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Challenges in Donor Funding in Zambia: the Example of HIV/AIDS

Funding

Preliminary observations

27 May 2008

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Outline of the Presentation A) Health Care Financing:

1. Main Sources of Health Financing. 2. Health Financing Modalities. 3. Recent changes to the Funding Modalities.4. Donor funding to health.

B) Challenges of HIV/AIDS funding for the health sector: 5. Overall6. Procurement 7. Management information systems

HR: talked about elsewhere…???? [Sylvia, you may have to include a few slides on this during the workshop; you decide]

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1. Main Sources of Health Financing MOFNP – taxes (and small? medical levy)Households – OOP, inc. user fees*; and

(community) pre-payments. External/donor funds – foreign taxes and

other external funds (through GIs).Other sources:

Medical saving scheme (mining companies);private health insurance, other e.g., fuel contribution by Totalpotentially SHI, etc

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2. Health Financing Modalities SWAp = GBS through MOFNP.SWAp = direct funding of expanded basket.

SWAp is strongly preferred by MOH.Vertical funding GAVI, GF, etc. earmarked to

specific interventions in health and is on-budget. Parallel funding: e.g., PEPFAR, which is earmarked

to specific interventions in health and is off-budget. Facility and community level financing:

User fees (now in urban areas only). Pre-payment schemes???Other income generating activities Sylvia, maybe provide a few

examples verbally during presentation (look in PETS report if you need ideas)

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3. Changes to the Funding Modalities Zambia Aids Policy (2005) & Joint Assistance

Strategy for Zambia (JASZ) defining Wider Harmonization in Practice (WHIP).

WHIP has involved: Movements from project to GBS. Interim movements were observed:

Movement to GBS e.g., EU, DfID, etc. Movement away from health to other sectors e.g.,

DANIDA initially moved to education.Some stayed in Health e.g., Sida, DfID (replacement fund

in 2005/06) but are intending to move.

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4. Donor Funding: Average Shares of Total Health Expenditure in 2004 (Source: NHA)

update with NHA 2007/08, if that is available…

MoFNP24%

Employers6%

Households29%

Donors38%

Other Sources3%

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B) Challenges of HIV/AIDS funding for the health sector:Recall:

5. OverallSize of the fundsPlanning difficulties Emerging difficulties in implementation

6. Procurement New systems and implication

7. Management information systemsNew systems and implication

Add “8. Human resource” if you included some slides on HR

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5. Overall Challenges of HIV/AIDS Funding (Size of the funds)

Donor Funding to HIV/AIDS and to Health (Excluding USAID Off-Budget Health Spending)

PEPFAR (off-budget)50.5%

USAID+CDC+ JPIEGO+SFH

2.2%WORLD BANK,

HIV/AIDS0.6%

GLOBAL FUNDS 15.8%

All other donors combined

31.0%

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5. Overall Size of HIV/AIDS Funding – cont’d

Donor Funding to HIV/AIDS and to Health (Inc. est. of USAID Off-Budget Health Spending)

All other donors

combined 22.7%

GLOBAL FUNDS 11.6%

WORLD BANK, HIV/AIDS

0.4%

USAID+CDC+ JPIEGO+SFH

1.8%

PEPFAR (off-budget)37.1% USAID (off-

budget, est.)26.6%

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5. Overall Size of HIV/AIDS Funding – cont’d

0.0

100.0

200.0

300.0

400.0

500.0

600.0

700.0

K billin

Total Health Budget 445.3 605.4

PEPFAR Treatment Budget 285.7 332.5

PEPFAR Total Budget 520.4 564.8

2005 2006

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5. Overall Challenges of HIV/AIDS Funding – Cont’dImplication of the size…:

National stewardship is potentially weakened.Preferred SWAp (all the systems, processes,

structures, tools, etc) is potentially undermined. Reporting allegiances are potentially formed

with funders. Mutual accountability is potentially weakened. Potential health systems distortions /

destabilization…

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5. Overall Challenges of HIV/AIDS Funding – Cont’d Potential health systems distortions /

destabilization:Planning cycle mismatches make coordination difficult. Unplanned HIV/AIDS spending that shows up in health

facilities at district level make it hard for MOH to request for supplementary budgets from MOFNP.

HR and other resource deflections (time, attention, etc) goes to well funded programme HIV/AIDS

Specific health system effects Procurement in health Management information systems

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6. Procurement in Health New systems: HIV Procurement.xls, and How involving is HIV procurement?

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6. Procurement in Health – cont’d Implication of new procurement systems

and demands:(+) More efficient HIV procurement systems,

e.g., less stock-outs. (-) Coordinator difficulties, e.g., with

transportation/distribution schedules. (-) Limited externalities LMU has limited spill-

over to general health procurement (PSU).(-) Further limitation of MOH stewardship (not

adequately involved in HIV procurement planning).

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7. Management Information Systems HIS: HIV & Health Info Systems.xls, and How is health information generated and collected?

HMIS Information Flow

Provincial Health Office

: Single direction flows from one agent to another, without direct feedback obligations.: Forward and backward flows between agents, with feedback obligations.

District Health Office

District (1st) level Hospital Health Centres

3rd & 2nd Level Hospitals

NGOs, Pvt Sector

Provincil level District level

MSL

Vertical/ parallel systems

MOH HQCSO; MHA

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7. Health information systems – cont’dImplication of new HISs and demands:

(+) Much more information generated. Note: HMIS has had its own weaknesses, but with HIV…

(-) Disproportionately more information for HIV/AIDS is generated – resource deflection: ARTIS is information heavy (combination of multiple

systems that previous existed) extra burden for HWs; & it has been unable to integrate with HMIS.

SMARTCare was originally for overall patient records/HMIS, but to date ART, ANC-PMTCT & VCT are the only automated services.

(-) Limited feedback to lower levels, does not improve with HIV/AIDS focus info. systems.

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Recommendation for Global Partners MOH point of view: Increased commitment/support to national

health systems and programmes; buy into SWAp (joint planning, joint procurements, integrated financing / accounting / information / reporting / etc. systems, etc.).

Improve information sharing about funding amounts and timings, towards improving predictability and fostering national planning/priority setting.

Full subscription by all partners to principle of mutual accountability.

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ConclusionPoint of view of the series of studies: A lot has not been covered here (further research

is required…)From preliminary observations:

Government systems require attention. Government is not sufficiently honouring Aduja

declaration & may be sending negative signal. Partners are not unified: in their willingness to lose some

amount of identity; & in buying into government systems.Long road ahead in building HS, which will

require dialogue and like mindedness.

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Thank you for your attention, enjoy Livingstone