HIV/AIDS Resource Tracking:Lessons learned and next steps

Prepared for:Fourth Global National Health Accounts Symposium

7-8 JulyBarcelona, Spain

Paul R. De LayDirector of Evaluation

UNAIDS

The AIDS epidemicThe role for national spending assessments

Rapidly increasing resources Performance based disbursements Non-health interventions Need for broad health sector strengthening Chronic care with increasingly complex and

expensive regimens

HIV/AIDS SpendingLow- & Middle-Income Countries, 1996-2004

*Grant component of concessional loans.

0

500

1,000

1,500

2,000

2,500

3,000

3,500

4,000

4,500

5,000

National

International NGOs

World Bank loans*

UN System

Bilateral

(US$ disbursements in millions)

*Grant component of concessional loan disbursements.

* Does not include GF or Foundation data

Key Issues

History of UNAIDS involvement Recent estimates for resources needed and

resources available The critical role for national spending

assessments (including National Health Accounts)

Challenges and future directions

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

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

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

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

Additional activities are included– Increase range of activities for prevention, care,

treatment, OVC support, including blood safety, PEP,

universal precautions, provider initiated testing

Defines coverage based on type of epidemic (low

prevalence, concentrated, generalized)

Includes programme and human resource costs

Prevention Related Activities

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

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

Low level Concentrated Generalized

Vulnerable populations AIDS education for primary and secondary students 30% 45% 100% Programmes focused on out-of-school youth (6-15) 10% 20% 50% Programmes focused on sex workers and clients 80% 80% 80% Programmes focused on MSM 80% 80% 80% Harm reduction programmes for IDU 80% 80% 80% Prevention for people living with HIV 80% 80% 80% Workplace prevention 0% 3% 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

Coverage ART

Million People

Total Resources

2006 55% 3.0 2 986 2007 67% 4.8 4 029 2008 75% 6.6 5 250 2009 79% 8.3 - 2010 80% 9.8 -

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

AIDS Resource Needs

* 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.

US$ billion 2006 2007 2008 Total for 2006-2008

* Prevention 8.4 10.0 11.4 29.8 Treatment and care 3.0 4.0 5.3 12.3

OVC 1.6 2.1 2.7 6.4 Programme costs 1.5 1.4 1.8 4.7 Human resources 0.4 0.6 0.9 1.9 Total 14.9 18.1 22.1 55.1

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

Figure 1

Projection of available resources for AIDS from all sources between 2004 & 2007

Private SectorMultilateral BilateralDomestic

2004 Estimated ResourcesAvailable

2005 Projected ResourcesAvailable

2

4

6

8

10

US$

Billio

ns

2007 Projected ResourcesAvailable

2006Projected ResourcesAvailable

0

Projected Resources Available from International Sources= US$7 billion in 2007

Private InternationalMultilateral BilateralDomestic

2

4

6

8

10

0

2004 EstimatedInternationalResources Available= US$3.7 billion

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.

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

(Global Fund and international research was not included)

EC (4.3%)

Canada (4.1%)

Germany (3.5%)

** Japan (3.4%)

France(0.9%)

Italy (0.5%)

*** Other DAC country members (13.1%)

$2.7 billion

US (49.6%)

UK(20.5%)

EC (4.3%)

Canada (4.1%)

Germany (3.5%)

** Japan (3.4%)

France(0.9%)

Italy (0.5%)

EC (4.3%)

Canada (4.1%)

Germany (3.5%)

** Japan (3.4%)

France(0.9%)

Italy (0.5%)

*** Other DAC country members (13.1%)

$2.7 billion

US (49.6%)

UK(20.5%)

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

$856 million

“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.

Japan 6%

Germany 3.2%

UK 4.2%

Canada 9.1%

Other DAC 13.6%

France 13.2%

EC 18.5%

US 32.2%

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 levelMajor issues:

Effectiveness of funding Equity of funding Additionality Impact on health and other social sectors External donor agendas

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

30

49

34

5036

82

41

82

44

114

42

128

43

155

0

20

40

60

80

100

120

140

160

1995 1996 1997 1998 1999 2000 2001 2002

Prevention Care

Sharper increase in care; moderate increase for prevention.

Source: SIDALAC/ Mexican Ministry of Health. 2001.

Preventive expenditure on MSM and percentage of AIDS cases among

MSM

Preventive Expenditure on MSM AIDS Cases among MSM

0.0

10.020.0

30.0

40.0

50.060.0

70.0

Argenti

na

Bolivia

Brazil

Chile

Costa

Rica

Domini

can R

El Salv

ador

Guatem

ala

Mexico

Panam

a

Paragu

ayPeru

Urugua

y

% Beneficiary Analysis in concentrated epidemics

Source: SIDALAC/ UNAIDS. 2001.

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

0

20,000

40,000

60,000

80,000

100,000M

inis

try o

fH

ealth

Oth

er C

entra

l G

over

nmen

t

NG

O’s

Hou

seho

lds

(OO

PE

)

Mul

tilat

eral

s(In

clud

ing

GFA

TM)

Bila

tera

ls

Inte

rnat

iona

lN

GO

s

2002

2003 PUBLIC PRIVATE INTERNATIONAL

CED

IS

Additionality of GFATM resources.

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

WB-- MAPS

GF

Mainly USG

05

101520253035404550

Rwanda Kenya Zambia

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

Sector

15%= US$10M

17%= US$104M

43%= US$77M

%

HIV/AIDS as a share of total health expenditures, 2002

per PLWHA US$52 US$104 US$93

Source: Abt / PHR +.

Is HIV/AIDS a Priority in Resource Allocation?

19% 75%5% 13%33% 54%Rwanda Kenya Zambia

There are many priorities competing for public funds

Source: Abt / PHR +.

0%

20%

40%

60%

80%

100%

Public Donor Public Donor Public DonorHIV/AIDS General health

Kenya Rwanda ZambiaPrevention and public health programsPharmaceuticals

Curative careHealth administration

Source: Abt / PHR +.

What is the money buying?

Pharmaceuticals3%Health adm

9%

Prevention and public health

programs65%

Curative care23% 9%

2%

4%

85%

4%

46%

5%

45%

National AIDS Spending AssessmentsFuture input from HIV-AIDS resource tracking

Gap analysis-– Can you subtract resources available from

resource needs?

Assessing sustainability/predictability of funding– By source?

• Domestic public and private– By type of expenditure?

• Commodities• Infrastructure

National AIDS Spending AssessmentsWork in progress for better spending in countries

Efficiency - bottlenecks Additionality – needed for Global Fund Tracking non-health expenditures Timeliness of data – “real time” Effectiveness – “funding for the right

interventions” Equity – “funding for the right populations” Linking spending assessments with

resource needs estimations