What can we learn from NHA and HIV spending accounts?

Jose Antonio Izazola

TOTAL annual resources available for AIDS in low and middle income countries, 1996-2009

$15.9

$15.6

$11.4

$8.9

$8.3

$6.1

$5.0

$0.3 $0.5 $0.5$0.9

$1.4 $1.6

$3.2

0.0

2.5

5.0

7.5

10.0

12.5

15.0

17.5

1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

US

$ b

illi

on

UN AIDS Gates Foundation

World Bank MAP launch

Signing of Decleration of Commitment on HIV/AIDS, UNGASS

PEPFAR

The Global Fund

$12,8

$09,9

$14,3

$17,0

UNITAID

HIP+

$14.4

$17.4

Resources Available for AIDS from All Sources, 2009

$15.9 billion available in 2009 for HIV in low and middle income countries

0.0

4.0

8.0

12.0

16.0

US

D b

illio

ns

Foundations (4%)

UN and otherMultilateral (4%)

Contribution toGFATM (11%)

Bilateralcontributions (37%)

Domestic-public andprivate- (44%)

Expenditures from international sources as percentage of total HIV spending

Principles:

National Aids Spending AssessmentNational Aids Spending Assessment

NASA is inspired from broader social accounting systems. Its methods rest mainly on principles sustained in the System of Health Accounts (SHA) –

National Health Accounts (NHA).

System of National Accounts

System of Health Accounts & National Health Accounts

National Aids Spending Assessment

National Health Sub Accounts (HIV, Malaria, etc)

NASA:

NASA does tracks resources of health services, social mitigation, education, labour, justice and other sectors to embody the multi-sectoral response.

National Aids Spending Assessment

Social MitigationHealth

Human Rights

HIV

Labour

Education

NASA divergence with NHA:

NASA does not confine itself to health expenditures and the sector boundary overlaps with other sub-accounts (i.e.: Reproductive Health, Education…)

NASA and NHANASA and NHA

General NHA

NASA

Health portion of HIV/AIDS expenditures

Nonhealth portion of HIV/AIDS expenditures

NASA- NHA Crosswalk

Health related

NHA HIV/AIDS subaccount (represents health and health related portions of HIV/AIDS expenditures)

General NHA

NASA

Health portion of HIV/AIDS expenditures

Nonhealth portion of HIV/AIDS expenditures

NASA- NHA Crosswalk

Health related

NHA HIV/AIDS subaccount (represents health and health related portions of HIV/AIDS expenditures)

NASA tracks health and non health related

HIV expenditures

e.g. Malaria, TB, hepatitis, etc

e.g. STI

HIV health related

HIV Spending - Defining BoundariesHIV Spending - Defining Boundaries

NHA

Health Spending

Health Accountants

NASA

HIV spending

NASA resource tracking team

NASA follows the space and time boundaries of national health accounts.

Both NASA and NHA aim to…

• Address critical policy questions (for both national and international stakeholders) i.e.– “what are we getting for the money?”

• What matters is not only how much is invested but…– How funds are invested– Whether or not funds are reaching intended targets

• Serve as advocacy and monitoring tools, supporting evidenced-based policy processes– e.g. informing resource allocation decision-making

• Provide country comparable data

Coordination complies with the UNAIDS “three ones principle”

• For coordination of national HIV/AIDS responses  

– ONE agreed HIV/AIDS action framework that provides the basis for coordinating the work of all partners,

– ONE National AIDS coordinating authority, with a broad-based multisectoral mandate, and

– ONE agreed country level monitoring and evaluation system.

