Tracking Expenditure for HIV and AIDS in Africa ~

Cross-Country Comparisons

Guthrie, T., Kioko, U.Inaugural Conference of the African Health Economics and Policy Association

Accra - Ghana, 10th - 12th March 2009PS 04/8

Objectives•Determine the total flows of financing and

expenditures for HIV/AIDS, from all international and public (domestic) sources of financing

•To identify the flow of expenditures by sources, agent, providers of services activities, and target population

•To make recommendations for improved efficiency and prioritization of HIV and AIDS spending, and for improved financial information systems.

Methodology• Review of UNGASS Indicator 1 for SSA countries

(Source: UNAIDS Global Report 2008 Annex2)• Review of Country NASA Reports for further detail:

Ghana, Botswana, Zambia, Swaziland• National AIDS Spending Assessment is an approach to

comprehensively measure:▫All spending for HIV/AIDS▫From all sources, through agents, providers, activities to

beneficiaries▫From a multi-sectoral perspective▫According to interventions reflected in the NSPs▫Allows countries to monitor their own progress towards

the national and international commitments.• Acknowledgements to UNAIDS, the NACs and NASA

team members for access to their data

Comparison of UNGASS Indicator1 - Sources of Financing for HIV/AIDS

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

SSA Low Income Countries Public and International Contributions to Spending on HIV/AIDS 2006

Internat. (av 75%)Public (av 25%)

% o

f Pu

blic

+ I

nter

nati

onal

Source: UNAIDS Global Report 2008 Annex 2

Comparison of UNGASS Indicator1 - Sources of Financing for HIV/AIDS

Cameroon Lesotho Swaziland Mauritius South Africa

Botswana0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%SSA Middle Income Countries Public and International Con-

tributions to Spending on HIV/AIDS 2006

Internat. (av 48%)Public (av 52%)

% o

f Pub

lic +

Inte

rnat

iona

l

Source: UNAIDS Global Report 2008 Annex 2

Low Middle Income Upper Middle Income

SSA Low Income Countries HIV Prevalence (%) and Spending per Capita on HIV/AIDS (2006, in current US$)

Nigeria DRC

Sene

gal

Ghana

Sierra

Leon

e

Eritre

aNige

rTo

go

Cote d'

Ivoire Mali

Burkin

a Fas

o

C.Afri

can R

epub

lic

Mozam

bique

Rwanda

Zimba

bwe

Zambia

0.00

2.00

4.00

6.00

8.00

10.00

12.00

14.00

16.00

18.00

20.00

Per Capita Spending on HIV/AIDS (US$) HIV prevalence (%)

Per Capita HIV/AIDS Spending (current US$) & HIV Prevalence (%) in Middle Income SSA Countries (2006)

Mauritius Cameroon South Africa Lesotho Swaziland Botswana

$1 $2 $13 $14

$51

$87

18.3 23.0 26.0 24.0

Per capita HIV/AIDS Spending (US$) HIV prevalence (%)

Source: UNAIDS Global Report 2008 Annex 2 (own calcs)

Using Detailed NASA dataFrom Botswana, Zambia, Swaziland, Ghana

Levels & Sources of Financing (US$m, 2006)

Botswana Swaziland Zambia Ghana -

50,000,000

100,000,000

150,000,000

200,000,000

250,000,000

Internat. Contrib. (av 58.8%)Public contrib. (av 41.2%)

Agents of HIV/AIDS Spending (US$m, 2006)

Botswan

a

Swaz

iland

Zambia

Ghana

-

50,000,000

100,000,000

150,000,000

200,000,000

250,000,000

Local (NGO / pvt) AgentsExternal AgentsPublic Agents

US$

Providers of HIV/AIDS Services (US$m, 2006)

Swaziland Zambia -

50,000,000

100,000,000

150,000,000

200,000,000

250,000,000

LNGO & other providersExternal ProvidersPublic providers

US$

AIDS Spending Activities ~ Priorities (US$m, 2006)

Ghana Botswana Zambia Swaziland0

50,000,000

100,000,000

150,000,000

200,000,000

250,000,000

Research (HIV- and AIDS-Related) Community Development & Enhanced Environment Social mitigationHuman Resource IncentivesProgrm. Devmt & Strengthen HCSOrphans and Vulnerable Children (OVC) Treatment and care components Prevention Programmes

Public Spending Categories (2003-2005)

0

100,000,000

200,000,000

300,000,000

400,000,000

500,000,000

600,000,000

700,000,000

800,000,000

900,000,000

1,000,000,000

2003 2004 2005

Pula

FN 8..HIV- and AIDS-Related Research

FN 7..Community Development &Enhanced Environment

FN 6..Social mitigation

FN 5..Human Resources for HIV andAIDS activities

FN 4..Prog.Devmt & HSS strengthening

FN 3..Orphans and Vulnerable Children(OVC)

FN 2..Treatment and care components Total

FN 1..Prevention Programmes

Botswana ~ Public Trends (Pula, 2003-2005)

Swaziland ~ HIV/AIDS Priorities by Source of Funds (SZL, 2006)

-

50,000,000

100,000,000

150,000,000

200,000,000

250,000,000

300,000,000

350,000,000

400,000,000

Public funds Internationalfunds

Total

Sources of funds

SZL

HIV and AIDS realatedresearch(Excluding operationalresearch)Enabling Environment and CommunityDevelopment

Social Protection and Social Services(EXCLUDING OVC)

