JOINT COMMITTEE ON FOREIGN AFFAIRS díospóireacht -
Wednesday, 2 Apr 2008

Global Pandemics: Discussion with Global Fund.

Chairman

The second item relates to tackling the global pandemics of AIDS, tuberculosis and malaria. It is a great pleasure to welcome Professor Michel Kazatchkine who is the executive director of the Global Fund. He was appointed to that position just a year ago. Prior to his appointment he served as France's ambassador for HIV-AIDS. Professor Kazatchkine is a distinguished physician who has treated people with AIDS for more than 20 years. His involvement with AIDS began in 1983 when as a young immunologist he treated a French couple who had returned from Africa with unexplained fever and severe immune deficiency. By 1985 he had started a clinic in Paris specialising in AIDS which now treats more than 1,600 people.

He has developed an international reputation for his work in the field of AIDS research and he has produced more than 600 research papers focusing on auto-immunity, drug therapy, immuno-intervention and HIV parthenogenesis. From 1998 to 2005 he directed the French national agency for AIDS research and during his time as director the agency began to focus its work on Africa and the developing world, including pioneering clinical trials of anti-retroviral drugs both for the treatment and the prevention of mother to child HIV transmission.

As director of the Global Fund, Professor Kazatchkine heads an organisation that has become a leading force in the fight against three diseases, provides two thirds of the international funding for the fight against malaria and TB and 20% of the global funding to fight AIDS. The Global Fund has approved grants for 550 programmes in 136 countries with a total commitment of more than US$10 billion. As of 1 December 2007, 1.4 million people have received anti-retroviral treatment through Global Fund supported programmes.

Ireland has been a strong supporter of the Global Fund since its inception in 2002 and has provided €80 million to the fund since then with a further €25 million committed for this year. The Global Fund is the biggest single recipient of Irish Aid funding for HIV and other communicable diseases. I invite Professor Kazatchkine to address the meeting. He is accompanied by Ms Grainne McDaid and Ms Nicola Brennan. I recommend that the professor keep the introduction to a maximum of 15 minutes because of the constraints we are under. We will have questions following the presentation.

Professor Michel Kazatchkine

I thank the Chairman for that introduction and the opportunity to meet the committee. I have already met parliamentary foreign affairs committees in the US, Britain and Norway. It is a privilege to be in Dublin today.

The role the committee may have in advocacy for these key issues of health and development is essential in any democracy. At a time when a number of competing priorities come on the development agenda, advocacy for foreign aid for health is a key priority.

The Global Fund is a young organisation. While only six years old, it has become the major multilateral fund for tackling the three major diseases in the developing world, AIDS, malaria and tuberculosis.

It was created in 2002 when the world realised the extent of the impact of the AIDS pandemic. It was created at a time when the world realised that while we have treatment for patients with AIDS, malaria and tuberculosis, 6 million people die every year of these diseases in the developing world. More than 2.5 million people, 8,000 every day, die from AIDS in the developing world. One child below the age of five years dies from malaria every 30 seconds in Africa although we know how to prevent and treat it. Tuberculosis, a neglected disease, kills the poorest of the poor in the world when easy and cheap treatment for it is available.

The world has realised that health is an investment for development and not an expenditure. In 2002 the former UN Secretary General, Kofi Annan, called for the world to come together in a major effort to fight these three diseases. The Global Fund was created with strong funding from several countries. Ireland was one of the first donors with several donors from the G8.

It was created on the basis of several guiding principles. The fund is a financial instrument and not an implementing agency or another of the existing ones in this area. It exists to raise large amounts of funds and disburse them to developing countries to implement their own programmes, operating with national ownership as a key principle.

The developing countries decide the amounts and nature of the funding. The Global Fund, through an independent panel, reviews requests made and judges them if they are fully relevant and scientifically, medically and programmatically sound. Such programmes, funded by the Global Fund, are aimed at supporting both prevention and treatment, as the two are strongly linked.

