Efficiency, Effectiveness, and Financial Sustainability: The Importance of Country Ownership

1. Efficiency, Effectiveness, and Financial Sustainability: The Importance of Country Ownership Dr Bernhard Schwartländer UNAIDS

2. 2011 Political Declaration on HIV/AIDS: resources for the HIV response • Programmes must become more cost-effective and evidence-based and deliver better value for money • Break the upward trajectory of costs through theefficient utilization of resources (simplification and integration) • Close the global resource gap by 2015 (USD 24 billion by 2015) • Support and strengthen existing financial mechanisms • Expand voluntary and additional innovative financing mechanisms

3. Total funding for AIDS in sub-Saharan Africa is slowingafter many years of growth AIDS investment in sub-Saharan Africa US$ billions Source: UNAIDS

4. Treatment programmes are highly aid-dependent International share (%)

5. Overview • Anew investment approach • We are gradually doing better – examples for incresed effectiveness and efficiency • Sustainable financing – a new global compact for shared responsibility

6. We have done a lot… • Unprecedented scale up of HIV prevention, treatment, care and support • Decline in rate of new HIV infections in many countries • More than 6.6 million people on ART • Millions of orphans receiving basic education, health, social protection But we can do better Scale up to date guided by a “commodity approach” • Unsystematic prioritisation and investment with limited basis in country epidemiology and context • Resources spread thinly across many parallel interventions • Focus on discrete interventions rather than overall results leading to a fragmented response

7. AIDS: a new Investment Framework CRITICAL ENABLERS BASIC PROGRAMME ACTIVITIES OBJECTIVES Eliminate new infections in children & keep mothers alive Keypopulations • Social enablers • Laws & policies • Community mobilization • Stigma reduction Stopping new infections Behaviour change Condoms • Programme enablers • Community-centered design & delivery • Management & incentives • Production & distribution • Research & innovation Keeping people alive Care & treatment Male circumcision SYNERGIES WITH DEVELOPMENT SECTORS Social protection; Education; Legal Reform; Gender equality; Poverty reduction; Gender-based violence; Health systems (incl. treatment of STIs, blood safety); Community systems; Employer practices.

8. - 2.5 - 2.0 - 1.5 - 1.0 - 0.5 - 0 Three investment scenariosImpact on the epidemic USD (Billions) Business as usual New HIV Infections (millions)

9. - 2.5 - 2.0 - 1.5 - 1.0 - 0.5 - 0 New HIV Infections (millions) Three investment scenariosImpact on the epidemic Investment framework USD (Billions) Business as usual

10. - 2.5 - 2.0 - 1.5 - 1.0 - 0.5 - 0 New HIV Infections (millions) Three investment scenariosImpact on the epidemic Rapid scale up previous projections Investment framework USD (Billions) Business as usual

11. Overview • Anew investment approach • We are gradually doing better – examples for incresed effectiveness and efficiency • Sustainable financing – a new global compact for shared responsibility

12. Resources available for HIV in low and middle income countries, globally, 2002-2010

13. ARV costs in South Africa

14. Above facility costs can be reduced ART costs per patient at the facility and program level Facility Level Cost National Programme Cost

15. Integrated services are more efficient The example of VCT: Costs per client Stand-alone VCT clinics Integrated into SRH services

16. Overview • Times of austericy – a new investment approach • We are gradually doing better – examples for incresed effectiveness and efficiency • Sustainable financing – a new global compact for shared responsibility

17. OECD countries can afford more 2010 overseas development assistance as a share of Gross National Income

18. Economic growth in Africa, 1970–2010 Third-fastest growing region in the World

19. Domestic AIDS spending needs to match the burden of disease Burden of disease from AIDS vs spending on AIDS Burden of diseasecaused by AIDS Domestic AIDS spendingas a share of health spending Median % across countries

20. Measuring national commitment to AIDS: the Domestic Investment Priority Index

21. Options for increasing domestic HIV investment in Africa Domestic public AIDS investment in sub-Saharan Africa Source: UNAIDS

22. Examples of innovative country-level approaches to HIV financing • Taxes on tobacco and alcohol are common to finance health initiatives • Zimbabwe’s ‘AIDS levy’ earmarks a part of individual and corporate income tax for the AIDS response • Kenya and Zambia are considering an AIDS trust fund • Several African countries collect a tax on airline flights to finance UNITAID’s efforts on AIDS, tuberculosis and malaria; own airline tax in Niger • Levy on mobile telephone air time: being explored in Gabon, Kenya, Burkina Faso • Leverage or tax remittance flows

23. A new global compact on shared responsibility: Domestic financing potential and international investment needs in sub-Saharan Africa

24. Conclusions • The leveling off in international resources is a threat – but also an opportunity • We need the experience and innovation of the practitioners of the global South • AIDS can lead the way – as it has done before • Country ownership is essential – but has accountability at its core • We can break the back of the epidemic • Within a new global compact on shared responsibility we can generate the resources we need