HIV/AIDS and human rights: public budgets for the epidemic in Argentina, Chile, Ecuador, Mexico and Nicaragua

8/8/2019 HIV/AIDS and human rights: public budgets for the epidemic in Argentina, Chile, Ecuador, Mexico and Nicaragua

http://slidepdf.com/reader/full/hivaids-and-human-rights-public-budgets-for-the-epidemic-in-argentina-chile 1/40



Funding the fight againstHIV/AIDS

A comparative report

of four African studies:Kenya, Mozambique, Namibia and South Africa



This report is part of a project carried out by African and Latin American organizations and

financed by the Swedish International Development Cooperation Agency. Please contact Idasa at

[email protected] for the African country studies and Fundar at finanzaspub [email protected] the Latin American country studies.

Editors: Teresa Guthrie and Alison Hickey

Design: Deikon.

Printed by: Mono comunicación, S.A. de C.V.

Octob er 2004, Fundar Centro de Análisis e InvestigaciónPopot la 96 5; Tizapán San Ángel; México, D.F.

Printed in Mexico



Funding t he fi ght against HIV/AIDS

A comparative report of four African studies:Kenya, Mozambique, Namibia and South Africa

Introduction ...................................................................................................................5

1. The Socioeconomic Environment ...................................................................................5

2. The Magnit ude of the HIV/AIDS Epidemic ....................................................................7

3. National Responses to HIV/AIDS...................................................................................8

3.1 Political Commitment

3.2 National Coordinating Structures

3.3 Tackling HIV/AIDS as a Development Issue

3.4 National HIV/AIDS Plans and Programmes

4. Reliance on Donor Aid .................................................................................................12

5. Funding and Budget Cont rol Mechanisms Used for HIV/AIDS Programmes..................13

6. Allocations Made to Public Health...............................................................................14

6.1 Public Health Allocations as a Share of GDP and Total Expenditure

6.2 Per Capita Public Health Allocations

7. Allocations Made to HIV/AIDS Programmes................................................................18

7.1 HIV/AIDS Nominal and Real Allocations

7.2 HIV/AIDS Allocationsas a Share of Total Expenditure and of Total Health Expenditure

7.3 HIV/AIDS Per Capita Al locations

8. Changing Priorit ies - Changing Types of Activit ies ......................................................26

9. Effi ciency and Equity in HIV/AIDS Spend ings ..............................................................29



4

10. Africa Regional Recomendations .................................................................................32

10.1 Policy Implications

10.2 Mainstreaming HIV/AIDS as a Development Issue

10.3 Institut ional Implications

10.4 Resource Implications

10.5 Funding and Budget Control Mechanisms

10.6 Coordinating Donor Funds

10.7 Monitoring Issues of Equity and Human Rights Promotion

References..........................................................................................................................37



5

Introduction

The African countries included in this study, Kenya, Mozambique, South Africa and Namibia,

presented differing scenarios in terms of socioeconomic indicators, HIV prevalence rates and

government response. All these factors, and many others, are intertwined and influence one other.

Thus an understanding of a government’s political commitment to the issue of HIV/AIDS is essential

when considering the policies and structures set in place to respond to the epidemic. These in turn

influence the amounts allocated and the funding mechanisms used to distribute funds. The degree

of reliance on donor funds to sustain national HIV/AIDS programmes is also a critical issue: the

fluctuating nature of donor funds can undermine a state’s ability t o determine and coordinate its own

response and to plan effectively over a medium-term expenditure period.

With escalating prevalence rates, increasing poverty and declining development in sub-Saharan

Africa, the pandemic has been identified as a development issue, and thus governments and donors

have been allocating increasing funds to the fight against it. These studies examine the trends in

real terms and consider the intervention priorities. However, it was beyond the scope of the research

to analyse the sufficiency of allocations, based on cost and needs analyses, or of the outcome and

impact of allocations.

This report gives an overview and comparison of the key issues as they relate to the four African

countries included here.

1. The Socioeconomic Environment

A ll four countries suffer, to varying degrees, from underdevelopment and socioeconomic

problems, such as slow or fluctuating economic growth, rising unemployment, increasing poverty andinequality, and generally limited state resources.

Table 1.1 sets out a few key socioeconomic and human development indicators in each country.

According to the human development index (HDI), South Africa is the highest ranked at 111th,

followed by Namibia at 124th, Kenya at 146th and Mozambique at 170th. The impact of HIV/AIDS has

been felt in declining life expectancy, causing countries to drop in their HDI ranking (UNDP, 2003).



6

Sources: World Bank, 2004. UNDP, 2003* The poverty rate given by the UNDP (2003) for South Africa is far lower than the in-country income and expendituresurveys show. Various analysts have indicated poverty levels around 50%, depending on the poverty line used (e.g.

Committee of Inquiry, 2002).

TABLE 1.1: Socioeconimic and d evelopment indicators

Indicator

Population density (peopleper km2) (World Bank, 2004)

Human development index(UNDP, 2003)

Human development rank(UNDP, 2003)

Life expentancy (yrs)(UNDP, 2003)

Adult literacy rate (%)(UNDP, 2003)

GDP per capit a (US$ PPP)(UNDP,2003)

GDP per capit a (US$)(UNDP,2003)

GDP per capita % grow th,2001-2002 (World Bank, 2004)

Human povert y index (%)(UNDP, 2003)

Population living below $2per day (%) (UNDP,2003)

Gini coefficient (UNDP, 2003)

Maternal mortalit y (per100,000) (UNDP, 2003)

Infant mor talit y (per 100,000live births) (UNDP, 2003)

Under-five mortality rate (per1000 live births) (UNDP, 2003)

36 ('02)

0.684 ('01)

111 ('01)

50.9 ('01)

85.6 ('01)

11.290 ('01)

2.620 ('01)

2.2

31.7 ('01)*

14.5 ('01)

0.59

340 ('95)

56 ('01)

71 ('01)

S. Af rica

2 ('02)

0.627 ('01)

124 ('01)

47.4 ('01)

82.7 ('01)

7.120 ('01)

1.730 ('01)

1.2

37.8 ('01)

55.8 ('01)

0.71

370 ('95)

55 ('01)

67 ('01)

Namibia

55 ('02)

0.489 ('01)

146 ('01)

46.4 ('01)

83.3 ('01)

980 ('01)

371 ('01)

-0.2

37.8 ('01)

58.6 ('01)

0.45

1300 ('95)

78 ('01)

122 ('01)

Kenya

24 ('02)

0.356 ('01)

170 ('01)

39.2 ('01)

45.2 ('01)

1.140 ('01)

200 ('01)

7.7

50.3 ('01)

78.4 ('01)

0.40

980 ('95)

125 ('01)

197 ('01)

Mozambique



7

HIV/AIDS has exacerbated the experience of poverty and hardship within households and

communities in these countries, causing declining life expectancies and decreasing household incomes.

The increasing numbers of orphans and vulnerable children have added to the burden of already

struggling households. The care of these children often falls on grandmothers and communities, and

increasingly on the state. Let us consider briefly the magnitude and scope of the HIV/AIDS problem in

each of the countries, as this relates to the sufficiency of allocated resources.

2. The Magnitude of t he HIV/AIDS Epidemic

Sub-Saharan Africa is the region that has been worst hit by the HIV/AIDS pandemic, with between25 million and 28 million people living with HIV/AIDS and an adult prevalence rate of between 7.5%

and 8.5% by the end of 2003, according to UNAIDS (2002).

Sources: UNAIDS, 2004

Sources: UNAIDS, 2004

Figure 2.1: HIV prevalence among adults,ages 15-49, as at the end of 2003 Percentage

25

20

15

10

5

0

South Africa Namibia Kenya Mozambique

Percentage

TABLE 2.1: HIV/AIDS prevalence in the four African countriesas at the end of 2003 (UNAIDS, 2004)

Indicator - as at end 2003

Prevalence among adults(15-49 years)

Estimated number of personsliving with HIV

Estimated number of AIDS

deaths

21.5 %

5,300,000

370,000

S. Af rica

21.3 %

210,000

16,000

Namibia

6.7%

1,200,000

150,000

Kenya

12.2 %

1,300,000

110,000

Mozambique



8

In the African countries included in this study, drastic increases in prevalence rates were evident

in the 1990s. In Kenya, however, there was a gradual decline from 13.5% in 2000 to 10.2% in 2002

among adults (aged 15-49) (MoH, 2002). The recent estimates from the Kenyan Demographic and

Health Survey in 2003 found that the prevalence rate had dropped further to 6.7% (MoPND, 2003).

