Health Policy 94 (2010) 54–60

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Estimation of Japanese international financial assistance forHIV/AIDS control for 2003–2007: Difficulties and limitations ofdata collection

Koichiro Moria,∗, Kiyoshi Yonemotob, Teiji Takei c, Jose Izazola-Liceac, Benjamin Gobetc

a Japan Medical Association Research Institute, 2-28-16 Honkomagome, Bunkyo-ku, Tokyo 113-8621, Japanb Fukushima National College of Technology, Fukushima, Japanc UNAIDS, Geneva, Switzerland

a r t i c l e i n f o

Keywords:International financial assistanceHIVAIDSJapanBilateral aidMultilateral aid

a b s t r a c t

The purpose of this paper is to: (1) collect relevant data and estimate Japanese internationalfinancial assistance for HIV/AIDS control; (2) discuss the difficulties in collecting relevantdata and the limitations of the collected data; and (3) conduct a comparative analysis onthe estimated data with OECD and Kaiser Family Foundation aggregate data. The point isthat we have comprehensively collected and estimated the data on Japanese internationalexpenditures for HIV/AIDS control while there is no reliable data that is totally managedand published. In addition, we discuss the difficulties and limitations of data collection:unpublished data; insufficient data; inseparable data; problems of exchange rates; gapsbetween disbursement and commitment; and difference in year period among calendar,fiscal and organization-specific years. Furthermore, we show the risk of underestimating

the Japanese international contribution to HIV/AIDS control on the basis of OECD and Kaiserdata. In this respect, it is significant to comprehensively collect and estimate the data onJapanese international assistance for HIV/AIDS control. Finally, we derive the implicationthat it is crucial for a relevant international organization and/or individual countries to com-prehensively collect and administer data for international cooperation in the development

or HIV/

of health policies f

1. Introduction

HIV/AIDS is a serious infectious disease that has spreadall over the world. The number of people with HIV is esti-mated to be 33 million people in 2007. In the countries thatthe HIV epidemic has seriously affected, life expectancy hasdecreased by more than 20 years. It has slowed economic

development and made people poorer. Particularly, in Sub-Saharan Africa, the epidemic has brought about nearly 12million orphan children aged under 18 years. As a result,the age distribution has been dramatically skewed by HIV,

∗ Corresponding author. Tel.: +81 3 3942 6141; fax: +81 3 3946 2138.E-mail address: k.mori@jmari.med.or.jp (K. Mori).

0168-8510/$ – see front matter © 2009 Elsevier Ireland Ltd. All rights reserved.doi:10.1016/j.healthpol.2009.08.008

AIDS.© 2009 Elsevier Ireland Ltd. All rights reserved.

which has enormously damaged social and economic livesin Sub-Saharan Africa. Sub-Saharan Africa has been mostheavily affected by HIV, accounting for 67% of all peo-ple living with HIV and for 75% of AIDS deaths in 2007[1].

Funds for HIV/AIDS control play an important rolein preventing the prevalence of HIV nationally, region-ally and globally. However, poor counties that have beenviciously affected by the HIV epidemic cannot afford toinvest and disburse expenditures for HIV/AIDS control.

Therefore, international financial assistance for HIV/AIDScontrol is considered crucial. In fact, low-income countriessuch as ones in Sub-Saharan Africa rely on internationalfinancial sources for HIV expenditures for the most part(approximately 80%) [1]. Financial assistance has been

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mplemented through both bilateral and multilateral chan-els.

Nonetheless, data on international financial assistanceor HIV/AIDS control have not been appropriately andrecisely collected mainly because the data related toIV/AIDS control are, for the most part, unpublished andolitically sensitive. Needless to say, it is critical to getgrasp of the appropriate data for international politi-

al cooperation among nations, although we recognize theifficulties in collecting relevant data precisely. Especially,

apan is important in that Japanese GDP is still the secondargest in the world, although Japan has been faced witherious recessions. Japan has been expected to contribute tohe international assistance for HIV/AIDS control. Thus, weeed to estimate the Japanese expenditures for HIV/AIDSontrol to the extent that the estimated data can be trusted.