The fund is there to impact on AIDS, malaria and tuberculosis. Until 2002, the world was struggling with these epidemics. Now we can demonstrate results and impact. The next slide shows the current regional distribution of our funding, of which 60% goes to sub-Saharan Africa and 70% to low income countries, which is of interest to Irish Aid and the Government, as they place a strong focus on the poorest of the poor. Of the remainder, 13% goes to east Asia and the Pacific, while China is the subject of a big portfolio for us. Eastern Europe and Central Asia, which are highly affected by AIDS, receive 8% of our funds. Latin America also receives 8%. South Asia, principally India, receives 10%, while the Middle East and North Africa receive about 5%.

The next slide shows that we are not only funding governments, government entities or ministries of health. Government entities only account for about 50% of our recipients; 40% of our funds goes directly to NGOs and FBOs. We know in the developing world that these organisations are capable of implementing programmes in areas such as prevention and are often as good as, if not better than, government entities.

The next slide shows figures explaining what has been achieved in less than six years. In six years the Global Fund has committed more than €10 billion to 136 poor countries to tackle the three diseases. Approximately 55% of our funding goes to tackle AIDS, 30% to 35% to tackle malaria and 10% to 15% to tackle TB. While nobody in the developing world was accessing treatment for AIDS in 2002-03, more than 1.4 million people are now supported by the Global Fund in accessing such treatment. A total of 3 million people worldwide are receiving such treatment. The other half are being supported by the US bilateral PEPFAR programme. Some 3.5 million people have been treated for TB, while close to 50 million bed nets have been distributed to prevent children and pregnant women from contracting malaria. This is having an impact, as we can demonstrate in the next slide.

We can demonstrate the impact because the Global Fund is based on the concept of working on an unprecedented scale on development and developmental aid in health to truly make a difference. None of us in public or private entities in any country can do it alone. When it comes to fighting an epidemic, the world must come together collectively. That is what is happening in the Global Fund. There is evidence of decreases in malaria mortality of up to 80% in a number of regions in Africa. There are areas such as Zanzibar where malaria has effectively been eradicated in the past two years. This is also true in Rwanda and parts of Tanzania, Zambia, Zimbabwe and Swaziland.

There has been significant progress in the fight against TB in some of the high prevalence and high burden areas such as China and the Philippines. In addition to the impressive exponential increase in access to anti-retroviral drugs in respect of HIV, there is evidence of a decline in mortality and morbidity in a number of countries, including Ethiopia and Malawi, two of the nine focus countries for Irish Aid.

The next slide details a major evaluation decided on at the inception of the fund five years ago. This multi-million euro five-year evaluation is a significant international exercise to assess the fund's organisational efficiency, model, weaknesses and strengths. It will also assess the degree to which what we call the Global Fund partnership environment is working. Since it is a funding mechanism, it transfers funds into countries, but it is for partnerships on the ground — countries, bilateral donors, the multilateral UN system and civil society — to ensure the programmes are supported in such a way as to allow for their implementation.

For the first time, study area 3 will assess the impact of the funding on the three diseases. I hope Ireland and other donors in the rich parts of the world will be convinced that this investment is paying off and that we are affecting the health of people, mortality, morbidity and, indirectly, poverty.

We can skip the next slide and move to the slide labelled "Global Fund and health systems". I want to show the committee this slide at a time when people are asking whether there is enough or too much funding for AIDS, TB or malaria and whether they should invest more in building systems. The disease versus health systems debate is a false dichotomy. People should not believe that when we state we fund the fight against disease, we do not fund health systems. In fact, we are active in funding health systems. As is evident from the slide, 23% of our resources go to support health care workers through training or salaries. In Ethiopia, we have trained and supported 30,000 health care workers to develop malaria and HIV programmes and refurbished 600 clinics that are obviously not just for treating AIDS patients but also whoever presents there. In addition, there is strong evidence in countries such as Haiti, Rwanda and Ethiopia that investing in AIDS, malaria and TB programmes is having a strong impact on health systems. By decreasing the burden placed on countries and their health systems by malaria and AIDS, we free them up. As the Rwandan Minister of Health stated recently, hospitals can become hospitals again because they are not over-burdened with disease.

