinshasa to interaction with patients in a primary health care facility. All this together, makes fighting the 3 epidemics of HIV, TB, and malaria in DRC an epic endeavour.”
Globally HIV is the single biggest killer among girls. We will never beat HIV if we don’t protect girls against the virus and girls will never fulfill their potential if we don’t stop HIV.
Peter Sands, Global Fund Executive Director
“The visit, and obviously this is backed by the monitoring of our interventions, showed that significant progress is being made across all three diseases the Global Fund partnership is fighting in DRC. But it is also clear that a lot still needs to be done. Look at antiretroviral treatment. This went up from 15% to 58%. Which is great, but it is still a lot lower than the 90% in 1999.”
You also visited one of the legal clinics, run by Cordaid partner RENADEF. These clinics provide legal aid and psychosocial support for sexual abuse victims. How important are these structures in the fight against HIV?
“It was very interesting to see the work they do. The session I attended showed how important it is to enforce the rights and the existing laws and to pursuit perpetrators, to effectively address gender-based violence and to change the behaviour and culture of sexual violence. This is an essential part of the fight against HIV. And in DRC I was impressed by how widespread and scaled these legal aid structures for sexual abuse victims actually are. I have seen similar structures elsewhere but on a smaller scale. It’s obvious one needs interventions like these, and that they are very difficult to get right and to scale. Unfortunately, I didn’t get to see much of the psychosocial support for victims, probably time didn’t allow for that. And one odd thing that struck me, was that men did the talking for the women who had been abused. Somehow that sent a discordant signal, inadvertently illustrating how much work still needs to be done.”
Looking more generally at the global fight against HIV, TB, and malaria, of which the Global Fund is a trailblazing partnership, how can we maximize our efforts? What do we need to improve?
“In general, stepping back from the detail and from the differences in the three diseases, we have made massive progress in reducing the numbers of people dying. In the last decade, the average death toll across the three diseases has halved. But we have made much less progress on reducing infection rates. HIV infection rates have come down, but not nearly fast enough to put us on track to end the epidemic by 2030. The number of malaria cases is actually going up in the most high-burdened countries. On TB, we have very low single-digit annual reductions in case rates. So we obviously need a step-change in reducing infection rates.”
How can we make this step-change?
“By having the courage to move beyond the narrowly biomedical. By investing more in a broader set of interventions that make prevention more effective. Both for HIV and TB there’s a whole set of issues that make key populations particularly vulnerable to infection. Marginalisation, human rights abuses, stigma, discrimination, economic disempowerment, educational disadvantage, human rights abuse, gender-based violence, sexual and behavioural norms. The legal clinics implemented by Cordaid with Global Fund support, are a good example of how to address these issues. The fact is, that you can’t effectively tackle the epidemics and solve the problem by only having better drugs and better diagnostics. You need broader interventions. This is where civil society organisations play a key role. They have the access and the understanding of communities. They can work with them, are part of them.”
We shifted from trying to stop people from dying to trying to stop them from dying in the future.
Peter Sands, Global Fund Executive Director
“One of the real challenges in the prevention arena is the lack of scale. In most countries, we can point to really good interventions, but often they are not big enough. They lack in quality of execution and in scale. These multi-dimension and multi-stakeholder prevention initiatives are complicated to put in place and to run. Even more to put in place and run at scale. But if we want to reduce the HIV infection rates among girls and young women, which we must, we absolutely need interventions at scale. Nice projects in provinces x, y or z are not enough. Through our partnership with Cordaid, we cover the whole of the DRC, in providing treatment and in reducing infection risks, especially among young women and girls.
Is the DRC an example for other countries in the fight against the three diseases? Or can it learn from what is being done elsewhere?
On the whole, the sophistication of the systems, the interventions and the way things work are not as advanced as you see in African countries that have made the most progress, like Rwanda, Ethiopia or Kenya. Take for example the way community health worker systems are being managed. In Ethiopia, you have different tiers of community health workers, with different credentials, qualifications, and different compensation scales. DRC doesn’t have that at this stage, like most countries in West and Central Africa. The health system is more basic. In part, this is due to the scale of the country and the differences within the country. But also to the fact that domestic financial commitment and leadership around health has been inconsistent. Just take the average government spending on health. In DRC in the last decade, this varied between 4 and 6% of the total public expenditure, compared to the Abuja targets of 15%. The reliance on donor contributions and out-of-pocket spending by people is very heavy. If you want to fix the human resource gap in health, there’s only so much you can do through donors. I met President Tshisekedi during my DRC visit. He made a very clear commitment towards putting health and the pathway to Universal Health Coverage more strongly on the agenda. Which is great. We will now look at how this will be clearly translated into more domestic resource commitments and financial support to health.
The Global Fund started its global effort to fight HIV, TB and malaria in 2002. What are the biggest milestones, the biggest achievements so far?
“When the Global Fund started, nobody talked about eradicating the diseases. The priority was to save lives. And we made huge progress in this. Our latest report shows that the cumulative total of people that were saved in countries where the Global Fund invests is 32 million. I have this poster in my office. It says, in French, ‘every day the Global Fund saves 14,600 people’. The fact that today we are talking about eradicating the epidemics, is a reflection of the success. But also a strategic shift. We shifted from trying to stop people from dying to trying to stop them from dying in the future.”
“There’s also a negative part. We are not on track to hit the Sustainable Development Goal of ending the epidemics by 2030. I believe we can still achieve that goal, but only if we radically reduce infection rates. Specifically, amongst adolescent women and girls. Globally HIV is the single biggest killer among girls. So we will never beat HIV if we don’t protect girls against the virus and girls, in DRC and elsewhere, will never fulfill their potential if we don’t stop HIV.”
What is the added value of working with Cordaid in fighting HIV and TB?
“In DRC, Cordaid plays an important role in helping the Global Fund address gender-based violence as part of the fight against HIV. They go beyond the purely biomedical and implement broader interventions at scale. As I said, this is essential if we want to beat the disease.”
Last year the Global Fund organised its sixth replenishment event in France, during which also Cordaid pledged a contribution. How do personally you try to convince donors to invest and join the fight of the Global Fund?
“By saying that helping prevent a 16-year-old Congolese girl from becoming HIV+ is the best, most compelling business case in the world. If she catches HIV the best thing we and she herself can do is to make sure she gets antiretroviral treatment. For the rest of her life. She can live with that, she can go to school, work later in life, run a household. But at great cost. Financially, it would cost around 200 dollars annually. But there’s also the human suffering, the stigma to deal with, the discipline and hard work it takes to stick to your treatment. These come on top of many other challenges we discussed before, like severe economic disempowerment, sexism, and gender-based violence. If with a few dollars, you can help us prevent her from getting infected, you help the health system save a huge amount of money. You also save the huge and often hidden cost of the individual that comes with HIV infection, which is the suffering and the stigma. By convincing others of the story of this 16-year old girl, we can raise funds. We can step up the fight and boost our infection prevention efforts. And beat the disease by 2030.”
The Global Fund and Cordaid
The Global Fund and Cordaid are staunch partners in the fight against HIV and Tuberculosis. In DR Congo, Cordaid is the primary recipient of the Global Fund and combines forces with many others to treat and prevent both diseases. In the Central African Republic and South Sudan, we serve the same cause as one of the Global Fund’s sub-recipients.
Or go to Cordaid’s Health Care page.