meeting ambitious art targets in tanzania: how will we...

Meeting

Ambitious ART

Targets in

Tanzania: How Will

We Pay?

Catherine Barker, Elise Lang,

& Bryant Lee

4 March, 2016

Learning Objectives

Participants will understand:

1. How to estimate ART costs

2. How HIV is financed in Tanzania

3. How Tanzania can fill the HIV funding

gap

Meeting 90-90-90 Targets

Numbers on ART in 2020 Costs(2015-2020)

Funding Gap(2015-2020)

48%

Source: Dutta A, Barker C, Kallarakal A (2015) The HIV Treatment Gap: Estimates of the Financial Resources Needed versus Available for Scale-Up of

Antiretroviral Therapy in 97 Countries from 2015 to 2020. PLoS Med 12(11): e1001907. doi:10.1371/journal.pmed.1001907

$53BCost categories:

ARVs, lab monitoring

commodities, and

facility-level

personnel and

overhead

Health Financing: Tanzania

$200

$310

$450

$690

$840

$930

$0

$200

$400

$600

$800

$1,000

$1,200

GNI per capita, Atlas method (current US$)

World Bank middle-income

1.5% of GDP: Health

sector funding gap in 2020

11.3% of government

expenditure is on health, falling

short of Abuja target of 15%

Source: National Health Accounts, World Development Indicators

48% 22% 25% 5%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Development partners Public Households Other private

Total health expenditure

Source: 2011-12 Tanzania HIV/AIDS and Malaria Indicator Survey (THMIS), National AIDS Control Program (2014)

HIV in Tanzania

1.6 million people living

with HIV

(PLHIV)

48% of PLHIV on ART

92,000 new infections each year

69,000 AIDS deaths each year

Tanzania’s HIV Targets

78,064 Deaths Averted

36,895 Infections Averted

2020

905,783 1,321,850

673,681

204,003

-

200,000

400,000

600,000

800,000

1,000,000

1,200,000

1,400,000

1,600,000

1,800,000

2016 2020

PLHIV on ART PLHIV not on ART

ART Targets ART Impacts

8,678,715 people counseled,

tested, and know their HIV status by 2020

1,646,300 males

circumcised from 2015-2017

Source: National AIDS Control Program

HIV Resource Requirement

Estimates for Tanzania

Source: HPP calculations, National Multisectoral Framework for HIV&AIDS, 2013/14 to 2017/18 (TACAIDS)

$612 $593 $595 $580 $581

$-

$200

$400

$600

$800

2013/14 2014/15 2015/16 2016/17 2017/18

USD

mill

ion

s

93% 5%

1% 1%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

% Share of HIV Financing

Donor Public OOP Insurance

Donors account for vast majority of HIV spending, but donor

support is projected to decline over time

Estimating ART Costs

Need to know…

How many people are living with

HIV, and how may this change over

time?

Who is eligible for ART?

Need for ARTConsumption-based:Estimates commodity needs based

on past consumption

Morbidity-based:Estimates commodity needs based

on need for ART, patient targets,

and standard treatment guidelines

Source: Tanzania 2015 Spectrum file

0

200,000

400,000

600,000

800,000

1,000,000

1,200,000

1,400,000

1,600,000

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020

Nu

mb

er

of

PL

HIV

eli

gib

le f

or

AR

T

2012: CD4

eligibility

raised from

200 to 350

2015: CD4

eligibility for

adults raised

from 350 to

500; all children

eligible

Setting ART Targets

Considerations in setting national coverage targets:• Past enrolment trends

• Desired health impact

• Global targets (e.g, 90-90-90)

Coverage: Percentage of people eligible for ART who will receive ART

905,783

(57% of

PLHIV)

1,072,210

(68%)

1,210,898

(78%)

1,294,112

(84%)

1,321,850

(87%)

1,579,464 1,571,189 1,559,155 1,543,526 1,525,853

-

200,000

400,000

600,000

800,000

1,000,000

1,200,000

1,400,000

1,600,000

1,800,000

2016 2017 2018 2019 2020

Nu

mb

er

of p

eo

ple

Number on ART All PLHIV

Commodities:

ARVs

Laboratory

supplies

Supply chain

(PSM)

Types of ART Costs

Service delivery:

Health workers

Site overhead

Equipment

Other supplies

Site-level

Health systems

strengthening:

Training

M&E

Infrastructure

Management

Estimating ART Commodity Unit

Costs

$160 $156 $144

$26 $24$25

$46 $44$41

$0

$50

$100

$150

$200

$250

Adults Children PMTCT

Co

st p

er

pe

rso

n p

er

ye

ar

(USD

)

ARVs Lab Supply Chain

ARVs:• Regimen unit costs

• Dosage needed per person per year

• Regimen mix

Laboratory monitoring:• Types of tests conducted

• Number of tests per year

• Cost per test

Supply chain:• Percentage of product cost

Number on ART Unit cost Total ART costs

Number eligible for ART Coverage (%)

HIV Commodity Costs

$110 $133 $160

$184 $201 $210 $19

$22

$25 $28

$29 $30

$32

$38

$46

$52 $57 $59

$-

$50

$100

$150

$200

$250

$300

$350

2015 2016 2017 2018 2019 2020

USD

Mill

ion

s

ARVs Labs PSM

Source: HPP calculations

ART Requires Investment in HRHEstimating HRH costs:

Full-time equivalents: Number of health workers needed based on how much time it takes to

deliver services

Average salaries by cadre

6,343 7,610 8,707 9,426 9,692

121,829128,381

135,450142,522

150,635

-

20,000

40,000

60,000

80,000

100,000

120,000

140,000

160,000

2016 2017 2018 2019 2020

Nu

mb

er

of H

RH

Number of HRH needed for ART

Number of HRH in Tanzania

By 2020:

6% of all health

workers needed

just for ART

$51.2 million is

needed just for the

salaries of HRH

delivering ART

JEOPARDY!

