Making smart decisions to end AIDS – an investment approach

1. Making smart decisions to end AIDS – an investment approach Mariângela Simão Rights, Gender and Community Mobilization Department

2. 2011 UN Political Declaration: concrete targets for 2015 3 5 4 1 2 Eliminate new HIV infectionsamong children and halve AIDS-related maternal deaths Halve sexual transmission 15 million people on HIV treatment Halve infections among injecting drug users Halve tuberculosis deaths among people living with HIV 7 10 9 8 6 Close the global resource gap and achieve annual investment of US$ 22-24 bn Eliminate gender inequalities and sexual violence and increase capacities of women and girls Eliminate parallel systems, for stronger integration Eliminate stigma and discrimination Eliminate travel related restrictions

3. Good progress towards 15 million people on antiretroviral treatment by 2015 Source: UNAIDS, 2012

4. Good progress towards elimination of new HIV infections among children (0–14 years) by 2015 Source: UNAIDS, 2012

5. HIV incidence: we are NOT on track to achieve the goal of reducing adult HIV infections by half by 2015 Source: UNAIDS, 2012

6. International resources for HIV have been flat since 2008 US$ billions International assistance Source: UNAIDS, 2012

7. Middle-income countries have steadily invested more of their own resources in HIV US$ billions Domestic resources in low-and middle-income countries International assistance Source: UNAIDS, 2012

8. Total resources continue to grow, but fall short of total needs US$ billions Domestic resources in low-and middle-income countries International assistance Total resources available, with estimated range Source: UNAIDS, 2012

9. Glass half empty or half full? • The evolving resource context is a threat • The evolving resource context is an opportunity “Our programme is already streamlined, but the issue of resources always comes up. We have so many dreams, but will we be able to achieve them?" Senior policy advisor Zimbabwe, March 2012 "The reduction in resources is an opportunity for us to take a step back and review whether we are really doing the right things." NAC Director Tanzania, January 2012

10. AIDS: investing strategically to maximize impact OBJECTIVES BASIC PROGRAMME ACTIVITIES Child infections & maternalmortality Keypopulations Stopping new infections Behaviour change CRITICAL ENABLERS Condoms • Social • Programme Keeping people alive Male circumcision Treatment & care SYNERGIES WITH DEVELOPMENT SECTORS

11. Critical enablers and development synergies are distinct, but on a continuum Development synergies HIV-specific (sole or primaryobjective is anHIV-related outcome) HIV-sensitive (HIV outcomeis one of manyobjectives) Critical enablers

12. A checklist for applying investment thinking

13. Value for money: doing the right things 300.000 Russian Federation Number of new HIV infections Brazil 0 1980 1990 2000 2010 Source: UNAIDS (2012)

14. Morocco: reallocation to invest where the epidemic is happening 80 Spending on HIV prevention (2008) Font size!!!!!! People acquiring HIV infection (2009) Percenetage (%) Proposed spending, National Strategic Plan for 2012–2016 0 IDU General population Sex workers and clients MSM Key populations (other) Source: Morocco Ministry of Health, National STI/HIV Programme, HIV modes of transmission in Morocco. August 2010.

15. Many countries are now applying an investment approach Latin America: • El Salvador • Guatemala Asia-Pacific: • Cambodia Eastern and Southern Africa: • Malawi • Namibia • Zimbabwe • Zambia • South Africa • Tanzania • Ethiopia Western and Central Africa: • Benin • Ghana

16. Country application: entry points and methods Countries are using a variety of entry points: • Re-programming of Global Fund grants • Joint AIDS programme reviews • Development of new national strategies, and review of existing ones Mix of analysis, advocacy and strategy: • Strategic information (MoT, NASA, SWAPs etc.) • High-level advocacy with NACs, Ministries of Health, Ministries of Finance and Plan, and Parliaments • Focused stakeholder discussion

17. Three levels of benchmarks could guide GFATM in investment-related processes • Bulk of funding directed towards core programs that directly reduce new infections, morbidity and mortality • Select critical enablers as needed to ensure a robust and sustainable response, but set high bar for impact • Invest in HIV-related interventions that support and have synergies with development goals, without crowding out core prevention and treatment interventions 1. Programs, vs. other 2. Program Areas • Ensure the right relative mix of core program interventions for a given context • Demonstrate effective targeting of new infections, morbidity and mortality • Allocations will vary by type of epidemic and country context – benchmark provides a starting point for discussion Etc. MC PMTCT ART 3. Unit Costs • Unit cost benchmarks for key interventions, pegged to appropriate economic indicator (e.g. GDP/capita) • Soft benchmarks for overall unit cost • Hard caps for critical commodity costs (e.g. ARVs)

18. Emerging Lessons and Observations • “Smart investment” is viewed by some as “just another donor-imposed approach” • Some key players exhibit the “we need more studies before we can take decisions” syndrome, which may be counterproductive • Investment approach perceived as a threat by some key partners who see the AIDS response as the road to political patronage, money, and institutional survival

19. Emerging Lessons and Observations • High-level leadership and political commitment to more strategic investment is key: including Ministries of Health, Planning, Finance, and NAC • Importance of a robust KYE/KYR analysis: recent Modes of Transmission study and a resource tracking exercise such as NASA at a minimum • Supplemental analytic work can enhance the investment case: cost-effectiveness studies, sustainable financing analyses, institutional analyses, size estimations for key populations • There is no quick fix, but there is no reason to wait: building an effective investment case requires a systematic and deliberate effort which will take time; the important thing is to begin it

20. To think about…. • What are the entry points for a new dialogue around efficiency and investment? • Are there obvious mis-matches between the epidemic and the response? • Which are the factors that make it difficult to scale up basic programme components? • How can partners help in application of the Investment Framework at the country level?