Cross-country comparison of domestic AIDS
expenditure and medium-term fiscal space
for AIDS programs
UNAIDS Economics Reference Group Meeting
November 8-9, 2012
Stephen Resch and Robert Hecht
Objective
 What proportion of AIDS spending is coming from domestic versus
external sources?
 How much more of the financial burden of AIDS programs could
countries reasonably shoulder themselves?
 With maximum domestic effort to support AIDS programs, what level of
external resources would still be required from external sources such as
PEPFAR, Global Fund, etc to meet the overall needs to operate an
effective national AIDS program?
 How can we monitor implementation of Partnership Frameworks
agreements?
Main findings
1. Room for domestic AIDS spending to double or triple in
medium term
2. Major work needed to strengthen financial information
NEEDS ESTIMATION
 National strategic planning with credible resource needs estimates
EXPENDITURE TRACKING
 Development and routine financial tracking to monitor PEPFAR
Partnership Framework agreements
 Need to improve turnaround time, completeness, comparability of ad hoc
expenditure analysis (e.g. NASA, NHA)
3. More work needed to explain variation between countries
in resource estimates and AIDS spending per person living
with HIV/AIDS (PLWHA)
Scope of study
Twelve original PEPFAR focus countries
(Over 50% of global AIDS burden)
Botswana
Cote d’Ivoire
Ethiopia
Kenya
Mozambique
Namibia
Nigeria
South Africa
Rwanda
Tanzania
Uganda
Zambia
(1) a retrospective review of AIDS program financing, comparing
countries to one another and to selected benchmarks
(2) a forward-looking analysis assessment of the potential for
increasing domestic financing of AIDS programs
$0
$9
$12 $28 $29 $30 $37
Tanzania 2008/09
Domestic AIDS financing Amount(millions)
400
$0
$4 $36 $20 $9 $24 $30 $9 $30
Domestic AIDS financing per PLWHA
South Africa
$800
Botswana
$96 $98
$200
Kenya
$600
Namibia
$229
Uganda
800
Nigeria
000
Zambia
Total (millions)
Ethiopia
$1,153
$1,000
Tanzania
200
Côte d'Ivoire
$1,200
Rwanda
400
Mozambique
South Africa 2009/10
Botswana 2008
Kenya 2008/09
200
Namibia 2008/09
Uganda 2008
Nigeria 2008
Zambia 2006
Ethiopia 2008
$6
Côte d'Ivoire 2009
$5
Rwanda 2008
Mozambique 2008
Domestic AIDS Expenditure
Per PLWHA
$715
$532
600
$400
$206
$65
Evaluating domestic effort and assessing the
potential for ‘fair’ increase in domestic
financing of AIDS programs
Normative benchmarks
1. Abuja Target for Government Health Expenditure (and
proportional increase in AIDS spending)
2. AIDS Share of Health Spending in proportion to disease
burden share (measured in DALYs)
FOUR IMPORTANT CAVEATS:
Government health expenditure (GHE) is not a clean measure of
domestically-sourced funding [Domestic Share of GHE ~70% (40-110%)]
Opportunity cost of increased AIDS spending / Cost-effectiveness
Consideration of downstream savings
Disease burden share may decline with ART scale up, while resource need
remains
Variation in government health spending levels
Variation in the size of resource bucket from which AIDS programs
are domestically financed
UMI
LI-LMI
18.0%
15.0%
12.0%
9.0%
6.0%
3.0%
0.0%
18%
15%
12%
9%
6%
3%
0%
Abuja
Abuja target: GHE/GGE = 15%
•
Issue: GHE  Public Funds for Health (PFH),
GHE doesn’t exclude ‘on-budget’ donor aid**
GHE per capita varies 5-fold among current
LICs
•
Botswana GHEpc is 2.5 times other 2 UMICs
Which bucket of money is the appropriate
reference point for evaluating domestic effort

Countries vary widely in the share of
national resources flowing into
downstream public resource buckets.