(Ministry of Finance)

(Ministry of Health)

$ M F

Clinic

MoH

(Ambulatory Center)

NASA: resource tracking

Source

Agent

Provider

Beneficiary Population

Aids Spending Categories

Financing Source Financing Agent Provider

ASC1

Production Factors1

Beneficiary Populations1

ASC2

Production Factors2

Beneficiary Populations2

Financial Flow

Consumption Flow

Financial and Expenditure FlowsFinancial and Expenditure Flows

The agents’ triangulationThe agents’ triangulation

Fina

ncin

g

Fina

ncin

g Provision

Provision

ConsumptionConsumption

====

==

Fina

ncin

g So

urce

s

Fina

ncin

g So

urce

s

& F

inan

cing

Age

nts

& F

inan

cing

Age

nts P

roviders &

Providers &

Production Factors

Production Factors

Aids Spending Categories & Beneficiary PopulationsAids Spending Categories & Beneficiary Populations

MoH

NACP

Central Lab

Public Hospitals

Blood Safety

SEIC

Min. of Defense

Military Hospital

Min. of Interior

Police Hospital

Min of Education

Public Schools

Minf of Social

DevelopmentINAU

Social Security SS Hospital

Private HospitalsMin of

Labour

INDA

Out of pocket

Households

Central Govt Revenue

Multilateral Funds

Corporations

NGOs

Prisons

Local Givt.Local Govt Revenue

Financing AgtentsProvider of Services

Pharmacies

NGOs

Local AIDS Authority

Financing Sources

International NGOs

Bilateral Funds

National HIV Response and financing and consumption flows

MoH

NACP

Central Lab

Public Hospitals

Blood Safety

Central Govt. Revenue

I.M.MLocal Covt. Revenue

Financing AgentsProviders of

ServicesFinancing Sources

Financing Source Financing Agent Provider

AIDS Spending Categories (ASC)

ASC1

Production Factors1Beneficiary

Populations1

ASC2

Production Factors2Beneficiary

Populations2

Financing Source Financing Agent Provider

AIDS Spending Categories (ASC)

ASC1

Production Factors1

Beneficiary Populations1

ASC2

Production Factors2Beneficiary

Populations2

National HIV Response and financing and consumption flows

Planned vs. executed - Nepal 2007

NAP and NASA (US $ '000)

21,294

7,037

466 418

8,346

2,976

5,110

1,2151,626

-269960

-

5,000

10,000

15,000

20,000

25,000

Prevention Treatment, Careand Support

Advocacy, Policy,Legal reform

Leadership andmanagement

Strategic info, M& E

Finance andresource mob

NAP NASA 2007

Top spenders – Last year reported

Total HIV spending GR 2010, last year reported - Top 15 Globally

0

100

200

300

400

500

600

700

800

900

Russia

n Fed

erat

ion 2

008

Kenya

200

9

Brazil

200

8

Nigeria

200

8

China

2009

Botsw

ana

2008

Ugand

a 20

08

Argen

tina

2008

Mex

ico 2

009

Thaila

nd 2

009

Moz

ambiq

ue 2

008

India

200

9

Rwanda

200

8

Colom

bia 2

009

Mala

wi 200

9

Mill

ion

s

Last year reported

US

D InternationalPublic

Top spenders per capita – Last year reported

Total HIV spending per capita GR 2010, last year reported - Top 15 Globally

0

20

40

60

80

100

120

140

160

180

200

Botsw

ana

2008

Swazila

nd 2

007

Leso

tho

2008

Kenya

200

9

Rwanda

200

8

Ugand

a 20

08

Gabon

200

9

Moz

ambiq

ue 2

008

Mala

wi 200

9

Cuba

2009

El Salv

ador

200

8

Argen

tina

2008

Belize

200

9

Russia

n Fed

erat

ion 2

008

Chile

2008

Last year reported

US

D International per capitaPublic per capita

Funding sources by income level, Last year reported

(n = 29) (n = 25) (n = 15)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Low income Lower middle income Upper middle income

International

Public

Sources of Financing for HIV/AIDS

Total HIV and AIDS Expenditure, Senegal 2007-2008Total HIV and AIDS Expenditure, Senegal 2007-2008

0

5

10

15

20

25

30

35

2007 2008

US

$ m

illi

on

PRIVATE

PUBLIC

INTERNATIONAL

International HIV and AIDS Expenditure, Senegal International HIV and AIDS Expenditure, Senegal 2007-20082007-2008

Bilateral, 10,223,460

GFATM, 7,640,509

Foundations and international NGOs,

531,441 UN agencies,

741,153

Other multilateral, 230,264

Profiles of Spending by Beneficiaries in Sierra Leone 2007Profiles of Spending by Beneficiaries in Sierra Leone 2007 

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Public Funds Bilateral Funds Multilateral

Funds

Other populations

Non-targeted

interventions

General population

Children and Youth in

school

Orphans and vulnerable

children (OVC)

MARP's

PLWHA

Providers of Services (PS) NASA - Nepal 2007

Spending by ProvidersMinistry of

Health (including.