These decreases are indeed welcome. Mozambique’s adult (15-49 years) prevalence rate in 2002

was found to be 13.6% (Multisectorial Technical Group, 2003). In South Africa, 14.2% of the total

populat ion, and 24% of adults (15-49 years), were estimated to be infected with HIV in 2002, based on

the Antenatal Clinic Survey (Dorrington et al., 2002). The highest HIV/AIDS prevalence rates are found

in Namibia, with 23.3% of the to tal population found to be infected in 2002 (MoHSS, 2002).

HIV prevalence rates vary between provinces or regions within countries. The most notable

example in this study was Namibia, where the HIV prevalence among pregnant women varied

between 9% (Kunene Region in the north-west) and 43% (Caprivi Region, in the north-east). The

high rates in Caprivi could be related t o its being on a transport route with great human mobility

(via the Trans-Caprivi), and possibly due to an increased number o f defence forces (in 1999/2000)

along the Angolan/Namibian border. The evidence from all the African countries confirms that

females are more vulnerable to infection than males.

It is predicted that the effects of HIV/AIDS will have a negative impact on economic developmentin these countries. Per capita GDP will fall due to reduced productivity, reduced population growth,

reduced human capital accumulation and reduced physical capital accumulation (World Bank, 2003). It

is therefore imperative that national governments and the international community commit adequate

resources to mitigating the impact of HIV/AIDS on countries.

3. National Responses to HIV/AIDS

“ For the most part governments have been extremely slow to react to the potential impacts of

the epidemic,” note Barnett and Whiteside (2002:297). The African countries included in this study

displayed d iffering levels of polit ical commitment to the HIV/AIDS issue, and this was clearly reflected

in their policies and programmes, as well as in the power and authority given to the national AIDS

co-ordinating bodies. The location of these bodies also affected their effectiveness and scope of

influence. Another factor influencing response was whether governments viewed HIV/AIDS as a

development issue or purely as a public health problem, requiring a health-dominated response.



9

3.1 Political Commit ment

Best pract ice example - Polit ical Commitment

In Kenya, as early as the 1980s, HIV/AIDS was recognised as a development issue, rather than

merely a public health problem. In 1999, the Kenyan president declared HIV/AIDS a national

disaster and established the National AIDS Control Council (NACC). The NACC falls directly

under the Office of the President and has the authority to determine budgets and hold all

departments accountable in their HIV/AIDS activities. It also has district-level structures which

receive allocated funds for their HIV/AIDS activities. The NACC thus tracks all funding flows at

all levels of government, down to district level.

The government of South Africa was somewhat slower in acknowledging the scope of the

problem of HIV/AIDS and in committing its efforts to lessening the impact. Comparing South Africa’s

socioeconomic status to that of the other countries included in this study leads one to assume that

South Africa is best placed, in terms of financial resources and infrastructural capacity, to develop a

comprehensive response, which would include the provision of antiretroviral (ARV) treatment. The

cabinet finally approved ARV treatment in November 2003 – after extensive pressure from civil society

movements, primarily organised by the Treatment Action Campaign (TAC).

“ The most extreme manifestation of government ’s inabilit y to respond has been in South Africa.

President Thabo Mbeki appeared transfixed by the looming catastrophe...There was consensus that

this [dissident ] debate was confusing and damaging to South Africa’s response to AIDS” (Barnett and

Whiteside, 2002:297-298).

3.2 Nat ional Coordinating St ructures

The existence of a national coordinating body, and its position and power, reflect the degree ofseriousness of the state’s response. It is important to note that all the African countries in the study

had national coordinating bodies, although their roles, responsibilities and authority varied.

Best Practice Example - National Coord inating St ructures

In Mozambique, the National AIDS Council (NAC) is chaired by the Prime Minister and includes

all the relevant sectors. This high-powered body coordinates the multisectoral response, since

HIV/AIDS was recognised early as a development issue. These structures are replicated at

provincial level and at district level, where they incorporate representatives of civil society and

service provides, such as NGOs.



10

Soon after Namibia gained independence in 1990, the President launched the National AIDS

Control Programme (NACP), located within the Ministry of Health and Social Services and mandated

to coordinate patient care and preventative activities. Where the national coordinating body is

located within a country’s health ministry, its coordination of the HIV/AIDS activities in all the other

sectors becomes more difficult to ensure. Similarly, regional AIDS coordinators operating within

regional departments of health find it difficult to coordinate the HIV/AIDS activities of the other

departments, resulting in a health-dominated and fragmented response.

The South African National AIDS Council (SANAC) was formed in 2002 to combine government

and civil society efforts in fighting the HIV/AIDS epidemic. The sectors represented in the executive

management committee include health, labour, agriculture, transport, defence, government, women,youth, traditional healers, traditional leaders, the hospitality sector and people living with HIV/AIDS.

Although officially located in the Office of the Deputy President, SANAC has its secretariat within the

Department of Health (DoH), which limits its multisectoral coordination somewhat. SANAC has been

criticised for ineffectiveness and for excluding representatives of civil society. In November 2003,

SANAC was restructured with increased representation from additional sectors.

3.3 Tackling HIV/AIDS as a Development Issue

Most national responses reflect a shift from viewing and addressing HIV/AIDS as a health problem

to treating it as a development issue. This is reflected in a more mul t isectoral response, which requires

good coordination and commitment among sectors and ministries.

As early as 1985, the Kenyan government realised that the Ministry of Health alone could not

respond adequately to the HIV/AIDS situation, and thus initiated the development of a comprehensive

and intersectoral plan.

Until 1999, the Mozambican government viewed HIV/AIDS as primarily a health p roblem. It then

developed a Nation al Strategic Plan which emphasised a multisectoral approach. Unfortunately,

Mozambique has been negatively affected by years of civil war and by natural disasters such as

floods, which have decreased the resources available for HIV/AIDS. Nevertheless, HIV/AIDS is viewed

as a development issue, and is now included in development policies and efforts.

Similarly, HIV/AIDS is located as a critical issue in Namibia’s National Development Plan and is

central to the country’s Vision 2030. However, the NACP falls under the Ministry of Health and Social

Services (MoHSS), which therefore del ivers most of the government ’s HIV/AIDS programmes.





12

• Treatment: initially primarily treatment of sexually transmitted infections (STIs) and opportunistic

infections (OIs) and more recently the provision of ARVs;

• Mitigation of the socioeconomic impact of AIDS, for instance by providing social assistance and

other benefits, food parcels, etc;

• Monitoring and evaluation (sometimes including research); and

• Management and coordination.

With regard to ARV treatment, South Africa and Namibia announced in 2003 their intention to

provide free ARV treatment to public patients and in 2004, Mozambique and Kenya announced

their intentions. Namibia has reportedly already commenced distribution of the drugs to public

hospitals, while, at the t ime of writing, South Africa was lagging in implementation due to delays inthe accreditation1 and tender processes2, as well as other factors. Civil society has heavily criticised

the South Africa DoH for delaying the rollout o f the ARV programme.

4. Reliance on Donor A id

Our ability to include an analysis of donor aid was determined by the availability of a centralised

system of tracking or recording all donor funds coming into each country. The Kenyan National AIDSControl Council (NACC) had a detailed t racking mechanism, while South Africa did not have any such

system or database. The four countries relied on donor aid to differing degrees. Unlike the other

countries, the South African response to HIV/AIDS was primarily funded from state revenue, with some

additional donor funds. In comparison, the majority of the Mozambican response was funded by donor

aid. In 2002, for example, 62% of the health budget was funded by international aid (MISAU-DPC,

2003). Such heavy reliance on donor funds, which tend to fluctuate, influences the sustainability of

programmes and the state’s ability to plan its medium-term expenditure framework (MTEF) effectively.

Table 4.1 provides the donor-aid reliance indicators used in the World Development Report.

