Challenges and Opportunities for Sustainable Actions to Address HIV among Special Populations in the Caribbean

1. Challenges and Opportunities for
Sustainable Actions to Address HIV
among Special Populations in the
Caribbean
National AIDS Spending
Assessments in the Caribbean
Andrew Fearon: afearon.consulting@gmail.com

2. Total HIV Expenditure 2002-
2009 Trinidad & Tobago
140
120
100
80
TT$m
60
40
20
0
2002 2003 2004 2005 2006 2007 2008 2009

3. Presentation Outline
1. BACKGROUND
- Why Track HIV Expenditures
- Why Track HIV Prevention Expenditures on MARPs
- HIV Prevalence in the Caribbean (Gen Pop, MSM, FSW)
2. METHODS
- National AIDS Spending Assessment (NASA)
- National Health Accounts (NHA)
- UNGASS Reporting on National HIV Spending
3. RESULTS
4. DISCUSSION
5. CONCLUSIONS AND RECOMMENDATIONS

4. Background

5. 1. Why Track HIV Expenditures
 Since 2001 there has been an unprecedented level in external financial
and technical assistance from mechanisms like the UN Joint
Team, PEPFAR, the GF, World Bank and other donors in the region
 While this surge in funding is a welcome development, perhaps more
critical than the amount invested is how those funds are spent and
whether or not they are meeting intended targets i.e. more efficiency
and with greater impact – or are they targeted at all?
 Tracking HIV expenditures can measure the extent of government /
donor commitment over time—towards a sustainable national and
regional response
 The Global Economic Crisis has forced all partners to do more to meet
unmet needs with finite resources.

6. Why Track HIV Prevention Expenditure
on Most At Risk Populations
 Three of the largest Anglophone Caribbean countries
(Jamaica, Trinidad and Tobago, and Guyana) report an
HIV prevalence of 20 percent or more among MSM.
(UNAIDS 2008).
 For many other countries, it is not clear if MARPs are
the drivers of the Epidemic
 Preventing HIV transmission among MARPS benefits
society as a whole because they can serve as a bridge
to spread HIV to the wider population

7. Comparing Adult HIV Prevalence
with HIV Prevalence in MSM (2005-2008)
35%
31.8% Adult HIV Prevalance
30% MSM Prevalance
25%
21%
20%
20%
15%
10% 8.2%
7%
6%
5% 2.4% 2.5% 3%
1.1% 1.5% 1.6%
0%
DOR T&T JAM SUR GUY BAH

8. Comparing Adult HIV Prevalence
with HIV Prevalence in FSWs (2008-2009)
30%
27%
Adult HIV Prevalance
25%
21% SW Prevalance
20%
15%
10% 9%
5% 3% 2.4% 2.5%
1.1% 1.6%
0%
DOR JAM SUR GUY

9. Methods

10. Study Methods
Data collected from the (UNAIDS) National AIDS Spending
Assessment (NASA), (WHO) National Health Accounts (SHA)
and UNGASS Indicator 1 on Four countries in the Caribbean
was utilized for this study. Using data collected from this study
we conducted the following analysis:
1. Described the trends in HIV expenditures related to GDP
2. Compare contributions of domestic and international
financing sources for HIV
3. Compared HIV expenditures on MARPS with overall
prevention expenditures.
4. Based on current HIV expenditure on MARPs, discuss
utility of expenditure tracking surveys for making resource
allocation and mobilization decisions with a view to
sustainability for MARPs programming

11. National AIDS Spending Assessment
(NASA)
 Developed by UNAIDS to track all financial flows relating to HIV and
AIDS
 Designed to give decision makers critical financial information to
enable improved decision making on sustained and efficient allocation
of resources.
 NASA is a globally recognized methodology, linked to the SHA that
reveals sources of funds, expenditure by provider, expenditure by
activity, expenditure by beneficiary population.
 Can point to greater efficiencies in resource utilization – Visualize
Resource Gaps
 Tracking trends in expenditure in HIV & AIDS performance can be
benchmarked against the priorities and objectives as outlined in the
NSP and facilitate a better understanding of needs and identify gaps
in programs
11

12. NASA Methodology
Financing Source Financing Agent Provider
AIDS Spending
Categories (ASCs)
ASC1 ASC2
Production Beneficiary Production Beneficiary
Factors1 Populations1 Factors2 Populations2

13. Results Trinidad & Tobago
2002-2009

14. Results: Trinidad and Tobago 2002-2009
Expenditure by Priority Area
Prevention
60
Treatment
50
A & HR
40 S&R
TT$m
30 Programme Mgmt
20
10
0
2002 2003 2004 2005 2006 2007 2008 2009

15. Results: Trinidad and Tobago
2002-2009
Prevention Expenditure
General Population
TT$m20
MARP
18
16 PMTCT and VCT
14
12
10
8
6
4
2
0
2002 2003 2004 2005 2006 2007 2008 2009

16. Results: Trinidad and Tobago
2002-2009
HIV Expenditure Targeting Beneficiary Populations 2002-20009
70%
60%
50%
PLWHA
40%
MARP
30%
General Population
20%
10%
0%
2002 2003 2004 2005 2006 2007 2008 2009

17. Results: Trinidad and Tobago
2002-2009
Sources of Funding for Prevention
Health 2002-2009
$25 NACC
Other Gov't
$20
International
$15 Private
TT$
$10
$5
$0
2002 2003 2004 2005 2006 2007 2008 2009

18. Results: Caribbean

19. HIV Expenditure % Share of GDP and
Total HIV Expenditure USD. 2008 2009 2010
1.20%
1.00%
0.80%
2008
0.60%
2009
0.40% 2010
0.20%
0.00%
A B C D
0.03
0.02
0.02
2008
2009
0.01
2010
0.01
-
A B C D

