The Okinawa International Conference on Infectious Diseases
1. Infectious Diseases: A Key to Poverty Reduction and Human Security
Good health is the key to prosperity. While better health contributes to poverty reduction, growth and human security, poor health both drives and is driven by poverty. Infectious and parasitic diseases, notably HIV/AIDS, Tuberculosis (TB), and malaria, are now the world's major killers of children and young adults, 1causing more than 13 million deaths a year. Most of them occur in developing countries, where the least money is spent on health care.
Infectious and parasitic diseases undermine societal structures, health systems and national economies. Calculations remain imprecise, but it is certain that the full economic costs of infectious diseases have been under-estimated. Recent studies suggest that those countries where 10 per cent of the population is affected by HIV/AIDS stand to lose up to one percentage point of GDP per year. Malaria, too, continues to undermine economic performance, diminishing potential growth by up to 1 per cent per year. The economic costs of TB could amount to more than $12 billion per year. Taken together, the costs in terms of human security, economic growth and development are staggering. The case for more rapid, sustained and concerted action is overwhelming.
Two decades of addressing the HIV/AIDS epidemic have demonstrated that the disease cannot be brought under control if we tackle it in conventional public health terms: HIV/AIDS has become a development issue, and, as recognized by the UN Security Council, an issue of human security. It requires action across the whole of society. The response to HIV/AIDS has succeeded in becoming political and social: there are important lessons to be learned from this in addressing TB, malaria and other infectious diseases.
2. Challenges and Opportunities for Global Actions
As stated above, major infectious and parasitic diseases increase poverty and seriously affect development. Health systems in developing countries often lack resources to provide even basic care and hardly reach the most affected individuals. Moreover, vulnerability to infectious diseases is increased by certain personal and social factors, including gender inequality, lack of safe water, social exclusion, displacement due to war, that are exacerbated by poverty. This situation is often aggravated by the lack of knowledge, skills and resources at the family level necessary for the prevention and care of infectious diseases. Finally, infectious diseases often cross national borders, and the failure of control measures may put global health at risk.
During the past years, significant progress has been made in fighting infectious diseases as a major health challenge against poverty. These initiatives include International Partnership against AIDS in Africa (IPAA), Stop TB Initiative, Roll Back Malaria (RBM), Multilateral Initiative on Malaria (MIM), Global Alliance for Vaccine and Immunization (GAVI) and International AIDS Vaccine Initiative (IAVI).
Here in Okinawa, the G8 leaders agreed to demonstrate their resolution to step up this fight and set out the following three numerical targets for HIV/AIDS, TB and malaria:
- Reduce the number of HIV/AIDS-infected young people by 25 per cent by 2010;
- Reduce TB deaths and prevalence of the disease by 50 per cent by 2010; and
- Reduce the burden of disease associated with malaria by 50 per cent by 2010.
To deliver these targets, the leaders committed themselves to fostering a new and innovative partnership with governments, the World Health Organization (WHO) as well as other international organizations, industry, academic institutions, foundations and other relevant actors in civil society.
Hence we, the stakeholders of this partnership, gathered to shape a concrete action plan to fulfill the leaders' commitment, by defining the operations of this new partnership, the area of priority and the timetable for action.
The challenges identified for the partnership to reach the 2010 targets include:
- The challenge of finance: Developing countries cannot reduce the negative social and economic impact of the diseases associated with poverty with current levels of spending. Achieving the targets that have been set will require an intensive effort over many years, and additional funds over and above resources already pledged or obligated. We recognize the responsibility of using existing and additional resources to maximize the impact in the fight against the major infectious diseases.
- The challenge of scale: While many effective interventions exist, they are accessible to the few rather than the many. Reaching people that suffer disproportionately from, or that are at greatest risk of, these conditions (particularly women and children) calls for effective action that builds basic health care systems deliverable to all.
- The challenge of new ways working: The challenge is not to add yet another new initiative, but to bring together existing endeavors in a more coherent and accelerated way. The approach adopted needs to be based on country leadership. It is increasingly clear that the public sector alone has not responded, and cannot respond, to the challenges outlined in this Summary. Finding ways of tapping the energy, entrepreneurial spirit and innovation of the private and voluntary sectors are critical to success.
- The challenge of health and development: We will not succeed in achieving the targets - particularly the HIV/AIDS target - if we fail to act from a broad developmental perspective. Behavioral change needs to be understood in a social, political and economic context. Reducing people's overall vulnerability to infectious disease is as important as reducing the factors - such as unsafe sex - that put them at immediate risk.
Principles for Operation of the New Partnership
The new partnership tackling the major infectious and parasitic diseases mentioned in the Okinawa Summit will facilitate developing global actions for poverty reduction and human security through infectious disease control, and reducing the illness and premature mortality suffered by the poor. This global movement for infectious disease control will encompass actions undertaken by a wide range of organizations and institutions, including governments, bilateral and multilateral donors, industry, academic institutions, NGOs, and other development partners. The partnership will be underpinned by core values, including 1) commitment and ownership, 2) accountability and impact, 3) people centered, and 4) international public goods.
