Financial Implications of HIV/AIDS in South Africa – the role of the Business Sector Findings from aids2031 costing & the efforts of the National AIDS Spending Assessment 9 June 2011 Silindile Shezi, CEGAA Acknowledgement to: Teresa Guthrie, Robert Hecht, Yogan Pillay, Mark Blecher, Kelsey Case

Overview of the Cost Estimates The aids2031 South African costing project was carried out during , sponsored and guided by a national Steering Committee composed of senior South Africa officials and other leading national figures. It was part of a larger international project led by R4D which included the estimation of global costs. It aimed to estimate the long-term costs of various response scenarios till

The South African Scenarios 1.Narrow NSP by Expanded NSP by Hard Choices by 2015 Baseline (maintaining 2009 coverage as comparator) 3

Scenario 2 – Expanded NSP Achievement of all NSP & extra targets by 2021 ART – new regime & CD4 350 eligibility from 2010, 90% reached by 2015/6 MMC introduced 2010, reaching 90% by 2021 Expanded workplace programmes, education and behaviour change Mobilization and higher coverage for CSW & MSM Expanded efforts for youth-out-of-school Programs to reduce violence against women Expanded mitigation interventions 4

Estimated Epidemiological Impact 5

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Adult (15+yrs) HIV Prevalence (2000–2031) 7

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9 Infant HIV-related Deaths (1993 –2031)

Key points from the Epi-projections 1.Only the expanded NSP will halve the new infections, as per the NSP goal, but only by Compared to Baseline, the expanded NSP will avert nearly 6,000 infections in total by 2031, where as continuing with the current NSP will only avert 3,000 – half! 3.With increasing treatment coverage, HIV prevalence is unlikely to reduce below 10%, best case scenario. 4.Numbers on treatment will continue to grow, up to 3million by 2018, but thereafter will start to decrease with the expanded NSP & the expanded prevention efforts. 5.PMTCT will significantly reduce infant mortality, in all scenarios since same coverage. 10

Estimated Resource Requirements 11

Total HIV/AIDS Costs by Scenario ( , ZAR Billions) 12 DRAFT-do not copy or disseminate NB. These estimations include all sectors and all sources of funding

Expanded NSP – Total Resources Required and their Distribution (ZAR billions) 13

Expanded NSP – Programme Disaggregation (ZAR billions) 14 DRAFT-do not copy or disseminate

Cost Implications 1.With Expanded NSP costs will double from 2010 to 2021 (but will be significantly reduced with new tender prices, should allow for all on at 350CD4 – greater prevention effects) 2.But thereafter they start to decrease significantly. Treatment taking 60% by 2020, but thereafter reducing. 3.Largest proportion will be DOH responsibility for the delivery of public ART – therefore important to increase the role of businesses in provision of ART and PMTCT. 4.Workplace programmes, especially business sector programmes, are important for other prevention interventions. 5.The role of NGOs could be expanded.

Sustainable Funding Sources? 17

Sources of Financing for HIV/AIDS in SA The current SA NASA is collecting the previous years' spending trends of all sectors (public, external & private). No comprehensive database of external sources (some from Burlington (2009). No database of business sector CSI activities (some from Trilogue) Budgetary allocations show national spending, conditional grants to provinces & some provincial voted allocations – limited disaggregation. OOPE – unknown. Development partners appear uneasy to share their longer-term commitments to HIV/AIDS in SA? DPs also struggle to provide year-specific expenditures by province. Business sector is not willing to share their expenditure for the NASA process. Therefore impossible to measure the projected financing gap. 18

SA Public HIV/AIDS Budget Allocations (2006/ /13) 19

Rough Questimate of Total Resource Gap (for all actors, not only public) 20

SA DOH Budget Allocations for HIV/AIDS (ZAR millions) 21

Rough Guestimate of public ART shortfall, assuming 90% coverage by

Importance of the National AIDS Spending Assessment (NASA) 23

Objectives of NASA in South Africa For the years 2007/08, 2008/09 & 2009/10, to identify in each province: All the sources (public, external and private) of financing for HIV/AIDS and TB The providers of the HIV/AIDS and TB services The activities services delivered – and their alignment with the PSP priorities The beneficiaries of the services In order to make recommendations for the improved targeting of funds and efficiency of spending, according to the provincial priorities. DRAFT - DO NOT DISSEMINATE. 24

Estimating & Securing Resource Requirements 1.Using estimates of the future costs of an expanded NSP 2.Comparing current spending per intervention  More detailed and accurate financing gaps can be calculated  Sustainable resources mobilised This requires all partners to: participate more actively in the achievement of the Expanded NSP be transparent & accountable about their past, current and future funding activities Improve the tracking of expenditure of businesses for HIV/AIDS. 25

SANAC, PACs, HASTs, etc UNAIDS Mark Blecher, National Treasury Drs Pillay & Mbengashe (NDOH) aids2031 Steering Committee Gesine Meyer-Rath & Lawrence Long, BU/HERO Kelsey Case, Imperial College London John, Lori & Steve, Futures Institute Leigh Johnson, UCT Susan Cleary, UCT Steve Cohen, SDC All the DoH departments that provided data The teams at CEGAA and Results for Development Institute Acknowledgements 26