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Domestic Financing for Health in Africa Prof Alan Whiteside Meeting of Ministers of Health and Finance on Domestic Financing for Health Addis Ababa, Ethiopia Global Fund and African Development Bank 11-12 November 2013. Outline. Where we are: AIDS, TB and Malaria in epidemiological terms :

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Outline

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  1. Domestic Financing for Health in AfricaProf Alan WhitesideMeeting of Ministers of Health and Finance on Domestic Financing for HealthAddis Ababa, EthiopiaGlobal Fund and African Development Bank11-12 November 2013

  2. Outline • Where we are: AIDS, TB and Malaria in epidemiological terms: • Global burden of disease • A Southern African example • AIDS and malaria a major issue • What we need for 2014 – 2016 • Where it is coming from • Mobilising Domestic resources • Where are we going?

  3. Years of life lost (women) by cause: Global, 2010 0-1 1-4 5-14 15-24 25-49 50 – 80 + Age Source: 2010 Global Burden of Diseases Study http://www.healthmetricsandevaluation.org/

  4. Years of life lost (women): Western Europe 2010 Maternal Neonatal HIV & TB 0-1 1-4 5-14 15-24 25-49 50 – 80 + Age Source: 2010 Global Burden of Diseases Study http://www.healthmetricsandevaluation.org/

  5. Years of life lost (women): Western Africa, 2010 Maternal Neonatal HIV & TB 0-1 1-4 5-14 15-24 25-49 50 – 80 + Age Source: 2010 Global Burden of Diseases Study http://www.healthmetricsandevaluation.org/

  6. Years of life lost (women): Central Africa, 2010 Maternal Neonatal HIV & TB 0-1 1-4 5-14 15-24 25-49 50 – 80 + Age Source: 2010 Global Burden of Diseases Study http://www.healthmetricsandevaluation.org/

  7. Years of life lost (women): Eastern Africa, 2010 Maternal Neonatal HIV & TB 0-1 1-4 5-14 15-24 25-49 50 – 80 + Age Source: 2010 Global Burden of Diseases Study http://www.healthmetricsandevaluation.org/

  8. Years of life lost (women): Southern Africa, 2010 Maternal Neonatal HIV & TB 0-1 1-4 5-14 15-24 25-49 50 – 80 + Age Source: 2010 Global Burden of Diseases Study http://www.healthmetricsandevaluation.org/

  9. Ante-natal prevalence South Africa 1990-2011

  10. HIV Prevalence Among Pregnant Women: Botswana

  11. What is needed for ATM 2014- 2016 • Estimated funding required $87 billion • Available estimated funding $76 billion or 87% • Domestic $23 billion certain • Domestic $14 billion potential • International $24 billion potential • Global Fund $15 billion potential

  12. How to sustain an ATM and HSS Response? • Increase donor support: getting more from existing donors or involving new donors • Increase domestic financing • Public or government • Private sector • Out of pocket • Decrease the cost of the current response by improving efficiencies in existing programs But prevent new infections!

  13. International Funding Uncertain

  14. Global Priorities Changing: Post 2015 MDG High Level Panel Report

  15. International versus Domestic Agendas Donors have their own agendas Countries adjust their plans based donor goals This may be ‘ants in the sugar bowl’ Image Credit: http://cdn.backyardchickens.com/0/0b/0b999fa8_2_ants.jpeg

  16. Africa has made commitments • Abuja Declaration on HIV/AIDS, Tuberculosis and Other Related Infectious Diseases, 2001: Heads of State commit to spend at least 15 % of budgets on Health. • Addis Ababa, African Union roadmap on shared responsibility and global solidarity for AIDS, TB and malaria response, 2012 Endorsed Roadmap on Shared Responsibility and Global Solidarity for HIV, TB and Malaria, Pharmaceutical Manufacturing Plan • Tunis Declaration on value for money, sustainability and accountability in the health sector, 2012 Enhance value for money, increase accountability improve sustainability of health resources.

  17. Domestic Investment 2011: % of total government expenditure Rwanda 23.7% Malawi 18.5% Zambia 16.0% Togo 15.4% Tanzania 11.1% South Africa 10.0% Botswana 8.7% Nigeria 7.5% Kenya 5.9% Source: UNAIDS, Oxford Policy Management, R4D and Authors own calculations

  18. What should the domestic commitment to health and ATM be? • According to minimum standard? ($44) • What is affordable? • What is cost effective? • Fair share between domestic and donors? • UNAIDS developed Domestic Index of Priority • More money for health or more health for money? This is a political decision at national and international levels.

  19. Criteria for Investment •Level of national income, GDP or GNI. An approximation of resources available within a country • Degree to which the Government is able to raise revenue through taxes, levies, domestic borrowing, or other means. • Proportion of Government budget devoted to debt •Pre-existing pattern of disbursement to different sectors. In health if historical allocations were low, poor infrastructure reducing capacity to absorb rapid increases and convert to service delivery.

  20. Plan for Analysing “Fiscal Space” • Macroeconomic analysis • Evaluating potential resource needs and resource availability, identifying future resource gaps and potential ways of eliminating such financial gaps. • Microeconomic analysis • Assessing potential opportunities to make the 3 largest interventions efficient: • ART • PMTCT • OVC

  21. Innovative Ways of raising money Source US $ billions 75% of an alcohol levy 3.9 Contributions from high-revenue enterprises 2.4 Airline levy by all African countries 1.7 2% of public sector budgets earmarked for AIDS 2.4 Mobile phone levy 2.0 1% income tax levy earmarked for AIDS 3.1 But how to 1. sell and 2. ring fence

  22. Increased Domestic Funding • Economic trends • Abuja Declaration at least 15 % of budgets on Health. • Economic trends plus DALY Even then there will be a gap

  23. Recommendations 1 •Need for better data. We are not clear on who is spending what. This is true of both domestic and international funding. Data needs to be improved and accessible. • Political leadership is critical, and we need to develop advocacy messages to ensure that health continues to be a priority. • Revisit the economic arguments for health, including the macro-economic ones. • Address rigid budgeting practices making it hard to reallocate revenues toward health. •Empowered Health officials to talk to finance and finance to understand health • Address the perception that “donors will take care of the AIDS program”.

  24. Recommendations 2 • • Recognized and improved the role of civil society . • • The core question: it is possible to define the “right” mix of domestic and international investment in any country. Initial thoughts this will vary country by country. • • We should establish on a country by country basis an acceptable “benchmark” for countries to invest from their own resources. • • The Global Fund should work with other key donors as a ‘thought leader’. In particular it should look to providing data and information. • This is a complex political question not just an economic one

  25. Understanding Curves: New Infections and Deaths

  26. Treatment Requirements People Requiring Treatment

  27. Economic Transition Economic Transition Credit Mead Over

  28. Economic Transition Occurs • HIV positive deaths • New infections when new infections fall below deaths of HIV positive people

  29. Epidemiologic Transition An Advocacy and Epidemiological Transition

  30. Epidemiologic Transition

  31. Thank You

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