- Commitment and Ownership: An international commitment to taking concrete actions and mobilizing resources is required to tackle infectious diseases. Tackling the major infectious diseases requires country level commitment, political leadership and country level and specific processes to define priorities. National governments of developing countries will be the stewards in the fight against infectious diseases, ensuring the development of appropriate policy frameworks to define priorities. Developing countries must support the development of the public health and scientific infrastructure, particularly human resource capacity building, to sustain and expand on the initial investments made by the donor community.
- Accountability and Impact: Both the global community and the national governments need to be held accountable to all development partners and their people for their actions in the fight against infectious diseases. This will be achieved if the success of the partnership is measured by its outcomes.
- People Centered: The partnership will depend upon national human resources and experience that are adequately trained, motivated and supported. The partnership must empower poor people and communities to both demand and have greater control for their own health. State and non-state health systems need to become more responsive to the needs of the poor.
- International Public Goods: International Public Goods (IPGs) may be defined as development resources capable of generating positive externalities that have a transnational reach. 2 Considering those resources as the means to achieve specific goals, IPGs include information, knowledge and technology such as drugs and vaccines for major infectious diseases. The partnership will work together to deliver these International Public Goods such as vaccines for HIV and malaria and new drugs for infectious diseases. This will require increased incentives to promote research and development in these IPGs and substantive support of capacity building for research and development work in developing countries and regions.
Priorities in Tackling the Major Infectious Diseases
1. The New Partnership
Investing in infectious disease control and research contributes to economic growth through reducing illness itself and premature deaths. Based on this premise, the G8 leaders are committed to meeting three global targets in relation to HIV/AIDS, TB, and malaria. Achieving these goals requires accelerated and concerted efforts of all development partners.
There are already existing global partnerships to fight against major infectious diseases, including International Partnership against AIDS in Africa (IPAA), Stop TB Initiative, Roll Back Malaria, Global Alliance for Vaccine and Immunization (GAVI), Multilateral Initiative on Malaria (MIM) and International AIDS Vaccine Initiative (IAVI). Many of us are involved in some or most of these initiatives. On the other hand, both bilateral and multilateral donors, NGOs, civil societies, and the private sector, embracing the same overall goals but taking varied approaches, have also been fighting infectious diseases on their own or in conjunction with some development partners. To optimize the impact of those efforts, we must develop dynamic mechanisms that enable a wide range of partnerships to effectively function at country, regional, and global levels.
(1) At Country Level
Partnership at the country level provides mechanisms for all relevant parties to come together, in principle under the leadership of the concerned government, to support national strategies against infectious diseases, in the context of poverty reduction strategies and through health systems development. Such partnerships can improve communication among all stakeholders, channel and mobilize resources, stimulate demand, ensure access to goods and services for every intended destination, and strengthen local research infrastructures.
To achieve sustainable improvements in the health outcomes of the poor, it is essential that national poverty reduction strategies and health sector programs incorporate infectious disease control measures that are tailored to specific country contexts. There are a number of mechanisms that are important in this regard, including the country-driven Poverty Reduction Strategy Papers (PRSPs) and Sector-Wide Approaches (SWAPs) to health sector development. We recognize the importance of these types of mechanisms to ensure developing country ownership. Through broad-based efforts, governments and donors can share information and objectives and coordinate action as appropriate towards a set of shared objectives that are fully owned by all development partners.
The ownership and commitment of a concerned government are the keys in the fight against infectious diseases. In those countries where development partners are already working within a government-led health policy, we will support the existing development processes. In order to increase the ownership of partner developing countries, we recognize the importance of supporting capacity building of governments through human resource development and institutional building. In those countries where the government devotes insufficient resources to addressing health sector problems, the partnership at the country level works on mobilizing political will through dialogue, to ensure the government takes effective infectious disease control measures.
Effective and equitable health systems are essential. Capacity-building at all levels will be required to ensure overall government stewardship, to promote fair financing and to increase the responsiveness of health systems to the needs of poor people. A key issue in relation to infectious diseases, however, is to stimulate demand for, and promote equitable services on a massive scale, while at the same time ensuring that poor people have better access to affordable services, commodities, and the information they need to improve the effectiveness of health interventions. This will demand appropriate attention to the response of communities.
Without the full and equal participation of the community, it will be impossible to develop and support preventive actions and provide sufficient care to those infected and affected by infectious diseases. In this respect, mobilizing existing resources within local communities deserves careful attention. Also, from the viewpoint of over all development, it is necessary to incorporate infectious disease control in holistic community development programs. At this point, the importance of improving public health and health systems at the community level, universal distribution of basic education, securing safe water, and gender equality in addressing the challenges of infectious diseases cannot be overemphasized. Furthermore, cultural, economic, and social environment should be taken into account in fight against infectious diseases.
NGOs, through their grass-root experiences, often have intimate knowledge of the countries concerned and know-how to directly assist the most seriously affected individuals, families and communities, whom public service often fails to reach, in planning and implementing community-based prevention and care activities. We encourage dialogue between NGOs and the public sector in the context of the dynamic mechanisms of the partnership at the country level so that they complement one another and make the most of each other's comparative advantages in tackling challenges of infectious diseases. Strengthened partnership among NGOs themselves is also encouraged, and we will focus on collaborating efforts between local and international NGOs to address the challenge of infectious diseases. Moreover, recognizing the importance of the roles that local NGOs play in the field of infectious disease control, we encourage donors to further support those local NGOs.
