Changes in Donor Financing Over Time: A Global Perspective International AIDS Economics Network Pre-Conference Meeting Jen Kates, PhD July 19, 2014 Vice President; Director, Global Health & HIV Policy Kaiser Family Foundation

While financial resources from all sectors have been integral to addressing the HIV epidemic, donor government financing has been particularly critical, accounting for much of the HIV funding in many hard hit countries –Donor governments provide more than 50% of all HIV funding in 79 countries; more than 75% in 51 countries (UNAIDS, 2013) The Kaiser Family Foundation and UNAIDS have been tracking donor government assistance for HIV in low- and middle- income countries since 2002 Latest report provides data for 2013, most recent period available, and trends over time Introduction

All 29 members of the OECD DAC included in analysis –Direct data collection from: Australia, Canada, Denmark, E.C., France, Germany, Ireland, Netherlands, Norway, Sweden, U.K., U.S. –Data for all other OECD DAC member governments from: OECD CRS database and UNAIDS (collectively, these donors account for less than 5% donor government assistance for HIV) Bilateral Funding: Any earmarked (HIV-designated) amount; does not include funding for international HIV research Multilateral Funding: Donor contributions to the Global Fund to Fight AIDS, Tuberculosis and Malaria and to UNITAID; adjusted to represent estimated “AIDS share” Methodology

Findings

Commitments: –Rose steeply until 2008, then flattened –In 2013, decreased by 3% compared to 2012, to US$8.07 billion –Decline is primarily due to decreasing bilateral funding commitments from the U.S. government Disbursements: –Also rose steeply until 2008, but have had more fluctuation –In 2013, increased by 8% to US$8.46 billion –Increase primarily due to the U.S. accelerating bilateral funding from prior years (the “pipeline”) –Without U.S. increase, donor government disbursements would have been essentially flat A Mixed Story for 2013 SOURCE: Kaiser Family Foundation and UNAIDS, Financing the Response to AIDS in Low- and Middle-Income Countries: International Assistance from Donor Governments in 2013.

International HIV Assistance from Donor Governments: Commitments & Disbursements, US$ Billions Commitments (Enacted Amounts) Disbursements SOURCE: Kaiser Family Foundation and UNAIDS, Financing the Response to AIDS in Low- and Middle-Income Countries: International Assistance from Donor Governments in 2013.

U.S. largest donor, accounting for 66% of total donor assistance (bilateral & multilateral) in 2013 U.K. second largest (10.0%), followed by France (4.8%), Germany (3.4%), and Denmark (2.3%) Five donor governments (Australia, Denmark, France, U.K., and U.S.) increased disbursements for HIV in 2013 Five (Germany, Ireland, Norway, Sweden, and the European Commission) remained essentially flat Three donor governments (Canada, Italy, and Japan) decreased HIV disbursements in 2013 Donor Highlights NOTE: HIV assistance from the Netherlands also decreased in 2013, but this was due to a shift in support from bilateral HIV funding to the Global Fund SOURCE: Kaiser Family Foundation and UNAIDS, Financing the Response to AIDS in Low- and Middle-Income Countries: International Assistance from Donor Governments in 2013.

International HIV Assistance: Donor Governments as a Share of Total Donor Government Disbursements, 2013 US$8.5 billion Total Disbursements SOURCE: Kaiser Family Foundation and UNAIDS, Financing the Response to AIDS in Low- and Middle-Income Countries: International Assistance from Donor Governments in 2013.

Trends by Donor Government, USD millions AustraliaCanadaDenmarkFranceGermanyIrelandItalyJapanNetherlandsNorwaySwedenU.K.ECOtherU.S. SOURCE: Kaiser Family Foundation and UNAIDS, Financing the Response to AIDS in Low- and Middle-Income Countries: International Assistance from Donor Governments in 2013.

Bilateral Assistance: Accounted for 76% (US$6.4 billion) of total donor government assistance Multilateral Assistance: Accounted for 24% (US$2.0 billion) and includes funding provided to the Global Fund and UNITAID Nine donor governments provided majority of their total HIV assistance through bilateral channels, while five channeled more than half through the Global Fund and UNITAID In recent years, many donor governments have provided an increasing share of their total donor assistance for HIV through the Global Fund Bilateral & Multilateral Assistance for HIV SOURCE: Kaiser Family Foundation and UNAIDS, Financing the Response to AIDS in Low- and Middle-Income Countries: International Assistance from Donor Governments in 2013.

International HIV Assistance: Funding Channels for Donor Government Disbursements (USD), 2013 $8.5b $2.4m $191.7m $842.1m $5.6b $59.8m$83.2m $186.4m $172.5m $144.0m $118.4m$285.3m $101.6m $141.4m $100.6m $409.8m SOURCE: Kaiser Family Foundation and UNAIDS, Financing the Response to AIDS in Low- and Middle-Income Countries: International Assistance from Donor Governments in 2013.

Rank by share of total donor government funding for HIV: U.S. ranked first in 2013, followed by the U.K., France, Germany and Denmark Share of total resources available for HIV compared to share of the global economy (as measured by GDP): U.S., Denmark, Sweden, and the U.K. provided greater shares of total HIV resources than their shares of global GDP Rank by funding for HIV per US$1 million GDP: When donor government disbursements are standardized by the size of their economies (GDP per US$1 million), Denmark ranked number one followed by the U.S., the U.K., Sweden, and Ireland Fair Share SOURCE: Kaiser Family Foundation and UNAIDS, Financing the Response to AIDS in Low- and Middle-Income Countries: International Assistance from Donor Governments in 2013.

NOTE: UNAIDS, preliminary estimate of resources available from all sources, This estimate includes domestic expenditures (public and private) for all low- and middle-income countries, including five countries that transitioned into high income levels in SOURCE: Kaiser Family Foundation and UNAIDS, Financing the Response to AIDS in Low- and Middle-Income Countries: International Assistance from Donor Governments in Assessing Fair Share 1: Donor Share of World GDP* Compared to Donor Share of All Resources Available for HIV, 2013 US$19.14 Billion Total Estimated Available Resources for HIV from All Sources

Assessing Fair Share 2: Donor Rank by Disbursements for HIV per US$1 Million GDP*, 2013 SOURCE: Kaiser Family Foundation and UNAIDS, Financing the Response to AIDS in Low- and Middle-Income Countries: International Assistance from Donor Governments in 2013.

Donor government funding commitments to address HIV in low- and middle-income countries fell in 2013 While disbursements increased, primarily driven by U.S. acceleration, this may be unsustainable: U.S. annual funding commitments are decreasing, and diminishing pipeline Future financing from donor governments therefore remains uncertain And financing gap remains: global resources available from all sources (estimated at $19.4 billion) still short of projected need (US$22 to US$24 billion by 2015) Conclusion NOTE: UNAIDS, preliminary estimate of resources available from all sources, This estimate includes domestic expenditures (public and private) for all low- and middle-income countries, including five countries that transitioned into high income levels in SOURCE: Kaiser Family Foundation and UNAIDS, Financing the Response to AIDS in Low- and Middle-Income Countries: International Assistance from Donor Governments in 2013.

Changes in Donor Financing Over Time: A Global Perspective International AIDS Economics Network Pre-Conference Meeting Jen Kates, PhD July 19, 2014 Vice President; Director, Global Health & HIV Policy Kaiser Family Foundation