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

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?

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

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

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

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

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

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

Ante-natal prevalence South Africa

1990-2011

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

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

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!

International Funding Uncertain

Global Priorities Changing: Post 2015 MDG

High Level Panel Report

• 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

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.

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

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.

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.

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

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

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

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”.

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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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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New Infections Deaths of HIV Positive People

Economic Transition

Credit Mead Over

Economic Transition

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

Thank You