The growing importance of public-private partnership is evident at the country level. Local private sector involvement complements public sector efforts in improving access to and affordability of health goods and services.
(2) At Regional Level
Regional partnership is intended to share resources within a region, including human resources, technology and knowledge, and to address cross-border issues that require regional responses. Such partnership functions through mechanisms that promote improved surveillance systems, regular stock-taking and monitoring performance at the regional level. The G8 members will take part in regional reviews through already established fora such as African Development Forum, ASEAN, SAARC, and SADC, on a regular basis in relation to the above functions.
"South-South" Cooperation is integral to the response to the infectious diseases and is at the root of good partnership and effective collaboration. When international partnership is mobilized in the form of South- South cooperation, the reward could be enormous and highly cost-effective. It can be used in planning, mobilization, partnership building and capacity building. This potential has not been fully tapped, however. South-South cooperation must be encouraged to share experiences and best practices among developing countries within a region. In addition, greater efforts need to be made to establish effective information systems, or "clearinghouses," that accumulate and distribute such information. Inter-country networking has proven very effective in developing appropriate operational strategies, strengthening technical capacities and monitoring progress for HIV/AIDS and malaria control in the Mekong region. Countries are encouraged to make use of the Internet and other electronic resources to share epidemiological data and research results.
(3) At Global Level
At the global level, there is a need for effective partnership mechanisms to achieve the objectives, including improving access to goods and services at the country level; increasing cooperation between developed and developing country research institutions, industry, and academia for the development of new infectious diseases prevention and treatment strategies; improving the affordability of essential drugs; increasing training of in-country personnel in laboratory and research techniques; and mobilizing international commitment.
In particular, inadequate access to affordable health commodities and drugs is a major problem in developing countries, especially among the poor. Improving the access and affordability requires global responses, especially to ensure that local health infrastructures and systems are improved so that commodities and drugs not only reach those who need them, but are used safely and effectively. Other issues that must be addressed include the cost of drugs, tariffs, taxation, distribution, and marketing. There is also an urgent need for innovative mechanisms that enhance the global partnership between the public and private sectors to address this challenge. We applaud recent announcements by countries and pharmaceutical companies to make more affordable those drugs and treatments necessary to treat HIV/AIDS and other diseases. Such partnerships should seek to expand their practices of making necessary drugs affordable to the poorest countries, and all partners should evaluate innovative new solutions to increase access to affordable drugs and commodities.
We are encouraged to participate in ongoing international partnerships such as UNAIDS, IPAA, STOP TB Initiative, RBM, MIM, GAVI, IAVI, and to use these fora as opportunities to share information, review ongoing initiatives, and identify unmet needs. At the Cologne Summit last year, the G8, expressing its concern over the spread of HIV/AIDS and other infectious and parasitic diseases, agreed to providing continuous support to those global initiatives led by UN agencies in the fight against infectious diseases. Recently, the UN General Assembly has Decided to convene HIV/AIDS special session from 25 to 27 June 2001to address the challenge of, and secure a global commitment to combat the epidemic.
To combat the global challenge of infectious diseases, it is essential to collaborate with international organizations through effective global partnership mechanisms. Those international organizations, including UN agencies and Multilateral Development Banks (MDBs), working closely with other development partners, are expected to contribute to monitoring and evaluation at the global level, as well as to collecting, accumulating, analyzing and disseminating best practices world-wide.
The World Bank and the Regional Development Banks also play major roles in partnerships at regional and global levels. We call on them to expand their assistance in infectious disease control with other development partners through lending and policy dialogue at the country level. We also welcome their innovative initiatives and approaches for targeting resources toward regional and global public goods. We encourage the MDBs to support the development of in-country laboratory capabilities, training and research, in order to ensure a long-term commitment to disease control and prevention.
2. Improvement of Availability of International Public Goods
(1) Research and Development of International Public Goods
Basic research on infectious diseases provides the foundation on which diagnostics, vaccines, biomedical and behavioral preventive interventions, and therapeutics may be developed. Important international public goods in the fight against infectious diseases include the development and use of vaccines and drugs, appropriate methods of treatment, and health commodities necessary for controlling these diseases such as male and female condoms, testing kits, and microbicides. Further research is necessary to develop cost-effective and socially acceptable methods for detecting and preventing the spread of infectious diseases. Additional needs include research to identify sustainable approaches to managing infected patients and operational research to determine how best to implement newly identified interventions.
In order to increase the availability and affordability of these international public goods for all affected people, stronger partnership at the global level to support research and development of these international public goods is urgently needed. The private sector has an enormous capability for the research and development of international public goods, and should be encouraged to use this potential further through cooperative initiatives with the public sector. Exemplifying such public-private initiatives are the International AIDS Vaccine Initiative (IAVI) and GAVI.
The private sector has difficulties in obtaining financing or justifying investment in the research and development of global public goods that do not have an assured market and lack protection. Uncertainties in marketing the developed products are another deterrent. Most demand for international public goods arises in developing countries, where the market size is not large enough to motivate the private sector to increase their investment for the research and development.