Human Resources' recruitments andRetention Incentive - Human Capital

ProgrammeManagement andadministration strengthening

OVC

Care and Treatments

Prevention

Swaziland ~ funds for Programme Management by NERCHA (SZL, 2006)

-

5,000,000

10,000,000

15,000,000

20,000,000

25,000,000

30,000,000

35,000,000

40,000,000

45,000,000

50,000,000

Other sources toNERCHA

GFATM toNERCHA

TOTAL

SOURCES OF FUNDS

SZL

Upgrading and construction ofinfrastructure not elsewhereclassified (n.e.c)

Upgrading laboratoryinfrastructure and new equipment

Serological-surveillance(Serosurveillance)

Monitoring and evaluation

Planning and coordination

Transaction costs

Programme Administration

Swaziland Prevention Spending (SZL, 05/06-06/07)

-

10,000,000

20,000,000

30,000,000

40,000,000

50,000,000

60,000,000

70,000,000

2005/ 2006 2006/ 2007

YEAR

SZL

Prevention activities not elsewhere classified (n.e.c.)

Post-exposure prophylaxis (PEP)

Blood safety

Prevention of mother-to-child transmission(PMTCT)

Prevention, diagnosis and treatment of sexuallytransmitted infections (STI) (Improving managementof STI) Public and commercial sector condom provision

Prevention programmes in the workplace

Prevention of HIV transmission aimed at personsliving with HIV (PLHA)

Prevention - Youth out-of-school

Prevention - Youth in school

Risk-reduction for vulnerable and specialpopulations (Programmes for vulnerable and specialpopulations)Voluntary counselling and testing

Community mobilization

Communication for social and behavioral change

Preventio

n

CommMob

l

VCT

CondomsPMTCTBlood Safety

Swaziland ~ Social Protection spending (SZL, 05/06-06/07)

-

5,000,000

10,000,000

15,000,000

20,000,000

25,000,000

2005/ 2006 2006/ 2007

YEAR

SZL

Social protection services and social servicesnot elsewhere classified (n.e.c)

HIV-specific income generation projects

Social protection through provision of socialservices

Social protection through in-kind benefits

Social protection through monetary benefits

Swazi~ environment and community development spending (SZL, 2006/07)

-

1,000,000

2,000,000

3,000,000

4,000,000

5,000,000

6,000,000

7,000,000

Public Funds International funds Total

SOURCES OF FUNDS

SZL

Enabling environment and communitydevelopment not elsewhere classified(n.e.c)

AIDS-specific programmes focused onwomen

AIDS-specific Institutional Development

Human rights

Advocacy and strategic communication

Beneficiaries of HIV/AIDS Spending(%, 2006)

Botswana Swaziland Zambia Ghana0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

General PopulationAccessibleVulnerableMARPSPLWHA

To what Degree Does HIV/AIDS Spending Contribute to

General health systems strengthening?

Botswana HIV Spending that may Contribute to general HSS (9.83% of THAE)

Blood safety 5%

Opportunistic infection (OI) prophylaxis

80%

Opportunistic infections’ (OI)

treatment 3%

Monitoring and evaluation

9%

Upgrading laboratory in-frastructure and new

equipment 4%

HIV/AIDS Spending on HSS & General Health:Zambia 2007, 15% of THAE Swaziland, 11% of THAE

Blood safety 11%

Lab. monitorg

1%OI

treatmt 20%

M&E16%

Operatn research

2%

Upgrade lab. In-frast.&

new equipmt

32%

Other infrast.

devpmt

17%

Blood safety 1%

Safe medical inject

1% Lab.

moni-torg

14%

OVC Basic health care 17%

M&E18%

Drug

supply systems 45%

Recommendations•Need for more sustainable predictable

financing for HIV/AIDS and health•Need for increasing public agents ie. Control

of funds ~ through common funds, DBS, IHPs.•LNGOs playing important role in delivery of

HIV/AIDS services ~ need to be supported through efficient funding mechanisms

•Treatment requiring increasing share of financing, prevention and other interventions requiring increasing, especially mitigation and social protection activities

Recommendations cont.•Increase public funds for enabling

environment esp. Promotion and protection of human rights

•Improve output indicators to enable beneficiary incidence analysis

•Increase funds for MARPs and vulnerable groups

•Increase HSS funding and mechanisms (eg.IHPs) and increase allocations to HIV/AIDS activities that contribute to general HSS (eg. Blood safety, laboratories, upgrading facilities)

Recommendations cont.• Increasing alignment with NSPs, but some

donors still have own agenda, own systems ~ need harmonisation

• Increase absorptive capacity:▫Reduce donor ‘dumping’ of funds at the end of the

financial year▫Improve predictability of donor commitments, over

longer period▫Increase speed of disbursements, reduce tedious

systems, while improving public accountability systems

▫ Improve public programmatic and human resource capacity to deliver services

Recommendations cont.•Improve public financial reporting &

information systems•Routine resource tracking ~ institutionalise

NASA in M&E systems•Harmonise to 1 national system for reporting

on commitments, disbursements & spending•Civil society play greater role in monitoring

public spending & in sharing their own spending activities

•Critical to have good financial monitoring systems in place before implementing IHPs etc.

Thank YouTeresa GuthrieCentre for Economic Governance and AIDS in Africa Email: teresa@cegaa.orgTel: +27-21-425-2852Cell: +27-82-872-4694