Guthrie, T., Kioko, U., Chitama, D., Asante, F., Chitsomia , A., Madadume , B.

1. Guthrie, T., Kioko, U., Chitama, D., Asante, F., Chitsomia, A., Madadume, B. ARE HIV ALLOCATIONS being aligned to national priorities: Tracking Expenditure in Southern Africa Inaugural Conference of the African Health Economics and Policy Association Accra - Ghana, 10th - 12th March 2009 PL 05/1

2. Objectives • To compare levels of spending, both domestic and international, for HIV/AIDS in 4 SADC countries: Botswana, Swaziland, Zambia, Lesotho -> Ghana (non-SADC comparison) • To consider the adequacy and alignment of the funds for the attainment of their National Strategic Plans (NSPs). • To measure the absorption of these funds according to the different funding mechanisms. • To compare unit costs for key interventions (where output data was available )

3. Methodology • Comparison of NASA Reports from the 4 countries • National AIDS Spending Assessment is an approach to comprehensively measure: • All spending for HIV/AIDS • From all sources, through agents, providers, activities to beneficiaries • From a multi-sectoral perspective • According to interventions reflected in the NSPs • Allows countries to monitor their own progress towards the national and international commitments. • Acknowledgements to the NACs and NASA team members for their data

4. Levels and Sources of Financing • Increasing amounts of spending on HIV/AIDS • Increasing public allocations, as well as international • Average contributions (in 4 countries): • International 58.8%. Public 41.2%. • Removing Botswana: • International 71.6%. Public 28.4%.

5. Levels & Sources of Funding for HIV/AIDS (US$mill, 2006)

6. Per Capita HIV/AIDS Spending & HIV Prevalence (US$, %, 2006)

7. Increasing Public Allocations: Botswana ~ Total Spending on HIV/AIDS (PulaMill, 2003-2005)

8. Swaziland ~ Sources of HIV/AIDS Financing (SZLmill, 2005/06-2006/07)

9. Zambia ~ Sources of HIV/AIDS Financing (US$, 2005&2006)

10. Ghana – Sources of HIV/AIDS Financing (US$mill, 2005-2006)

11. Lesotho (prelim) ~ Financing Sources for HIV/AIDS (M, 2005/06 & 2006/07)

12. Alignment with National Priorities

13. Swaziland ~ Comparison of Costed NSP with NASA Spending (SZL, 2006/07)

14. Zambia ~ NSP Costed Priorities vs Actual Spending (%, 2006)

15. Botswana ~ NSP Priorities Compared to Actual Spending (%, 2005/06)

16. Ghana ~ Costed APOW vs Actual Spending (US$, 2006)

17. Lesotho ~ Spending Compared to Costed NSP Priorities (%, 2006/07)

18. Botswana ~ Spending on HIV/AIDS by Source (%, 2005)

19. Swaziland ~ Effects of Reducing External Aid (SZL, 2005/06-2006/07)

20. Care and treatment services not elsewhere classified (n.e.c.) Opportunistic infections’ (OI) treatment 90,000,000 Home-based care 80,000,000 Palliative care 70,000,000 Psychological treatment and support 60,000,000 services 50,000,000 Specific HIV-related laboratory monitoring SZL 40,000,000 Nutritional support associated to ARV therapy 30,000,000 Antiretroviral therapy not-desegregated by age or line of treatment 20,000,000 Adult antiretroviral therapy not- desegregated by line of treatment 10,000,000 Pediatric antiretroviral therapy not- desegregated by line of treatment - 2005/ 2006 2006/ 2007 Opportunistic infection (OI) prophylaxis YEAR Swaziland ~ Reducing Treatment (Nutrition Supplements) Spending (SZL, 2005/06-2007/08)

21. Absorptive Capacity

22. Dimensions of Absorptive Capacity • Program Management • Procurement and Supply Chain • Financial management • Governance & oversight • Performance and measurement • This focus is on the financial aspects

23. Financial Absorptive Capacity • Ability of implementing agencies to utilise funds in the planned time period and for the purposes intended • Rate and manner by which funds received are turned into physical resources of materials, equipment, infrastructure, and personnel • Encompasses financial flow: • from commitment • through transfer or disbursement • to procurement or expenditure

24. Zambia – absorption rates improving (US$, 2005 & 2006)

25. Factors Limiting Absorptive Capacity • Limited human resources & skills at all stages of project conceptualisation, implementation & monitoring • High rate of turn-over and deaths of staff • Preferential use of funding (according to source) • Governmental ceilings for development / social sector spending – frozen posts • Delayed disbursements (some funding mechanisms worse than others) • Complexity of reporting and accounting requirements and other conditionalities – absorb staff time • Govt procurement systems very slow • Short project cycles and disbursement cycles

26. Summary of Findings • Evidence of improving public contribution to total spending on HIV/AIDS • Some decreases in external sources (Swaziland & Lesotho) • Treatment (specifically ART) requiring increasing amounts • Prevention not receiving notably increased allocations • Other interventions (mitigation, enabling environment, research) receiving relatively little

27. Findings cont. Comparing the costed NSP priorities with the actual spending: • NSPs generally poorly costed and may not have been accepted in country • NASA captured more than was included in the NSP costing • Improving costings and use of NASA will better provide estimates of funding gaps by intervention • There are improvements ito donor alignment with national priorities (according to the Paris Declaration) • Eg. Increasing allocations through common funds for HIV/AIDS, managed by the NACs • However, there are some notable exceptions • Parallel systems of financial management remain

28. Findings cont. • Comparison of unit costs of key interventions within the SADC region has been difficult due to poor or non-comparable out-put indicators. • The funding mechanism appears to influence the degree of absorption of funds, among many other factors • Often poor absorption due to delays in disbursement systems, and ‘dumping’ by donors • Measuring the absorption of funds proved difficult because the NASA approach initially did not collect the allocations/ commitments / disbursements – only the actual spending so the rate could not be calculated. • Only in Zambia....

29. NASA Provides Data for Evidence-based Allocative Decisions • Adequacy of funding – public & external • Allocative decisions – priorities • Efficiency of spending & absorption rates/ challenges • Coordination, Harmonisation and Alignment • Enhanced Transparency, Accountability & Economic Governance • Standardization & Comparability • Need for institutionalization of resource tracking in routine M&E systems:

30. Routine Resource Tracking would…. • Increase pressure (& desire) for mutual accountability by all players • Promote a framework to ensure all partners report through a national resource tracking system • Link framework to the National Resource Mobilisation and Management Strategy • Contribute to harmonised standards of reporting and costing among different partners • Ensure transparent procurement systems & best pricing within and between countries & regions

31. Thank You • Teresa Guthrie • Centre for Economic Governance and AIDS in Africa • Email:teresa@cegaa.org • Tel: +27-21-425-2852 • Cell: +27-82-872-4694