Peter Sands is not expected to take up his new duties as the Executive Director of the Global Fund until mid-March, but he has already been in the public eye through interviews he has given to the media and a speech he made at an international conference. And he has been raising issues that suggest that he may be getting ready to take the Global Fund in some new directions.
Sands touched on taxes in implementing countries; innovative finance mechanisms; the three diseases; and global health security.
Focus on taxes
In a wide-ranging interview with Devex on 6 February, Sands said that while innovative financial mechanisms can help address critical gaps in health care funding, the global health community also needs to be more focused on taxes and helping implementing countries mobilize domestic resources for basic health care services. Sands said:
“I think people in the world of global health need to be thinking about and talking about taxes rather more than we do, because if you have a country that is only mobilizing — in terms of fiscal mobilization, i.e. tax revenues — a single digit percentage of GDP, it’s extremely unlikely they will be able to sustainably finance a health system delivering even the basics to all its population.”
Countries need to become more self-reliant, and less reliant on international development assistance to fund their health systems, Sands said. To get there, countries need to work on tax raising and tax deployment strategies. Once the basics are covered, he said, other financing can be sought to support other aspects of health systems.
For this to happen, Sands said –– reiterating a theme he touched on when he was selected as executive director –– countries and organizations such as the Global Fund need to get better at communicating the economic or investment case for funding disease prevention and eradication. “There are very strong, hard-nosed economic reasons for taking action, but we are not making that argument as well as we could.”
Too often, the global health and development community preaches to the converted, Sands said, but to change perceptions there must be an effort to convince the skeptical, be it the civil servant in charge of budget prioritization in a finance ministry, or a capital markets analyst at an investment bank. “The way we need to do that requires a degree of rigor around what is it about health issues that impedes development.”
Innovative financing mechanisms — from impact bonds, to blended finance, matching funds and results-based funding — can all play “a significant and important role in what we’re doing both in terms of improving the effectiveness with which we deploy existing funds and in attracting new monies,” Sands said in his interview with Devex.
“Sometimes these things look like tools looking for a problem and I think we need to be very rigorous in identifying the underlying economics of the problem we are trying to solve and then picking the financing instrument that is best suited to that particular problem,” he said.
The three diseases
Sands told Devex that he has been meeting with Global Fund staff and learning about the key challenges for each of the diseases.
Regarding TB, Sands said that the fund cannot just work on its own, because so much of the TB burden is in middle-income countries. “We have to act as a bit of a catalyst here, getting others to think differently, mobilize funds more aggressively, deploy them more effectively in countries in which we're not necessarily delivering our funding directly, but that’s the only way we're going to get to our objective of ending the epidemic of TB.”
There has been less progress in reducing infection rates and mortality on TB than on AIDS or malaria, Sands said, and there hasn’t been as much scientific support, political leadership or community mobilization. Concerning AIDS, he said, the tools now exist to end the epidemic, but questions remain about whether enough resources will be dedicated to doing so.
Sands said that on malaria, the tools may be there, but globally the community is not delivering as well as it needs to and “arguably we are at some risk of sliding backwards not least because of increased resistance to the drugs and the insecticides.”
Sands said that in his discussions with staff he has been learning about the importance of data, and that he’s likely to see the Global Fund continue to improve how it gathers data, analyzes it, and uses it to inform future decisions.
Global health security
In a speech delivered at the Prince Mahidol Award Conference in Bangkok, Thailand on 1 February 2018, Peter Sands said:
“When you frame the risk of infectious disease threats as a human and economic security issue, it seems clear that we haven’t got our act together sufficiently to protect mankind from such threats. Few risks can cause as much economic damage as the fear sparked by a major infectious disease outbreak. Yet we devote a fraction of the resources we deploy to other risks –– of war, financial crises, nuclear disasters, even climate change –– to preventing, preparing for and responding to infectious disease threats.”
The text of the speech was printed in “Voices,” on the Global Fund website.
