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