We are committed to increasing our support at the global level for the research and development of the international public goods such as AIDS vaccines; treatment drugs of AIDS, TB and malaria; microbicides; and other health commodities. Measures include the creation of enabling circumstances, such as tax credits, purchase funds and other creative means to promote the investment in, and financing of, such research and development by private industry. Furthermore, the G8 and MDBs could consider providing financial and other incentives.
Additionally, cooperation between the public and private sectors in research on marketing the international public goods should be advanced. Initiatives to accommodate bulk procurements for these goods are cited as one of the measures.
(2) Information and Knowledge as International Public Goods
The nature of infectious diseases crossing over national boundaries requires countries to cooperate in monitoring and detecting the spread of disease, and to share epidemiological data. Research efforts to understand the underlying ecological and biological mechanisms that lead to the emergence and transmission of infectious diseases are also needed. Such information is one of the international public goods. Efforts to raise the accuracy of information and achieve the appropriate timing for collecting and sharing information are necessary. We support the cooperation among concerned research funders and bilateral and multilateral donors, as a means of strengthening existing international surveillance systems.
Governments, donors, NGOs, and academic and private sectors have experienced success in their pilot behavioral interventions and mobilization of societies against infectious diseases. The factors for such success, however, have yet to be thoroughly analyzed, and the lessons extracted from the analysis that has been done have not been fully disseminated, either. We promote research about innovative approaches and best practices and support establishing the function of clearinghouses of information on these approaches and practices.
Continuation of Support for Other Health Priorities
While there is a growing concern over the three major infectious diseases, HIV/AIDS, TB, and malaria, as key health challenges, it is also important to recognize that other health conditions, notably childhood infectious diseases such as pneumonia, diarrhea and measles, are often cited as health priorities among the poorest populations. At the Okinawa Summit, the G8 leaders acknowledged that, together with the international community, they have successfully arrived at the final stage of polio and guinea worm eradication and have begun to control onchoserciasis. Remarkable progress has been made in the fight against polio and some areas of parasitic diseases in the past decades. In the meantime, continuous efforts have yet to be made in those areas as health priorities.
Polio is now endemic only in parts of sub-Saharan Africa and the Indian sub-continent. The global target was set to certify the world as polio-free by 2005. Accelerated efforts are needed for the final battle to wipe out polio. It is estimated that the total external financial support needed through 2005 is US $1 billion.
The accelerated efforts to wipe out polio focus more on geographical priority areas. They include the countries and areas affected by conflict where eradication activities started relatively late, and those with large and dense populations and intense virus transmission. In addition, the growing importance of extending polio control measures to reach the remotest areas in the endemic countries is recognized.
Notably, schistosomiasis and soil-transmitted helminths represent more than 55 percent of the disease burden due to tropical diseases, excluding malaria. Most morbidity is seen in children, ranging from malnutrition, anemia, growth retardation, and cognitive impairment. Moreover, schistosomiasis and soil-transmitted helminth infections are more prevalent among the poorest populations in the least-developed countries. Towards this effect, it is necessary to scale up the control measures for reducing the impact of schistosomiasis and soil-transmitted helminth infections. We recognize the importance on the four strategies in fighting against parasitic diseases that were identified in the recommendation to the Birmingham Summit (Hashimoto Initiative).
School health programs have been recognized as important efforts to fight against health challenges in developing countries. These programs can simultaneously contribute to reducing common health problems including the above parasitic diseases, increasing the efficiency of the education system and advancing public health development. 3
Confronting Three Major Infectious and Parasitic Diseases: Commitment in Okinawa
(1) Current Situation
- Over 36 million people are living with HIV/AIDS in the year 2000 - over 50 per cent more than projections made in 1991 on the basis of data then available.
- The number of newly infected people in the year 2000 is estimated at 5.3 million; over 20 million people have died from AIDS since the start of the epidemic.
- 95 per cent of all HIV infections are in developing countries, causing a dramatic reduction in growth and having a severe impact on the most vulnerable groups, including the poor, children and women.
- So far, the AIDS epidemic has claimed the lives of 4.3 million children. Another 1.4 million children are living with AIDS today. Worldwide, one in ten of those newly infected in 2000 was a child.
- There have been over 13 million children orphaned because of AIDS, most of them in Sub-Saharan Africa.
- Sub-Saharan Africa is the worst affected continent. There, more than 25 million people are now living with HIV/AIDS, with 3.8 million new infections in 2000.
- In China and India, which account for around 36 per cent of the world's population, even the low HIV prevalence rate means that a huge number of people are living with the virus.
- HIV/AIDS is having a dramatic effect on economic growth and has reduced life expectancy in some countries. In particular, in most of sub-Sahara African countries, it is significantly undermining the achievement of decades of development efforts. The scale of the HIV/AIDS epidemic is now far greater than a decade ago. It has become a threat to human security.
(2) Future Target
At the Okinawa Summit, G8 members endorsed the global target: Reduce the number of HIV/AIDS infected young people by 25 per cent by 2010 (UN Secretary General Report to the General Assembly on 27 March 2000).
