The potential for domestic spending on care & treatment for HIV/AIDS How has domestic HIV/AIDS financing responded to declines in development assistance for HIV/AIDS? The potential for domestic spending on care & treatment for HIV/AIDS Annie Haakenstad, Harvard, IHME ahaakenstad@gmail.com

Outline Background Data & Methods Results Discussion

Outline Background Data & Methods Results Discussion

Background Development assistance for HIV/AIDS declining globally Ambitious global goals: 90% of HIV- positive people on antiretroviral therapy Newly available domestic HIV/AIDS financing estimates

Study objectives How much domestic resources can be mobilized as DAH declines? What are the implications for ART coverage? $8.7 billion from the viz tool  2017 USD, converted to 2015 USD it is $8 billion Miranda converted the total HIV spend, which was 16 billion in 2015 USD in 2015, 29.7% of that is 4.8 billion in 2015 USD

Outline Background Data & Methods Results Discussion

Data HIV/AIDS expenditure by source and function (GBD Health Financing Collaborator Network 2018) Care and treatment spending: HIV/AIDS spending on inpatient and outpatient care Domestic HIV/AIDS spending: including government expenditure sourced domestically, prepaid private spending and out-of-pocket payments Development assistance for care and treatment (DAH-CT) Since one estimation framework used for estimation, HIV spending domestically and on care and treatment comparable across countries

Data ART covered lives Number of people on ART (Global Burden of Disease Study 2016) Healthcare access and quality index (HAQI) Summary measure based on deaths from causes that should not occur in the presence of quality healthcare (Barber et al. 2017) Sociodemographic index (SDI) Index of ten-year lag-distributed income per capita, total fertility rate and educational attainment Used HAQI because it captures the comprehensive quality of the health system and thus its latent capacity to realize additional gains in ART coverage (as opposed to its current reach/state, particularly given the vertical nature of HIV programming) Also because it is important to think about maintaining the overall quality and access to health care given what we know about health system strength and given our pursuit of UHC goals Definition of the HAQI: ability of the health system to prevent the onset and death of diseases amenable to personal health care Highly correlated >.8 with health spend per capita, UHC tracer index Propiton of population wit hformal health coverage Less good for PHC intervations (~.6) And hospital beds per 1000 HIV not included (~.7)

Methods Stochastic frontier analysis of domestic HIV/AIDS expenditure Cross sectional regression (2015) of care and treatment spending per year on ART Covariates: Development assistance for care and treatment, HIV prevalence, population, ART coverage, SDI and HAQI Shapley decomposition of the explained variation of care and treatment expenditure SFA covariates: Covariates: log LDI pc, log domestic health spending less domestic HIV spending per capita, log general government expenditure per capita less all government (?) health expenditure, log HIV prevalence, log HIV mortality, log HIV incidence, and dummy variable for each year from 2000 to 2015. SFA: To benchmark our domestic spending estimates against other countries with similar characteristics Assumes a functional form of the inputs – how they relate to the outputs MLE approach DEA doesn’t account for uncertainty Shapley decomposition: to calculate the share/relative importance of each covariate, the contribution of each to the R squared was calculated by averaging over orders Lindemann, Merenda and Gold (1980)

Outline Background Data & Methods Results Discussion

Potential domestic spending on HIV/AIDS (2015) Closer to one  closer to potential spending ceiling What are the right hand side variables here?

Care & treatment spending per year of ART (2015) Resch 2011: Program-level recurrent costs (of which the Global Fund finances a portion alongside domestic and other donor resources) were estimated by summing the cost of antiretroviral drugs (ARVs), lab`oratory testing and service delivery (personnel, supplies, facilities, etc.). Across the countries in our study, the median annual cost per patient was $204 and $1,238, respectively (see [7]). 

Elasticities: Cross-sectional regression results DAH-CT: positive that it is not statistically significant – spending sourced externally does not push up the overall spend per ART covered life coef.names coef lower upper log_sdi SDI 0.9547650 0.21969551 1.68983446 log_hiv_prev HIV prevalence -0.4079962 -0.49739347 -0.31859894 log_art_cov ART coverage -0.7762045 -0.94151763 -0.61089143 log_pop Population -0.1072851 -0.19045299 -0.02411714 log_haq HAQI 2.0990185 0.85789688 3.34014002 log_dah_cureNMpc DAH-CT pc 0.0999329 0.04750243 0.15236337 Elasticity (Uncertainty Interval)

Shapley decomposition Share of R-squared Will change the legend to be more readable and switch the view of the y-axis

Outline Background Methods Results Discussion

Discussion: Domestic spending Some countries may be able to spend substantially more of their domestic resources on HIV/AIDS, relative to current spending Some of the countries with the highest burden of HIV/AIDS and the most dependence on DAH may not be able to spend much more, however SFA covariates: Covariates: log LDI pc, log domestic health spending less domestic HIV spending per capita, log general government expenditure per capita less all government (?) health expenditure, log HIV prevalence, log HIV mortality, log HIV incidence, and dummy variable for each year from 2000 to 2015.

Discussion: Care and treatment spending Care and treatment spending per ART covered life varies widely Projections for scale-up need to incorporate both economies of scale but some aspect of the quality of health care access and delivery

Thank you Annie Haakenstad ahaakenstad@gmail.com