The next slide shows some of our current innovative actions, including four of the measures we are taking in round 8, our current call for offers for 2008 when we request countries to send us their proposals. Four measures in 2008 add up to a number of innovative models of intervention. The first is dual track financing, that is, a country sending a request can ask that part of the funds go to a principal recipient such as a government entity and part go to a second primary recipient from civil society. This is one more major effort to fund civil society in addition to government.

The second innovation is further increasing our effort to fund health systems. Just as the Global Alliance on Vaccines and Immunisation, GAVI, has, we have a window for funding health systems to which countries can apply. The third innovation is a specific line of funding, called community systems strengthening, that exists to empower civil society and to allow networks to be built and those in the community to handle the flow of money that comes with our grants. We were asked by the board to increase our effort and attention to gender issues, whether for women and young girls in the AIDS epidemic in southern Africa or sexual minorities in other parts of the world.

I refer to our resource outlook for 2008-10. At our last replenishment conference in Berlin in September 2007, co-chaired by Mr. Kofi Annan and Chancellor Merkel, the total of firm pledges received for that period is $9.7 billion, including the three year commitment from Ireland, which I was pleased to sign and confirm with the Minister of State at the Department of Foreign Affairs, Deputy Michael Kitt, a few moments ago. That figure does not include the contributions from Japan and Canada, two major donors that were not in a position to pledge in September 2007 for government transition reasons. It does not include the 2008 and 2009 contributions from the US. I expect the figure to be $12 billion for the next three years. This will allow us to continue the ongoing 550 programmes to which the Chairman referred and to launch new rounds every year of amplitude of $1 billion to $3 billion per year. Even if these figures are impressive, and maybe unprecedented in health and development, they are far below the estimated needs by UNAIDS and WHO for these three killer diseases in the developing world.

On behalf of Global Fund and the millions of people alive thanks to these efforts, I thank the Irish Government, the Irish Parliament and the committee for its support of the Global Fund. I thank the committee for the opportunity to speak here. It is a privilege to speak to foreign affairs committees in parliaments. The commitment of the committee and its involvement in advocacy to keep health and development high on the political agenda on the national and international scene is essential. I do not know how many members are part of the international interparliamentary groups that deal with these diseases but when I travel to countries I see the important role that parliamentary support can play.

I extend to the committee a standing invitation, if ever its members wish to travel, to visit some of the countries concerned. While every developing country is a Global Fund recipient, they might prefer to visit one of the nine countries on which Irish Aid's work is focused. We would be pleased to arrange such a visit. We have already hosted parliamentarians from the US, Italy, Germany, Britain, France, Norway and Sweden and we would be pleased if members could see for themselves the impact of what is decided by this Parliament. I thank the committee for its support and for the opportunity of meeting it.

Chairman

I thank Professor Kazatchkine for the clarity of his presentation, which was helpful and useful. He must understand parliamentarians very well because his points were made concisely. Our members appreciate the work being done by the Global Fund and we have taken a great interest in it. The professor has our full support.

He referred to our role in advocacy. Members have accompanied me to various functions and we always encourage people to realise the value of the Global Fund's work. We have visited various places, including Ethiopia and Rwanda, and we have seen the value of the work being done on the ground, as well as the importance of the area with which the Global Fund is dealing. This country has experienced TB and other diseases, so we realise the importance of supporting remedies.

I ask members to bear in mind our time constraints. Another committee will meet in this room and we will have our photographs taken before we conclude.