(3) Priority Areas
There are three core priorities in the fight against HIV/AIDS: (1) preventing the spread of HIV/AIDS, (2) providing care and support to those infected and affected by HIV/AIDS, and (3) enhancing research and development for international public goods.
Preventing the spread of HIV
We should continue to focus on the preventive measures that have proven to be effective. Those include:
- Promotion of healthy and safer sexual behaviors, especially among young people;
- Ready access to the essential commodities for prevention; 4
- Prevention of mother to child transmission especially in countries and regions where prevalence of HIV infection among pregnant women is high;
- Voluntary counseling and testing;
- Treatment of STI (Sexually Transmitted Infection);
- Control measures for those most at risk for HIV;
- Safe blood transfusion; and
- Prevention of transmission related to substance abuse.
Among the above, increasing emphasis will be placed on the prevention of mother-to-child transmission as part of a comprehensive prevention package. A recent expert meeting at WHO Geneva has confirmed the safety and effectiveness of antiretrovial (ARV) regimens that prevent HIV transmission from mother to child and recommended their use on a large scale. Research is underway on strategies for feeding of infants born to HIV+ mothers.
We believe that those interventions will not be successful unless they are implemented with an understanding of the social and economic factors that determine both behavior and the response to the epidemic. Thus, priority should be given to efforts that address social stigma/disclosure issues, alcohol and drug use, role of the family and non-formal health care, development and testing of educational materials, and social acceptability of interventions, including vaccines, barrier technologies, and voluntary counseling and testing.
Providing care and support to those infected and affected by HIV/AIDS
While prevention must remain a priority, there is a need to plan for and mitigate the impact of the epidemic. Priorities in this area include:
- Strengthened health system to ensure people with HIV/AIDS with access to care and treatment;
- Sustainable supply of essential commodities for care and support 5 including opportunistic infections control caused by HIV infection; and
- Social support for those affected by the disease such as AIDS orphans.
Increasing attention is placed on the recent initiative for public-private partnership by countries, pharmaceutical companies, and international foundation to make AIDS care and treatment more accessible through a comprehensive care and treatment package. This approach includes the effective and sustainable provision of affordable antiretrovirals, provision of AIDS care and treatment, and human resource development making use of existing health systems in developing countries.
Enhancing research and development for international public goods
We encourage the promotion of research and development of international public goods, including, particularly:
- HIV/ADIS preventive vaccines that are safe, effective, affordable, and appropriate for use in resource-poor settings;
- HIV/AIDS prevention products, especially microbicides;
- HIV/AIDS treatment products and regimens appropriate that are safe, effective, and affordable for use in resource-poor settings, especially for the prevention of maternal-infant transmission and the prevention and management of opportunistic infections (e.g., tuberculosis and cryptococcosis); and
- Enhanced epidemiologic research to identify at-risk populations and evaluate the effectiveness of education and prevention programs.
(4) Time Table for Actions
In June 1999, the ICPD+5 United Nations General Assembly Special Session (UNGASS) set a new internationally agreed target for addressing HIV/AIDS, and governments, UNAIDS and donors have been called upon to take the steps necessary to ensure that, by 2005:
Source: UNAIDS. 2000. The International Partnership against AIDS in Africa: A Framework for Action
(1) Current Situation
- One third of the global population is infected with TB.
- 8 million people develop active TB every year.
- TB causes nearly 2 million deaths annually.
- Over 90% of cases and deaths are in developing countries.
- 22 countries together account for 80% of global TB burden.
- Economic costs to the poor is estimated to be $12 billion per year.
- A person with TB loses on average 20-30% of annual income.
- HIV and spread of drug resistance threaten TB control. TB is the leading cause of death in people with HIV/AIDS. Multi drug resistant TB is increasing in many countries, due to poor treatment practices.
- TB in children is increasing and poses diagnostic problems especially in the context of high HIV prevalence.
- The proportion of people treated in DOTS 6 programs has increased from 1% in 1991 to 21% in 1998. At this rate the global target to treat 70% of people with infectious TB in DOTS programs will not be reached until 2012.
(2) Future Target
At the Okinawa Summit, G8 members endorsed the global target: Reduce TB death and prevalence of the disease by 50 per cent by 2010 (WHO Stop TB Initiative).
(3) Priority Areas
The immediate priority is to expand Directly Observed Therapy, Short-course (DOTS) strategy 7 of TB control for a wider population. The expansion of the strategy and its effective use require:
- Government commitment to give high priority to TB control;
- Strengthened health system to ensure every person with TB has access to treatment and cure; and
- Sustainable supply of anti-TB drugs with good quality and improved access to drugs in countries most impacted by the TB epidemic.
As the long-term priority, research should also be encouraged to develop new or improved international public goods, particularly:
- Rapid, inexpensive, diagnostic tests that are sensitive and specific for the diagnosis of Mycobacterium tuberculosis;
- New or improved anti-tuberculosis drugs and/or combination drug regimens that are effective in the treatment of Mycobacterium tuberculosis, especially multi-drug resistant tuberculosis;
- A safe, effective, affordable tuberculosis vaccine; and
- Enhanced epidemiologic research to identify at-risk populations and evaluate the effectiveness of education, treatment, and prevention programs.
