Where are the data on health spending and HIV? Understanding and using the evidence

1. Where are the data on health spending and HIV? Understanding and using the evidence Anna Vassall (PhD) HIV Modelling and Economics Group London School of Hygiene and Tropical Medicine

2. Introduction Why estimate expenditures? What do we know? Different efforts/ sources available Some patterns Key issues – the way forward Methods Analysis/ Use

3. Definitions What are we trying to measure? Expenditures not commitments/ budgets Disbursements vs. expenditures vs. ‘getting there in the end’

4. Why estimate expenditures? To assess whether countries and donors adhere to their policy commitments and are meeting the resource requirements for services for populations impacted by HIV/AIDS

5. Why estimate expenditures? Broader perspective – country level Tracking costs/ cost control Showing ‘value for money’ Sector/ institution wide – enables the planning revenues/ financial impact Evaluation (cost-effectiveness, but also resource allocation) Comprehensive planning and priority setting

6. Why estimate expenditures? Some examples – global analysis Patterns of flows for different epidemic and country settings (Izazola-Licea et al 2009) Examining what outcomes can be achieved within current expenditure projections (Barnighausen et al IAEN 2010) Assessing fungability; examining net increases in HIV/AIDS expenditures, compared to DAH funds. (Lu et al 2010)

7. Levels of data? Advocacy - Aggregate estimates of expenditures, but also an assessment of allocations by different groups/ countries Research - Detailed expenditure data possibly on specific interventions - Large datasets for cross-country analyses National policy - Breakdowns by region, different interventions, time series

8. Levels of data? Not ‘one size fits all’ but look for standardisation and complementarity Eg. micro-cost estimates used for national estimates and then validating global results global methods can feed into country planning processes

9. Sources NASA/UNAIDS Detailed country based estimates using a combination of sources Annual monitoring report – 170 countries report, supplemented by other data sources, by financing sources and categories (details to be presented later)

10. Sources UNFPA resource flows (NIDI) Survey of donors/ case studies/ projections 2008- 2010 OECD DAC/CRS Annual reporting from OECD countries, some development banks and multi-laterals, includes coding for HIV/AIDS at the aggregate and project level OECD ‘Plus’ - eg IHME/ PLAID Filling gaps, other donors, errors, unreported data

11. Where are we? • NASA • Large subset of countries (50 countries) enabling cross country analysis • Some examples of links with NHA (Kenya) • OECD-DAC/ Plus • Time series data emerging (comparable across sectors), • Likely to under-estimate HIV/AIDS expenditures/ budget support. • Private sector/NGO DAH expenditure tracking weak • Country level • Positive case studies of NASA/ NHA exercises influencing policy, • Patchwork availability of information, and linkage with government processes

12. The context: DAH funding • Overall DAH growing rapidly • 1990 – US$ 5.59 billion • 2007 – US$ 21.79 billion • Increases in both volumes and % for HIV/AIDS related DAH expenditures, until 2008 • $US 0.2 billion 1990/ $US 0.7 billion 2000/$ US 4.9 billion 2007 • Health systems support stagnated • MNH maintained %, (increasing amounts) • Tuberculosis and malaria increasing (although later than HIV/AIDS) (Ravishankar, N et al, Lancet 2009. Lu et al, Lancet 2010) All figures in 2007 US$

13. Other observations • Some shift towards poorer countries and burden of disease (SSA 9.7%- 22.7%) • Health sector suffers from large numbers of donors with specific projects. • High admin costs • Duplication • High levels of fungability in the health sector, (at the aggregate level)

14. Some issues:Methodology - Estimation • Data quality • Substantial investment in primary data collection • Donor reporting • NGO sector expenditures • Bringing disease/ health area focused efforts and broader efforts. • General/ sector budget support • I

15. Example - PEPFAR Expenditure Reporting Routine partner reporting of expenditures can provide critical data for PEPFAR field team planning and management • Provides fresh data on expenditures to capture dynamic aspects of program • Provides estimation of USG costs-per-output across program areas • Partner expenditures are mapped to outputs, by program area • Allows PEPFAR teams to identify efficient and effective programs and redirect outliers • Will ultimately support national level efforts to improve programming and efficiency

16. Sample Output from PEPFAR Expenditure Analysis: Mean USG Cost Per Client Receiving Pre-ART Care SAMPLE Cost Per Client by Cost Category (USD) $71.82 30% 38% Distribution of Costs by Category 32%

17. IssuesUse - analysis/ research Costs that achieve ‘value for money’ Understanding the links between resource allocation and outcomes in HIV programmes Additionality and complementarity Sustainability/ financial impact Amounts/modalities/processes

18. Use at the country level Country level Linking to national planning processes Timely nature Role of ‘brokers’ at the country level Not a ‘one off’ effort Incremental effort on country capacity Layered efforts (full use of NHA flexibility) Co-ordinated approach (not sellers of different products) HIV/AIDS and NHA ‘ piggy –backing’ Projections limited (MTEFs)

19. Example: GAVI use of funds to support NHA in Sudan GAVI funded the first NHA A new expanded health economics unit Indirectly supports training No previous information on private sector in Sudan or even public expenditures But perhaps does not meet immediate need, and is it sustainable?

20. Conclusions/ Way Forward HIV/ AIDS programmes will be increasingly asked to show ‘value for money’ Co-ordination of efforts (standardise not blueprint approach) Continuing support for OECD-DAC / internal donor reporting systems Long-term approach (in the same way as building HMIS or other systems)

21. London School of Hygiene and Tropical Medicine Anna. Vassall@lshtm.ac.uk