Sands said that the world also faces a growing threat from antimicrobial resistance which, when combined with infectious disease outbreaks, pose huge dangers to global health security. “We neglect them at our peril,” he said. “When we talk about potential risks to global health security, we implicitly tolerate a base level of human loss and economic burden that shouldn’t be acceptable.”
“ At a time when many of our public leaders seem afflicted by tunnel vision –– seemingly only interested in what’s within their borders and what’s happening within their term of office –– we need to be pointing out that viruses don’t need visas and don’t respect election timetables.”
–– Peter Sands
Most discussion of global health security focuses on emerging infectious diseases or on the perils of antimicrobial resistance, rather than on the endemic infectious diseases, Sands said. “But I think we need to rethink this way of framing the discussion about global security. It’s an odd definition of security that only focuses on the things that might kill you and excludes those that are actually killing you.” (See the editor’s note at the end of this article about how the term “global health security” is defined.)
Strengthening health security has to start from tackling the infectious diseases that are killing people now, Sands said. We need to take a more integrated approach to health security, one that encompasses both endemic and emerging diseases, he added.
“Too often the multiple agendas, initiatives and institutions that characterize the global health space compete rather than collaborate and sometimes only accidentally leverage the synergies between them.” Sands said. “Yet much of what we do to tackle individual diseases involves building capabilities and infrastructure that can serve multiple purposes –– community health workers, supply chains, diagnostic labs, disease surveillance, infection control regimes, vector control… We can get smarter about working together to help build stronger and more resilient health systems that can achieve multiple purposes and respond to multiple challenges.”
“ If global health security is seen as code for making only those who live in the rich world safer from infectious disease threats, then it’s both dodgy morally and won’t be effective as a strategy.
–– Peter Sands
Sands said that a practical reason for taking an integrated approach is that the roots of the next emerging threat can originate from, or be intertwined in, today’s problem. He cited drug-resistant TB (DR-TB) as a good example. About a third of total antimicrobial resistant deaths are caused by DR-TB, Sands said. “So, if we want to address the antimicrobial resistance challenge we have to tackle the TB challenge. More generally, the increasing incidence of resistance –– whether to antiretrovirals in AIDS, or to artemisinin or pyrethroids in malaria –– poses threats that could take us backwards if we don’t address them. And given the scale of these diseases, any slip-up is measured in tens or hundreds of thousands of lives.”
Sands listed five things that he said need to happen:
- “The global health community has to get better at articulating what’s at stake in making the world safer from infectious disease threats – both in terms of lives and economics.”
- “We need to talk about health security in a way that makes sense both to taxpayers in high-income countries and to the people most at risk from infectious diseases – often those who are living in marginalized communities.”
- “We have to embed and broaden our approach to antimicrobial resistance, so that antimicrobial resistance becomes an integral component of how we tackle infectious disease.”
- “We need to get better at working together to tackle specific diseases and to build stronger, more resilient health systems.”
- “We need to ensure that gender considerations inform health security strategies in a powerful, practical –– and effective –– way.”
In conclusion, Sands said:
“We need to translate the rhetoric of One Health into action, so that it becomes the norm, not the exception. We must minimize institutional turf battles. And we must find better models of collaborating with the private sector. I don’t have a magic wand to achieve this, but I can promise that under my leadership the Global Fund will take a big picture view of its mission, and a collaborative approach towards achieving its goals.”
Editor’s note: What is “global health security”?
We could not find a universally accepted definition of the term. For the purposes of its 2008 World Health Report, the World Health Organization defined “global public health security” as “the activities required … to minimize vulnerability to acute public health events that endanger the collective health of populations living across geographical regions and international boundaries.” (Source: http://www.who.int/whr/2007/overview/en)
Some experts have said that the WHO definition is too narrow. A statement describing the raison d’être of the Global Health Security Agenda (GHSA), which was launched in 2014, may provide the best explanation: “GHSA pursues a multilateral and multi-sectoral approach to strengthen both the global capacity and nations’ capacity to prevent, detect, and respond to human and animal infectious diseases threats…” (Source: https://www.ghsagenda.org)