Teresa Guthrie M.PH (Health Economics)

1. HIV modelling for in-country ownership solutions – generation of evidence IAS Conference, Washington DC, 19-20 July 2012 Teresa Guthrie M.PH (Health Economics)

2. Rationale The Centre for Economic Governance and AIDS in Africa (CEGAA) believes that: • Governments require information to improve their estimates of need & resource requirements, their allocative decisions, to ensure efficient expenditure on effective programmes, and to promote transparency, accountability and good governance. • Civil society needs to generate evidence on quality of services, spending & hold govt accountable. • With this evidence governments can take leadership and full ownership of the national response to HIV/AIDS and TB.

3. Modelling & Collecting Data in the Fiscal Cycle DP alignment DP long-term commtmts Budget Monitoring Revenue & tax watch Assessment of Resource Need – costing analysis. Impact modelling & CEA Fin.Gap Analysis Resource Mobilisation Budget Allocations Investment Framework? Modelling HIV Epidemiological Trends, Population Projections, Scenario Building Systems for reporting: Public, Private & DPs Outcome analysis – long-term indicators. Impact assessment Execution of budget –Fin.Info systems for Expenditure Tracking. Absorption of budget/committed? Proportion DP aid spent in country? All Levels: National Provincial District Clinical Trials Cohort studies Life years saved Quality of life Reduced prevalence rates Cost Effectiveness (CEA/CBA/CUA) Analysis of Process Finance channels Intended Spending Auditing (financial) Systems-Accountability Output analysis – interim indicators. Achievement of budget Objectives? Quality? Auditing (internal performance) Community Social Auditing

4. Examples of Modelling Data Costings & Resource Mobilisation Options: • 2031 Estimates of Impact & Costs of various scenarios – SA & Thailand • SA-ART cost estimates (BU&HERO) – modelled & costed increased CD4 eligibility & impact • South Africa created new National Strategic Plan (NSP) for HIV, TB and STIs (2012/13 - 2015/16) – costs estimated by the costing team

5. SA New Adult (15-49yrs) HIV infections (’93–’31)

6. SA Adult (15-49yrs) HIV Prevalence (2000–31)

7. SA - Total HIV/AIDS Resources Required by Scenario 2009 –2031 (ZAR billions) NB. These estimations include all sectors and all sources of funding

8. SA Expanded NSP – Total Costs and their Distribution (ZAR millions)

9. South Africa’s new NSP cost est. 2016: R32b (US$4b) 2012: R18.6b (US$2.3b) Presentation Name PRESENTATION DATE

10. Examples of Modelling Data Expenditure Tracking, Alignment & Gap Analysis: • NASA in ESA • South African National AIDS Council (SANAC) commissioned the National AIDS Spending Assessment (NASA) (2007/08 - 2009/10). • Compared the estimated cost of SA NSP (new & old) implementation with estimated current and future available funds, and measured the potential funding gap. • Considered various scenarios for funding options.

11. Sources of Funding in ESA

12. Spending Alignment with Country Priorities Looking backwards to previous SA NSP costing & NASA (09/10) Presentation Name PRESENTATION DATE

13. Alignment of All SA Partners?

14. Is SA spending efficiently on ART? (ZAR, 2009/10) NB. GP also spent PEPFAR funds on public ART, not included above

15. Is SA spending on the best prevention interventions? (%, 2009/10) DRAFT - DO NOT DISSEMINATE.

16. Are we targetting the right Beneficiaries? (2006-2009) DRAFT - DO NOT DISSEMINATE.

17. Projected funding availability – gap?? Forward projected available funding vs NSP costs (2012) Presentation Name PRESENTATION DATE

18. Anticipated gap/surplus by intervention Presentation Name PRESENTATION DATE

19. Modelling Funding Scenarios

20. Findings – Funding Options 4. Mixed Scenario – 20% private, 20% increase in external, 22% public increase

21. Best Funding Scenario? 5. Alternative (Innovative?) Domestic Financing Options Presentation Name PRESENTATION DATE

22. Conclusions i. • Sound objective evidence - modelling, costs, spending, quality of services, impact – all increase the govt’s ability to lead the response and inform policy choices. • Research agenda should be aligned to national priorities, not pushed by development partners’ agendas. • Aid dependency, and its unpredicatbility, short-cycles & lumpiness seriously hinders the country’s ability to future project available funding, plan, and manage the response. • Improved public accountability & transparency re budgets, spending, outputs & outcomes – improve financial systems! • Improved transparency of development partners’ commitments, disbursements and actual spending, so as to measure alignment, prioritisation & gaps Presentation Name PRESENTATION DATE

23. Conclusions ii. • Need to model alternative domestic funding sources & mechanisms, such as a national health insurance, financial transaction tax, a currency conversion levy or an additional AIDS tax on individuals and businesses – to give greater power to governments in taking the leadership role. • Far greater commitment and transparency from the business sector, the private health insurance industry and the development partners in terms of predictable, aligned and accountable spending on HIV/AIDS. • Build capacity of civil society to monitor govt budgets & spending • Building local capacity & systems – govt and service providers – real local ownership & investing in their longer-term systems strengthening before funding programme implementation. Presentation Name PRESENTATION DATE

24. Thank you Teresa Guthrie Centre for Economic Governance and AIDS in Africa teresa@cegaa.org www.cegaa.org