1. HIV/AIDS Resource Tracking: Lessons learned and next steps Prepared for: Fourth Global National Health Accounts Symposium 7-8 July Barcelona, Spain Paul R. De Lay Director of Evaluation UNAIDS

2. The AIDS epidemic The role for national spending assessments l Rapidly increasing resources l Performance based disbursements l Non-health interventions l Need for broad health sector strengthening l Chronic care with increasingly complex and expensive regimens

3. HIV/AIDS Spending Low- & Middle-Income Countries, 1996-2004 *Grant component of concessional loans. (US$ disbursements in millions) *Grant component of concessional loan disbursements. * Does not include GF or Foundation data

4. Key Issues l History of UNAIDS involvement l Recent estimates for resources needed and resources available l The critical role for national spending assessments (including National Health Accounts) l Challenges and future directions

5. The Role of UNAIDS in Estimating Resource Needs Ongoing estimation process since 2001 l June 2001- Prepared for UNGASS – $10 billion by 2005 ($4.8 prevention, $4.8 treatment) l Nov 2002- Post Barcelona- project out to 2007 (include UP, PEP, med injections ($10.5 in 2005 and $15.2 in 2007) l July 2004- Used 3X5 public health model, decrease in ARV prices, OI Rx, PEP, nutritional support, increased T&C, included gap analysis ($11.6 2005 and $19.9 in 2007)

6. What is new about these latest estimates l Additional activities are included –Increase range of activities for prevention, care, treatment, OVC support, including blood safety, PEP, universal precautions, provider initiated testing l Defines coverage based on type of epidemic (low prevalence, concentrated, generalized) l Includes programme and human resource costs

7. Prevention Related Activities l Mass media l Community mobilization l Voluntary counselling and testing l Youth in school l Youth out of school l Programmes focused on sex workers and their clients l Programmes focused on MSM l Harm reduction programmes for IDU l Workplace l Prevention programs for people living with HIV l Special populations l Condom social marketing l Public and commercial sector condom provision l Improving management of STI l Prevention of mother-to-child transmission l Blood safety l Post-exposure prophylaxis (health care setting, rape) l Safe medical injections l Universal precautions

8. Coverage by type of epidemic Source: Resource Needs for an Expanded Response to AIDS in Low and Middle Income Countries. UNAIDS, 2005. Table 2.

9. Total treatment and care resource needs and ART coverage Source: Resource Needs for an Expanded Response to AIDS in Low and Middle Income Countries. UNAIDS, 2005. Table 5.

10. AIDS Resource Needs * The totals for 2006-2008 have been rounded to the first decimal place with the result that there may be small differences with the figures for sub-totals in the text because of rounding. Source: Resource Needs for an Expanded Response to AIDS in Low and Middle Income Countries. UNAIDS, 2005. Table 1.

11. Figure 1 Projection of available resources for AIDS from all sources between 2004 & 2007 Private SectorMultilateralBilateralDomestic 2004 Estimated Resources Available 2005 Projected Resources Available 2 4 6 8 10 US$ Billions 2007 Projected Resources Available 2006 Projected Resources Available 0 Projected Resources Available from International Sources = US$7 billion in 2007 Private InternationalMultilateralBilateralDomestic 2 4 6 8 10 0 2004 Estimated International Resources Available = US$3.7 billion

12. Others: includes direct reports Australia, Finland, Ireland, Sweden & Switzerland, and estimates for Austria, Belgium, Denmark, Greece, Luxembourg, Netherlands, New Zealand, Norway, Portugal and Spain. Japan: 2004 information on commitments was still incomplete, thus these are UNAIDS estimates. UK: Preliminary estimates. The UK (DFID) holds a policy not to separate the commitments for AIDS and sexual and reproductive health. Reproductive health activities were reviewed and included if there was a substantial portion focused on AIDS. France: These are preliminary estimates and might be revised later. 2004 Direct Bilateral Donor Commitments to Recipient Countries for HIV and AIDS (Global Fund and international research was not included) Source: Resource Needs for an Expanded Response to AIDS in Low and Middle Income Countries. UNAIDS, 2005. Figure 1.

