HIV/AIDS Resource Tracking: Lessons learned and next steps

Prepared for: Fourth Global National Health Accounts Symposium 7-8 July Barcelona, Spain Paul R. De Lay Director of Evaluation UNAIDS

The AIDS epidemic The role for national spending assessments

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Rapidly increasing resources

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Performance based disbursements

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Non-health interventions

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Need for broad health sector strengthening

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Chronic care with increasingly complex and expensive regimens

HIV/AIDS Spending Low- & Middle-Income Countries, 1996-2004 (US$ disbursements in millions) 5,000 4,500 4,000 3,500 National International NGOs 3,000 2,500 2,000 World Bank loans* UN System Bilateral 1,500 1,000 500 0 19 96 19 97 19 98 19 99 20 00 20 01 20 02 20 03 20 04

*Grant component of concessional loans.

* Grant component of concessional loan disbursements.

* Does not include GF or Foundation data

Key Issues

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History of UNAIDS involvement

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Recent estimates for resources needed and resources available

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The critical role for national spending assessments (including National Health Accounts)

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Challenges and future directions

The Role of UNAIDS in Estimating Resource Needs Ongoing estimation process since 2001

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June 2001- Prepared for UNGASS – $10 billion by 2005 ($4.8 prevention, $4.8 treatment)

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Nov 2002- Post Barcelona- project out to 2007 (include UP, PEP, med injections ($10.5 in 2005 and $15.2 in 2007)

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July 2004- Used 3X5 public health model, decrease in ARV prices, OI Rx, PEP, nutritional support, increased T&C, included gap analysis ($11.6 2005 and $19.9 in 2007)

What is new about these latest estimates

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Additional activities are included

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Increase range of activities for prevention, care, treatment, OVC support, including blood safety, PEP, universal precautions, provider initiated testing

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Defines coverage based on type of epidemic (low prevalence, concentrated, generalized)

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Includes programme and human resource costs

Prevention Related Activities

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Mass media Community mobilization Voluntary counselling and testing Youth in school Youth out of school Programmes focused on sex workers and their clients Programmes focused on MSM Harm reduction programmes for IDU Workplace Prevention programs for people living with HIV

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Special populations Condom social marketing Public and commercial sector condom provision Improving management of STI Prevention of mother-to-child transmission Blood safety Post-exposure prophylaxis (health care setting, rape) Safe medical injections Universal precautions

Coverage by type of epidemic

Vulnerable populations AIDS education for primary and secondary students

Programmes focused on MSM Low level

30%

Programmes focused on out-of-school youth (6-15) 10% Programmes focused on sex workers and clients 80% 80% Harm reduction programmes for IDU Prevention for people living with HIV Workplace prevention 80% 80% 0% Concentrated Generalized

45%

20% 80% 80% 80% 80% 3%

100%

50% 80% 80% 80% 80% 50% Source: Resource Needs for an Expanded Response to AIDS in Low and Middle Income Countries. UNAIDS, 2005. Table 2.

Total treatment and care resource needs and ART coverage

US$ million 2006 2007 2008 2009 2010

Coverage ART

55% 67% 75% 79% 80%

Million People

3.0 4.8 6.6 8.3 9.8

Total Resources 2 986 4 029 5 250

- -

Source: Resource Needs for an Expanded Response to AIDS in Low and Middle Income Countries. UNAIDS, 2005. Table 5.

AIDS Resource Needs

US$ billion

2006 2007 2008 Prevention Treatment and care OVC

8.4 3.0 1.6 10.0 4.0 2.1 11.4 5.3 2.7

Programme costs Human resources

1.5 0.4 1.4 0.6 1.8 0.9

Total 14.9 18.1 22.1

* The totals for 2006-2008 have been rounded to the first decimal place with the result that there may be small differences with the figures for sub-totals in the text because of rounding.

Total for 2006-2008 * 29.8 12.3 6.4 4.7 1.9 55.1

Source: Resource Needs for an Expanded Response to AIDS in Low and Middle Income Countries. UNAIDS, 2005. Table 1.

Projection of available resources for AIDS from all sources between 2004 & 2007 Projected Resources Available from International Sources = US$7 billion in 2007 2004 Estimated International Resources Available = US$3.7 billion

2004 Estimated Resources Available 2005 Projected Resources Available 2006 Projected Resources Available 2007 Projected Resources Available

Figure 1

2004 Direct Bilateral Donor Commitments to Recipient Countries for HIV and AIDS

(Global Fund and international research was not included) ***

Other DAC country members

Others: includes direct reports Australia, Finland, Ireland, Sweden & Switzerland, and estimates for Austria, Belgium, Denmark, Greece, Luxembourg, Netherlands, New Zealand, Norway, Portugal and Spain.