Deputy Michael D. Higgins

I join the Chairman in welcoming our distinguished guest. The work of the Global Fund has been explained with great clarity in terms of its fundamental principles. In regard to the three diseases, HIV-AIDS, malaria and TB, it would be valuable to the committee — I am thinking of a previous presentation by the Global Fund — if we could be provided with an atlas of risk. I find it sometimes difficult to hold in my head the precise degree of risk arising from these diseases in different parts of the world. We would need that information if we are to establish benchmarks on whether we are making progress. Advocacy is not solely about increasing the fund. We need to know, for example, the figures for the part of the millennium development goals addressed to these issues, the proportion of the pledges made that are on track to be received and the shortfall in funding and its consequences. That relates to my previous point.

In regard to the production of an atlas of the globe at risk from these three diseases, the figures reveal imbalances that should concern politicians. For example, in regard to the pledges for HIV-AIDS in Africa, we would be very naive if we did not realise that two tracks are running in opposite directions. For example, Chinese investment in Africa is increasing greatly. However, when one examines the Asian contribution to the elimination of diseases, even through the Global Fund, the trend is in the opposite direction. When one examines the three year programme presented by our distinguished guest one notices across a period of years that only the EU figure is stable or increasing significantly across the next three to ten year programmes. The appropriate measure for deciding the degree for engagement of the international community with the elimination of these three illnesses is probably best indicated not by a gross figure but by the per capita contribution. It makes no sense to put the gross contribution of the United States in without noting the per capita figure of, say, Norway or Ireland. I presume everybody in the committee supports Irish Aid’s contribution and its extension into this route. As a Labour Party member I certainly do. That goes without saying. I am talking about trying to be of most use regarding the role of this committee. There are differences and we must reflect on them.

There is not enough progress in Africa on HIV. I read from the figures about a better prospect in Asia. That is significant and while the Global Fund is not an implementing agency we must be aware of the factors impeding and assisting in the achievement of our goals. For example, on gender equality I have yet to see a fundamental report from an agency that is involved on HIV impact on young female children. When a mother makes the decision on which child is to be kept out of school to look after an ill person there are major gender differences. I am worried about the way the fund is aimed at the elimination of diseases. It is a reflection on humanity that malaria has not been eliminated. It is an outrage that in certain parts of countries such as Peru tuberculosis has increased.

All this must be put into a social cultural model. I repeat a controversial point I have often made. When the administration of colonisers and imperialists in the 19th century was necessary, Africa was coming down with social anthropologists. I have yet to see a social anthropologist's name related to some of the programmes answering the question I mentioned on the role of young girls, the transmission of information, the question of the use of condoms and the notion of what is impeding or assisting the distribution of the mosquito nets in Ethiopia.

I say this to be of assistance because I strongly support what is going on. If we could only make it more contextual in terms of using existing social and cultural skills and medical expertise and present it such that we have an atlas that would allow us to measure the degree of the problem we face and our progress, it would be a valuable educational tool for use in schools.

Deputy Seán Ardagh

I thank Professor Kazatchkine for his presentation. His five year evaluation and the result that there should be an increase in communication of his plans and model came over very well. He has given new information and I am sure other committee members will agree. I am particularly impressed with the public health impact of the work to date and the extent of the decline. We are speaking of a decline of more than 50% or perhaps up to 90% in the number of deaths caused by malaria in Zambia. The work done on TB and HIV is to be lauded. It is very significant in terms of effect and quantum in comparison with the micro-steps taken in other areas.

I have two questions, the first of which relates to the work done and efforts made by the former US President, Bill Clinton, Bill Gates, Warren Buffett and the major philanthropists who have put money into AIDS and malaria research. What is the connection and what are the people in question doing? How is the effort being pulled together?

