Domestic Financing for Health in Africa: The Road of Sustainability and
Ownership

Prof Alan Whiteside
The Global Fund Sat...
Outline
1. Where we are: AIDS, TB and Malaria in epidemiological terms:
• Global burden of disease
• A Southern African ex...
Years of life lost (women) by cause: Global, 2010

0-1

1-4 5-14 15-24

25-49
Age

50 – 80 +

Source: 2010 Global Burden o...
Years of life lost (women): Western Europe 2010

Maternal
Neonatal
HIV & TB

0-1

1-4 5-14 15-24

25-49

50 – 80 +

Source...
Years of life lost (women): Western Africa, 2010

Maternal
Neonatal
HIV & TB

0-1

1-4 5-14 15-24

25-49

50 – 80 +

Sourc...
Years of life lost (women): Central Africa, 2010

Maternal
Neonatal
HIV & TB

0-1

1-4 5-14 15-24

25-49

50 – 80 +

Sourc...
Years of life lost (women): Eastern Africa, 2010

Maternal
Neonatal
HIV & TB

0-1

1-4 5-14 15-24

25-49
Age

50 – 80 +
So...
Years of life lost (women): Southern Africa, 2010

Maternal
Neonatal
HIV & TB

0-1

1-4 5-14 15-24

25-49
Age

50 – 80 +
S...
Ante-natal prevalence South Africa
1990-2011
HIV Prevalence Among Pregnant
Women: Botswana
40%

37.4%

33.4%

35%

32.4%

33.7%

2005

2006

2007

31.8%

30.4%

2009

...
What is needed for ATM 2014- 2016

• Estimated funding required $87 billion
• Available estimated funding $76 billion or 8...
International Funding Uncertain
Global Priorities Changing: Post 2015 MDG
High Level Panel Report
How to sustain an HIV/AIDS Response?
1. Increase donor support: getting more from
existing donors or involving new donors
...
Criteria for Investment in Health and ATM
• Level of national income, GDP or GNI. An approximation of
resources available ...
Plan for Analysing “Fiscal Space”
• Macroeconomic analysis
– Evaluating potential resource needs and resource
availability...
Understanding Curves: New Infections and
Deaths
Deaths of HIV Positive People

Number of people

New Infections

Time
Treatment Requirements
Treatment needed

Number of people

People Requiring
Treatment

Time
Economic Transition
Deaths of HIV Positive People
Economic Transition
Credit Mead Over

Number of people

New Infections

...
Data from South Africa
7000000

HIV
infections

6000000

5000000

4000000

AIDS cases

3000000

2000000

AIDS deaths

1000...
Data from South Africa
700000

600000

No Economic Transition
on the horizon

500000

New infections
(Incidence)

400000

...
Epidemiologic Transition
New Infections
Treatment

Deaths of HIV Posive People
New people needing treatment

Number of peo...
Epidemiologic Transition
Deaths of HIV Posive People
New people needing treatment

Number of people

New Infections
Treatm...
Table 1: Domestic Investment 2011: % of
total government expenditure
Rwanda
Togo
Botswana
Malawi
Zambia
Nigeria
Kenya
Tanz...
Summary of three diseases

Source
US $ billions
75% of an alcohol levy
3.9
Contributions from high-revenue enterprises
2.4...
Recommendations 1
•
Need for better data. We are not clear on who is spending what. This is true of
both domestic and inte...
Recommendations 2
•

Recognized and improved the role of civil society .

•
The core question: it is possible to define th...
Conclusions
1. Treatment is crucial





Medical
Moral
Ethical
Economic

2. Prevention is essential


We have to turn...
This meeting is about
how do we find
innovative ways of
mobilising more
resources?
Thank You
Domestic Financing for Health in Africa: The Road of Sustainability and Ownership
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Presentation delivered by Prof Alan Whiteside at the 17th ICASA Conference in Cape Town, South Africa as a panel participant on ‘The End of AIDS: Myth or reality?'

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Domestic Financing for Health in Africa: The Road of Sustainability and Ownership