13. HIV/AIDS share of the Contributions to the Global Fund From Donor Governments, Donors’ FY 2004 $856 million “Others”: Includes direct reports from Australia, Finland, Ireland, Sweden & Switzerland for 2004 commitments and preliminary estimates for Austria, Belgium, Denmark, Greece, Luxembourg, Netherlands, New Zealand, Norway, Portugal and Spain. Preliminary reports for Japan. UK figures include selected activities for Sexual and Reproductive Health and/or HIV and AIDS which contained AIDS activities. Japan 6% Germany 3.2% UK 4.2% Canada 9.1% Other DAC 13.6% France 13.2% EC 18.5% US 32.2% Source: Resource Needs for an Expanded Response to AIDS in Low and Middle Income Countries. UNAIDS, 2005. Figure 2.

14. Projection of available resources for AIDS from all sources between 2005 and 2007 Source: Resource Needs for an Expanded Response to AIDS in Low and Middle Income Countries. UNAIDS, 2005. Figure 4.

15. Tracking resources at country level Major issues: l Effectiveness of funding l Equity of funding l Additionality l Impact on health and other social sectors l External donor agendas

16. HIV/AIDS Expenditures in prevention and care. MEXICO 1995-2002. (Million USD$) Sharper increase in care; moderate increase for prevention. Source: SIDALAC/ Mexican Ministry of Health. 2001.

17. Preventive expenditure on MSM and percentage of AIDS cases among MSM Preventive Expenditure on MSMAIDS Cases among MSM 0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 Argentina Bolivia Brazil Chile Costa Rica Dominican R El Salvador Guatemala Mexico Panama Paraguay Peru Uruguay % Beneficiary Analysis in concentrated epidemics Source: SIDALAC/ UNAIDS. 2001.

18. HIV/AIDS Expenditures in Local Currency. Ghana, 2002-2003 0 20,000 40,000 60,000 80,000 100,000 Ministry of Health Other Central Government NGO’s Households (OOPE) Multilaterals (Including GFATM) Bilaterals International NGOs 2002 2003 PUBLICPRIVATEINTERNATIONAL CEDIS Additionality of GFATM resources. Source: SIDALAC/ UNAIDS / Ghana AIDS Commission. 2004. WB-- MAPS GF Mainly USG

19. 0 5 10 15 20 25 30 35 40 45 50 RwandaKenyaZambia Providing HIV/AIDS Prevention, Treatment and Care: A Heavy Toll on the Health Sector 15% = US$10M 17% = US$104M 43% = US$77M % HIV/AIDS as a share of total health expenditures, 2002 per PLWHA US$52 US$104 US$93 Source: Abt / PHR +.

20. Is HIV/AIDS a Priority in Resource Allocation? 19% 75%5%13%33%54% RwandaKenyaZambia There are many priorities competing for public funds Source: Abt / PHR +. 0% 20% 40% 60% 80% 100% PublicDonorPublicDonorPublicDonor HIV/AIDSGeneral health

21. KenyaRwandaZambia Prevention and public health programs Pharmaceuticals Curative care Health administration Source: Abt / PHR +. What is the money buying? Pharmaceuticals 3% Health adm 9% Prevention and public health programs 65% Curative care 23% 9% 2% 4% 85% 4% 46% 5% 45%

22. National AIDS Spending Assessments Future input from HIV-AIDS resource tracking l Gap analysis- –Can you subtract resources available from resource needs? l Assessing sustainability/predictability of funding –By source? Domestic public and private –By type of expenditure? Commodities Infrastructure

23. National AIDS Spending Assessments Work in progress for better spending in countries l Efficiency - bottlenecks l Additionality – needed for Global Fund l Tracking non-health expenditures l Timeliness of data – “real time” l Effectiveness – “funding for the right interventions” l Equity – “funding for the right populations” l Linking spending assessments with resource needs estimations