My second question relates to small-scale operators in sub-Saharan Africa, in particular. We are very glad we are heading towards an aid GDP contribution of 0.7%. It has been stated parliamentarians would be welcome to visit the areas mentioned. I had the opportunity, under the auspices of the Department responsible for the provision of aid, to visit Zambia recently. There are a number of small-scale operators there who are not tied into the Global Fund or projects run by Warren Buffett or Bill Clinton. They are doing significant work and putting in a huge number of hours, particularly those which I saw working with people with HIV. There are hospitals and schools for children of sufferers. How are these operators being helped and can the aid given to them be increased? They appear to have great potential.

I thank the delegates for their exposition which I found very informative.

Deputy Billy Timmins

I thank Professor Kazatchkine for his presentation. We have been involved in the fight against AIDS for a quarter of a century; the battle commenced when many of us did not even know what it was. I am only articulating my own view but there is a perception that there is only an AIDS epidemic in Africa. I know other countries are affected such as Brazil and Vietnam. Is there something we do not know about the epidemic? Perhaps it is spreading to regions with which we are not familiar or we are missing something because, by and large, people were terrified of AIDS in the early stages but now it seems there is a comfort zone in the western world. There is a perception that the difficulty will no longer threaten us. What is the view of the delegation?

Fine Gael supports the giving of funding by Ireland to the Global Fund. It was set up in 2001-02 and, to date, a sum of €80 million has been allocated. In the next couple of years it proposes to allocate a sum of €90 million. However, with the downturn in the economy there is a desire on the part of the public to see value for money.

I note there is an evaluation programme over a period of five years. Will the delegation briefly elaborate on this programme? To date, the Department of Foreign Affairs has been somewhat reluctant to give information on its evaluation with regard to programme countries. I hope that will change in the very near future, as it is important that we see where the money is spent.

I have two final points. According to one diagram, 43% of the funds allocated goes to commodity products and drugs and 10% to others. Funds are also allocated to meet administration and human resources costs. How much of the funding goes to education in the countries in question or are such funds allocated under another heading?

Deputy Higgins briefly touched on the final point I wish to make which concerns the investment made by China in countries in Africa in particular. There is a proposal to invest €20 billion in the next few years in infrastructure in the Congo in return for mining the equivalent amount in iron ore. This is not aid per se but a thirst for mineral resources. We see the increasing involvement of China and its investment in Africa. Do the representatives think this will indirectly assist the fight against the various diseases focused on by the Global Fund?

Deputy Rory O’Hanlon

I thank Professor Kazatchkine for his very informative address. We appreciate the work being done by the Global Fund and the contribution of Irish Aid. The three diseases mentioned are obviously a major impediment to development in Africa. The most important aspect of this is the devastation to families in terms of personal loss and misery, and the difficulties they create within the health services, which are very limited anyway. I visited a medical colleague of mine in Moshi, Tanzania, last summer, and heard that, for example, tuberculosis cases are being treated in open wards, and that there is much drug resistance, which is a problem. With regard to AIDS, my colleague's hospital, which is a university hospital, sees 1,000 more people each year on anti-retroviral drugs, which, again, creates a problem.

Professor Kazatchkine mentioned the possibility of operating in a more gender-based fashion and concentrating particularly on young women, because it appears that men contract the disease, bring it back to their homes and spread it to the women, while women do not spread the disease in the same way. It is important that younger women are targeted and encouraged to avoid contact with these men, as well as prostitutes. It is also important to target the men who visit prostitutes, who are a major contributor to the spread of the disease. Are these groups being targeted specifically?

Another question relates to the cost of the anti-retroviral drugs. Is the professor satisfied that the best value for money is being achieved and that no effort is being made by the pharmaceutical industry to cash in on a major epidemic?

When I was in Tanzania, my colleague informed me that there was no textbook for teaching about AIDS in Africa. He has contributed to many journals and has written a chapter for the Oxford Textbook of Medicine, but as a consultant at a university hospital he does not have a textbook to teach about AIDS, which again would appear to be a deficiency in terms of coming to grips with the disease.