  1. 1. Domestic Financing for Health in Africa: The Road of Sustainability and Ownership Prof Alan Whiteside The Global Fund Satellite Meeting Cape Town 7 December 2013
  2. 2. Outline 1. Where we are: AIDS, TB and Malaria in epidemiological terms: • Global burden of disease • A Southern African example • AIDS and malaria a major issue 2. What we need for 2014 – 2016 3. Two tipping points • The economic transition theory • The epidemiological and advocacy transition theory • Real data 4. This meeting
  3. 3. Years of life lost (women) by cause: Global, 2010 0-1 1-4 5-14 15-24 25-49 Age 50 – 80 + Source: 2010 Global Burden of Diseases Study http://www.healthmetricsandevaluation. org/
  4. 4. Years of life lost (women): Western Europe 2010 Maternal Neonatal HIV & TB 0-1 1-4 5-14 15-24 25-49 50 – 80 + Source: 2010 Global Burden of Diseases Study http://www.healthmetricsandevaluation.org/
  5. 5. Years of life lost (women): Western Africa, 2010 Maternal Neonatal HIV & TB 0-1 1-4 5-14 15-24 25-49 50 – 80 + Source: 2010 Global Burden of Diseases Study http://www.healthmetricsandevaluation.org/
  6. 6. Years of life lost (women): Central Africa, 2010 Maternal Neonatal HIV & TB 0-1 1-4 5-14 15-24 25-49 50 – 80 + Source: 2010 Global Burden of Diseases Study http://www.healthmetricsandevaluation.org/
  7. 7. Years of life lost (women): Eastern Africa, 2010 Maternal Neonatal HIV & TB 0-1 1-4 5-14 15-24 25-49 Age 50 – 80 + Source: 2010 Global Burden of Diseases Study http://www.healthmetricsandevaluation.org/
  8. 8. Years of life lost (women): Southern Africa, 2010 Maternal Neonatal HIV & TB 0-1 1-4 5-14 15-24 25-49 Age 50 – 80 + Source: 2010 Global Burden of Diseases Study http://www.healthmetricsandevaluation.org/
  9. 9. Ante-natal prevalence South Africa 1990-2011
  10. 10. HIV Prevalence Among Pregnant Women: Botswana 40% 37.4% 33.4% 35% 32.4% 33.7% 2005 2006 2007 31.8% 30.4% 2009 2011 30% 25% 20% 15% 10% 5% 0% 2003
  11. 11. What is needed for ATM 2014- 2016 • Estimated funding required $87 billion • Available estimated funding $76 billion or 87% – Domestic $23 billion certain – Global Fund $12 billion: pledging 2- 4th December – Domestic $14 billion potential – International $10 billion very likely $24 billion hoped for • Mind the gap: $13 to $39 billion
  12. 12. International Funding Uncertain
  13. 13. Global Priorities Changing: Post 2015 MDG High Level Panel Report
  14. 14. How to sustain an HIV/AIDS Response? 1. Increase donor support: getting more from existing donors or involving new donors 2. Increase government support 3. Decrease the cost of the current response by improving efficiencies in existing programs But prevent new infections!
  15. 15. Criteria for Investment in Health and ATM • Level of national income, GDP or GNI. An approximation of resources available within a country • Degree to which the Government is able to raise revenue through taxes, levies, domestic borrowing, or other means. • Proportion of Government budget devoted to debt • Pre-existing pattern of disbursement to different sectors. For health if historical allocations have been low, infrastructure may be poor reducing the short-run capacity to absorb rapid increases and convert to service delivery.
  16. 16. Plan for Analysing “Fiscal Space” • Macroeconomic analysis – Evaluating potential resource needs and resource availability, identifying future resource gaps and potential ways of eliminating such financial gaps. • Microeconomic analysis – Assessing potential opportunities to make the 3 largest interventions efficient: • ART • PMTCT • OVC
  17. 17. Understanding Curves: New Infections and Deaths Deaths of HIV Positive People Number of people New Infections Time
  18. 18. Treatment Requirements Treatment needed Number of people People Requiring Treatment Time
  19. 19. Economic Transition Deaths of HIV Positive People Economic Transition Credit Mead Over Number of people New Infections Time
  20. 20. Data from South Africa 7000000 HIV infections 6000000 5000000 4000000 AIDS cases 3000000 2000000 AIDS deaths 1000000 0 1985 1990 1995 2000 2005 2010 2015 2020 2025
  21. 21. Data from South Africa 700000 600000 No Economic Transition on the horizon 500000 New infections (Incidence) 400000 300000 200000 AIDS deaths 100000 0 1985 1990 1995 2000 2005 2010 2015 2020 2025
  22. 22. Epidemiologic Transition New Infections Treatment Deaths of HIV Posive People New people needing treatment Number of people An Advocacy and Epidemiological Transition Time
  23. 23. Epidemiologic Transition Deaths of HIV Posive People New people needing treatment Number of people New Infections Treatment Time
  24. 24. Table 1: Domestic Investment 2011: % of total government expenditure Rwanda Togo Botswana Malawi Zambia Nigeria Kenya Tanzania 23.7% 15.4% 8.7% 18.5% 16.0% 7.5% 5.9% 11.1% Source: UNAIDS, Oxford Policy Management and Authors own calculations
  25. 25. Summary of three diseases Source US $ billions 75% of an alcohol levy 3.9 Contributions from high-revenue enterprises 2.4 Airline levy by all African countries 1.7 2% of public sector budgets earmarked for AIDS 2.4 Mobile phone levy 2.0 1% income tax levy earmarked for AIDS 3.1
  26. 26. Recommendations 1 • Need for better data. We are not clear on who is spending what. This is true of both domestic and international funding. Data needs to be improved and accessible. • Political leadership is critical, and we need to develop advocacy messages to ensure that health continues to be a priority. • Revisit the economic arguments for health, including the macro-economic ones. • Address rigid budgeting practices making it hard to reallocate revenues toward health. • Empowered Health officials to talk to finance and finance to understand health • Address the perception that “donors will take care of the AIDS program”.
  27. 27. Recommendations 2 • Recognized and improved the role of civil society . • The core question: it is possible to define the “right” mix of domestic and international investment in any country. Initial thoughts this will vary country by country. • We should establish on a country by country basis an acceptable “benchmark” for countries to invest from their own resources. • The Global Fund should work with other key donors as a „thought leader‟. In particular it should look to providing data and information. • This is a complex political question not just an economic one
  28. 28. Conclusions 1. Treatment is crucial     Medical Moral Ethical Economic 2. Prevention is essential  We have to turn off the tap
  29. 29. This meeting is about how do we find innovative ways of mobilising more resources?
  30. 30. Thank You

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