“We must not fail on SDGs. The consequences of failure will be profound for people and the planet. Michel Sidibé, who served as the Executive Director of UNAIDS for over a decade, until early this year emphasises in this interview with our Special Edition Guest Editor reGina Jane Jere.
Michel Sidibé is renowned for his people-centred approach to health and development and his uncompromising advocacy for social justice. During his tenure at UNAIDS, Sidibé (now Minister of Health and Social Affairs in Mali), drove remarkable progress in the HIV/Aids response, which saw a 170% increase in the number of people accessing antiretroviral therapy, from 8m in 2010 to 21.7m in 2017. There was also a 45% drop in Aids-related deaths, from 1.7m in 2008 to 940,000 in 2017, while new HIV infections declined by 22%, from 2.3m in 2008 to 1.8m in 2017.
Q: Let me first take you back to when you were Executive Director at UNAIDS. During that time you told us in one of our interviews that you are an ‘incorrigible optimist’. When you reflect back, do you still remain that positive and think that by 2030, things are going to be as you had hoped?
Sidibé: I am an optimist by nature, so certainly I remain optimistic. But I am also a realist. We are three years into the SDGs and most of the health-related goals are still off-track in most countries. Within months of the SDGs being adopted in 2015, I had a global strategy agreed for UNAIDS which was organised around the SDG framework and identified ways to work, not just on SDG 3.3 on ending AIDS, TB and malaria, but also on other health, gender, and institutional targets – with an integrated and holistic approach. Too many organisations and countries are talking SDGs, but not yet doing things differently enough.
But we still have 12 years and I am convinced that we can make a success of it. Actually, we must not fail. The consequences of failure will be profound for people and the planet.
What gives you most cause for concern in the current dispensation?
My concern, as I have just said regarding the SDGs, is that the challenges we face are interlinked, and we need to address them in a similar way. However, the foremost challenges facing the world today are arguably, climate breakdown – and here in Mali we are on the sharp edge of it; the erosion of democratic norms and institutions – such as those linked to the use of big data to undermine democratic processes and in the curtailment of civic and political liberties and established human rights; and I will also mention that the level of inequality is unprecedented in the modern era.
The fight against Aids on the continent can be considered a success. And you played a major role when you led UNAIDS. What do you attribute this to?
First of all, let me state for the record that Aids is not over, there are miles to go. And Aids can be used as a metaphor – that the struggle for social justice is never over; this is perhaps the central lesson from the Aids response.
That said, let’s remind ourselves that Aids was symptomatic of and reflected western misconceptions about Africa – that Africa was a basket case, that it was dependent, that it had no resources.
So, yes, progress in the Aids response proved all the naysayers wrong – Africans can indeed tell the time, we can take our pills, we can undertake domestic manufacturing of drugs, we can mount effective treatment and prevention programmes, we can mobilise domestic resources.
And what are the lessons learned from HIV/Aids control, that can be adapted elsewhere?
There are many lessons from the HIV/Aids response that are transferable and are being transferred. I remember when I took over as head of UNAIDS, only 7m people were receiving treatment worldwide. Today, we have more people undergoing treatment than people waiting for treatment. In Africa, we did not even have 50,000 people under treatment. Today, we have more than 14m people being treated across the continent.
South Africa was completely dependent on external funding. Today, South Africa is putting almost $2bn of its own budget towards HIV/Aids and despite its past history, it now has the biggest programme of treatment in the world.
However, looking at the overall scenario, health reforms and outcomes must be people-centred and there need to be community-led services. Authorities must break down silos and provide integrated services and programmes, which also have a gender lens and a human rights-based approach. More also needs to happen in terms of having a global strategy driven by a leading institution, backed by political commitment, including at the UN General Assembly level. Then there needs to be a robust monitoring system which also supports communities, and holds governments to account.
Importantly too, success stories should not lead to us dropping our guard.
So from your experience, what is the best approach to radically transform health outcomes?
I have stated a number of important elements in relation to the progress of the AIDS response, but let me just add: we can’t treat our way out of health challenges. We must therefore refocus our efforts on the main original determinants. But such a re-focussing on prevention needs leadership. Right now we are all too biomedically focused: what we need is fresh institutional leadership to drive the agenda, both at country and regional levels. And if we are to transform the lives of billions, we need to invest in communities, we need to support them, and we need to link them to systems and services that support their needs.
Take the example of Rwanda, where they are using drones to drop vaccines or blood in remote areas. We need to tap into this innovative approach to reduce our delivery costs, to change our approach and so reach people where they are, to quicken the pace of action in some cases, and bring in more transparency in how to manage services. For me, this is very important.
Let me state for the record that Aids is not over, there are miles to go. And Aids can be used as a metaphor – that the struggle for social justice is never over.
But Honourable Minister, supporting ordinary people’s needs also comes with respecting their rights and you are quite outspoken on human rights, and have even advocated for gay rights and those of sex workers. Now you are back in Mali as a government minister, a country with a hardline stance on these issues and a country which still performs harmful cultural practices, such as girl-child fattening and FGM. How do you reconcile your social advocacy, and what is happening in your country?