Senator Ann Ormonde

I welcome Professor Kazatchkine and thank him for his fine presentation. I am particularly interested in this area. Deputy O'Hanlon mentioned the aspect of gender and how we can move forward in prioritising programmes and educating young women. What programmes are in place to deal with that?

With regard to programme management, how are the programmes evaluated on the ground? Is the money being spent properly? I have spent some time investigating this. I welcome the invitation to visit and see the programmes at first hand and I am interested in taking up the invitation. Sometimes, however, money does not get to the right sources, and whatever programmes or systems are in place, they are not reaching out to the core areas. Deputy O'Hanlon touched on this as well.

I do not want to hold up the meeting. My points are similar to those made by Deputy O'Hanlon, particularly with regard to the protection of women, because that is how we will make progress. Otherwise the problems will continue. Professor Kazatchkine mentioned the health system versus the actual health care and training programmes put in place. How are they working on the ground? The professor does not have time to answer these questions in detail but perhaps we could get a briefing in some other way.

Deputy Michael Noonan

I thank the professor for a clear and informative account. My party is fully in support of the Irish contribution to the Global Fund. I ask him to comment briefly on its audit system and especially how it audits the 50% of the fund that goes to national governments. Is there external monitoring of the audit or does he rely completely on the internal audit systems of the governments to which he directs aid?

Senator Mark Daly

I seem to always follow Deputy Noonan and to agree with him at the same time. I am concerned that 50% of the money goes to governments. I am also concerned at the corruption levels and the auditing system. I am not entirely happy that most of the money goes on administration. The drugs have to be dispensed but I am concerned that so much money is spent on getting it to where it needs to go. Is Global Fund happy with that and how does it compare with other world organisations or even NGOs who can be very efficient? They will tell us that 60% or 70% goes to where it is needed. That more than half is spent on getting it there is a concern. Are there any plans to get that figure beyond 50%?

Senator David Norris

I welcome our distinguished guest. In response to one of the points, I would say that a number of us are involved with parliamentary representatives who support the UNFPA. We have a grouping here that is very effective and assists in debates by providing us with efficient and detailed briefings which are very useful. Many of us support this initiative.

I noted the same trends as my colleague, Deputy Michael D. Higgins, with regard to funding. It is worrying that the United States plays such a relatively insignificant role and also frequently, under the Bush Administration, attaches conditions of a moral nature, which is completely regrettable in a scientific area and an area which deals with the treatment of human beings. While there may not be time for the professor to address this issue given that there is so little time, there is a worrying development in regard to TB. The Chairman referred to our national history with regard to TB but now as a by-product of AIDS there is the development of drug resistant TB. If time permits I would appreciate a comment on that issue.

My final question and comment is the business, which a number of colleagues have raised, of gender equity and so on, but they neglected to mention the other rather coy phrase "sexual minorities". I wonder how many sexual minorities there are. Is there a wonderful efflorescence of sexual minorities? I can think of one in particular, homosexual men, gay men. I have had experience of going to the meetings of the interparliamentary union in India and being the only person to raise there, about ten years ago, the question, which was a time bomb. I discovered that in the previous year the first national conference on AIDS had been held in the Ashok Palace Hotel and it excluded by police force women sex workers, or as we used to call them, prostitutes and gay men, who wanted to take part.

Many of us here have the privilege in northern Europe of being able to speak openly about these issues. There is a real political difficulty in the east, in Asia and in Muslim countries. We owe it to these people to indicate our very strong support for gay men who, certainly in the west, were simultaneously attacked as being the principal mechanism of transmission and then ignored. The professor should know of our strong support. I doubt if any of my colleagues would dissociate themselves from that.

Chairman

The professor does not have to answer all those questions.

