Transcript Challenges of donor funding in Zambia

Challenges in Donor Funding in
Zambia: the Example of HIV/AIDS
Funding
Preliminary observations
7/20/2015
27 May 2008
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Outline of the Presentation
 A) Health Care Financing:
1. Main Sources of Health Financing.
2. Health Financing Modalities.
3. Recent changes to the Funding Modalities.
4. Donor funding to health.
 B) Challenges of HIV/AIDS funding for the
health sector:
5. Overall
6. Procurement
7. Management information systems
 HR: talked about elsewhere…???? [Sylvia, you may have to include
a few slides on this during the workshop; you decide]
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1. Main Sources of Health Financing
MOFNP – taxes (and small? medical levy)
Households – OOP, inc. user fees*; and
(community) pre-payments.
External/donor funds – foreign taxes and
other external funds (through GIs).
Other sources:
Medical saving scheme (mining companies);
private health insurance,
other e.g., fuel contribution by Total
potentially SHI, etc
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2. Health Financing Modalities
 SWAp = GBS through MOFNP.
 SWAp = direct funding of expanded basket.
SWAp is strongly preferred by MOH.
 Vertical funding  GAVI, GF, etc. earmarked to
specific interventions in health and is on-budget.
 Parallel funding: e.g., PEPFAR, which is earmarked
to specific interventions in health and is off-budget.
 Facility and community level financing:
User fees (now in urban areas only).
Pre-payment schemes???
Other income generating activities Sylvia, maybe provide a few
examples verbally during presentation (look in PETS report if you need ideas)
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3. Changes to the Funding Modalities
 Zambia Aids Policy (2005) & Joint Assistance
Strategy for Zambia (JASZ)  defining Wider
Harmonization in Practice (WHIP).
 WHIP has involved:
Movements from project to GBS.
Interim movements were observed:
 Movement to GBS e.g., EU, DfID, etc.
 Movement away from health to other sectors e.g.,
DANIDA initially moved to education.
 Some stayed in Health e.g., Sida, DfID (replacement fund
in 2005/06) but are intending to move.
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4. Donor Funding: Average Shares of Total
Health Expenditure in 2004 (Source: NHA)
update with NHA 2007/08, if that is available…
Other Sources
3%
MoFNP
24%
Donors
38%
Employers
6%
Households
29%
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B) Challenges of HIV/AIDS funding for
the health sector:
Recall:
5. Overall
Size of the funds
Planning difficulties
Emerging difficulties in implementation
6. Procurement
New systems and implication
7. Management information systems
New systems and implication
 Add “8. Human resource” if you included some slides on HR
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5. Overall Challenges of HIV/AIDS
Funding (Size of the funds)
Donor Funding to HIV/AIDS and to Health
(Excluding USAID Off-Budget Health Spending)
PEPFAR (offbudget)
50.5%
All other donors
combined
31.0%
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USAID+CDC+
JPIEGO+SFH
2.2%
WORLD BANK,
HIV/AIDS
0.6%
GLOBAL
FUNDS
15.8%
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5. Overall Size of HIV/AIDS Funding –
cont’d
Donor Funding to HIV/AIDS and to Health (Inc.
est. of USAID Off-Budget Health Spending)
All other
donors
combined
22.7%
PEPFAR (offbudget)
37.1%
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USAID+CDC+
JPIEGO+SFH WORLD BANK, GLOBAL
FUNDS
1.8%
HIV/AIDS
11.6%
0.4%
USAID (offbudget, est.)
26.6%
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5. Overall Size of HIV/AIDS Funding –
cont’d
700.0
600.0
500.0
400.0
K billin
300.0
200.0
100.0
0.0
2005
2006
Total Health Budget
445.3
605.4
PEPFAR Treatment Budget
285.7
332.5
PEPFAR Total Budget
520.4
564.8
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5. Overall Challenges of HIV/AIDS
Funding – Cont’d
Implication of the size…:
National stewardship is potentially weakened.
Preferred SWAp (all the systems, processes,
structures, tools, etc) is potentially undermined.
Reporting allegiances are potentially formed
with funders.
Mutual accountability is potentially weakened.
Potential health systems distortions /
destabilization…
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5. Overall Challenges of HIV/AIDS
Funding – Cont’d
 Potential health systems distortions /
destabilization:
Planning cycle mismatches make coordination difficult.
Unplanned HIV/AIDS spending that shows up in health
facilities at district level make it hard for MOH to request
for supplementary budgets from MOFNP.
HR and other resource deflections (time, attention, etc)
goes to well funded programme  HIV/AIDS
 Specific health system effects
Procurement in health
Management information systems
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6. Procurement in Health
 New systems: HIV Procurement.xls, and
 How involving is HIV procurement?
MSL Products Reciveved: Setp 07 - Jan 08
ESSENTIAL
MEDICINE , 19.4
ARVs, 51.6
OTHER
SUPPLIES, 13.7
LAB ITEMS, 13.7
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HOSPITAL
EQUIP., 1.6
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6. Procurement in Health – cont’d
Implication of new procurement systems
and demands:
(+) More efficient HIV procurement systems,
e.g., less stock-outs.
(-) Coordinator difficulties, e.g., with
transportation/distribution schedules.
(-) Limited externalities  LMU has limited spillover to general health procurement (PSU).
(-) Further limitation of MOH stewardship (not
adequately involved in HIV procurement
planning).
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7. Management Information Systems
 HIS: HIV & Health Info Systems.xls, and
 How is health information generated and collected?
HMIS Information Flow
MOH HQ
CSO; MHA
Vertical/
parallel
systems
MSL
Provincil level
District level
Provincial
Health
Office
3rd & 2nd Level Hospitals
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District Health Office
District (1st) level
Hospital
NGOs,
Pvt Sector
Health Centres
: Single direction flows from one agent to another, without direct feedback obligations.
: Forward and backward flows between agents, with feedback obligations.
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7. Health information systems – cont’d
Implication of new HISs and demands:
(+) Much more information generated.
Note: HMIS has had its own weaknesses, but with HIV…
(-) Disproportionately more information for
HIV/AIDS is generated – resource deflection:
ARTIS is information heavy (combination of multiple
systems that previous existed)  extra burden for
HWs; & it has been unable to integrate with HMIS.
SMARTCare was originally for overall patient
records/HMIS, but to date ART, ANC-PMTCT & VCT
are the only automated services.
(-) Limited feedback to lower levels, does not
improve with HIV/AIDS focus info. systems.
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Recommendation for Global Partners
MOH point of view:
 Increased commitment/support to national
health systems and programmes; buy into
SWAp (joint planning, joint procurements,
integrated financing / accounting / information /
reporting / etc. systems, etc.).
 Improve information sharing about funding
amounts and timings, towards improving
predictability and fostering national
planning/priority setting.
 Full subscription by all partners to principle of
mutual accountability.
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Conclusion
Point of view of the series of studies:
 A lot has not been covered here (further research
is required…)
 From preliminary observations:
Government systems require attention.
Government is not sufficiently honouring Aduja
declaration & may be sending negative signal.
Partners are not unified: in their willingness to lose some
amount of identity; & in buying into government systems.
 Long road ahead in building HS, which will
require dialogue and like mindedness.
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Thank you for your attention,
enjoy Livingstone
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