20. Total HIV Expenditure per
Capita USD 2008 2009 2010
35.00
30.00
25.00
20.00
2008
2009
15.00
2010
10.00
5.00
-
A B C D

21. HIV Expenditure by Priority
Country A 2008 2009
50.0%
45.0%
40.0%
35.0%
30.0%
25.0%
2008
2009
20.0%
15.0%
10.0%
5.0%
0.0%
Prevention Treatment OVC Programme Human Social Enabling Research
Managment Resources Protection Enviroment

22. HIV Expenditure by Priority
Country B 2008 2009
50.0%
45.0%
40.0%
35.0%
30.0%
25.0%
2008
2009
20.0%
15.0%
10.0%
5.0%
0.0%
Prevention Treatment OVC Programme Human Social Enabling Research
Managment Resources Protection Enviroment

23. HIV Expenditure by Priority
Country C 2009 2010
45.00%
40.00%
35.00%
30.00%
25.00%
2009
20.00%
2010
15.00%
10.00%
5.00%
0.00%
Prevention Treatment OVC Programme Human Social Enabling Research
Managment Resources Protection Enviroment

24. HIV Expenditure by Priority
Country D 2008
2008
45.00%
40.00%
35.00%
30.00%
25.00%
20.00% 2008
15.00%
10.00%
5.00%
0.00%
Prevention Treatment OVC Programme Human Social Enabling Research
Managment Resources Protection Enviroment

25. Percentage Share HIV
Expenditure Prevention: Sex
Workers 2008 2009 2010
4.00%
3.50%
3.00%
2.50%
2008
2.00%
2009
2010
1.50%
1.00%
0.50%
0.00%
A B C D

26. Percentage Share HIV
Expenditure Prevention: MSM
2008 2009 2010
3.50%
3.00%
2.50%
2.00%
2008
2009
1.50%
2010
1.00%
0.50%
0.00%
A B C D

27. Percentage Share HIV
Expenditure Prevention: Drug
Users 2008 2009 2010
0.035
0.03
0.025
0.02
2008
2009
0.015
2010
0.01
0.005
0
A B C D

28. Percentage Share HIV
Expenditure Prevention: General
Population 2008 2009 2010
70.00%
60.00%
50.00%
40.00%
2008
2009
30.00%
2010
20.00%
10.00%
0.00%
A B C D

29. Percentage Share HIV
Expenditure Stigma &
Discrimination 2008 2009 2010
8.0%
7.0%
6.0%
5.0%
2009
4.0%
2009
2010
3.0%
2.0%
1.0%
0.0%
A B C D

30. Percentage Share HIV
Expenditure Civil Societies 2008
2009 2010
40%
35%
30%
25%
2008
20%
2009
2010
15%
10%
5%
0%
A B C D

31. Measurement Challenges
 Inaccessibility and unavailability of expenditure data
 Unavailability and limited recognition of the need for
expenditure to be disaggregated by activity and by
beneficiary population.
 Lack of financial coordination between funding agents -
donors and governments – varying
budgeting, accounting and financial reporting
 Donors financial plans are not harmonised with Country
National HIV Strategic Plans
 Not all National Strategic Plans are costed –
comparison of expenditure against the budgets..
31

32. Measurement Challenges
 Lack of an Agenda. Expenditure analysis is seen as a
donor led activity with limited country buy-in
 Piecemeal implementation reduces the value of the
expenditure analysis for decision making

33. Challenges
 Lack of Institutionalisation of expenditure
tracking – UNGASS Indicator 1 findings:
 Little emphasis on data collection
 Confusion between Budgets and Expenditure
 Confusion between Objectives and Activities
 Technical Capacity – emphasis on data
production, not translation into policy
 Lack of transfer of capacity to local staff
 Lack of Dissemination of expenditure reports
 Lack of understanding between Expenditure
Analysis and Auditing

34. Recommendations
 Governance –
 expenditure assessments should be
incorporated into the strategic planning
cycle,
 International agencies should promote
capacity building in financial policy making,
 CSO need to ensure that financial
commitments are maintained by
Governments and Donors

35. Recommendations
 Human Resources–
 Commitment to Learn by doing
 Support by external consultants should focus
on capacity building rather than data collection.
 Training in financial capacity building –
government, international and CSO sector
 Financial Information
 Develop systems that can link financial
information to activity based budgeting
 Integrate expenditure analysis into the country
planning and budgeting process

36. Recommendations For
Sustainability
 Align external support to national Strategic Plans
which are costed.
 Recognise where the funding is currently flowing
from and where it is flowing to.
 Identify current challenges in funding
 Recognise what funding (Technical Support as well
as cash transfer) the government already provide
 Examine areas that can gradually be incorporated
into government annual plans and commitments
 Develop a domestic sustainable funding strategy

37. Conclusions
 Expenditure on HIV prevention programs for MSM
and CSW is very low relative to overall prevention
expenditure—despite the proportion of HIV
transmission attributed to sex between men.
 The evidence, both on the magnitude of the issue
and the effectiveness of MSM
interventions, demands that countries increase
resource allocations for MSM programming.
 Government policymakers and program planners
will require more evidence of the cost-
effectiveness of MSM interventions so that they
understand the value of investing in programs for
most-at-risk groups—this needs to be part of
future research agendas

38. Post Script – International
Agencies Commitment
 PANCAP
 Caribbean Based Resource Mapping Project
 Resource Mapping in the British Overseas Territories
 World Bank. The Global Strategic Action Plan
for the Promotion of National Health Accounts
 UNAIDS. The National AIDS Spending
Assessment
 OECD, World Bank, WHO and USAID. Where
is the money and what are we doing with it?
Creating an Evidence Base for Better Health
Financing and Greater Accountability