Professor Michel Kazatchkine

If I were to do so we would be in session for many more hours. I will run through a few of them. I thank members for raising so many important points. I will answer a number of points raised by Deputy Higgins about contributions. He is correct in suggesting one should examine the figure per capita as much as absolute numbers. It is true that the US has made an unprecedented effort with regard to AIDS with the $15 billion for the President’s emergency plan for AIDS relief, PEPFAR I, programme and President Bush’s request for $30 billion, which is now being considered by Congress and the US Senate, for the PEPFAR II programme. When one examines the percentage of GDP the US gives to development, it is far below the mean European figures. As Europeans we can be proud of the effort of Europe, which is supporting close to 65% of Global Fund funding. Many EU countries have committed to increasing overseas development aid towards 0.56% and then 0.7% of GDP. Ireland is among the high donors. I measure this as the percentage of overseas development aid that goes to Global Fund, which is 2.65% in Ireland’s case. The highest donor gives 3% of overseas development aid to Global Fund and the mean is approximately 1.9-2.1%. Ireland is among the strong donors.

China is investing in bilateral efforts, particularly in infrastructure and with regard to malaria. It is not linking with the multilateral groups on the ground and with Global Fund but these developments are recent and we must build relationships. China is a small donor to Global Fund, giving tens of millions but receiving $440 million from our portfolio in China.

I look forward to the next three years as years when the contributions Global Fund receives from rapidly emerging economies will increase. We are targeting fundraising efforts at the Chinese Government, India and Russia, which is the best example. Russia has been a beneficiary of Global Fund to the extent of $270 million. Last year, Russia decided to reimburse all the funds it has received by 2010. I would like to use that model to address China, India and Brazil. The patterns of donors will change and the growing economies in Asia will be represented in Global Fund donors.

I thank several members for raising the impact we have. This is where the advocacy of members is needed. Some may say that since there is impact and people hear marvellous results about malaria, they do not have to worry anymore about AIDS and other diseases. This could lead to complacency but we need the opposite attitude. Here is a global issue that the world is coming together to tackle. We are making significant progress but let us eradicate malaria and make an impact on tuberculosis. It is amazing that the world is still confronted with an increasing epidemic of tuberculosis in 2008.

Deputy Ardagh referred to philanthropists. There are two ways in which they invest money. The main investment of Mr. Gates and Mr. Buffet is in technology or research, upstream investment. However, at the Toronto AIDS conference two years ago, Bill Gates committed €500 million to the Global Fund. He is giving us €100 million per year for the next three years. I am in close contact with Bill and Melinda Gates and their foundation and hope its work will expand with the Buffet money. Their key investment is in the area of future technology.

A question was raised about the spread of AIDS. Several years ago, we were concerned that AIDS could spread throughout the world if we did not deal with it urgently. It is now fairly clear from an epidemiological perspective that two types of epidemic exist in the world. The first is the African, or I would even say the southern African, epidemic, which is a generalised epidemic of unbelievable scope. Next week I will travel to Swaziland, where one person in three is infected by HIV. In the rest of the world, epidemics are concentrated among, for example, intravenous drug users or homosexual men. We should be able to stop these epidemics because we can access these people for treatment fairly easily. However, the issue of how we deal with southern Africa is very difficult to address, particularly in respect of prevention. I do not think there is any hidden or unknown aspect to the progression of the epidemic.

With regard to the point made on multi-drug resistant tuberculosis, not only is the AIDS epidemic extremely worrying in southern Africa but now we are also concerned about the tuberculosis epidemic and resistant tuberculosis. HIV-AIDS and tuberculosis are linked because people whose immune systems are compromised by AIDS are particularly vulnerable to tuberculosis. We now see the spread of multi-drug resistant tuberculosis in eastern Europe and Central Asia. The Global Fund is currently the only funder of resistant tuberculosis prevention and treatment. I recently visited Georgia to open a new facility for multi-drug resistant tuberculosis. We are the only provider of multi-drug resistant tuberculosis in the world. The support of this committee for our activities in that regard is therefore very important.

