1. 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

2. Outline
Background Data & Methods Results Discussion

3. Outline
Background Data & Methods Results Discussion

4. 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

5. 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

6. Outline
Background Data & Methods Results Discussion

7. 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

8. 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)

9. 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)

10. Outline
Background Data & Methods Results Discussion

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

12. 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]). 

13. 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
log_hiv_prev HIV prevalence
log_art_cov ART coverage
log_pop Population
log_haq HAQI
log_dah_cureNMpc DAH-CT pc
Elasticity (Uncertainty Interval)

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

15. Outline
Background Methods Results Discussion

16. 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.

17. 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

18. Thank you
Annie Haakenstad