Linking NHA and NASAA country perspective - Rwanda

Agnès Binagwaho, MD, PaedExecutive Secretary, National AIDS Control

Commission

NASA and NHA• National AIDS Spending Assessment (NASA), Generally conducted by NAC (with UNAIDS), to monitor the annual flows of funds used to finance the multisectoral response to HIV/AIDS

• National health accounts (NHA), Generally conducted by MOH (with WHO, USAID), to track expenditures on overall health care with particular attention of health sub accounts as HIV/AIDS

NASA 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)

UNAIDS

NHA-NASA crosswalk

FS.1.1.1.1 Ministry of Finance

FS.1.1.2 Local Authorities

FS.3. Rest of the world

HC.1.1 Inpatient curative care

W Z

HC.1.3.1 Out patient curative care- VCT

Y

HC.6.3.1 VCT Programs

X

FS.1.1 Territorial government: central

FS.1..2 Territorial government: state/provincial

FS.3. International funds

ASC 2.2. Inpatient care W Z

ASC 1.3. VCT( incl. (programmatic and personal)

X Y

NHA HIV/AIDS subaccount

NASA – UNGASS table

UNAIDSImplemented in Rwanda by MOH and CNLS team

Rwanda experience:Both NHA (for health and non-health) and

NASA were carried out in 2007

The teams of NACC and MOH worked together to harmonise the findings of the two exercises in one table only, with some difficulties:

• respondent fatigue given two sets of surveys (one for NASA and one for NHA)

• in some case estimates were conflicting

• inefficient use of human resources (two teams!)

• some gaps and inconsistencies were identified in the harmonization process

Current gaps and inconsistencies for harmonization

• NHA treats all donor funding into one basket called “Rest of the World” while NASA/UNGASS requires distinction for each donor funding

• NHA had a non-health addendum, but not comprehensively addressed (insufficient to fill UNGASS matrix) – e.g. no data on income generating activities

Rwandan Experience

Current gaps and inconsistencies for harmonization

con’t• With a small team of consultants and resources NASA

exercise was only able to identify declared expenditure by funding agents and not to track funding flows down to the implementers to avoid double counting – NHA could do that (the team was bigger and with more resources)

• Expenditure for condoms distribution under NASA is totally attributed to HIV, while NHA makes a distinction with family planning (need to include data from the RH sub-account as well)

Rwandan Experience

Current gaps and inconsistencies for harmonization

con’t

It is very difficult for NACC with a small NASA team to collect data country wide. e.g. from private sector and for out-of pocket expenditure

Rwandan Experience

RecommendationsAt international level

(UNAIDS, WHO, and USAID)• Refine (disaggregate) categories of expenditure for NHA

to allow a better “crosswalk” with NASA (for UNGASS table)

• For NHA, maintain distinction across donors (who finance what for each category) in order to allow UNGASS reporting

• Better one complete exercise from the beginning than two parallel ones with “last minute” harmonization

• Keep all stakeholders at country level informed

Recommendations cont’ At country level

• One exercise only (one questionnaire only): NHA or NASA

• Need to know real expenditure by implementers in country (declared expenditure by donors is not sufficient)

• If using NHA, make sure it includes non-health information as well, it keeps each donor funding separate, and make sure representative from NAC are included into the MOH team

• Make use of existing data collection (e.g. information on expenditure by stakeholders at district level included into the CDLS database) – define “crosswalk” between existing database and NHA/NASA

Lessons learned: AIDS money is a catalyst for

improvements in all sectors.Tool for making the money work:

• With this exercise we had a better tracking of funds

• We are improving our financial reporting • e.i: We gave evidence of 40% PEPFAR money, voted for

Rwanda, missing in country reports

This will lead to better allocation of funds and planning• We are applying the methodology to other sectors

• A better tracking of other sectorial money will assure alignment to EDPRS and our vision 2020

Malaria, HIV/AIDS, and RH in the context of general health expenditures 2006

RH; 6,2%

Other remaining

health; 57,1%

Malaria; 13,9%

HIV/AIDS; 23,5%

2006

Households2%

Public sources

3%

Private companies and others

1%

Donor94%

Financing Sources:Where do HIV/AIDS monies come from?

2002

Donor75%

Households16%Public

8%

Other private1%

Financing Sources:Where do HIV/AIDS monies come from?

Providers:Where do PLHIV spend their money?

2006

Independent pharmacies

19%

Agréé health centers

3%

Public health

centers 23%

Traditional healer 11%

Private clinics

6%

Private hospitals

7%

Public hospitals

23%

Not specified by kind

8%2002

Public health centers

27%Private clinics

6%

Private hospitals

5%

Public hospitals

35%

Independent pharmacies

16%

NGO health centers

7%

NGO hospitals

4%

= RWF 1,020,258,690 ($1,849,166)

=RWF 950,475,493 ($1,722,687)

Thank you to make our day to day work simple