NAPs/NACPs) , 2,247,182 , 13%

Other Ministry, 5,785 , 0%

Hospitals, 82,151 , 0%

Multilateral agencies ,

430,696 , 2%

NGO, INGOs, CBO, 14,895,801

, 85%

Beneficiaries Population - Nepal 2007

Expenditure by BPUS $ 17,661,653

BP.02 Most at risk populations

30%

BP.05 Non-targeted

interventions27%

BP.99 Specific targeted

populations not elsewhere

classified (n.e.c.) 3%

BP.01 People living with HIV (regardless of

having a medical/clinical

diagnosis of AIDS)12%

BP.03 Other key and accessible

populations19%

BP.04 General population

9%

Allocation of resources by programmatic area by type of epidemic

(n = 41) (n = 30) (n = 20)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

C G L

Research

Enabling Environment

Social Protection and Social Services excludingOrphans and Vulnerable ChildrenHuman resources

Program Management and AdministrationStrengthening Orphans and Vulnerable Children

Care and Treatment

Prevention

Allocation of resources by programmatic area by Funding Source, Sub-Saharan Africa last year available USD

0

500

1,000

1,500

2,000

2,500

Public International

Mill

ion

s

Research

Enabling Environment

Social Protection and Social Services excludingOrphans and Vulnerable ChildrenHuman resources

Program Management and AdministrationStrengtheningOrphans and Vulnerable Children

Care and Treatment

Prevention

MARPS Funding sources by UNAIDS regions, Last year reported

(n = 3)

(n = 11)

(n = 1)

(n = 11)

(n = 3) (n = 1)

(n = 1)

(n = 11)

(n = 11) (n = 21)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Car

ibbe

an

Cen

tral

and

Sou

thA

mer

ica

Eas

t Asi

a

Eas

tern

Eur

ope

and

Cen

tral

Asi

a

Mid

dle

Eas

t and

Nor

th A

fric

a

Nor

th A

mer

ica

Oce

ania

Sou

th a

nd S

outh

-E

ast A

sia

Sub

-Sah

aran

Afr

ica

Wes

tern

and

Cen

tral

Eur

ope

InternationalPublic

HIV spending by broad category and detailed prevention distribution. Botswana 2007. Million USD. Public and International funds.

$- $20 $40 $60 $80 $100 $120 $140 $160

Prevention

Care and Treatment

Other

Millions

HIV spending by broad category and detailed prevention distribution. Botswana, 2007. (Million USD)

Prevention activities not elsewhere classified

1%

Communication for social and

behavioral change

3% Community mobilization

16%

VCT1%

Workplace activities

10%

Blood safety11%

Youth in school4%

PMTCT53%

Youth out-of-school

1%

Spending in programs specifically directed to the populations Spending in programs specifically directed to the populations most at risk for HIV as a percentage of total preventionmost at risk for HIV as a percentage of total prevention

8.0%

1.8% 0.5%

2.8%

3.3%

0.1%

8.6%

4.7%

0.0%

0%

5%

10%

15%

20%

25%

Low Concentrated Generalized

Type of Epidemic

Harm reduction programsand IDUs

Programs for men havingsex with men

Programs for sex workersand their clients

A health system comprises all organizations, institutions and

resources devoted to producing actions whose primary intent is to

improve health.

Most national health systems include public, private, traditional and

informal sectors. The four essential functions of a health system

have been defined as service provision, resource generation,

financing and stewardship.