Source: World Bank, 2004:261.

TABLE 4.1: Country reliance on donor aid (2001)

Indicator

Aid per capita (US$)

Aid as % of GNI

Aid as % of government expedit ure

10.0

0.4

1.3

S. Af rica

61.0

3.4

12.3

Namibia

15.0

4.0

no data

Kenya

52.0

28.2

no data

Mozambique

1 Sites for distribution had to be screened and approved before provision could begin.2 The state followed a protracted tender procedure for purchasing drugs.



13

It is imperative that governments have some system for recording and coordinating donor aid

entering a country, in particular for HIV/AIDS activities. Donors could assist this process by reporting

on any of their funding which might not be channelled through the government. The development

budget system used by Namibia (described below) allows for some tracking of the donor aid to the

country.

5. Funding and Budget Control Mechanisms Used for HIV/AIDS Programmes

Funding sources and budget control systems for HIV/AIDS programmes varied from country to

country. The Namibian National Development Plan (NDP) pays specific attent ion to mainstreamingHIV/AIDS activities, sets targets and performance indicators and provides cost estimates for each

programme within each ministry. In theory the NDP was intended to guide ministries’ HIV/AIDS

plans and budgets, but in practice this does not happen to any large degree. The National Planning

Commission (NPC) prepares the three-year rolling development budget, which allocates donor

funds, either inside or outside the State Revenue Fund (SRF), and includes a sector classification

dedicated to HIV/AIDS. The Namibian country report was therefore able to present the donor

allocations going to the HIV/AIDS sector through the development budget. However, the

recurrent budget (primarily state revenue funded) does not have specific line it ems for HIV/AIDSprogrammes, which makes it d ifficult to capture all the state HIV/AIDS expenditure. While other

ministries implement HIV/AIDS programmes, their recurrent and development budgets do not

have sufficiently d isaggregated data to provide info rmation on the amounts allocated and spent

by those ministries on HIV/AIDS.

Kenya has proposed a new coordination and funding framework for the activities of the NACC,

which will use two key funding streams. The allocation for the NACC will flow directly from the

Office of the President. After retaining a proportion for its coordinating functions, the NACC willchannel the funds in two directions: some directly to the AIDS Control Units, which support the

implementation of the strategic plan through mainstreamed and integrated spending in all relevant

ministries, and the remainder to the constituency AIDS control committees, which coordinate HIV/

AIDS activities, including NGO projects, in constituencies and communities. These funding flows

would appear to support an integrated and grass-roots response.

The remainder of this chapter compares the allocations made to health and HIV/AIDS in the four

participating African countries. For further detail on individual health systems, budget processes and

allocations; please refer to the country-specific reports.



14

Best Pract ice Example - HIV/AIDS Funding and Budget Control Mechanisms

South Africa is fortunate to have detailed and easily accessible national and provinical budgets,

as well as national and provincial revenue and expenditure statements published regularly by

the National Treasury. These track mainly public funds channelled through the National Treasury,

making it easier to monitor and track national and provincial government budgets and spending.

South Africa’s national budget employs two key HIV/AIDS funding mechanisms. First there

are “ conditional grants,” ring-fenced amounts that have certain conditions attached and must

be spent on specific activities. National departments transfer such grants to their provincialcounterpart departments for spending on specific HIV/AIDS interventions in the health,

education and social development sectors. It is therefore easy to identify in the budget

ddocuments what has been allocated for HIV/AIDS through condit ional grants. In addit ion, the

mechanisms for reporting on the spending of these grants are well developed, and thus allow

for analysis of spending efficiency.

Secondly, in addition to the conditional grants, South Africa also uses a non-targeted funding

mechanism, referred to as the “ equitable share,” which allows discretionary spending by theprovinces. Funding from the equitable share can be used to mit igate the indirect consequences

of HIV/AIDS, for instance by strengthening health care systems, and supporting responses

across departments. It was particularly difficult to ascertain how much provinces were spend ing

on HIV/AIDS out of their equitable share allocations.

It appears that this mix of funding mechanisms, which allows both ensured delivery of specific

HIV/AIDS services and the “ untraceable spending” required to address the indirect impact of

HIV/AIDS, can produce a more integrated, multisectoral response.

6. Allocat ions Made t o Public Health

In April 2001, the Organisation of African Unity (OAU) committed itself to certain responses to the

HIV/AIDS pandemic, and these are contained in the Abuja Declaration (OAU, 2001). The declaration

called for African governments to allocate 15% of their national budgets to health spending, with

more emphasis on HIV/AIDS programmes. This commitment echoed that of the United Nations

General Assembly special session on HIV/AIDS (UNGASS), which called for spending on HIV/AIDS

programmes to be increased to US$7-10 billion by 2005. The declaration of commitment by the Africa



15

Union called for sufficient spending to provide coverage of essential prevention, care and mit igation

services in an effort to reduce the spread of the epidemic.

The analysis undert aken in each coun try at tempted to ascertain the state all ocations made to

public health, and the key sources of these funds – namely, state revenue or donor aid. It is important

to understand that this study d id not consider all public heath allocations, including private and out-

of-pocket expenditure. Therefore, the shares of state contributions presented here may be lower

than those calculated by either the national health accounts (NHA) or national AIDS accounts (NAA)

approach, both of which include all expenditures and include donor allocations in public health

expenditure. In order to consider the level of prioritisation of health spending, the allocations were

calculated as a proportion of each country’s gross domestic product (GDP) and total state expenditure.Where possible, per capita health allocations were also calculated.

The countries cannot be compared without qualification. For example, in the case of Mozambique,

it was difficult to distinguish state funds from donor funds as a large proportion of the health budget

was donor-funded (62% in 2002, according to MISAU-DPC, 2003), which may have contributed to the

slightly higher proportions reported here.

With regard to Namibia, health and social services both fall under one ministry (MoHSS) and theirrecurrent budgets are combined. It was therefore not useful to compare the full Namibian MoHSS

budget with the other countries’ MoH budgets, so the health-specific allocations within the MoHSS had

to be extracted and, where appropriate, compared with the health allocations of the other countries.

However, it was impossible to compare the Namibian development allocatio ns to HIV/AIDS with the

other countries’ state HIV/AIDS funding. Hence the Namibian HIV/AIDS allocations are omitted from

some of the comparative graphs below.

6.1 Public Health A llocations as a Share of GDP and Tot al Expend it ure

Consideration of the state-alone health allocations in the government budget as a share of GDP

shows that South Africa’s share remained fairly stable at around 3% over the study period (2000/01-

2005/06), while Kenya’s increased gradually, from 1.48% in 2000/01 to a proj ected 1.88% in 2004/05.

Mozambique’s health allocation as a share of GDP experienced a drastic increase from 2.9% in 2000/01

to 4.2% in 2002/03, which may have been due to injections of donor aid to alleviate the effects of the

floods in 2000 and 2001. The total budget for Namibia’s MoHSS remained around 12% to 13% of

total expenditure, while the health-specific allocations of that budget made up 9.65% in 2001/02 and

decreased to 9.24% in 2004/05, which would undermine the state’s commitment to health services.



16

These trends are replicated when health allocations are viewed as a share of total state

expenditure, shown in figure 6.1. Only Mozambique appears to have met the 15% target of the Abuja

Declaration, with 15.4% in 2003/04. South Africa’s remains constant over the period at around 11.3%,

while Kenyapeaks at 6.33% in 2004/05. Again the Mozambique data included donor funds, which may

account for the higher apparent proportion there.

Sources: INE, 2003 (Mozambique); NT, 2003a and NT, 2003c (South Africa); GoK, 2003 and NACC, 2003b (Kenya).Republic of Namibia. 2001/02, 2002/03, 2003/04 (Namibia).

The Namibian MoHSS showed gradually increasing allocations – not adjusted for inflation, however

– but with a slight decrease projected for 2004/05. Health-specific spending makes up around three-

quarters of the total ministry expenditure.

6.2 Per Capit a Public Health A llocations

Comparing the real per capita health expenditure (state-only contributions) in the four countries

shows huge inequalities, with South Africa’s allocations being the highest at US$95 3 in 2005/06 (per

capita of the public population only4). Kenya and Mozambique’s health allocations remain fairly constant

at around US$8 and US$9 respectively, with a projected increase to almost US$10 for Kenya in 2004/05.