AIDS spending lies primarily in the
health sector and could be bound by
GHE level
At what level of government are
AIDS resource allocations
determined?
What does it say about a country’s AIDS
financing effort if a health ministry
allocates a relatively large portion of
the health budget to AIDS, but this level
of GAE is low relative to GDP, because
the health budget is relatively small?
GDP
GGE
(17-48% GDP)
GHE
(5-18% GGE)
GAE
(1-26%
GHE)
Variation in government AIDS expenditure (GAE) as a
share of health spending
…compared to AIDS’ share of disease burden
100%
Countries fall into 3
groups:
80%
60%
40%

Kenya, Uganda & Ethiopia
(70-90%)

Namibia, Botswana,
Zambia, South Africa, and
Cote d’ Ivoire
(29-54%)

Nigeria, Tanzania,
Mozambique, Rwanda
(5-12%)
20%
DALY Share
Spending
to – Burden
Spending–Fraction
as %Ratio
of DALY Share
Rwanda
Mozambique
Tanzania
Nigeria
South Africa
Zambia
Botswana
Namibia
Côte d'Ivoire
GAE/GHE
Ethiopia
Uganda
Kenya
0%
Summary Indicators of Domestic Priority for AIDS
Comparison of DIPI measures
1.00
0.90
0.80
0.70
0.60
0.50
0.40
0.30
0.20
0.10
0.00
0.12
0.08
0.06
0.04
0.02
UNAIDS DIPI
Health Exp-based 'DIPI'
Botswana
Uganda
Namibia
Ethiopia
Zambia
Kenya
Rwanda
South Africa
Côte d'Ivoire
Tanzania
Nigeria
0.00
UNAIDS DIPI
0.10
Mozambique
Health Expenditure-based DIPI
UNAIDS DALY DIPI and Health Expenditure-based DIPI
Potential for increase fiscal space for AIDS
Three scenarios for increasing domestic GAE
Countries fell into 3 groups…
Domestic AIDS spending per PLWHA
Abuja target already met, All
opportunity in DALY share only
$90
Mozambique
DALY share target nearly met,
All opportunity in Abuja only
$250
Kenya
$80
$200
$70
$60
$150
$50
$40
$100
$30
$20
$50
$10
$0
$0
Actual
Abuja
DALY Abuja &
Share DALY
Similar countries:
ZAM, TZA, RWA, NAM, BWA
Actual Abuja
DALY Abuja
Share & DALY
Similar countries:
UGN
Opportunity for both meeting
Abuja and DALY share targets
$200
$180
$160
$140
$120
$100
$80
$60
$40
$20
$0
Côte d'Ivoire
Actual Abuja
DALY Abuja &
Share DALY
Similar countries:
ZAF, NGA, ETH
Actual = Status Quo, Abuja = (GHE/GGE=15%), DALY Share = GAE/GHE proportional to AIDS DALY share,
Abuja & DALY = Maximal domestic contribution
Resource needs estimates
$1,800
$1,600
$1,400
$1,200
$1,000
$800
$600
$400
$200
$0
 Difficult to assess the
reasonableness of this
variation
 Not simply explained by
input price levels (GNI
proxy)
Mozambique
Tanzania
Rwanda
Nigeria
Uganda
Ethiopia
Côte d'Ivoire
Kenya
Zambia
Namibia
South Africa
Botswana
Amount Needed per PLWHA
NSP estimates, adjusted for epidemic size, vary much
more than UNAIDS Investment Framework model
NSP per PLWHA (2011)
UNAIDS IF per PLWHA (2011)
 Partly explained by the
scale or mix of planned
activities?
 Inaccurate estimation or
‘gaming’?
Scenarios for Increasing Domestic Effort:
Annualized Amounts for 2012-16.
UNAIDS: $7.4 B NEEDED
Scenario
Government
AIDS
Expenditure
NSP: $9.5 B NEEDED
DOMESTIC
SHARE
GAP
REQUIRING
EXTERNAL
SUPPORT
DOMESTIC
SHARE
GAP
REQUIRING
EXTERNAL
SUPPORT
1. GROWTH
$2 B
27%
$5.4
21%
$7.5
2. ABUJA
$3 B
41%
$4.4
32%
$6.5
3. DALY
$4.4 B
59%
$3.0
46%
$5.1
4. MAX (2+3)
$5.2 B
70%
$2.2
55%
$4.3
Share of AIDS program cost covered with
‘maximum domestic effort’ (Abuja + DALY Share)
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Econ Growth only
Max Additional
Biggest relative increase
Main findings
1. Room for domestic AIDS spending to double or
triple in medium term, but need for donor
support will remain
2. Major work needed to strengthen financial
information
RESOURCE NEEDS ESTIMATION
ROUTINE EXPENDITURE TRACKING
3. More work needed to explain variation between
countries in resource estimates and AIDS
spending per person living with HIV/AIDS
(PLWHA)
THANK YOU
Stephen Resch
stephen_resch@harvard.edu
Center for Health Decision Science
Harvard School of Public Health
Robert Hecht
rhecht@resultsfordevelopment.org
Results for Development Institute
and the R4D Team:
Richard Skolnik, Toby Kasper,
Theresa Ryckman, Gabrielle Partridge, Kira Thorien