Transcript Document

Financing HIV/Aids in South Africa
and role of major donors
Meeting to inform Council for
Foreign Relations
January 2010
Mark Blecher National Treasury
Keith Cloete WC DOH
Scale of problem
• SA has largest number of HIV infected persons in world >5m
• Largest number of persons on treatment
• Number of persons on treatment growing rapidly – will exceed
400 000 pa in 10/11
• Soon to exceed 1 mil on treatment but this will grow to over 3
million
• 400 000 new infections pa with prevention programmes not
sufficiently effective
• Highest spending of any country on HIV ….but this will need to
triple over time
• Huge implications for struggling health services
2
HIV costing
• NSP costing suggested scenarios of R11b-R13b per
annum by 2011
• New draft costing by aids2031 suggest costs could
reach R40 billion by 2030
• This includes other sectors and private – but
amounts are huge – could rise from 18% to 40% of
health budget
• And these don’t fully factor costs of lower treatment
threshold of cd4 350
• Need to continue to strive to reduce unit costs
3
NSP: Summarized total costs for
the low cost scenarios (million
Rands, 2005/06 prices)
Year
Priority area
Prevention
Goal
intervention
Reduce sexual transmission
Behavioural change interventions
Condom provision
Life skills
PEP for sexual assault
STI management
Reduce transmission through occupational exposure
PEP for occupational exposure
Care, support and health system strengthening
Scale-up access to VCT
HIV testing
Maintain health of HIV-infected adults
Antiretroviral treatment for adults
Food support for adults
Home and Community Based Care
Address the special needs of mothers and children
Antiretroviral treatment for children
OVC
PMTCT dual therapy and infant testing
Strengthen the health system
Strengthen TB programme management
Increase CHC coverage
Grand Total
2007
643
2008
792
2009
951
2010
1,098
2011
1,247
% Total
12%
642
300
145
158
10
30
1
1
790
400
152
168
10
60
1
1
949
500
172
177
11
90
1
1
1,097
600
180
186
11
120
1
1
1,245
700
188
195
12
150
1
1
12%
6%
2%
2%
0%
1%
0%
0%
4,042
5,612
6,960
8,474
10,012
88%
260
260
2,495
1,588
521
386
1,007
245
452
310
280
30
250
420
420
3,365
2,296
586
483
1,267
359
561
348
560
60
500
423
423
4,250
3,115
652
483
1,447
488
589
370
840
90
750
426
426
5,301
4,036
782
483
1,627
635
618
374
1,120
120
1,000
428
428
6,360
5,014
912
435
1,823
791
649
383
1,400
150
1,250
5%
5%
55%
40%
9%
6%
18%
6%
7%
4%
11%
1%
9%
4,685
6,404
7,910
9,572
11,259
100%
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Aids 2031 Draft scenario
Aids 2031 Draft scenario
Projected growth in number of ART patients if
80% target is met (Dorrington)
3 500 000
3 000 000
2 500 000
2 000 000
1 500 000
1 000 000
500 000
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
0
Financing
• Both graphs (cost and number of arvs) level off
• Once level off govt can fully carry costs
• However period from 2010 to 2015 is one of v rapid
scale-up
• Esp given lower treatment thresholds, move to 80%
coverage, improved prevention …..and many other
health sector issues and priorities
• Require >R2bil new funds annually during scale-up
• Difficult to sustain this level of scale-up and
simultaneously replace existing donor funding
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Some major financing
streams 09/10 approximate
R million
HIV and AIDS conditional grant
Provincial own contributions
National Department of Health (core)
Health: CG+prov own+nat own
Education CG
Social Development
Subtotal
PEPFAR
Global fund and other donors
Provinces - hospital and PHC care
Total
09/10
4,376
1,077
500
5,053
177
678
6,631
4,314
1,000
5,000
17,631
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Two broad positions of
donors
1) Middle income countries must look after themselves
or
2) Very high burden of disease middle income
countries merit support
• We support second option. SA has little need for
donors beyond HIV, but the HIV problem is very
large and difficult
• Sustainable as govt will take over funding as
treatment numbers start stabilising
• Govt has sought partnership with major donors eg
PEPFAR and Global Fund
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Major donors
• Pepfar and Global Fund have played major role in