Figure 6.1Priorisation of health - public health allocations as ashare of tot al state expendi ture 2000/ 01 - 2005/06

Mozambique

Abuja target

Namibia - total MoHSS

South Africa

Namibia - health only

Kenya

18

16

14

12

10

8

6

4

2

0

2000/01 2001/02 2002/03 2003/04 2004/05 2005/06

Percentage

3 State-only contributions to public health.4 The population in South Africa using public health facilities is estimated at 85.7% of the total population, according to the Actuarial Society of South Africa

(ASSA). Thus it was considered appropriate to use only that port ion of the p opulati on (the “ publi c populati on” ) in these calculations. In comparison, a very high

proportion of Mozambique’s and Kenya’s population depend on the state health services. Per capita public calculations for South Africa gave a one-quarter

weighting to the 14.3% of the population who benefit from medical aid, while calculations for the other countries used their total populations.



17

Source: Republic of Namibia. 2001/02, 2002/03, 2003/04.

Sources: INE, 2003 (Mozambique); NT, 2003a and NT, 2003c (South Africa); GoK, 2003 and NACC, 2003b (Kenya).Dorrington et al., 2002.* The allocations for Mozambique could not be obt ained for after 2002/03.** The amounts have been adjusted for inflation and conver ted to US$ using the relevant exchange rate for each year.*** South Africa calculations use public population.

Figure 6.2Namibian MoHSS expenditure

2001/02 - 2003/04 (nominal) - millions of Namibian dollars

Total health-specificexpenditure

Social security andwelfare affairs and services

1,800

1,600

1,400

1,200

1,000

800

600

400

200

02001/02 2002/03 2003/04 2004/05

N$ millions

Figure 6.3Per capita public health allocations 2000/01 - 2005/06 - US dollars (real)

100

90

80

70

60

50

40

30

20

10

0

Mozambique Kenya South Africa

US $

2000/01

2001/02

2002/03

2003/04

2004/05

2005/06



18

7. Allocations Made to HIV/AIDS Programmes

The feasibili ty of analysing th e HIV/AIDS allocat ions with in each country was dependent upon

its budget process and structure, and on the degree of disaggregation of expenditure, and thus va-

ried f rom one country to an other. Some count ries, such as South Africa, h ad specific HIV/AIDS line

items in th eir budgets, while others did not. Namibia had a specific HIV/AIDS line item, but only

in it s development budget, so only the funds coming from development agencies and targeted

for HIV/AIDS activities could be tracked, but not the state allocations going through the SRF in the

recurrent budget. For all the countries it was difficult, if not impossible, to track what was being

spent on non-targeted, or “ mainstreamed” , HIV/AIDS activities. In addition, except for South Africa,

all the traceable HIV/AIDS allocations were within the MoH budgets. Therefore it was difficult toascertain the deg ree to which a multisectoral response was being funded. Where the national AIDS

coordinating bodies tracked all funds entering the country for HIV/AIDS activities, the analysis was

greatly facilitated. The research process highlighted the d ifficult ies in accessing such data, and thus

collecting and analysing the data took longer than was anticipated. Because of the different sources

and differing levels of “ totality of funds captured” , this study undertook cross-country comparisons

with caution, attempting to ensure common units of comparison and indicating any differences.

The Kenyan National Aids Resource Envelope – that is, the information collected by the MoHin their NHA process – made access to HIV/AIDS-specific spending relatively easy, and provided

disaggregated data by source, by service provider and by service provided. However, it must

be remembered that this was limited to health expenditure and did not consider multisectoral

spending. In South Africa, it was easier to track the HIV/AIDS-targeted conditional grants sent to

provinces (provincial health, education and social development departments) and the allocations to

the national programme. It proved more difficult to capture the indirect spending by provinces and

departments on HIV/AIDS activities, which were funded through the equitable share mechanism.

However, efforts were made to capture most of these, and they are presented here.

The Namibian development budget (both inside and outside the SRF) included identifiable

HIV/AIDS-related development projects, but it was not possible to determine the HIV/AIDS

amounts allocated in the recurrent budget, specifically in the budget of the MoHSS. Thus the

figures provided here could not include all the Namibian HIV/AIDS spending, and are therefore an

underestimation. Nevertheless they give an indication of the baseline spending on HIV/AIDS in the

country and should enable civil society to mobilise for increased state allocations and improved

reporting of these.



19

7.1 HIV/AIDS Nominal and Real Allocat ions

The countries’ nominal and real HIV/AIDS allocations are set out below, in the local currencies.

Each country’s funding mechanisms and the key policies and programmes being funded are described

in the individual country reports. Figure 7.1 demonstrates that Kenya’s HIV/AIDS health-related

allocations are steadily rising, while South Africa’s show more drastic increases. The South African

figures include allocations within the three social sectors, as well as those provincial “ discretionary”

or additional allocations that could be ascertained. Mozambique’s allocations reflect fluctuations,

primarily due to influxes of donor aid, and only a small overall real increase. The Namibian HIV/AIDS

allocations made through the development budget, sourced primarily from donors, also show large

increases in funding to HIV/AIDS activities in that country.

Source: NACC, 2003b, b ased on NHA estimates.

The figure above shows the Kenyan state allocations directly to the ACUs, then public funds (made

up of state and some donor contributions), and finally from donors, the private sector and NGOs

committed to HIV/AIDS activities. Massive increases were experienced in 2001/02 (almost 400% in

state allocations in real terms). However these are slowing down, and declines are projected over the

MTEF period. The 51% decrease in state allocations in 2004/05 might be due, in part, to a limited

ability to project future state resources. Despite the forecasted decrease, the average annual real

Figure 7.1Kenyan HIV/AIDS allocations - state and donor funds2000/01 - 2005/06 (real) - billions of Kenya shillings

State (only)

Public sector -state an donor

Donors, private,

NGOs etc

16

14

12

10

8

6

4

2

0

2000/ 01 2001/ 02 2002/ 03 2003/ 04 2004/ 05 2005/ 06

Billions, Kenya shillings



20

growth rate in state-specific allocations to HIV/AIDS over the study period is almost 80%, strongly

indicative of the government’s commitment to the fight against HIV/AIDS.

Source: INE, 2003 (Mozambique).

The amounts allocated for the South African response include the national HIV/AIDS budget,the provincial health, education and social development allocations made through the HIV/AIDS

conditional grants to those three sectors, and the discretionary spending made from the provinces’

equitable shares. This indicates not only the targeted HIV/AIDS allocations to p rovide specific services,

but also non-targeted allocations from departments to support an integrated, mult isectoral response.

These two funding mechanisms are a useful model to support both forms of spending. The difficulty

inherent in the non-targeted allocations is that of tracking the funds which ministries or departments

might spend additionally on HIV/AIDS.

The figure above indicates what the Mozambican authors refer to as the “ lumpiness” of funding

due to fluctuations in the donor aid being directed to HIV/AIDS in Mozambique. This variability and

unpredictabil ity makes planning d ifficult and undermines the sustainabili ty of projects. When corrected

for inflation, an average annual real decrease of 11.3% is experienced in Mozambique between 2000/

01 and 2003/04. Such an erratic funding situation will seriously hamper the government’s HIV/AIDS

programmes, particularly its recently announced ARV treatment programme.

Figure 7.2Mozambique HIV/AIDS allocations 2000/01-2002/ 04

(nominal and real) - billions of meticals

Total HIV/AID

budget (nominal)

Total HIV/AIDS

budget (real)

250

200

150

100

50

0

2000/01 2001/02 2002/03 2003/04

Meticais billions



21

Source: Republic of Namibia (2001-2006).

The small proportion that goes through the SRF is the allocation to the NACP. The increasing

allocations to this programme will greatly enhance the government’s ability to coordinate a multisectoral

and integrated response to HIV/AIDS in Namibia.

7.2 HIV/AIDS Allocat ionsas a Share of Tot al Expend it ure and of Tot al Healt h Expendit ure

It is useful to compare the allocations to HIV/AIDS in each country as a share both of total stateexpenditure and of the state’s total public health expenditure. This gives a good indication of the

priority that states give the issue over other expenditure, and also assists in cross-country comparison.

