1. Guthrie, T., Kioko, U., Chitama, D., Asante, F., Chitsomia, A., Madadume, B. Inaugural Conference of the African Health Economics and Policy Association Accra - Ghana, 10th - 12th March 2009 PL 05/1

2. Objectives  To compare levels of spending, both domestic and international, for HIV/AIDS in 4 SADC countries: Botswana, Swaziland, Zambia, Lesotho -> Ghana (non-SADC comparison)  To consider the adequacy and alignment of the funds for the attainment of their National Strategic Plans (NSPs).  To measure the absorption of these funds according to the different funding mechanisms.  To compare unit costs for key interventions (where output data was available )

3. Methodology  Comparison of NASA Reports from the 4 countries  National AIDS Spending Assessment is an approach to comprehensively measure: All spending for HIV/AIDS From all sources, through agents, providers, activities to beneficiaries From a multi-sectoral perspective According to interventions reflected in the NSPs Allows countries to monitor their own progress towards the national and international commitments.  Acknowledgements to the NACs and NASA team members for their data

4. Levels and Sources of Financing  Increasing amounts of spending on HIV/AIDS  Increasing public allocations, as well as international  Average contributions (in 4 countries):  International 58.8%. Public 41.2%.  Removing Botswana:  International 71.6%. Public 28.4%.

5. Levels & Sources of Funding for HIV/AIDS (US$mill, 2006)

6. Per Capita HIV/AIDS Spending & HIV Prevalence (US$, %, 2006)

7. Increasing Public Allocations: Botswana ~ Total Spending on HIV/AIDS (PulaMill, 2003-2005)

8. Swaziland ~ Sources of HIV/AIDS Financing (SZLmill, 2005/06-2006/07)

9. Zambia ~ Sources of HIV/AIDS Financing (US$, 2005&2006)

10. Ghana – Sources of HIV/AIDS Financing (US$mill, 2005-2006)

11. Lesotho (prelim) ~ Financing Sources for HIV/AIDS (M, 2005/06 & 2006/07)

13. Swaziland ~ Comparison of Costed NSP with NASA Spending (SZL, 2006/07)

14. Zambia ~ NSP Costed Priorities vs Actual Spending (%, 2006)

15. Botswana ~ NSP Priorities Compared to Actual Spending (%, 2005/06)

16. Ghana ~ Costed APOW vs Actual Spending (US$, 2006)

17. Lesotho ~ Spending Compared to Costed NSP Priorities (%, 2006/07)

18. Botswana ~ Spending on HIV/AIDS by Source (%, 2005)

19. Swaziland ~ Effects of Reducing External Aid (SZL, 2005/06-2006/07)

20. Swaziland ~ Reducing Treatment (Nutrition Supplements) Spending (SZL, 2005/06-2007/08) - 10,000,000 20,000,000 30,000,000 40,000,000 50,000,000 60,000,000 70,000,000 80,000,000 90,000,000 2005/ 20062006/ 2007 YEAR SZL Care and treatment services not elsewhere classified (n.e.c.) Opportunistic infections’ (OI) treatment Home-based care Palliative care Psychological treatment and support services Specific HIV-related laboratory monitoring Nutritional support associated to ARV therapy Antiretroviral therapy not-desegregated by age or line of treatment Adult antiretroviral therapy not- desegregated by line of treatment Pediatric antiretroviral therapy not- desegregated by line of treatment Opportunistic infection (OI) prophylaxis

22. Dimensions of Absorptive Capacity  Program Management  Procurement and Supply Chain  Financial management  Governance & oversight  Performance and measurement  This focus is on the financial aspects

23. Financial Absorptive Capacity  Ability of implementing agencies to utilise funds in the planned time period and for the purposes intended  Rate and manner by which funds received are turned into physical resources of materials, equipment, infrastructure, and personnel  Encompasses financial flow:  from commitment  through transfer or disbursement  to procurement or expenditure

24. Zambia – absorption rates improving (US$, 2005 & 2006)

25. Factors Limiting Absorptive Capacity  Limited human resources & skills at all stages of project conceptualisation, implementation & monitoring  High rate of turn-over and deaths of staff  Preferential use of funding (according to source)  Governmental ceilings for development / social sector spending – frozen posts  Delayed disbursements (some funding mechanisms worse than others)  Complexity of reporting and accounting requirements and other conditionalities – absorb staff time  Govt procurement systems very slow  Short project cycles and disbursement cycles

26. Summary of Findings  Evidence of improving public contribution to total spending on HIV/AIDS  Some decreases in external sources (Swaziland & Lesotho)  Treatment (specifically ART) requiring increasing amounts  Prevention not receiving notably increased allocations  Other interventions (mitigation, enabling environment, research) receiving relatively little

27. Findings cont. Comparing the costed NSP priorities with the actual spending:  NSPs generally poorly costed and may not have been accepted in country  NASA captured more than was included in the NSP costing  Improving costings and use of NASA will better provide estimates of funding gaps by intervention  There are improvements ito donor alignment with national priorities (according to the Paris Declaration)  Eg. Increasing allocations through common funds for HIV/AIDS, managed by the NACs  However, there are some notable exceptions  Parallel systems of financial management remain

28. Findings cont.  Comparison of unit costs of key interventions within the SADC region has been difficult due to poor or non-comparable out-put indicators.  The funding mechanism appears to influence the degree of absorption of funds, among many other factors  Often poor absorption due to delays in disbursement systems, and ‘dumping’ by donors  Measuring the absorption of funds proved difficult because the NASA approach initially did not collect the allocations/ commitments / disbursements – only the actual spending so the rate could not be calculated.  Only in Zambia....

29. NASA Provides Data for Evidence-based Allocative Decisions  Adequacy of funding – public & external  Allocative decisions – priorities  Efficiency of spending & absorption rates/ challenges  Coordination, Harmonisation and Alignment  Enhanced Transparency, Accountability & Economic Governance  Standardization & Comparability  Need for institutionalization of resource tracking in routine M&E systems:

30. Routine Resource Tracking would…. Increase pressure (& desire) for mutual accountability by all players Promote a framework to ensure all partners report through a national resource tracking system Link framework to the National Resource Mobilisation and Management Strategy Contribute to harmonised standards of reporting and costing among different partners Ensure transparent procurement systems & best pricing within and between countries & regions

31. Thank You Teresa Guthrie Centre for Economic Governance and AIDS in Africa Email: teresa@cegaa.org Tel: +27-21-425-2852 Cell: +27-82-872-4694