My view is always that you can never be a successful society by excluding people. When we are talking about fighting stigma, discrimination, it is not just a story, it is about bringing equality, it is about completely balancing the opportunities for people, and leaving no one behind. It is about giving everyone a chance to have access to services. But you don’t transform society by just using slogans. Having led the fight against HIV/Aids for almost the last 20 years, one of the first things that I learnt was the importance of breaking the conspiracy of silence.
People don’t like to talk about the issues you are mentioning. We really need to work on bringing in societal dimensions, which have an inclusive approach. We can do this by bringing in gate-keepers, such as our cultural and religious leaders, and make them understand, for example, the importance of keeping girls at school. In Mali we are working on protecting these rights and addressing the social problems created, but we need local and global advocacy, to foster political courage.
Specifically in the case of Mali, where you are now the Minister of Health and Social Affairs, what are the main challenges of a country with limited financial resources and in a region that has experienced instability – social and political – as well as considerable insecurity? And what are you doing about it?
The security crisis in north-central Mali has been catastrophic for our country, and has led to the deterioration of the health system and infrastructure. We have had the theft of medical equipment, and death threats to medical staff, leading to the formation of medical deserts in the region.
Since I took office, we having been working to restore hope to our people and to strengthen the bonds of trust between citizens and public authorities by substantially contributing to the provision of basic and essential services, reaching people where they are, and making health a vehicle for peace and reconciliation. But we need to stop the violence and completely change our service delivery systems.
We must also realise that we cannot win or transform our country, without putting young people at the forefront. We need to not only create hope and a lasting solution for them, but ensure they don’t feel they are just passive beneficiaries of our programme but agents of change.
Talking about tangible solutions, many believe the private sector is key, and you have also been vocal that its role in investing in the health sector should be bigger. But where does the impetus really lie?
Let’s be honest, in the 21st century, the extent to which we live in good or ill health, the extent to which we die young or old, here in Mali or anywhere in this world, depends overwhelmingly on the actions of the private sector. Only the foolish would not consider the private sector a key partner in health. Whether they like it or not, the private sector plays a hugely important role in people’s health and well-being.
The question therefore is, how can we get the private sector to play the most beneficial role possible and how can negatives be minimised?
For me, we need to move beyond thinking of the private sector as a pathway of benevolent resources. Instead, we must encourage and enable the private sector to share responsibility in creating a just and fair society that works for everyone, not just for the few. My son is in private finance, so I am aware of that potential. We also need the development banks and sovereign wealth funds and others to crowd in blended finance.
What about the role of African business, for example the recently launched African Business Coalition for Health, which the likes of Aliko Dangote are involved in?
I strongly welcome the idea and I think African business getting involved in the continent’s health is very important.
But what is also very important is that as governments and leaders, we should understand the need to create an enabling environment. We need to have a normative function, which will really help to attract private sector investments, and that should be done not in a hectic or rushed way but with strategy visions, which also tap into new innovations.
When you look at today’s artificial intelligence, when you look at telemedicine, when you look at all the things that are happening, they are not necessarily happening in government places, they are happening in the private sector, so we need to create that space. And to do so, we must convince shareholders and others about the return on investing in health.
That said – but also, when you were with UNAIDS – you emphasised the need for Africa to move away from its dependency on foreign aid to fund its health plans. Financing for health in Africa is very aid-dependent. You have also mentioned in the past, the paucity of health research in Africa. How can we progress or move on from this dependency?
You have touched an issue that is very close to my heart. Firstly, it is very important that we understand that health is not just about disease. It is about building a healthy society. Without healthy societies, Africa cannot build healthy economies. For me this is critical. But to really build a healthy society you need to have sustainable frameworks and be health self-reliant.
Financial dependency is a very serious concern. For example, 80% of people who have HIV in Africa, are receiving treatment funded from resources coming from outside. Africa also has one of the biggest burdens of disease, and yet we produce only 3% of the medicines that we consume.
So we cannot sustain the future with this type of status quo and it is a potential crisis. That is not to say global solidarity and support is not important. But we need to really start mobilising, like we are doing with the private sector, and come up with local resources and solutions, looking into our budget inputs and making sure that governments invest more. If we do not re-define our resource base on health, we will never be able sustain anything.
So, where does leadership come in, because you have also talked about political commitments and political will? With the failure to actually finance our own development, including in health – as we are discussing – what is it that you, as government officials, are not getting right?
I think we have a serious problem, and let me tell you this: We generally see health as a cost and expenditure. We do not see health as an investment.
We have to be realistic; we have to be honest; we need to make sure that we have a broad and transparent system, and better-managed resources.
For a while now, there has been quite a lot of emphasis put on HIV, TB and malaria – rightly so, but there is also evidence that deaths from the non-communicable diseases such as diabetes, cancer or high blood pressure are actually on the increase. What are your views?
My view is very clear. You cannot walk on one leg. It is very important for Africa to also pay attention to non-communicable diseases. These are expensive diseases to treat. And this is why, as I said earlier, there has to be a shift in how we talk about health in our societies. This includes educating our societies about the importance of a healthy lifestyle, changing mindsets and talking more about good nutrition, exercise and even sanitation.