I was asked about administration but I am unclear on the question. The Global Fund is extremely cheap from an administrative perspective. We are spending between 4% and 6% on overheads. We have a comprehensive funding policy so that, whenever we approve a programme for €10 million or €100 million, we immediately put that money aside in the bank so we are sure there is no risk to continuity. That money goes to the World Bank, which invests it, and the returns on our investments pay our administrative costs. Every euro that Ireland contributes to the Global Fund goes to the developing world. We are proud that Geneva does not retain a single euro.

Several questions were asked regarding the feminisation of the epidemic, which is currently a major issue in southern Africa. The risk for a young woman to acquire HIV-AIDS is about six times that of a young man. That means prevention must include education for young women, although obviously it must also focus on men. There are limits to what we can do. One can educate, court or inform as much as possible. When these young women are confronted with poverty and violence there is no way to respond for them. If they have to sell sex for money because they are hungry, no education effort will help. Some members spoke about the socio-cultural context. These diseases cannot be separated from the overall context of the fight against poverty and for human rights.

I should address some remarks by Deputy Noonan and others on audits and how we can be accountable apart from the five-year evaluation. We are the only development funding agency that works according to a performance-based funding model. When we sign a grant with a country, that country sets a number of objectives, for example by three years it wants to reach 20,000 people with anti-retroviral treatment. The country will aim to reach 5,000 people in year one, 10,000 in year two and 15,000 in year three and request annual budgets accordingly. We will disburse the first tranche and will not disburse the second tranche before objective one is reached and we see how the money related to that objective is spent. Every six months — or every three months for countries we examine more carefully — our principal recipients give us reports on the programme achievements and the budget that has been spent.

We also have independent auditors in countries, usually accounting firms such as KPMG or PricewaterhouseCoopers, which we subcontract. Every six or three months these people send us a similar report to the one we request from the principal recipient. If the two reports are consistent and if the programme achievements have been achieved I disburse the second tranche. If there is inconsistency between the two reports, we investigate. One of the members mentioned the risk of corruption, of which we are very conscious. A few months ago The Irish Times published a report on a country I cannot name, and which was not named in the newspaper because it is the subject of a police investigation. The report was on some of the Global Fund’s money being used inappropriately in an African country. That report was correct. From time to time I receive such evidence. Because of our legitimacy, because we are global and our board comprises donors and recipients, public sector and civil society, the Global Fund is the only board with the strength and legitimacy to tell a country we are discontinuing the grant. For a bilateral country it is difficult to suspend bilateral efforts because bilateral efforts often have some political visibility purposes. I will stop here.

Chairman

We must wind up because we are going to be put out, never mind Professor Kazatchkine.

Professor Michel Kazatchkine

As members may know, we have suspended grants in Ukraine, Uganda and in a few other countries and are threatening some countries with temporary suspensions, so we have strict control over corruption. Let us keep our fingers crossed. We have been doing reasonably well, particularly if one thinks of the very large flows of money through the Global Fund.

Chairman

I thank Professor Kazatchkine. People are mostly concerned about where governments receive money directly and wish to ensure it gets through to where it is needed. We have visited various places and seen audits being conducted, even by our own officials. It is an issue which is raised in the media and elsewhere.

The delegation is very much on top of its brief, as is very obvious to everybody present and clear from the presentation made and replies given to questions. We all agree that if there is to be an impact, it must not lead to complacency. That is very important. We must aim for total eradication. We are all much more aware of the great work being done by the Global Fund in combating the scourge of AIDS, malaria and TB. Coping with the challenges posed by these pandemics is not an easy task but it is welcome that the delegation is focused on the issue.

Professor Kazatchkine is to be congratulated on the work he has done in his first year as director of the Global Fund and we wish him every success with his future plans. We will communicate and keep in close contact with him. We will also follow up on the invitations mentioned. I again thank the delegation.

The joint committee went into private session at 1.42 p.m. and adjourned at 1.45 p.m. until 3.30 p.m. on Wednesday, 9 April 2008.