BUDGETING FOR HIV/AIDS - Costing the ‘Indirect Impact’ on the Health Sector Namibia, Aug 2003. Teresa Guthrie Research Unit on AIDS & Public Finance Budget Information Service

Measuring the ‘Indirect Impact’ of HIV/AIDS on the Health System The HIV/AIDS pandemic has become the greatest challenge not only to health in Southern Africa, but to development in general. Various socio-economic impact studies have been done, projections of costs of specific HIV interventions (prevention, treatment, support etc.), public, private & personal costs Research Unit on AIDS and Public Finance ~ Idasa ~ 12 Aug 2003

Indirect expenditure as result of impact of HIV/AIDS e. g Indirect expenditure as result of impact of HIV/AIDS e.g. increased demand for social security grants, higher hospital bed occupancy, medicine for OIs Direct expenditure on HIV/AIDS programmes e.g. condoms, PMTCT, public awareness campaigns On recurrent or operation budget (State Revenue Fund) On development budget (partially covered by donors) Usually requires unconditional transfers or general budget support Best addressed using earmarked/ring-fenced funds

Quantifying those ‘indirect costs’... That is, the extra ‘burden’ on existing health services due to the increased demand for treatment and care of OIs, LRTIs, TB, STDs etc More difficult to quantify the less direct costs and losses, to individuals, families, communities and the state. How much should govt. allocate to enable the over-stretched health services to continue ot provide quality care? Research Unit on AIDS and Public Finance ~ Idasa ~ 12 Aug 2003

Challenges of Costing the Indirect Impact Notifiability and Identification HIV infection is not a notifiable disease in many African countries. Many countries do not conduct routine voluntary HIV testing on patients. Confidentiality of HIV status must be respected Thus, it is almost impossible to identify HIV+ patients attending health facilities, to quantify the cost of their services and to compare these costs with those of HIV- patients.

Challenges of Costing the Indirect Impact (2) Stages of the Syndrome HIV infection presents as a syndrome of many infections, illnesses. In the earlier stages of the illness, OIs, STDs, TB are common, but cannot be directly attributed to HIV without test results. Thus surveillance usually only captures patients once they reach stage 3 or 4 of the illness, when more symptomatic. At same time, mainstreaming efforts would not wish to distinguish HIV-specific services from non-HIV.

Challenges of Costing the Indirect Impact (3) Varying costs Obviously the costs in the later stages are greater than in the earlier stages. But costs of earlier stages difficult to separate from general health service costs - little info. Many studies use these infections as ‘proxies’ to identify HIV+ patients - this is not ideal/accurate. Research Unit on AIDS and Public Finance ~ Idasa ~ 12 Aug 2003

Challenges of Costing the Indirect Impact (4) Data Limitations Inaccuracies of prevalence data/ projections - can’t accurately calculate how many people are currently infected and at which stage, can’t quantify and cost their need for services. Limited availability, quality, validity & reliability of data on which to base costings. Lack of sophisticated information systems and trained personnel to use them. Even less data at district level, where the services are delivered and the greatest impact felt…. Research Unit on AIDS and Public Finance ~ Idasa ~ 12 Aug 2003

Limitations of Existing ‘Indirect’ Costing Studies Many studies use ‘proxies’ forf HIV status. Most single studies (‘snap-shot’ vs longitudinal), over a short specific time - therefore do not capture the frequency of visits as patient becomes more ill. Usually single site, problematic to extrapolate to national costs. Most limited to financial costs to the service-provider, do not measure economic impact to all role-players, such as costs to family (financial, time, energy etc).

Research Unit on AIDS and Public Finance ~ Idasa ~ 12 Aug 2003 Other considerations... The background burden and demand for services (non-HIV related) remains. Increasing HIV+ patients at health facilities may decrease the access for patients with other chronic conditions. Rationing - anecdotal evidence that HIV+ patients are being turned away from health services, due to high demand for services and a sense of not being able to ‘do anything’. Research Unit on AIDS and Public Finance ~ Idasa ~ 12 Aug 2003

Importance of Estimating the Indirect Costs…. In order to allocate sufficient funds to service-delivery, for infra-structural and capacity development to accommodate the greater demand due to HIV. “The important message is that there is still much to be done to help policy makers plan and manage this epidemic so that it has as minimal impact as possible on the health system” (Franklin, Desmond, Manning, 2001) Research Unit on AIDS and Public Finance ~ Idasa ~ 12 Aug 2003

Overview of Available Literature Few African studies. Some infection-specific costings eg. TB (but can’t assume that all are HIV-related). No. of visits, length of stay, cost per visit (vs non-HIV), bed occupancy, no. of admissions. Costs to families (some looking at funeral costs). Level of service differences, rural/urban differences. Little/ none out-patient care/ primary health care. Some HBC costs but not compared to hospital costs. Little on child health needs and costs.