Figure 7.4 shows the HIV/AIDS allocations as a share of total expenditure. Mozambique’s sharp

decline in 2002/03 may have been due, in part, to the fluctuating nature of donor funds. Thereafter

their allocations stabilise at around 0.4%.

Figure 7.3Namibian development budg et allocations to HIV/AIDS

2000/01 - 2005/ 06 - millions of Namibian dollars

Outide SRF

Inside SRF

90

80

70

60

50

40

30

20

10

0

2000/01 2001/02 2002/03 2003/04 2004/05 2005/06

N$ millions



22

Sources: INE, 2003 (Mozambique); Budget Review, 2003/04 and Estimates of National Expenditure, 2003 (south Africa);Estimates of Recurrent and Development Revenue, 2003, and National Aids Resource Envelope, 2003 (Kenya)

South Africa’s HIV/AIDS allocations as a share of total state expenditure have been steadily

increasing over the period of study and are projected to continue doing so, rising to 0.56% in 2005/

06. The recent increases have been due to the allocations specifically for the roll-out of the free ARV

treatment programme.

Out of the four countries studied, Kenya’s HIV/AIDS allocations form the largest share of total

state expenditure, jumping from under 0.1% to just over 0.85% of total state expenditure. Similar

patterns are revealed for HIV/AIDS allocations as a share of total state public health expenditure.

The HIV/AIDS line item in the Namibian development budget is absorbing an increasing amount

of the total donor funds captured in the MoHSS development budget. Figure 7.6 shows it as less

than 5% in 2000/02 and rising sharply to almost 38% in 2003/04. This certainly reflects the changing

priorities of donors towards HIV/AIDS, but also demands an analysis of whether the government’s

funding to HIV/AIDS has decreased in light o f these funding flows, or if the “ additionality” principle

of the Global Fund to Fight AIDS, Tuberculosis and Malaria is being honoured by recipient states.

Figure 7.4HIV/AIDS allocations as a share of t ot al expendit ure 2001/ 01 - 2005/ 06

South Africa - HIV/AIDSas % of total budget

Mozambique - HIV/AIDSas % of total budget

Kenya - HIV/AIDSas % of total budget

1.0

0.9

0.8

0.7

0.6

0.5

0.4

0.3

0.2

0.1

0

2000/01 2001/02 2002/03 2003/04 2004/05 2005/06

Percentage



23

Sources: INE, 2003 (Mozambique); NT, 2003a and NT, 2003c (South Africa); GoK, 2003 and NACC, 2003b (Kenya)

Sources: Namibian Rolling Development Budgets (2000/01, 2001/02-2003/04, 2003/04-2005/06).

Figure 7.6Namibian HIV/AIDS development allocations as a share

of t otal M oHSS development allocations 2000/01 - 2005/ 06

40

35

30

25

20

15

10

5

02000/01 2001/02 2002/03 2003/04 2004/05 2005/06

Percentage

Figure 7.5HIV/AIDS allocations as a share o f

the tot al public health budget 2000/01 - 2005/06

South Africa - HIV/AIDSas % of total health budget

Mozambique - HIV/AIDSas % of total health budget

Kenya - HIV/AIDSas % of total health budget

18

16

14

12

10

8

6

4

2

0

2000/01 2001/02 2002/03 2003/04 2004/05 2005/06

Percentage



24

The graphic presentation in the figures on the previous page are set out in tabular form in table 7.1.

Sources: INE, 2003 (Mozambique); NT, 2003a and NT, 2003c (South Africa); GoK, 2003 and NACC, 2003b (Kenya).

TABLE 7.1: State public health and HIV/AIDS prop ort ional shares

Health and HIV/AIDS shares (%)

SA: health as % of totalbudget

SA: healt h as % of GDP

SA: HIV/AIDS as % of to talbudget

SA: HIV/AIDS as % of to talhealth budget

MoZ: health as % of t ot albudget

MoZ: health as % of GDP

MoZ: HIV/AIDS as % of totalbudget

MoZ: HIV/AIDS as % of totalhealth budget

Ken: health as % of t otalbudget

Ken: health as % of GDP

Ken: HIV/AIDS as % of totalbudget

Ken: HIV/AIDS as % of total

health budgetNam: MoHSS as % of t ot alSRF budget

Nam: health only as % oftotal SRF budget

11.56%

2.96%

0.09%

0.67%

9.90%

2.90%

0.50%

5.20%

4.36%

1.48%

0.10%

2.24%

2000/1

11.60%

3.03%

0.13%

0.87%

12.60%

3.60%

0.80%

6.40%

4.80%

1.53%

0.147%

9.86%

13.37%

9.65%

2001/2

11.66%

3.04%

0.29%

1.88%

15.40%

4.20%

0.30%

1.60%

5.47%

1.69%

0.62%

11.41%

12.92%

9.45%

2002/3

11.35%

3.07%

0.39%

2.94%

15.40%

4.20%

0.40%

2.60%

5.12%

1.74%

0.88%

17.10%

13.55%

9.43%

2003/4

11.33%

3.06%

0.49%

3.86%

15.90%

4.30%

0.40%

2.60%

6.33%

1.88%

0.48%

7.63%

12.85%

9.24%

2004/5

11.16%

3.01%

0.56%

4.55%

15.90%

4.20%

0.40%

2.60%

5.85%

1.64%

0.46%

7.86%

2005/6



25

7.3 HIV/AIDS Per Capit a Allocations

For a cross-country comparison that takes into account the size of the population and the size ofthe epidemic in each country, it is useful to consider the HIV/AIDS allocations per capita, using public

populations as well as the HIVpositive populations (where possible). Amounts were converted in US$

equivalents, to allow comparison.

The per capita HIV/AIDS allocations varied greatly between the countries, and comparison

was problematic. Note the huge increases revealed in figure 7.7 with regard to the South African

allocations. In comparison, Kenya’s HIV/AIDS per capita allocat ion t ended to remain const ant over

the study period at around US $ 2.

Sources: NT, 2003a; NT, 2003c; NT, 2003d; NT, 2003g (South Africa); Dorrington, Bradshaw & Budlender, 2002;

Idasa calculations. NACC, 2003 (Kenya). Author’s pr ojections.Note: Kenya public HIV/AIDS allocations includes state and donor funds.

The use of calculations involving different target groups in South Africa adds detail that puts the

size of the allocations into the context of the severity of the epidemic in that country. The recent

increases in allocations have been primarily due to the policy decision to roll out free ARV treatment

to the population through the public health facilities. Figure 7.8 shows per capita figures based on

the total, HIV-positive and AIDS-sick population respectively. This cannot be interpreted as directly

indicating the amount of public resources allocated for each HIV-positive or AIDS-sick person, since

HIV/AIDS activities funded include preventative activities aimed at the HIV-negative population and

Figure 7.7South African and Kenyan annual per capita

HIV/AIDS allocations - 2000/01-2005/06 (real) - US dollars

SA state HIV/AIDS percapita (public population)

Kenya public HIV/AIDSper capita spending

6

5

4

3

2

1

0

US$

2000/01 2001/ 02 2002/03 2003/ 04 2004/05 2005/ 06

26



26

other responses that the HIV-positive population can benefit from, without necessarily being AIDS-

sick. Nevertheless, the figure gives a broad overview of the increasing allocations by beneficiary

group.

Sources: NT, 2003a; NT, 2003c; NT, 2003d; NT, 2003g; Dor rington, Bradshaw & Budlender, 2002; Idasa calculations.

8. Changing Priorit ies - Changing Types of Act ivit ies

The analysis of the composition of the HIV/AIDS allocations, (e.g. p revention versus treatment,multisectoral or health-dominated) relied heavily on the degree of disaggregation and codification

of budget documents and other sources within each country. For example, the Mozambican and

Namibian data did not disaggregate sufficiently to allow for this detailed analysis. The comparison

was further complicated by the differing categorisation and definitions used in the countries for

“ treatment” as opposed to “ preventative” activities. For purposes of this analysis, any action that

intends to prevent an HIV transmission is categorised as “ preventative” even where it involves

medical treatment. For example, PMTCT and the treatment of STIs are considered preventative.