(4) Time Table for Actions
Research and Development Milestones:
For 22 High Burden Countries
Based on Tuberculosis: accelerated action for poverty alleviation, Draft, 19/10/2000 (submitted by WHO for the preparation of the Okinawa International Conference for Infectious Diseases)
(1) Current Situation
- 40 per cent of the world's population is at risk of malaria.
- From 300 to 500 million people suffer from malaria each year.
- Malaria kills at least 1 million people each year.
- More than 90% of the episodes of clinical illness due to malaria and 90% of the deaths occur in Africa, mainly among young children.
- The number of people dying from malaria has been increasing over the past two decades.
- The deterioration and failure of health systems, growing drug and insecticide resistance, environmental changes and human migration which have led to an increase in epidemics all contribute to the worsening global malaria problem.
- Malaria has slowed economic growth in African countries by 1.3 percent per year; as a result of the compounded effect over 35 years, the GDP for African countries is now up to 32 percent lower than it would have been in the absence of malaria.
(2) Future Target
At the Okinawa Summit, G8 members endorsed the global target: Reduce the burden of disease associated with malaria by 50 per cent by 2010 (Roll Back Malaria).
(3) Priority Areas
It is recognized that the priorities in malaria control today are:
- Rapid diagnosis and effective treatment both at family and community levels for uncomplicated cases and in public and private health facilities for more serious cases;
- Prevention through use of insecticide-treated bednets;
- Providing malaria prevention and treatment to pregnant women;
- Early detection of malaria outbreaks and effective and prompt response; and
- Development of new or improved methods to control malaria transmission and prevent disease, including drugs, vector control strategies and vaccines. In view of the increasing levels of parasite resistance to antimalarial drugs currently in use, there is an urgent need to optimize the use of existing drugs and to develop new antimalarial compounds.
In addition, we also support the new multi-sectoral approach to fight against malaria, which incorporates viewpoints on malaria prevention in operations of various development programs including infrastructure, agriculture, and education programs.
Research should be encouraged to develop new or improved international public goods, particularly:
- Improved diagnostic tests suitable for use in resource-poor settings;
- New or improved affordable drugs or combination therapies that are safe and effective in the chemoprophylaxis and treatment of malaria, particularly drug-resistant malaria;
- Safe, effective, affordable malaria vaccines to protect against infection (sporozoite, merozoite) and transmission (gametocyte) vaccines against falciparum and vivax malaria;
- Innovative and environmentally safe methods to control mosquito vector populations; and
- Enhanced epidemiologic research to identify epidemics and evaluate the effectiveness of education, treatment, and prevention programs.
(4) Time Table for Actions
In April 2000, Africa's heads-of-state at the Abuja Summit on Roll Back Malaria set new internationally agreed upon targets for addressing malaria in the Africa region. Governments and donors have been called upon to initiate appropriate and sustainable action to strengthen the health system to ensure that by the year 2005:
Other regions of the world affected by malaria hae set similar targets for the prevention and control of malaria.
Agenda for Action: Tackling the Major Infectious Diseases
Working to the timetable requires a result-oriented agenda for actions for G8 members. Without establishing any G8 structures, the G8 commits itself to:
- mobilizing additional resources for tackling infectious diseases commensurate with increases in the capacity and strength of health systems to tackle the major infectious diseases effectively.
- improving co-ordination of the G8 members with governments, the UN, MDBs and other donors and civil society to ensure that international support for tackling infectious diseases unites around country-driven policies and strategies. Our support will build upon and support existing country level development policies, poverty reduction strategies, medium-term expenditure plans and sector programs fostering national government ownership.
- increasing the long term security of basic commodities needed to address major infectious diseases. The partnership will aim to ensure that no country will fail to achieve its objectives of tackling these diseases through a lack of key affordable commodities.
- ensuring necessary financial and technical support for building capacity and strengthening national systems to deliver appropriate interventions. In recognition of the critical role that local communities and civil society must play in slowing down the epidemics of major infectious diseases, we will seek to ensure that capacity building, nationally and locally forms a key part of international development support.
- increasing incentives for the development of international public goods according to the priorities for vaccines, drugs and diagnostics set out in the Chairman's Summary.
- challenging the UN system to increase its support for national capacity building, and to develop within its own membership a shared agenda and well-defined roles and responsibilities for tackling infectious diseases.
- reviewing the impact of the global and national dimensions of this new partnership and progress towards the international targets and targets set by countries. This will not duplicate monitoring towards achievement of the international development targets undertaken by the UN. These reviews will also provide an opportunity to track resource flows from G8-members and the functioning of the partnership that we have proposed. In addition, an early and broad consultations with respective developing country government is necessary for G8 on ways to carry forward this agenda in line with country-driven priorities.
- dynamic mechanisms, as proposed, should bring current international initiatives (Stop TB, RBM ,GAVI etc) into the framework of this partnership with a purpose of working to achieve a common infectious disease agenda, learning from these initiatives and integrating efforts for outcome-based health systems in the public and private sectors. To this end, further work should be done to deepen our understanding of partnership mechanisms prior to Genoa.
- encouraging and where appropriate, assisting South-South cooperation to address infectious diseases in various areas, inter alia human resources development and institution building, placement of experts, exchange of information and networking.
