Wenjuan Wang USAID/Africa Bureau Brown bag November 24, 2009

1. Has the donor fund influx for HIV/AIDS affected the domestic investments?- Results from the multicountry analysis Wenjuan Wang USAID/Africa Bureau Brown bag November 24, 2009

2. Background • Unprecedented increases in external assistance for HIV/AIDS • Donor influx: PEPFAR (18.8 bill), GFFATM (5.7 bill), WB MAP(879 M) • Funds started pouring in to countries around 2004 • While the influx is needed, more important are -- • How those funds are spent in the country • whether or not meeting intended targets • As the global HIV/AIDS response shifts from emergency relief to long-term sustainability, it is critical to • Understand the effects of donor surge on domestic investments and if the surge is indeed additional to local investment as originally intended.

3. Methods • Data: Country National Health Accounts (NHA) that include HIV/AIDS subaccounts, which are focused HIV/AIDS health expenditure reviews. • NHA resource tracking levels (figure) • NHA data sources: Donor, NGO, employer, insurance, PLWHIV surveys and Government and Provider records • Country studied: Kenya, Rwanda, Malawi, Tanzania and Zambia -similar economic context and HIV epidemic, accessibility of time-series data • Analyses focus on financing source level, comparing relative and absolute HIV/AIDS spending changes over time in given countries • Time frame comparison: Estimates before 2004 (pre influx period) with estimates after 2004 (post influx period) • Inflation adjusted, converted to US$

4. NHA resource tracking levels How much money was spent? Where does the money come from? Ministry of Finance, Donors, Private Companies, Households, Local Foundations Who manages the money? Gov. Ministries and Councils (e.g. MoH and NAC), Public Insurance NGOs, Priv. Insurance, Priv. Companies, Out-of-pocket, Local Foundations Where and how is the money spent? Prov. of Programs & Admin. Public Hospitals, Health Clinics PNFP Hospital, Health Centers Private pharmacies/ shops PFP Hospitals, Clinics Traditional Healers

5. Who are financers of HIV/AIDS health care? How their roles have changed since donor influx? Financing sources

6. Total health expenditure on HIV/AIDS significantly increased since the donor influx Total HIV/AIDS health expenditure before and after influx

7. Donor funding primarily contributed to the increase in HIV/AIDS spending

8. Government investments decreased on HIV/AIDS in some countries

9. 7% 13% 28% 9% 19% 4% 3% 20% 23% 7% Government investments on the total health increased cross the board Absolute government spending to HIV/AIDS and as a percentage of government on general health

10. Private company contribution drops in four countries

11. 23% 9% 1% 15% 3% 9% 14% 18% 0% 5% Private company contribution to the general health increased Absolute private company contributions to HIV/AIDS health care and as a % of private company spending on general health

12. Large and increased reliance on donor funding for HIV/AIDS health care Relative share of donors and other sources of funding for HIV/AIDS health care

13. Implications • Spending on HIV/AIDS heavily rely on donor investments, crowded out private sectors • Sustainability: need to explore ways to foster continued and greater involvement of local contributors: e.g. government, private firms, insurance schemes. • Resource tracking is critical for monitoring the impact of the HIV/AIDS response: needed at both the global and country level

14. Acknowledge • Country NHA teams in Kenya (MoH and KNBS), Rwanda (MoH and CNLS), Malawi (MoH), Tanzania (MoH), Zambia (MoH) • Abt contributors: Susna De, Jenna Wright, Takondwa Mwase • Health Systems 20/20 project