“ Treatment” is defined narrowly as medical treatment fo r HIV-positive people, primarily ARV drugtreatment.

Figure 7.8Annual per capita HIV/AIDS expenditure in South Africa

2000/01 - 2005/06 (real) - rands

For public population

For HIV + population

For AIDS - sick population

2,000

1,800

1,600

1,400

1,200

1,000

800

600

400

200

02000/01 2001/02 2002/03 2003/04 2004/05 2005/06

Rand (real)

27



27

The best example of changes in policy being reflected in budget allocations is that of South Africa

and its recent commitment to providing free ARV treatment. Figure 8.1 on the following page shows

a rapid increase in the proport ion of the budget allocated for ARV treatment in South Africa, asopposed to the other HIV/AIDS activities. In addition, the actual allocations for ARVs (in both nominal

and real terms) are risin g dramatically. The figure demonstrates that allocations for prevention and

care and support activities are not increasing con currently. Figure 8.2 shows th e tot al HIV/AIDS-

earmarked budget in relation to the funds for the new ARV treatment programme. The figure also

includes the funds going to the departments of education (classified as preventative) and social

development (classified as care and support activities).

Sources: South Africa 2003/04 Budget . NT, 2003e. Idasa calculations.Note that the health conditional grant for HIV/AIDS (excluding ARV funds) is roughly divided as follows:50% for preventative measures, 40% for care and support and 10% for coordination.

These important shifts in policy, reflected in the budget allocations, came about because of

a number of factors, primarily the increasing need evident in rising mortality, morbidity and their

resultant hardship. Also critical was the effective pressure exerted by civil society organisations and,

importantly, accurate costing, which showed that providing free ARV treatment was within the state’s

financial capacity.

Figure 8.1Changing p riorit ies in HIV/AIDS spending in South Afr ica

according t o activity type 2000/02 - 2005/06 - millions of rands

1,800

1,600

1,400

1,200

1,000

800

600

400

200

0

Research

Management

Treatment

Care and support

Prevention

NGO transfers

2000/01 2001/02 2002/03 2003/04 2004/05 2005/06

28



28

Figure 8.2 shows the upward climb of the total HIV/AIDS allocations in real terms. The ARV

conditional grant funds will consume an increasing proportion of the health HIV/AIDS conditional

grant. In the first year of ARV rollout (2004/05), 38% of the funds transferred as conditional grantsto the provinces by the DoH will be intended for ARV treatment programmes. However, beginning

in 2005/06, national government will be sending more funds to provinces for ARV programmes

specifically than for all other HIV/AIDS interventions in the health sector. By 2006/07, 64% of the HIV/

AIDS conditional grant funds are intended for ARV treatment (Hickey, 2004).

Sources: NT, 2003c:407; NT,. 2003e:82. Idasa calculations.

Kenya’s total HIV/AIDS allocations (including donor funds) have remained relatively stable over

time in terms of service type (figure 8.3). The largest proportion goes to “ treatment and care” .However, since the Kenyan government does not provide free ARVs, much of this component would

be treatment of STIs and OIs funded by donor allocations and health care services offered by the

MoH.

Rough estimates for the composition of allocations in Mozambique were obtained through

interviews with the country’s National AIDS Council, which indicated that treatment activities receive

approximately 60% of the budget, while prevention receives approximately 40%.

Figure 8.2Contribution of ARV treatment funds to total

HIV/AIDS budgets in South A frica 2000/01 - 2005/ 06 - millions of rands

ARV treatment funds

HIV/AIDS budget excludingARV treatment funds

2,500

2,000

1,500

1,000

500

0

2000/ 01 2001/ 02 2002/ 03 2003/ 04 2004/ 05 2005/ 06

Billions, Kenya shillings

29



29

Sources: Estimates of Recurrent and Development Revenue, 2003, and National Aids Resource Envelope, 2003 (Kenya).* Incorporated under ‘prevention’ are: behaviour change, blood safety, PMTC and STI treatment. Incorporated under

" care" is mitigation of socioeconomic impact.

With regard to the Namibian data, compositional analysis was not possible based on data on

allocations and expenditure. However, based on the projected resource usage for the duration of

the country’s NDP (2001-2006), which provides targets and cost estimates for each programme and

ought to guide actual allocations, it was found that the majority of projected budgets (92%) were to

intended to be used for “ care and support” activities, primarily through the MoH.

9. Effi ciency and Equit y in HIV/ AIDS Spend ing

As noted above, this study has focused primarily on budget allocations. Analysis of actual

expenditure against allocated amounts is limited, largely due to the unavailability of expenditure

reports. Only South Africa has detailed quarterly expenditure reports published by the National

Treasury. Where spending data is available, it tends to indicate underspending of the actual

disbursements (such as the di screpancies between Mozambique’s allocated, disbursed and spent

health funds). Furthermore, there were cases of actual disbursements being lower than the amountsoriginally allocated in budget documents.

Figure 8.3Compositio n of tot al Kenyan HIV/AIDS allocations

by t ype of service 2000/01 - 2004/ 05 - billions of Kenya shillings

Policy developmentand managment

Care and suppor t(incl. IGAs)

Research and M&E

Treatment and care

(not i ncl. free ARVs)

Prevention activities(incl. PMTCT)

16

14

12

10

8

6

4

2

02000/01 2001/02 2002/03 2003/04 2004/05

K e

n y a

s h i l l i n g s b i l l i o n s

30



Best pract ice example – improving effi ciency in spending HIV/AIDS allocations

In South Africa, the increasing allocations to HIV/AIDS in recent years have placed extraordinarydemands on departments, requiring them to spend allocations that double or t riple from one

year to the next. For example, from 2000/01 to 2001/02 the National Treasury increased the

earmarked funds for HIV/AIDS sent to provinces by over 160%. In 2002/03, the amount national

government expected provinces to spend tripled in relation to the previous year. Including

expenditure on roll-overs , provincial HIV/AIDS managers succeeded in spending R109 million

in 2001/02 – six times the amount spent in the previous year. Moreover, in 2002/03 actual

spending increased again by over 250%, to R385 million (Hickey et al., 2003).

Despite these massive increases, the aggregate provincial spending records on the HIV/AIDS

conditional grants for the three years provide evidence of huge improvement. Overall, 85% of

HIV/AIDS conditional grant funds were spent in 2002/03, compared to a low 36.5% in 2000/01

(excluding the roll-over amounts indicated above). Beginning in 2001/02, aggregate spending

on HIV/AIDS conditional grants matched or exceeded average spending on conditional grants

generally, which indicates that the usual difficulties experienced with conditional grant spending

were surmounted by rapid improvement in HIV/AIDS programme structures and spending pro-

cedures (Hickey et al., 2003).

The lack of disaggregated data by region made it difficult to analyse whether HIV/AIDS resource

allocation was equitable, with respect to the burden of the disease carried in the different areas of

each country and according to the socioeconomic status, infrastructure and accessibi lity of health and

other state services in those areas.

In Kenya, the NACC ensures that the HIV/AIDS resources are allocated according to geographical

need. The new financing framework enables the NACC to allocate resources based on agreed priorit ies,

geographical targets set by the NACC and poverty reduction targets set by the government. It also

considers population size, prevalence rates and morb idit y rates, and well as the cost and effectiveness

of interventions and coverage rates. However, Kioko and Njeru, in the Kenyan report presented here,

indicate that this new “ resource allocation formula in enhancing regional equality has not funct ioned

as expected,” due in part to the incapacity of regions to prepare adequate funding proposals in order

to apply for HIV/AIDS allocations.

In South Africa it was possible to undertake a geographical comparison of HIV/AIDS allocations

based on provincial shares of the HIV-positive population. Figure 9.1 on the following page presents

31



the per capita amounts for the provincial health HIV/AIDS allocations as against the provincial HIV

positive population.

Figure 9.1 compares the provincial HIV/AIDS health-budgeted amounts per HIV-positive person

with the provincial share of the total HIV-positive population, according to 2000 model projections by

ASSA (Dorrington et al., 2002). Although the Western Cape is the province with the second lowest

number of HIV-positive people, its health department budgets the highest amount per HIV-infected

person (Hickey, 2003).

