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Cross-country comparison of domestic AIDS expenditure and medium-term fiscal space for AIDS programs. Stephen Resch and Robert Hecht. UNAIDS Economics Reference Group Meeting November 8-9, 2012. Objective. What proportion of AIDS spending is coming from domestic versus external sources? - PowerPoint PPT Presentation
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UNAIDS Economics Reference Group Meeting November 8-9, 2012
Stephen Resch and Robert Hecht
Cross-country comparison of domestic AIDS expenditure and medium-term fiscal space for AIDS programs
Objective
What proportion of AIDS spending is coming from domestic versus external sources?
How much more of the financial burden of AIDS programs could countries reasonably shoulder themselves?
With maximum domestic effort to support AIDS programs, what level of external resources would still be required from external sources such as PEPFAR, Global Fund, etc to meet the overall needs to operate an effective national AIDS program?
How can we monitor implementation of Partnership Frameworks agreements?
Main findings
1. Room for domestic AIDS spending to double or triple in medium term
2. Major work needed to strengthen financial information
NEEDS ESTIMATION
National strategic planning with credible resource needs estimates
EXPENDITURE TRACKING
Development and routine financial tracking to monitor PEPFAR Partnership Framework agreements
Need to improve turnaround time, completeness, comparability of ad hoc expenditure analysis (e.g. NASA, NHA)
3. More work needed to explain variation between countries in resource estimates and AIDS spending per person living with HIV/AIDS (PLWHA)
Scope of study
(1) a retrospective review of AIDS program financing, comparing countries to one another and to selected benchmarks
(2) a forward-looking analysis assessment of the potential for increasing domestic financing of AIDS programs
Twelve original PEPFAR focus countries(Over 50% of global AIDS burden)
Botswana Cote d’Ivoire Ethiopia Kenya Mozambique Namibia
Nigeria South Africa Rwanda Tanzania Uganda Zambia
Domestic AIDS Expenditure
Per PLWHATotal (millions)
Evaluating domestic effort and assessing the potential for ‘fair’ increase in domestic financing of AIDS programs1. Abuja Target for Government Health Expenditure
(and proportional increase in AIDS spending)
2. AIDS Share of Health Spending in proportion to disease burden share (measured in DALYs)
FOUR IMPORTANT CAVEATS:
Government health expenditure (GHE) is not a clean measure of domestically-sourced funding [Domestic Share of GHE ~70% (40-110%)]
Opportunity cost of increased AIDS spending / Cost-effectiveness
Consideration of downstream savings
Disease burden share may decline with ART scale up, while resource need remains
Normative benchmarks
Variation in government health spending levels
Abuja target: GHE/GGE = 15%
Issue: GHE Public Funds for Health (PFH), GHE doesn’t exclude ‘on-budget’ donor aid**
Variation in the size of resource bucket from which AIDS programs are domestically financed
• GHE per capita varies 5-fold among current LICs
• Botswana GHEpc is 2.5 times other 2 UMICs
Abuja
GDP
Which bucket of money is the appropriate reference point for evaluating domestic effort Countries vary widely in the
share of national resources flowing into downstream public resource buckets.
AIDS spending lies primarily in the health sector and could be bound by GHE level
GGE (17-48% GDP)
GHE (5-18% GGE)
GAE(1-26% GHE)What does it say about a country’s AIDS
financing effort if a health ministry allocates a relatively large portion of the health budget to AIDS, but this level of GAE is low relative to GDP, because the health budget is relatively small?
At what level of government are AIDS resource allocations determined?
Variation in government AIDS expenditure (GAE) as a share of health spending …compared to AIDS’ share of disease burden
Countries fall into 3 groups:
Kenya, Uganda & Ethiopia
(70-90%)
Namibia, Botswana, Zambia, South Africa, and Cote d’ Ivoire (29-54%)
Nigeria, Tanzania, Mozambique, Rwanda(5-12%)
Summary Indicators of Domestic Priority for AIDSUNAIDS DALY DIPI and Health Expenditure-based DIPI
Potential for increase fiscal space for AIDSThree scenarios for increasing domestic GAE
Actual = Status Quo, Abuja = (GHE/GGE=15%), DALY Share = GAE/GHE proportional to AIDS DALY share, Abuja & DALY = Maximal domestic contribution
Dom
estic
AID
S sp
endi
ng p
er P
LWH
A
Similar countries:ZAM, TZA, RWA, NAM, BWA
Similar countries:UGN
Similar countries:ZAF, NGA, ETH
Countries fell into 3 groups…
Abuja target already met, All opportunity in DALY share only
DALY share target nearly met, All opportunity in Abuja only
Opportunity for both meeting Abuja and DALY share targets
Resource needs estimates
Difficult to assess the reasonableness of this variation
Not simply explained by input price levels (GNI proxy)
Partly explained by the scale or mix of planned activities?
Inaccurate estimation or ‘gaming’?
NSP estimates, adjusted for epidemic size, vary much more than UNAIDS Investment Framework model
Scenarios for Increasing Domestic Effort:Annualized Amounts for 2012-16.
ScenarioGovernment
AIDS Expenditure
UNAIDS: $7.4 B NEEDED NSP: $9.5 B NEEDED
DOMESTIC SHARE
GAP REQUIRING EXTERNAL SUPPORT
DOMESTIC SHARE
GAP REQUIRING EXTERNAL SUPPORT
1. GROWTH $2 B 27% $5.4 21% $7.5
2. ABUJA $3 B 41% $4.4 32% $6.5
3. DALY $4.4 B 59% $3.0 46% $5.1
4. MAX (2+3) $5.2 B 70% $2.2 55% $4.3
Share of AIDS program cost covered with ‘maximum domestic effort’ (Abuja + DALY Share)
Biggest relative increase
Main findings
1. Room for domestic AIDS spending to double or triple in medium term, but need for donor support will remain
2. Major work needed to strengthen financial information
RESOURCE NEEDS ESTIMATION
ROUTINE EXPENDITURE TRACKING
3. More work needed to explain variation between countries in resource estimates and AIDS spending per person living with HIV/AIDS (PLWHA)
THANK YOU
Stephen Resch [email protected] for Health Decision ScienceHarvard School of Public Health
Robert [email protected] for Development Institute
and the R4D Team: Richard Skolnik, Toby Kasper, Theresa Ryckman, Gabrielle Partridge, Kira Thorien