Teresa Guthrie M.PH (Health Economics) HIV modelling for in-country ownership solutions – generation of evidence IAS Conference, Washington DC, July 2012

Rationale The Centre for Economic Governance and AIDS in Africa (CEGAA) believes that: Governments require information to improve their estimates of need & resource requirements, their allocative decisions, to ensure efficient expenditure on effective programmes, and to promote transparency, accountability and good governance. Civil society needs to generate evidence on quality of services, spending & hold govt accountable. With this evidence governments can take leadership and full ownership of the national response to HIV/AIDS and TB.

3 Modelling & Collecting Data in the Fiscal Cycle Assessment of Resource Need – costing analysis. Impact modelling & CEA Fin.Gap Analysis Resource Mobilisation Budget Allocations Investment Framework? Execution of budget –Fin.Info systems for Expenditure Tracking. Absorption of budget/committed? Proportion DP aid spent in country? Systems for reporting: Public, Private & DPs DP alignment DP long-term commtmts Budget Monitoring Revenue & tax watch Analysis of Process Finance channels Intended Spending Auditing (financial) Systems-Accountability Output analysis – interim indicators. Achievement of budget Objectives? Quality? Auditing (internal performance) Community Social Auditing Outcome analysis – long-term indicators. Impact assessment Clinical Trials Cohort studies Life years saved Quality of life Reduced prevalence rates Cost Effectiveness (CEA/CBA/CUA) All Levels: National Provincial District Modelling HIV Epidemiological Trends, Population Projections, Scenario Building

Examples of Modelling Data Costings & Resource Mobilisation Options: 2031 Estimates of Impact & Costs of various scenarios – SA & Thailand SA-ART cost estimates (BU&HERO) – modelled & costed increased CD4 eligibility & impact South Africa created new National Strategic Plan (NSP) for HIV, TB and STIs (2012/ /16) – costs estimated by the costing team

SA New Adult (15-49yrs) HIV infections (’93–’31) 5

SA Adult (15-49yrs) HIV Prevalence (2000–31) 6

SA - Total HIV/AIDS Resources Required by Scenario 2009 –2031 (ZAR billions) NB. These estimations include all sectors and all sources of funding

SA Expanded NSP – Total Costs and their Distribution (ZAR millions) 8

Presentation Name PRESENTATION DATE South Africa’s new NSP cost est. 2016: R32b (US$4b) 2012: R18.6b (US$2.3b)

Examples of Modelling Data Expenditure Tracking, Alignment & Gap Analysis: NASA in ESA South African National AIDS Council (SANAC) commissioned the National AIDS Spending Assessment (NASA) (2007/ /10). Compared the estimated cost of SA NSP (new & old) implementation with estimated current and future available funds, and measured the potential funding gap. Considered various scenarios for funding options.

Sources of Funding in ESA

Presentation Name PRESENTATION DATE Spending Alignment with Country Priorities Looking backwards to previous SA NSP costing & NASA (09/10)

Alignment of All SA Partners?

Is SA spending efficiently on ART? (ZAR, 2009/10 ) 14 NB. GP also spent PEPFAR funds on public ART, not included above

DRAFT - DO NOT DISSEMINATE. 15 Is SA spending on the best prevention interventions? (%, 2009/10)

Are we targetting the right Beneficiaries? ( ) DRAFT - DO NOT DISSEMINATE.

Presentation Name PRESENTATION DATE Projected funding availability – gap?? Forward projected available funding vs NSP costs (2012)

Presentation Name PRESENTATION DATE Anticipated gap/surplus by intervention

Modelling Funding Scenarios

Findings – Funding Options 4. Mixed Scenario – 20% private, 20% increase in external, 22% public increase

Presentation Name PRESENTATION DATE Best Funding Scenario? 5. Alternative (Innovative?) Domestic Financing Options

Presentation Name PRESENTATION DATE Conclusions i. Sound objective evidence - modelling, costs, spending, quality of services, impact – all increase the govt’s ability to lead the response and inform policy choices. Research agenda should be aligned to national priorities, not pushed by development partners’ agendas. Aid dependency, and its unpredicatbility, short-cycles & lumpiness seriously hinders the country’s ability to future project available funding, plan, and manage the response. Improved public accountability & transparency re budgets, spending, outputs & outcomes – improve financial systems! Improved transparency of development partners’ commitments, disbursements and actual spending, so as to measure alignment, prioritisation & gaps

Presentation Name PRESENTATION DATE Conclusions ii. Need to model alternative domestic funding sources & mechanisms, such as a national health insurance, financial transaction tax, a currency conversion levy or an additional AIDS tax on individuals and businesses – to give greater power to governments in taking the leadership role. Far greater commitment and transparency from the business sector, the private health insurance industry and the development partners in terms of predictable, aligned and accountable spending on HIV/AIDS. Build capacity of civil society to monitor govt budgets & spending Building local capacity & systems – govt and service providers – real local ownership & investing in their longer-term systems strengthening before funding programme implementation.

Thank you Teresa Guthrie Centre for Economic Governance and AIDS in Africa