Japan: 2004 information on commitments was still incomplete, thus these are UNAIDS estimates.

UK: Preliminary estimates. The UK (DFID) holds a policy not to separate the commitments for AIDS and sexual and reproductive health. Reproductive health activities were reviewed and included if there was a substantial portion focused on AIDS.

France: These are preliminary estimates and might be revised later.

Source: Resource Needs for an Expanded Response to AIDS in Low and Middle Income Countries. UNAIDS, 2005. Figure 1.

HIV/AIDS share of the Contributions to the Global Fund From Donor Governments, Donors’ FY 2004 Germany 3.2% France 13.2% Japan 6% UK 4.2% EC 18.5% US 32.2% Canada 9.1% $856 million Other DAC 13.6%

“Others”: Includes direct reports from Australia, Finland, Ireland, Sweden & Switzerland for 2004 commitments and preliminary estimates for Austria, Belgium, Denmark, Greece, Luxembourg, Netherlands, New Zealand, Norway, Portugal and Spain.

Preliminary reports for Japan. UK figures include selected activities for Sexual and Reproductive Health and/or HIV and AIDS which contained AIDS activities.

Source: Resource Needs for an Expanded Response to AIDS in Low and Middle Income Countries. UNAIDS, 2005. Figure 2.

Projection of available resources for AIDS from all sources between 2005 and 2007

Source: Resource Needs for an Expanded Response to AIDS in Low and Middle Income Countries. UNAIDS, 2005. Figure 4.

Tracking resources at country level Major issues:

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Effectiveness of funding

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Equity of funding

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Additionality

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Impact on health and other social sectors

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External donor agendas

HIV/AIDS Expenditures in prevention and care. MEXICO 1995-2002. (Million USD$)

160 140 120 100 80 60 40 30 49

Sharper increase in care; moderate increase for prevention.

155 Prevention 34 Care 50 36 82 41 82 44 114 42 128 43 20 0 1995 1996 1997 1998 1999 2000 Source: SIDALAC/ Mexican Ministry of Health. 2001.

2001 2002

Preventive expenditure on MSM and percentage of AIDS cases among MSM

Beneficiary Analysis in concentrated epidemics

% 70.0

60.0

50.0

40.0

30.0

20.0

10.0

0.0

Preventive Expenditure on MSM

Source: SIDALAC/ UNAIDS. 2001.

AIDS Cases among MSM

HIV/AIDS Expenditures in Local Currency. Ghana, 2002-2003

100,000 80,000 60,000 40,000 20,000 0

Additionality of GFATM resources

.

WB- MAPS

Mainly USG GF 2002 2003

PUBLIC PRIVATE INTERNATIONAL

Source: SIDALAC/ UNAIDS / Ghana AIDS Commission. 2004.

Providing HIV/AIDS Prevention, Treatment and Care: A Heavy Toll on the Health Sector

50 45 40 35 30 25 20 15 10 5 0 HIV/AIDS as a share of total health expenditures, 2002 15% = US$10M Rwanda

per PLWHA US$52

17% = US$104M Kenya

US$104

43% = US$77M Zambia

US$93 Source: Abt / PHR +.

100% 80% 60% 40% 20% 0%

Is HIV/AIDS a Priority in Resource Allocation?

Rwanda 5% 33% Kenya 13% 54% Zambia 19% 75% Public Donor Public HIV/AIDS Donor General health Public Donor

There are many priorities competing for public funds Source: Abt / PHR +.

What is the money buying?

4% 5% 45% Pharmaceuticals Health adm 3% Curative care 23% 9% 4% 9% 2% 46%

Kenya

Prevention and public health programs 65%

Rwanda

Prevention and public health programs Pharmaceuticals

Source: Abt / PHR +.

85%

Zambia

Curative care Health administration

National AIDS Spending Assessments Future input from HIV-AIDS resource tracking

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Gap analysis-

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Can you subtract resources available from resource needs?

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Assessing sustainability/predictability of funding

– –

By source?

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Domestic public and private By type of expenditure?

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Commodities

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Infrastructure

National AIDS Spending Assessments Work in progress for better spending in countries

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Efficiency - bottlenecks

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Additionality – needed for Global Fund

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Tracking non-health expenditures

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Timeliness of data – “real time”

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Effectiveness – “funding for the right interventions”

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Equity – “funding for the right populations”

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Linking spending assessments with resource needs estimations