Efficiency, Effectiveness, and Financial Sustainability:The Importance of Country Ownership

Dr Bernhard SchwartländerUNAIDS

2011 Political Declaration on HIV/AIDS: resources for the HIV response

Programmes must become more cost-effective and evidence-based and deliver better value for money

Break the upward trajectory of costs through the efficient utilization of resources (simplification and integration)

Close the global resource gap by 2015 (USD 24 billion by 2015)

Support and strengthen existing financial mechanisms Expand voluntary and additional innovative financing

mechanisms

Total funding for AIDS in sub-Saharan Africa is slowingafter many years of growth

Source: UNAIDS

AIDS investment in sub-Saharan AfricaUS$ billions

Treatment programmes are highly aid-dependent

International share (%)

• A new investment approach

• We are gradually doing better – examples for incresed effectiveness and efficiency

• Sustainable financing – a new global compact for shared responsibility

Overview

But we can do betterScale up to date guided by a “commodity approach”

Unsystematic prioritisation and investment with limited basis in country epidemiology and context

Resources spread thinly across many parallel interventions

Focus on discrete interventions rather than overall results leading to a fragmented response

We have done a lot…

Unprecedented scale up of HIV prevention, treatment, care and support

Decline in rate of new HIV infections in many countries

More than 6.6 million people on ART Millions of orphans receiving basic education,

health, social protection

AIDS: a new Investment Framework

SYNERGIES WITH DEVELOPMENT SECTORS

CRITICAL ENABLERS

Care & treatment

Male circumcision

Keeping people alive

Keypopulations

Eliminate new infections in children & keep mothers alive

Condoms

OBJECTIVES

Stopping new infections

Behaviourchange

BASIC PROGRAMME ACTIVITIES

Social enablers• Laws & policies• Community mobilization• Stigma reduction

Programme enablers• Community-centered

design & delivery• Management & incentives• Production & distribution• Research & innovation

Social protection; Education; Legal Reform; Gender equality; Poverty reduction; Gender-based violence; Health systems (incl. treatment of STIs, blood safety); Community systems; Employer practices.

0

5

10

15

20

25

30

35

2011 2012 2013 2014 2015 2016 2017 2018 2019 2020

Three investment scenariosImpact on the epidemic

USD

(Bill

ions

)

- 2.5- 2.0- 1.5- 1.0- 0.5- 0 N

ew H

IV In

fecti

ons

(mill

ions

)

Business as usual

0

5

10

15

20

25

30

35

2011 2012 2013 2014 2015 2016 2017 2018 2019 2020

USD

(Bill

ions

)

Business as usualInvestment framework

- 2.5- 2.0- 1.5- 1.0- 0.5- 0 N

ew H

IV In

fecti

ons

(mill

ions

)

Three investment scenariosImpact on the epidemic

0

5

10

15

20

25

30

35

2011 2012 2013 2014 2015 2016 2017 2018 2019 2020

USD

(Bill

ions

)

Rapid scale upprevious projections

Business as usualInvestment framework

- 2.5- 2.0- 1.5- 1.0- 0.5- 0 N

ew H

IV In

fecti

ons

(mill

ions

)

Three investment scenariosImpact on the epidemic

• Anew investment approach

• We are gradually doing better – examples for incresed effectiveness and efficiency

• Sustainable financing – a new global compact for shared responsibility

Overview

Resources available for HIV in low and middle income countries, globally, 2002-2010

ARV costs in South Africa

0

50

100

150

200

250

300

350

ABACAVIR300mg

EFAVIRENZ200mg

EFAVIRENZ600mg

LAMIVUDINE150mg

NEVIRAPINE50mg/5ml

TENOFOVIR300mg

Pric

e pe

r pac

k (R

and)

SA tender price(June 2010)

Internationalbenchmark price

SA tender price(Jan 2011)

Above facility costs can be reduced

$0

$100

$200

$300

$400

$500

$600

Rwanda Zambia South Africa

Facility Level Cost

National Programme Cost

ART costs per patient at the facility and program level

Integrated services are more efficient

The example of VCT: Costs per client

Stand-alone VCT clinics

Integrated into SRH services

• Times of austericy – a new investment approach

• We are gradually doing better – examples for incresed effectiveness and efficiency

• Sustainable financing – a new global compact for shared responsibility

Overview

OECD countries can afford more

2010 overseas development assistance as a share of Gross National Income

0.12%0.15%

0.17%0.20%0.21%

0.26%0.29%

0.32%0.32%0.33%

0.38%0.41%

0.43%0.50%

0.53%0.55%0.56%

0.64%0.81%

0.90%0.97%

1.09%1.10%

0.0% 0.7%

KoreaItaly

GreeceJapan

United StatesNew Zealand

PortugalAustralia

AustriaCanada

Germanyswitzerland

SpainFranceIrelandFinland

United KingdomBelgium

NetherlandsDenmarkSweden

LuxembourgNorway

Economic growth in Africa, 1970–2010Third-fastest growing region in the World

Domestic AIDS spending needs to match the burden of disease

Domestic AIDS spendingas a share of health spending

Burden of diseasecaused by AIDS

Median % across countries

Burden of disease from AIDS vs spending on AIDS

Measuring national commitment to AIDS:the Domestic Investment Priority Index

Options for increasing domestic HIV investment in Africa

Source: UNAIDS

Domestic public AIDS investment in sub-Saharan Africa

Examples of innovative country-level approaches to HIV financing

Taxes on tobacco and alcohol are common to finance health initiatives

Zimbabwe’s ‘AIDS levy’ earmarks a part of individual and corporate income tax for the AIDS response

Kenya and Zambia are considering an AIDS trust fund

Several African countries collect a tax on airline flights to finance UNITAID’s efforts on AIDS, tuberculosis and malaria; own airline tax in Niger

Levy on mobile telephone air time: being explored in Gabon, Kenya, Burkina Faso

Leverage or tax remittance flows

A new global compact on shared responsibility: Domestic financing potential and international investment needs in sub-Saharan Africa

Conclusions

The leveling off in international resources is a threat – but also an opportunity

We need the experience and innovation of the practitioners of the global South

AIDS can lead the way – as it has done before

Country ownership is essential – but has accountability at its core

We can break the back of the epidemic

Within a new global compact on shared responsibility we can generate the resources we need