Health Systems

HIV/AIDS Spending on HSS & General Health:

Zambia 2007, 15% of THAE Swaziland, 11% of THAE

The categories included as HSS or for general health spending were:• Blood safety• Safe medical injections• Universal precautions• Opportunistic infection (OI) prophylaxis• Specific HIV-related  laboratory monitoring• Opportunistic infections' (OI) treatment (??)• Patient transport and emergency rescue• OVC Basic health care• Monitoring and evaluation• Operations research• Drug supply systems• Information technology• Upgrading and construction of infrastructure• Upgrading laboratory infrastructure and new equipment• Construction of new health centres• Upgrading and construction of infrastructure n.e.c• Home-based care• Human Resources and Training• Research, • Capacity strengthening

34

Health System Spending 2006

1.22 Universal precautions 118,231

2.01.05 Laboratory monitoring 759,507

4.04 Operations research 205,420

4.08 Information technology 77,993

4.10 Upgrading laboratory infrastructure 1,858,515

5.05 Training 4,170,419

8.01 Biomedical research 27,912

Other

Total USD 21,364,523

Mozambique, National AIDS Spending Assessment, 2006

020

4060

8010

0%

of

Tot

al E

xpen

ditu

res

Low Lower middle Upper middle High nonOECD High OECD

Number of Countries: Low (17), Lower middle (19), Upper middle (14), High nonOECD (2), High OECD (3)

Total Expenditures per capita by income level and type of expenditures, 2006

Health System Strengthening Health

Non Health

0 20 40 60 80 100% of Total Expenditures

Western and Central Europe

Sub-Saharan Africa

South & South East Asia

Oceania

MENA

Latin America

Eastern Europe & Central Asia

East Asia

Caribbean

Number of countiries: Sub-Saharan Africa(17), Latin America(12), Eastern Europe & Central Asia(10),South & South East Asia(5), Caribbean(4), East Asia(2), MENA(3), Oceania (1), Western and Central Europe(1)

Total Expenditures by region and type of expenditures, 2006

Health System Strengthening Health

Non Health

1.18 Blood safety 5,468,810

1.20 Safe medical injections 1,123,027

1.21 Male Circumsicion 1,356

1.22 Universal precautions 625,010

2.01.02 Opportunistic infection (OI) prophylaxis 1,132,522

2.01.05 Specific HIV laboratory monitoring 7,947,858

2.01.06 Dental care 139,716

2.01.07 Psychological treatment and support services 2,742,365

2.01.08 Palliative care 18,749,251

2.01.09 Home-based care 26,416,981

2.02.1 Opportunistic infection (OI) treatment 9,215,228

3.02 OVC Basic health care 5,754,995

4.03 Monitoring and evaluation 12,373,568

4.04 Operations research 2,892,772

4.07 Drug supply systems 9,831,338

4.08 Information technology 1,314,477

4.10 Upgrading laboratory infrastructure 14,387,863

4.11 Construction of new health centres 8,335,027

5.05 Training 11,457,021

8.01 Biomedical research 113,912

8.02 Clinical research 185,706

8.03 Epidemiological research 259,651

8.04 Social science research 72,633

HSS or general health spending SSA, 2006

0 20 40 60 80 100% of Total Expenditures

Western and Central Europe

Sub-Saharan Africa

South & South East Asia

Oceania

MENA

Latin America

Eastern Europe & Central Asia

East Asia

Caribbean

Number of countiries: Sub-Saharan Africa(17), Latin America(12), Eastern Europe & Central Asia(10),South & South East Asia(5), Caribbean(4), East Asia(2), MENA(3), Oceania (1), Western and Central Europe(1)

Total Expenditures by region and type of expenditures, 2006

Health System Strengthening Health

Non Health

1. Improved financial information system for quality and accuracy of data

2. Improving implementers reporting and alignment as well as harmonisation of classification

3. Institutionalising NASA as a part of national M&E system

4. National capacity and EDPs role questioned

Use of NASA/policy implications

5. Useful in assessing the expenditures and getting a broad picture of resource availability in the reporting period.

6. Used extensively in reports at country and global level. Highlighting resource gaps

7. Referred during Global Fund Proposal development.

Use of NASA//policy implications

Thank you very much!