ARE HIV ALLOCATIONS BEING ALIGNED TO NATIONAL PRIORITIES:

Tracking Expenditure in Southern Africa

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

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 )

Methodology Comparison of NASA Reports from the 4

countries National AIDS Spending Assessment is an

approach to comprehensively measure:All spending for HIV/AIDSFrom all sources, through agents, providers,

activities to beneficiariesFrom a multi-sectoral perspectiveAccording to interventions reflected in the NSPsAllows countries to monitor their own progress

towards the national and international commitments. Acknowledgements to the NACs and NASA

team members for their data

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%.

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

Botswana Swaziland Zambia Ghana -

50,000,000

100,000,000

150,000,000

200,000,000

250,000,000

Internat. Contribution

Public contribution

US

$

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

Botswana Swaziland Zambia Ghana

$136.98

$51.51

$17.62 $1.38

24.1

26.017.0

3.4

Per capita spending (US$, 2006) HIV prevalence rate (%, 2006)

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

2003 2004 20050

200,000,000

400,000,000

600,000,000

800,000,000

1,000,000,000

1,200,000,000

International FundsPublic funds

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

2005/06 2006/070

50,000,000

100,000,000

150,000,000

200,000,000

250,000,000

300,000,000

350,000,000

400,000,000

InternationalPublic

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

2005 20060

50,000,000

100,000,000

150,000,000

200,000,000

250,000,000

Int'l NGO Bilaterals Multilaterals Public

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

2005 2006 -

5,000,000

10,000,000

15,000,000

20,000,000

25,000,000

30,000,000

35,000,000

InternationalPublic

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

2005/06 2006/070

50000000

100000000

150000000

200000000

250000000

300000000

InternationalPublic

Alignment with National Priorities

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

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

0.0% 5.0% 10.0% 15.0% 20.0% 25.0% 30.0% 35.0% 40.0% 45.0% 50.0% Percentage

I. Intensifying Prevention

II. Expanding Treatment, Care and Support

III. Mitigating the Socio-economic impact of HIV and AIDS

IV. Strengthening the Decentralized Response and mainstreaming HIV and AIDS

V. Improving the monitoring of the multisectoral Response

VI. Integrating Advocacy and Coordination of the Multi-sectoral

Response

Theme

Actual expenditure NASF Priorities

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

13.6

49.4

14.4

22.2

0.5

10

54

7

17

0

0.0 10.0 20.0 30.0 40.0 50.0 60.0

Prevention

Care & Support (inclARVs)

Mgmt of NationalResponse

Psychosocial &Economic Impact

Strengthen Legal &Ethical Enviro.

NS

F G

oal

s

%NSF %

Actual Spending %

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

Po

licy,

Ad

vo..

.

Co

ord

. &

M..

.

Miti

ga

ting

t..

.

Pre

ven

tion

...

Tre

atm

en

t, .

..

Re

sea

rch

, S

...

Mo

bili

zatio

n..

.0

5,000,000

10,000,000

15,000,000

20,000,000

25,000,000

30,000,000

Costed APOWAct.ExpenditureU

S$

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

Mgmt, Coord, Support

Prevention Treatment & Care Impact Mitigation0

5

10

15

20

25

30

35

40

45

50

Costed NSPAct.Spending

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

Public sector Internat.Orgs Total Pula0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

FN 8. Research

FN 7. Community Develmt & Environment

FN 6. Social mitigation

FN 5. Human Resources Incen-tives

FN 4. Prog.Devmt & HSS strengthening

FN 3. OVCs

FN 2.Treatment and care

FN 1..Prevention Programmes

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

-

50,000,000

100,000,000

150,000,000

200,000,000

250,000,000

300,000,000

350,000,000

400,000,000

2005/ 2006 2006/ 2007

YEAR

SZL

HIV and AIDS realatedresearch(Excluding operational research)

Enabling Environment and CommunityDevelopment

Social Protection and Social Services(EXCLUDING OVC)

Human Resources' recruitments andRetention Incentive - Human Capital

ProgrammeManagement andadministration strengthening

OVC

Care and Treatments

Prevention

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/ 2006 2006/ 2007

YEAR

SZ

L

Care and treatment services not elsewhereclassified (n.e.c.)

Opportunistic infections’ (OI) treatment

Home-based care

Palliative care

Psychological treatment and supportservices

Specific HIV-related laboratory monitoring

Nutritional support associated to ARVtherapy

Antiretroviral therapy not-desegregated byage 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

Absorptive Capacity

Dimensions of Absorptive Capacity Program Management Procurement and Supply Chain Financial management Governance & oversight Performance and measurement

This focus is on the financial aspects

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

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

2005 2006 -

50,000,000

100,000,000

150,000,000

200,000,000

250,000,000

AllocationsActual Spending

Av.72%

Av.88%

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

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

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

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....

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:

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

Thank YouTeresa GuthrieCentre for Economic Governance and AIDS in Africa Email: teresa@cegaa.orgTel: +27-21-425-2852Cell: +27-82-872-4694