100 200

300 400

Finished!

ANSWER

100: What is “coverage”?

HOME

100: Percentage of the people

in need of ART who receive ART

ANSWER

200: What three types of ART

commodity costs did we

discuss and calculate?

HOME

200:

1. ARVs

2. Laboratory monitoring

3. Supply chain

ANSWER

300: What are the two types of

methodologies that can be

used to calculate ART

commodity costs?

HOME

300:

1. Consumption-based

2. Morbidity-based

ANSWER

400: What three things are

usually considered when

setting ART targets?

HOME

400:

1. Past enrolment

2. Health impact

3. global targets

HIV Financial Landscape

Donor ART Commodity

Financing by Source

$43 $16

$41

$85 $168

$168

$7

$-

$50

$100

$150

$200

$250

2015 2016 2017

USD

mill

ion

s

PEPFAR Global Fund Other

GOT Contribution to HIV

Commodities

$7 $8 $10

$128

$184

216

$-

$50

$100

$150

$200

$250

2015 2016 2017

USD

mill

ion

s

Domestic Donors

ART Commodity Funding Gap

$193

$226 $220

$222 $223

$193

$231

$264 $287 $299

$-

$50

$100

$150

$200

$250

$300

$350

2016 2017 2018 2019 2020

USD

mill

ion

s

Total Resources Resource Need

$76MGap

Filling the ART Funding Gap

What mechanisms or funding

sources could fill the gap?

Increased government

allocation to health

Health insurance

Earmarked tax

revenue for health

Public-private

partnerships

Development Impact

Bonds

Short-term GOT solution

8.9%

9.1%

11.3%

15%

6.0%

7.0%

8.0%

9.0%

10.0%

11.0%

12.0%

13.0%

14.0%

15.0%

16.0%

2014 2015 2016 2017 2018 2019 2020

Budget Allocation to Health

Abuja Target

This Year's Budgetary 'ASK'

$111MPurchase

Core Commodities

$104MFund Fully Functional

Supply

$65MClear MSD

Debt

GoT Budget Request for

Medicines and Health

Commodities

…reducing reliance on donors

Long Term Sustainability

Challenges:

Transparency and

Accountability

Funding mechanism

AIDS Trust Fund

Objectives:

Mobilize

Resources

Invest Strategically

Manage GrantsATF Unit

ATF Board

of TrusteesTACAIDS

Executive

Director

Vision

Mission

Goal

A Tanzania whose national HIV and AIDS response is sustainably financed.

To mobilize, manage and disburse resources to support comprehensive HIV and

AIDS interventions in Tanzania according to the national priorities.

To secure sufficient and sustainable resources, financial and in-kind, to support

comprehensive HIV and AIDS interventions in Tanzania, according to the national

priorities.

Longer-term health financing

reforms

Earmarked Taxes

• Increasing Tax Base

• Improving Collection & Administration

Ministry of Labor

$78 million from earmarked

taxes in 2013/14 for vocational

training

Ministry of Infrastructure

Collects 1.5% levy from

consumption taxes for railway

development

Longer-term health financing

reforms

Social Health Insurance

1%

21%

78%

Private Insurance NHIF/CHF Uninsured

Uninsured

• Financial Protection from Catastrophic OOP Expenses

• Pooled risk and cross-subsidization

• HIV Services Included in Benefits Packages

Longer-term health financing

reforms

Other Innovative Financing Mechanisms

• Development Impact Bonds

• Social Success Notes

SNHI

pool

Health Bond

Share Class

(25%)

Normal Investor

Share Class

(75%)

Sovereign

Infrastructure

Bond

(10yr, 12%)

JEOPARDY!

100 200

300 400

Finished!

ANSWER

100: What is a short-term

solution to filling the ART

funding gap?

HOME

100: Increase GOT budget

allocation

ANSWER

200: Name one example we

presented for an earmarked

tax?

HOME

200:

1.Ministry of Labor

$78 million from earmarked taxes in 2013/14

for vocational training

2. Ministry of Infrastructure

Collects 1.5% levy from consumption taxes

for railway development

ANSWER

300: What are the three

strategic objectives of the ATF?

HOME

300:

1. Mobilize resources

2. Invest strategically

3. Actively manage grants

ANSWER

400: What is one reason why

health insurance is a

sustainable source of financing

for HIV?

HOME

400:

1. Offers financial protection, or

2. Less dependence on donors

(costs paid for by members of

risk pool)

Tanzania has set ambitious ART targets

Estimated costs exceed estimated

resources available

Domestic resource mobilization and

sustainable financing mechanisms are

needed for HIV

Conclusion

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The Health Policy Project is a five-year cooperative agreement funded by the U.S. Agency for International

Development under Agreement No. AID-OAA-A-10-00067, beginning September 30, 2010. The project’s HIV

activities are supported by the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR). It is implemented by

Futures Group, in collaboration with CEDPA (part of Plan International USA), Futures Institute, Partners in

Population and Development, Africa Regional Office (PPD ARO), Population Reference Bureau (PRB), RTI

International, and the White Ribbon Alliance for Safe Motherhood (WRA).