Financial Commitment by the G8
To achieve the targets endorsed by the G8, we will also seek the financial commitment from the G8 members, along with intensive efforts in the fight against infectious and parasitic diseases.
Japan: At the Kyushu-Okinawa G8 Summit, Japan announced the "Okinawa ID initiative (IDI)" for enhancing its assistance, with the target of allocating a total of US$ 3 billion over the next 5 years, for measures against infectious and parasitic diseases (such as HIV/AIDS, TB, malaria/parasitic diseases and polio), as well as those for the improvement of public health, the development of research networks, basic education, and the access to safe water. In the framework of the IDI, Japan has accelerated its actions in these areas in this fiscal year and more than US$ 300 million financial commitments and other various assistance have been decided and implemented as of today. To further strengthen the efforts to achieve the target, a new grant aid item on bilateral basis is under consideration in the FY2001 budget appropriation for being specifically allocated to infectious diseases as one of the priority areas. In addition, Japan decided to implement infectious disease control projects that amount to about US$ 10 million through the "Trust Fund for Human Security" established in the United Nations to strengthen its support to the national NGO activities.
France: France has been involved in fight against infectious diseases in developing countries for a long time, both in bilateral and multilateral cooperations. Beside support to health systems, France currently spends 100 million French francs a year on HIV/AIDS and 50 million on malaria. We should increase our fight against AIDS, through programs that will support global approach, from information to access to ARV drugs, through the International Therapeutic Solidarity Fund, including prevention and care of opportunistic infections. Support to clinical and therapeutic research in developing countries will continue. France is the most important multilateral contributor per capita income to the European development funding. The European Union (Commission and Member States) is the first sponsor worldwide of public development assistance including to health. In the framework of the HIPC initiative, many developing countries should benefit from poverty reduction programs that will help them in supporting their health system and fighting against infectious diseases. France should contribute to this initiative up to 10 billion euros and will help developing countries through "debt reduction and development contracts."
United States of America: In Okinawa, the U.S. committed to increasing funding for HIV/AIDS, malaria, TB and other infectious diseases that disproportionately affect the developing world. The Fiscal Year 2001 international budget for Infectious Diseases and Child Survival is over $1.2 billion. This reflects a near doubling of funding for international HIV/AIDS programs to $466 million (pending final Congressional action), through a multi-agency effort, including the U.S. Agency for International Development (USAID), Centers for Diseases Control and Prevention (CDC), the Department of Labor, and the Department of Defense. This funding emphasizes prevention, education, care of those affected by AIDS, including orphans, and infrastructure development. In addition, the U.S. has nearly tripled its tuberculosis funding to $60 million and doubled its malaria funding to $50 million. The U.S. also anticipates providing more than $120 million (TBD) to eradicate polio, and another $525 million for other child survival disease programs including $50 million for the Global Alliance on Vaccines and Immunizations (GAVI). On the research side - through the National Institutes of Health (NIH) - the U.S. is investing this year: more than $2.1 billion on AIDS research, including more than $260 million on the development of an AIDS vaccine; approximately $55 million on malaria research; and $86 million on TB research.
United Kingdom: In 1999-2000 UK spent $488 million on tackling the health problems of the poorest. $354 million was spent through DFID's bilateral programmes and $134 million centrally through multilateral agencies, including the World Bank, WHO, UNAIDS and UNFPA. It is difficult to separate DFID spending according to different themes because the UK's approach is to develop long term, sustainable health systems. DFID spending on SWAPs and other health systems development initiatives contributes to the fight against the communicable diseases of the poor in a way which is difficult to measure. The following is an indicative breakdown of DFID spending for 1999-2000.
Total DFID Health Spend 1999/2000: $488 million
Spending priorities include:
Reproductive and Sexual Health $84 million
Health Sector Reform/Health Care Management $65 million
Health Care in Unstable Areas $78 million
Environmental Health $60 million
Communicable Disease $131 million
In addition in the next 3 years DFID central health spending through multilateral and other channels will double, mostly due to an increased focus on communicable diseases. Furthermore, the UK is prepared to consider additional resources for tackling infectious diseases, if the international community, and in particular the UN agencies, can demonstrate improved and better coordination at country level in support of national leadership to deliver this agenda. The most significant increase in DFID health spending will be in response to the HIV/AIDS epidemic. In addition, the UK provides significant research and development funding into communicable disease through other developmental budgets that are not reflected here. Lastly the UK is a significant contributor to the EC European Development Fund.
Germany: Germany is committing its bilateral assistance based on country cooperation strategies agreed upon with cooperation partners annually or biannually. The volume of programs related to infectious diseases therefore highly depends on priorities set by individual countries. In the year 2000 projects which aim at strengthening the health service delivery in partner countries will reach a volume of around 250 Mio DM. This also includes Malaria and TB specific activities. AIDS related bilateral funding in developing countries increased from 35 Mio DM in 1999 to 102 Mio DM in 2000 and is expected to reach 140 Mio DM in 2001. In addition to that, Germany supports through its regular contributions the AIDS related programs of the EC and of multilateral organizations, including UNAIDS with 2,5 Mio DM in 2000 and contributions in the same order of magnitude for the coming year.
