Domestic financing africa
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Domestic Financing for Health in Africa
Prof Alan Whiteside
Meeting of Ministers of Health and Finance on Domestic Financing for Health
Addis Ababa, Ethiopia
Global Fund and African Development Bank
11-12 November 2013
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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. Where it is coming from
4. Mobilising Domestic resources
5. Where are we going?
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Years of life lost (women) by cause: Global, 2010
Source: 2010 Global Burden of
Diseases Study
http://www.healthmetricsandevaluation.
org/
0-1 1-4 5-14 15-24 25-49 50 – 80 +
Age
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Years of life lost (women): Western Europe 2010
Source: 2010 Global Burden of Diseases Study
http://www.healthmetricsandevaluation.org/
Maternal
Neonatal
HIV & TB
0-1 1-4 5-14 15-24 25-49 50 – 80 +
Age
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Years of life lost (women): Western Africa, 2010
Source: 2010 Global Burden of Diseases Study
http://www.healthmetricsandevaluation.org/
Maternal
Neonatal
HIV & TB
0-1 1-4 5-14 15-24 25-49 50 – 80 +
Age
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Years of life lost (women): Central Africa, 2010
Source: 2010 Global Burden of Diseases Study
http://www.healthmetricsandevaluation.org/
Maternal
Neonatal
HIV & TB
0-1 1-4 5-14 15-24 25-49 50 – 80 +
Age
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Years of life lost (women): Eastern Africa, 2010
Source: 2010 Global Burden of Diseases Study
http://www.healthmetricsandevaluation.org/
Maternal
Neonatal
HIV & TB
0-1 1-4 5-14 15-24 25-49 50 – 80 +
Age
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Years of life lost (women): Southern Africa, 2010
Source: 2010 Global Burden of Diseases Study
http://www.healthmetricsandevaluation.org/
Maternal
Neonatal
HIV & TB
0-1 1-4 5-14 15-24 25-49 50 – 80 +
Age
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Ante-natal prevalence South Africa
1990-2011
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HIV Prevalence Among Pregnant Women: Botswana
37.4%
33.4% 32.4% 33.7%31.8%
30.4%
0%
5%
10%
15%
20%
25%
30%
35%
40%
2003 2005 2006 2007 2009 2011
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What is needed for ATM 2014- 2016
• Estimated funding required $87 billion
• Available estimated funding $76 billion or 87%
– Domestic $23 billion certain
– Domestic $14 billion potential
– International $24 billion potential
– Global Fund $15 billion potential
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How to sustain an ATM and HSS Response?
1. Increase donor support: getting more from
existing donors or involving new donors
2. Increase domestic financing
– Public or government
– Private sector
– Out of pocket
3. Decrease the cost of the current response by
improving efficiencies in existing programs
But prevent new infections!
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International Funding Uncertain
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Global Priorities Changing: Post 2015 MDG
High Level Panel Report
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• Donors have their own
agendas
• Countries adjust their
plans based donor
goals
• This may be „ants in
the sugar bowl‟
International versus Domestic Agendas
Image Credit:
http://cdn.backyardchickens.com/0/0b/0b999fa8_2_ants.jpeg
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Africa has made commitments
• Abuja Declaration on HIV/AIDS, Tuberculosis and Other Related Infectious Diseases, 2001: Heads of State commit to spend at least 15 % of budgets on Health.
• Addis Ababa, African Union roadmap on shared responsibility and global solidarity for AIDS, TB and malaria response, 2012 Endorsed Roadmap on Shared Responsibility and Global Solidarity for HIV, TB and Malaria, Pharmaceutical Manufacturing Plan
• Tunis Declaration on value for money, sustainability and accountability in the health sector, 2012 Enhance value for money, increase accountability improve sustainability of health resources.
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Domestic Investment 2011: % of total government expenditure
Rwanda 23.7%
Malawi 18.5%
Zambia 16.0%
Togo 15.4%
Tanzania 11.1%
South Africa 10.0%
Botswana 8.7%
Nigeria 7.5%
Kenya 5.9%
Source: UNAIDS, Oxford Policy Management, R4D and Authors
own calculations
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What should the domestic commitment
to health and ATM be?
• According to minimum standard? ($44)
• What is affordable?
• What is cost effective?
• Fair share between domestic and donors?
• UNAIDS developed Domestic Index of Priority
• More money for health or more health for money?
This is a political decision at national and international levels.
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Criteria for Investment
• 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. In health if
historical allocations were low, poor infrastructure reducing capacity to
absorb rapid increases and convert to service delivery.
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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
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Innovative Ways of raising money
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
But how to 1. sell and 2. ring fence
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Increased Domestic Funding
• Economic trends
• Abuja Declaration at least 15 % of budgets on Health.
• Economic trends plus DALY
Even then there will be a gap
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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”.
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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
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Nu
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of
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Time
New Infections Deaths of HIV Positive People
Understanding Curves: New Infections
and Deaths
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Col 1
People Requiring
Treatment
Treatment Requirements
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Nu
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New Infections Deaths of HIV Positive People
Economic Transition
Credit Mead Over
Economic Transition
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HIV positive deaths
New infections
HIV positive deaths
New infections
HIV positive deaths
New infections
HIV positive deaths
New infectio
ns
Economic Transition Occurs
when new infections fall below deaths of HIV positive people
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New Infections Deaths of HIV Posive People Treatment
An Advocacy and
Epidemiological Transition
Epidemiologic Transition
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New Infections Deaths of HIV Posive People Treatment
Epidemiologic Transition
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Thank You