Country Studies Refer to Article

Namibia Inpatient Services Research Unit on AIDS and Public Finance ~ Idasa ~ 12 Aug 2003

Burkino Faso: Impacts of HIV/AIDS on the Health-Care Sector for Various Scenarios growing proportion of hospital beds (30 to 50 percent) are monopolized by PLWHA. At the Notre-Dame de la Paix Clinic in Ouagadougou, 45 percent of patients admitted are HIV-positive (Bicaba and La Palme, 1998; Soumahoro, 199), and in the infectious disease department (57 beds), 30 percent of the patients are HIV-positive (Soumahoro, 1999). increase in the demand for care due to HIV/AIDS is estimated at 30 percent (UNDP, 2000). If the hospitalization expenditures per AIDS patient are estimated at 1.26 million CFAF,19 the total cost of hospitalization related to AIDS in itself will represent 13.5 billion CFAF in 2005 in the best-case scenario, 16.36 billion CFAF for the middle-of-the-road scenario and 19.23 billion CFAF in the worst-case scenario.20 This represents between 58.7 and 83.8 percent of the projected health-care budget21 for 2005. Hospitalization expenditures would actually represent over 100 percent of the health-care budget in the worst-case scenario. 19 Hypothesis: 190 days of hospitalization at an average cost per hospitalization of 6,648 CFAF (Brenzel 1994). 20 Estimates made using the AIM program (Stover 1999b). 21 As compared to the 1999 health-care budget, i.e. 22.96 billion CFAF. The proportion of the government budget earmarked for the struggle against HIV/AIDS is growing each year, but a bit more slowly than increases in the donors’ budget (Figure 4). It has grown from an average amount per year of $3,000 US (coming from matching funds) from 1987 to 1989, to an average of more than $600,000 US per year since 1996. In 1999, 11 percent of the health-care budget was set aside for the fight against HIV/AIDS. ** As a percentage of the 1999 budget. Source: Boily, Larivière, Martin at the IDEA International Institute

TANZANIA : Recurrent and development health expenditure Research Unit on AIDS and Public Finance ~ Idasa ~ 12 Aug 2003

South Africa: Estimates of public health (indirect) expenditure on HIV/AIDS DOH estimates very significant expenditure incurred by public health system: Combined national and provincial expenditure on HIV/AIDS = R4.4448 bn or 15.0% of 2001/2 consolidated public health expenditure In 2000, estimated 628 000 admissions to public hospitals for AIDS-related illnesses, or 24% of all public hospital admissions (DoH, Abt) Cost of hospitalising AIDS patients (public facilities) = R3.6 billion in 2001/2 = 12.5% of total public health budget IGFR 2001 g. 52 “A recent estimate puts provincial spending on AIDS related illnesses at nearly R4billion, including spending on essential drugs for opportunistic infections.” Also quoted in ANC Today 15 Feb 2002. DoH estimates provincial health depts collectively will spend nearly R 4 billion on treatment and care of AIDS-related illnesses in 2001. Enhanced Response to HIV/AIDS September 2001: Anticipates by 2004/5 SR will be having to spend over R7billion per annum on prevention, treatment and care of HIV (check this!) largest single impact on the public health sector in hospital sector Other local studies (Bateman, 2001) tend to report even more acute impacts at particular hospitals. BURKINO FASO STUDY Scenario 1: 7.17 percent prevalence rate in 1997, stabilizing at 8 % in 2005 (best-case) Scenario 2: 7.17 percent prevalence rate in 1997, stabilizing at 10 % in 2005 (middle) Scenario 3: 7.17 percent prevalence rate in 1997, stabilizing at 12 % in 2005 (worst-case) HIV+ patients occupying 39% beds in Kenyatta Natl Hospital in Nairobi 70% in Prince Regent Hospital in Bujumbura (anarfi, pg. 36) in mid 1990s estimated treatment of HIV+ persons was 66% public health spending in Rwanda; over 25% in Zimbabwe (anarfi, pg. 36)

Research Unit on AIDS and Public Finance ~ Idasa ~ 12 Aug 2003 Recommendations (1) Improve systems : data collection and information management budgeting and planning accounting and tracking capacity building to manage these systems Research Unit on AIDS and Public Finance ~ Idasa ~ 12 Aug 2003

Research Unit on AIDS and Public Finance ~ Idasa ~ 12 Aug 2003 Recommendations (2) Public Health Facilities Improvement: Allocate funds to improve services for the prevention and treatment of OIs, TBs, STDs, RTIs, diarrhoea, etc. Funds for general improvement of health services, personnel, infrastructural development etc Funds for ‘step-down’ facilities for last stages of illness Research Unit on AIDS and Public Finance ~ Idasa ~ 12 Aug 2003

Research Unit on AIDS and Public Finance ~ Idasa ~ 12 Aug 2003 Recommendations (3) Funding Mechanisms Conditional grants to ensure delivery of specific programmes Non-conditional transfers to regions for general improvement of health services Co-ordination of donor funds Research Unit on AIDS and Public Finance ~ Idasa ~ 12 Aug 2003

Thank you For more information, contact: Teresa Guthrie Research Unit on AIDS & Public Finance, Budget Information Service Idasa teresa@idasact.org.za