However, although this per capita analysis gives us some insight into sufficiency and equity

considerations in resource allocation across provinces, it should be treated with caution. Thisis because the graph does not take into account HIV/AIDS spending in sectors outside health,

nor does it include the indirect or “ hidden” HIV/AIDS-related expenditure in regular health care

services.

There is indeed a need for more detailed analysis of country HIV/AIDS allocations according to

indicators of equity, but this will require a significant degree of disaggregation and detail in budgets

and spending reporting mechanisms. The tracking of resources to different vulnerability groups and

beneficiary groups would be extremely useful, and a gendered perspective in tracking the resources

would be vital.

Sources: 2003 IGFR; 2003 Estimates of National Expenditure; 2003 Budget Review; 2003 Provincial Budget Statements;Dorrington et al ., 2002; Idasa calculations.

Figure 9.1Provincial HIV+population vs per capita HIV/AIDS

provincial health expenditure 2003/04

30

25

20

15

10

5

0

300

250

200

150

100

50

0

Percentage

Provincial share ofcountry's HIV +population 2003according to ASSAmodel projections

2003/4 provincialHIV/AIDS healthbudgeted amountper HIV + person(public population)

E a s t e

r n C a

p e

F r e e S

t a t e

G a u t e

n g

K w a Z u l u

N a t a l

N o r t h

W e s t

N o r t h

e r n C a p e

M p u m

a l a n g

a

L i m p o

p o

W e s t e r

n C a p e

32



10. Af rica Regional Recomendat ions

Each country report includes recommendations relevant to the specific country situation. Therecommendations pulled together here are those that are common to the countries and relevant to

the whole region, and that relate primarily to, or influence, budget allocations and processes. These

should inform a range of policy-makers, decision-makers, programme planners and implementers, as

well as civil society representatives and research agencies.

10.1 Policy Implicat ions

The International Guidelines on HIV/AIDS and Human Rights (1997) should guide and inform

countries’ National HIV/AIDS Strategic Plans (NSPs), and it is suggested that countries develop their

own charters of the rights of persons infected and affected by HIV/AIDS, emulating the Namibian HIV/

AIDS Charter of Rights. The UNGASS commitments and the Millennium Development Goals should

also influence NSPs and national development plans (NDPs).

Commitment to NSPs should be reflected in the adequate allocation of resources for their

implementation. Departments require increased capacity – infrastructurally and in terms of personnel,

financial systems and skills – in order to implement NSPs effectively. The implementation of all NSPs

should be monitored carefully.

NSPs should incorporate the provision of ARV treatment as a matter of urgency. In addition,

the delivery of PMTCT interventions, where missing or inadequate, should be incorporated or

strengthened. However, emphasis on the provision of ARV treatment should not be at the expense of

preventative, care and support activities.

10.2. Mainst reaming HIV/ AIDS as a Development Issue

HIV/AIDS should be incorporated into NDPs and poverty reduction strategy papers as a cross-sectoral,

goal-level priority. HIV/AIDS should also feature prominently in debt-relief negotiations and Heavily-

Indebted Poor Countries (HIPC) documents. Plans should have specific commitments and targets, linked

to actual budget allocations, which should be based on accurate costings (UNAIDS, 2003b:8).

33



Dealing with HIV/AIDS as a development issue requires an integrated and mult isectoral response.

However, the integration of HIV/AIDS into the activities of all ministries can only occur with adequate

budgetary allocations. Clear targets, performance indicators and cost estimates would assist ministriesto fund and execute their HIV/AIDS plans.

A mainstreamed response requires appropriate funding mechanisms: a combination of “ ring-

fenced” or condit ional amounts, which have clear directives for use, and “ non-allocated” or indirect

transfers that allow for ministries’ discretion in their HIV/AIDS activities. These mechanisms would

foster an integrated and flexible approach, while also ensuring the provision of certain essential

components.

Most of the country studies presented here could only capture health-related HIV/AIDS spending.

This emphasises the lack of data on multisectoral responses to HIV/AIDS. Therefore, all ministries

should allocate portions of their budgets to HIV/AIDS activities, and should provide regular and

detailed financial and performance reports to the national HIV/AIDS coordinating body.

10.3 Instit utional Implicat ions

A national AIDS coordinating body requires high-level authority to manage a multisectoral response

and should be composed of all key sectors, with both government and civil society representatives.

Therefore it is recommended that such bodies be situated in the highest office, preferably that of the

country ’s President or Prime Minister, and be autonomous of the MoH. Their powers , functions, and

lines of accountability should be clearly defined.

The national AIDS coordinating body should influence budget processes and allocations for

HIV/AIDS activities, and also coordinate and channel donor funds. This ensures that donor priorities

are in line with national priorities and reduces duplication, gaps and the fragmentation of services.

“ Mob ilising responses to HIV/AIDS and co-ordinating efforts should be the... core business” of

national co-ordinating structures (Strode and Barrett Grant, 2004:46). There should also be adequate

institut ional linkages between the national HIV/AIDS coordinating body and the Ministry of Finance or

Planning (UNAIDS, 2003b:8).

National coordinating bod ies require adequate funds and staff to ensure their efficiency and ability

to coordinate across all ministries and sectors, and should have a specific line item budget in the

national budget.

34



National AIDS coordinating bodies should have decentralised structures with representation at all

levels of government , throughout civil society and in every sector. The decentralised structures should

have adequate funds to support their activities.

Equally important, parliamentarians should be equipped and empowered to interrogate state

budgets and call for necessary changes. Members of parliament often do not have access to

information on HIV/AIDS spending, so efforts should be made to improve their access to, and

understanding of, such data (Lush et al., 2004). The national AIDS coordinating structure should rou-

tinely report on its activities to the cabinet.

10.4. Resource Implicat ions

Most countries in Africa are heavily dependent upon donor aid to support their HIV/AIDS activities.

The unpredictability of this source can undermine the state’s ability to plan and manage its response

to the epidemic and also has the potential to threaten the sustainability of programmes in the event

of decreasing funds. States should allocate increasing amounts to their HIV/AIDS programmes from

their own revenue, while continuing to work to improve the coordination of nationally sourced funds

with donor resources.

State allocations to health over the period of this study tended to be below the Abuja target

of 15%. There is a need for greater commitment by states to the achievement of this target. The

increasing allocations, from both states and donors, to HIV/AIDS activities are welcomed and

encouraged. In addition, funds must continue to be committed to general development, poverty

alleviation and the strengthening of the health sector, to ensure comprehensive efforts to mitigate the

impact of HIV/AIDS.

Massive injections of resources to strengthen financial, human, infrastructural and management

systems are required to ensure the efficient delivery of ARV and PMTCT treatment programmes.

These should be based on efforts to strengthen health systems generally. At the same time, resources

must continue to be directed to systems for prevention and for care and support. A balanced response

to HIV/AIDS, one which is not “ overmedicalised” , is imperative.

Increased resources are required for NGOs, CBOs and FBOs, which are the primary service

providers in many Africa countries. There is need for more efficient and robust transfer and

accountability systems for grant-making.

35



10.5. Funding and Budget Control Mechanisms

The mechanisms for the funding of HIV/AIDS activities should be improved, so as to allow foradequate funds and their efficient use. Two mechanisms have been suggested: ring-fenced funding

and unconditional fund transfers.

It is important for programmes to have specific HIV/AIDS budget line items to allow for improved

tracking and monitoring of HIV/AIDS expenditure. In addition departments should be required to

report on their discretionary spending on HIV/AIDS. Medium-term expenditure frameworks should

account for all HIV/AIDS-related expenditure, including resources expended by national AIDS

coordinating units (UNAIDS, 2003b.)

More comprehensive, accurate, timely and accessible data is required, from all relevant ministries

and departments, on disaggregated programme allocations and actual expenditure. Such information

should be made available to civil society and parliamentarians.

Bottlenecks in spending can be reduced with improved provincial and local financial management,

planning and accountability mechanisms.