Italy: Italy is paying growing attention to health as an important outcome of development policies and programs. Italy privileges an integrated approach to health, rather than a disease oriented one. Resources are used according to partner country's plans and priorities and mainly follow a sector wide approach. Resources allocated for the improvement of health for the present triennium (2000-2002) sum up to about US $ 400 millions. This includes approximately US $30 millions specifically directed to support health systems in the fight against infectious diseases. Additional, important, however non easily quantifiable resources for health are included in "Poverty reduction programmes" and other intersectoral initiatives, voluntary contributions to UN and other multilateral organization as well as in Humanitarian interventions and NGO promoted projects with substantial ODA contributions.
Canada: In September 2000, Canada's Minister for International Cooperation, Maria Minna, announced the Canadian International Development Agency's new Framework for Social Development Priorities, that includes Health and Nutrition and HIV/AIDS. Over the next five years, Canada will double its annual funding to health, nutrition, water and sanitation programs from CA$ 150 million to 305 million per year (total 5yr. CA$ 1,213 million) and quadruple funding to HIV/AIDS programs from CA$ 20 million to 80 million per year (total 5 yr. CA$ 270 million). As part of the Social Development Priorities, CIDA is working with partners on a grant this year for the Global TB Drug Fund to procure anti-TB drugs for needy countries.
Russia: In spite of a difficult economic situation the Russian Federation within the last years was able to pay its contributions liabilities to the WHO regular budget-the sum of more than US$ 120 million. In 1997, 1999 and 2000 the Russian Federation paid US$500,000 a year as voluntary contributions to UNAIDS budget. The Russian Federation is ready to:
- provide material, technological and intellectual potential of research institutions and experts for solving global tasks of infectious diseases control,
- provide training of experts in malaria diagnostics, treatment and prevention for developing countries,
- supply (as part of its annual WHO and UNAIDS contribution) diagnostic test-systems, laboratory equipment, drugs (more than 20 high quality products) to developing countries at the cost 2-2.5 times lower than average world prices.
In order to accomplish the WHO strategic plan on global poliomyelitis eradication by the year of 2005, the Russian Federation may participate in vaccine shipment campaign, supplying various international organizations with Russian polio vaccine on a for-fee basis. The vaccine is manufactured at the Chumakov Research Institute of Poliomyelitis and Viral Encephalitis of the Russian Academy of Medical Sciences. In this connection, we could additionally increase production of live polio vaccine up to 30-40 million doses per year provided that the market for this project is ensured, and continue the vaccine supply until the total eradication of poliomyelitis and the termination of polio immunization process.
European Commission: The EC is committing an average of 500-700 million Euro per year on health, aids and population, and will continue to increase this commitment year after year. This amount comes in addition to the substantial effort of debt relief through the HIPC trust fund. The EC will also make specific efforts to accelerate spending in relation to action in favour of confronting the three main diseases. In addition, the EC is committed to enhancing technical assistance for the implementation of the WTO TRIPS agreement. The forthcoming programming exercise in developing countries and regions will take the communicable disease problems more into account and our partnership arrangements will be strengthened and improved. Spending related to the three diseases on Research and Development out of the 5th EC R&D Framework Programme should exceed 130 million Euro by the end of 2002.
1 Children and young adults implies ages from 0 to 44 years old. World Health Organization. 1999. Removing Obstacles to Health Development
2 Marco Ferroni. 2000. Reforming Foreign Aid: The Role of International Public Goods. OED Working paper Series No.4. World Bank.
3 There is a partnership initiative called the International School Health Initiative (ISHI). ISHI is an action-oriented partnership that focuses specifically on promoting the quality of school health and nutrition programs. Partners include MDBs such as the World Bank, the UN-agencies such as WHO and PAHO, major bilateral agencies such as USAID, and international NGOs such as Save the Children and the Partnership for Child Development (PCD), the leading technical NGO working in this area (which is partially-financed by the World Bank).
4 The essential commodities for preventing HIV/AIDS are 1) male and female condoms, 2) testing kits for voluntary counseling and testing, 3) drugs for treating sexually transmitted infections, 4) commodities for strengthening blood banks eg HIV test kits, 5) drugs for preventing mother to child transmission and diagnostic tests. UNAIDS. 2000. HIV/AIDS commodity security for Sub-Saharan Africa.
5 The essential commodities for care and support are 1) basic drugs for palliative care and treatment for pneumonia, diarrhoea, oesophageal thrush, oral thrush, vaginal candidasis and pulmonary tuberculosis, 2) drugs to prevent infection using cotrimoxazole prophylaxis for symptomatic HIV positive people. UNAIDS. 2000. HIV/AIDS commodity security for Sub-Saharan Africa.
6 DOTS, the internationally recommended strategy to control TB, is a package to ensure accurate diagnosis and successful treatment of people with TB.
7 DOTS strategy has five key components: 1) Governments commitment to sustained TB control activities, 2) Case detection by sputum smear microscopy, 3) Standardized treatment regimen of six to eight months, 4) A regular, uninterrupted supply of all essential anti-TB drugs, 5) A standardized recording and reporting system.
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