SA
• Especially helped to build capacity through
supporting govt treatment points
• Supported large numbers of worthy projects
• Amounts are large and partnership is valuable
• Donors potentially bring technical expertise,
flexibility, support
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Problem areas
• Value for money huge amounts being spent – are we
getting best value – we may have sufficient funds if
we optimally used the combined pool
• Weak coordination between provincial and donor
funded services
• Fragmentation between large numbers of
organisations poorly coordinated
• Difficulty aligning services and funding coming via
multiple routes
• Difficulty allocating tasks and funding around a
common plan
12
Potential improvements
• Build shared commitment around common plan and
agreement on division of work –responsibilities,
services and funding
• Funding on budget (WC Global Fund) worked v well
• Would be good to develop a five year plan and clear
partnership (there is huge amount to do – scale up to
3 m on Rx)
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Western Cape case study
Scenarios for uptake of ART in the Western Cape
Province
(assuming guideline change for ART eligibility to 350 cells/µl)
40,000
Total New S4 and starting ART
35,000
30,000
25,000
20,000
15,000
Current financial year
10,000
New Stage IV - public sector estimate
Actual provision
Roundtable scenario
National model for policy change to CD4 350
Current trajectory following roundtable scenario
5,000
0
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
Background
•
The Current (Expiring) Western Cape GF Grant Programme
–
–
Round 3 (originally 5-year grant)
Sub-CCM: Western Cape Provincial AIDS Council
•
Title: Strengthening & Expanding the Western Cape HIV/AIDS Prevention,
Treatment & Care Programme
•
Four Objectives in the Grant Programme
1.
2.
3.
4.
•
ARV treatment services
Peer education HIV prevention intervention in selected secondary schools
Palliative care services
Community Based Response (small grants programme to local CBOs/NGOs)
Special circumstances of Western Cape Phase 2 Grant Programme
–
4-year Phase 2 period in respect of Objectives 1 & 3 in order to provide for a
Grant exit strategy (funding ends June 2010)
–
3-year Phase 2 period in respect of Objectives 2 & 4 (funding ended June 2009)
ARV Treatment Services – Western Cape
• Costing Model
– Revised normative staffing model for medical, nursing, pharmacy,
clerical & adherence support (NGO) staff
• Task shifting/sharing
• First year’s treatment norms vs norms for subsequent years
• 2009 public service salary scales + 7% inflator p.a.
– Revised model for patients on first & second line ARV treatment
• All patients start on first line
• Average of 0.2% per month changed to second line
– Average ARV medicine cost/patient
• In 2009: First line: R215 p.m.; Second line: R642 p.m.
• Constant unit cost/patient over RCC period
– Lab tests (NHLS): CD4 Count & Viral Load
• 6 monthly tests per patient (ART Protocol)
• Average 5% p.a. inflator over RCC period
W CAPE RCC PROPOSAL DEVELOPMENT
• Addressing Long Term Financial Sustainability
– Government’s ability to meet the funding requirements of the Western
Cape HIV/AIDS Programme (from own revenue sources) has been
seriously affected by the global economic downturn since 2008.
– Problem is likely to persist over the coming MTEF period, followed by
economic & fiscal recovery.
– RCC Proposal is therefore structured in order to:
• Request maximum possible Grant funding for Years 7 – 9
• Followed by incremental transfer of Grant Programme activities to
government funding sources in Years 10 – 12
Conclusion
• HIV treatment and prevention will need to scale up massively
over next 5 -10 years
• This has huge cost implications – spending doubling to tripling
• However ultimately sustainable as numbers and costs level off
• Partnership and support will be valuable during this period of
rapid scale-up
• There are many advantages to developing an improved
partnership arrangement over next 5+ years
• We value support that has been given and would hope to see
an ongoing and strengthened partnership for next 5 years
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