10.6. Coordinating Donor Funds

As mentioned above, in order for governments to have increased control in planning and

managing their response to the epidemic, it is necessary for national coordinating bodies to have

greater control over, or at least greater knowledge of, all HIV/AIDS funds entering the country. To

assist this process, a centralised database should be established to which donors frequently submit

updated records of their funding activities, such as the Investment Budget in Mozambique, which

registers external funds.

Synchronisation of donor funding requirements and reporting mechanisms would greatly relieve

the burden on governments with regard to their reporting responsibilities to donors. At the moment,

duplication and excessively burdensome administrative procedures are crippling the ability of

governments to manage the expenditure of these funds effectively.

This study did not consider contributions from the private sector to HIV/AIDS activities. It is

recommended that a system for capturing and tracking these funds be developed in-country, andthat public-private partnerships be promoted.

36



10.7 Monitoring Issues of Equity and Human Rights Promotion

Increased efforts are required to develop performance indicators that measure the inputs, outputsand impact of budget allocations, particularly to the extent that they promote and protect the

achievements of the rights of citizens.

Such monitoring should measure allocations based on need (the disease burden, prevalence

rates and the demand for services). Geographical distribution, including the accessibility of health

services and other facilities and the capacity of regions to absorb, manage and utilise funds, should be

considered in the equitable distribution of resources. Allocations should also be analysed according

to beneficiary groups, ensuring that women, children and other vulnerable g roups are given priorityin resource distribution. It is important that such allocations translate into equal access to affordable

and quality services for all vulnerable persons.

There is a need to build the capacity of local civil society organisations to routinely monitor

government expenditure on HIV/AIDS and track donor funds, so that they can engage more actively

in the national budget process. Governments must be accountable to their citizens for their spending

of public funds, and should report on outputs and the achievement of their performance indicators.

This study has provided an effective capacity-building programme for NGOs in the countries

studied, in that their ability to monitor their government’s HIV/AIDS allocations has been enhanced.

The research process developed a valuable framework for comparative analysis, while also allowing

for countryspecific nuances in data collection and analysis. This project has been an important first

step in the empowerment of civil society to understand and interrogate budget processes and

allocations to HIV/AIDS. It has clearly identified gaps in budget allocation data, and therefore makes

an earnest appeal for greatly improved budget and spending records. It is hoped that this initiation

into budget analysis will lead to ongoing t racking of state and donor funds.

It is recommended that projects aiming to capacitate civil society to monitor HIV/AIDS allocations

should be supported, p romoted and expanded. The analysis should deepen to include an evaluation

of the outputs and impact of budgetary allocations. These allocations should also be evaluated

according to the estimated costs of required interventions, and in terms of the burden of disease.

37



References

• Barnett , T., & Whiteside, A., 2002. AIDS in the twenty-first century: disease and globalization. NewYork: Palgrave Macmillan.

• Commit tee of Inquiry into a Comprehensive Social Security System. 2002. “ Transforming the

present, Protecting the Future: Consolidated report” . Dept of Social Development. RSA.

• Dorrington, R., Bradshaw, D., & Budlender, D., 2002. HIV/AIDS profile in the provinces of South

Africa: indicators for 2002. CARE, MRC, ASSA.

• GoK, 2003. Printed Estimates of Recurrent and Development Expenditure, 2003/04. Govt. printers.

• Hickey, A. 2003. What are provincial health departments allocating for HIV/AIDS from their own

budgets? Ida sa Bud get Brie f No.135. Available: http ://www.idasact.org.za/bis/ [1 August 2004]

• Hickey, A., 2004. New allocations for ARV treatment: an analysis of the 2004/05 budget from an

HIV/AIDS perspective. Idasa Occasional Paper.

• Hickey, A., Ndlovu, N., & Guthrie, T., 2003. Budgeting for HIV/AIDS in South Africa: report

on intergovernmental funding flows for an integrated response in the social sector. Idasa-BIS.

Available: http :// www.idasact.org.za/pdf/1057- report.pdf [1 August 2004]

• INE, 2003. Database. Instituto Nacional de Estatística, Mozambique.

• International Guidelines on HIV/AIDS and Human Rights. 1997.

• Lush, D., Sherbourne, R., & Mbaindjikua, K., 2004. More questions than answers: the response of

the Namibian legislature to HIV and AIDS. Institute for Public Policy Research, Namibia. Pending.

• Martin, G., 2003. A comparative analysis of the financing of HIV/AIDS programmes in Botswana,

Lesotho, Mozambique, South Africa, Swaziland and Zimbabwe. Human Sciences Research Council:

Pretoria.

• MISAU-DPC, 2003: Donor Resource Survey 2001-2003. Directorate of Planning and Cooperation.

Ministry of Health, Mozambique.

38



• MoH, 2002. Financial performance of the cost sharing programme. Annual Report, 2001/02.

Division of Health Care Financing, Ministry of Health, Kenya.

• MoHSS, 2002. Epidemiological report on HIV/AIDS. Namibia: Ministry of Health and Social

Services.

• MoPND, 2003. Kenya demographic and health survey. Preliminary report. Nairobi: Ministry of

Planning and National Development.

• Multisectorial Technical Group, 2003. Official launch of new HIV prevalence rates. MISAU-PNC/

DTS/HIV-SIDA. November. Mozambique.

• NACC, 2003: The Kenya National HIV/AIDS Resource Envelope. Nai robi: National AIDS Control

Council, Office of the President.

• NT. 2003a. Budget Review. Pretoria: National Treasury. Available:

http:// www.treasury.gov.za/documents/budget /2003/review/ [17 August 2004]

• NT. 2003b. Division of Revenue Bill. Pretoria: National Treasury. Available:

http://www.finance.gov.za/document s/bu dge t/2003/drb/d rb.pdf [17 August 2004]

• NT. 2003c. Estimates of National Expenditure. Pretoria: National Treasury. Available:

http:// www.finance.gov.za/document s/budget/2003/en e/ [17 August 2004]

• NT. 2003d. Intergovernmental Fiscal Review. Pretoria: National Treasury. Available:

http:// www.finance.gov.za/document s/ifr/2003/ [17 August 2004]

• NT. 2003e. Medium-term bud get policy statement . Pretoria: National Treasury. Available:http:// www.finance.gov.za/documents/mtbps/2003/ [17 August 2004]

• OAU, 2001. Abuja declaration on HIV/AIDS, tuberculosis and other related infectious diseases.

Available: http://www.uneca.org/adf2000/Abuja%20Declaration.htm [15 July 2004]

• PHRplus. 2004. Harmonisation of methodologies: SIDALAC and PHR plus. Presentation made to

the UNAIDS Global Consort ium for Resource Tracking for HIV/AIDS. Geneva.

39



• Republic of Namibia. 2001/02, 2002/03, 2003/04. Estimates of Revenue and Expenditure.

Windhoek: Ministry of Finance.

• Strode, A., & Barrett Grant, K., 2004. Understanding the institutional dynamics of South Africa’s

response to the HIV/AIDS pandemic. Cape Town: Idasa.

• UN, 2001. Declaration of Commitment on HIV/AIDS. UN Special Session on HIV/AIDS. 25-27 June

2001. United Nations. Available:

http://www.un.org/ga/aids/coverage/FinalDeclarationHIVAIDS.html [28 July 2004]

• UNAIDS, 2002. AIDS epidemic update. December 2003. UNAIDS & WHO.

• UNAIDS, 2003a. Monitoring the Declaration of Commitment on HIV/AIDS: guide-lines on

construction of core indicators. UNAIDS. http://www.unaids.org

• UNAIDS. 2003b. Planning, costing and budgeting framework. User’s manual.

• UNAIDS, 2003c. Progress report on the global response to the HIV/AIDS epidemic. UNAIDS.

http://www.unaids.org

• UNAIDS. 2004. 2004 Report on the g lobal AIDS epidemic: 4th g lobal report. UNAIDS.

http//www.unaids.org

• UNDP, 2003. Human development report, 2003.

• World Bank, 2002. HIV /AIDS: Impact on education intensifies downfall. Washington DC: World

Bank.

• World Bank, 2004. World development report, 2004 . Washington DC: World Bank.

Documents

HIV/AIDS and human rights: public budgets for the epidemic in Argentina, Chile, Ecuador, Mexico and Nicaragua