The purpose of this paper is: (1) collect relevant datand estimate Japanese international financial assistanceor HIV/AIDS control; (2) discuss the difficulties in collect-ng relevant data; and (3) conduct a comparative analysisn the estimated data with the Organization for Economico-operation and Development (OECD) and Kaiser Familyoundation aggregate data.

. Materials and methods

It is important to recognize that there is no core source ofata on Japanese international assistance for HIV/AIDS con-rol. Japanese international assistance has been executedhrough bilateral and multilateral channels via severalnternational and governmental organizations. In addition,everal ministries of Japan individually administer funding.hus, we should rest on various data sources depending onunding channels.

In the beginning, we select and specify data itemselated to international assistance for HIV/AIDS control.he point is that we must find and specify relevant datatems by searching for relevant information on projectsor HIV/AIDS control on the basis of trial and error. Theres, a priori, no information on it. Table 1 shows the rele-ant data categories and items in which we should collectata and evaluate Japanese financial contribution. Weave two major categories: bilateral and multilateral aid.ilateral aid is composed of free financial aid (Officialevelopment Assistance (ODA) grants), technical cooper-tion through the Japan International Cooperation AgencyJICA), loan aid through the Japan Bank for Internationalooperation (JBIC), and other bilateral aids such as sub-idies and trainings. Multilateral aid consists of Unitedation (UN) organizations, the World Bank, and the Globalund to Fight AIDS, Tuberculosis and Malaria (GFATM). Wehould note that we focus on earmarked multilateral aidor evaluating Japanese expenditures for HIV/AIDS control.here are several multilateral aids as general contributions:nited Nations Population Fund (UNFPA), United Nationsevelopment Fund for Women (UNIFEM), United Nations

hildren’s Fund (UNICEF) and United Nations Developmentund (UNDP). We do not put these data into the total expen-iture.

Let us explain concrete approaches for collecting, evalu-ting and analyzing the data in the following. To begin with,

94 (2010) 54–60 55

we collect relevant data from public information throughthe Internet. Some organizations publish databases, statis-tics, technical papers and annual reports on these websites.If we cannot access appropriate data through the Inter-net, we try to obtain relevant paper-based documentsthat include the data. Furthermore, we directly ask rele-vant organizations for the data if we cannot find the datathrough materials and media.

In evaluating the obtained data, we compare them withthe data in the Okinawa Initiative for Infectious Disease Pre-vention (IDI) that the Japanese Ministry of Foreign Affairs(MOFA) has provided. IDI data are not published, but theyare officially accepted. If we detect gaps between them,we directly ask MOFA to discuss them for data modifica-tion.

The data include loans and grants. We distinguish loansfrom grants. They are different because repayment andinterest payment are required for loans. For internationalloans in the context of ODA, (i) the start of repayment isdeferred, (2) the period of repayment is longer, and (iii)the interest rates are lower than those in conventionalcommercial loans. We can treat the advantages in suchinternational loans (ODA) relative to commercial loans asthe amount of grants. The advantage is equivalent to thewell-known concept of the “grant element”. The grant ele-ment is fundamentally given as a percentage (%). If the grantelement of a loan is 100%, the loan is equal to the sameamount of grant. If the grant element of a loan is 50%, theloan is equal to half the amount of the grant. Using the grantelement, relevant loans are converted into the appropri-ate amount of grant. Then, we can conceptually aggregatefinancial expenditures including loans (JBIC), using the con-version.

We divide the data into two categories: “pledge,approval, contract, budget and commitment” and “dis-bursement”. The former is referred to as “plan-basedexpenditures” while the latter is treated as “actual pay-ments”. The former is used in our research only if the dataon disbursements are unavailable, because we focus onexpenditures that have been paid.

We categorize the data into two groups: “exclusively forHIV/AIDS” and “not exclusively for HIV/AIDS”. If the pur-pose of projects is only for HIV/AIDS control, we record thefinancial data as the ones “exclusively for HIV/AIDS”. If thepurpose of projects includes control of other infectious dis-eases or if it is in a large category such as “reproductivehealth” and “prevention of infectious diseases (includingHIV/AIDS)”, their financial data are recorded as the ones“not exclusively for HIV/AIDS”.

Finally, we aggregate the individual data that we obtainfrom various sources, and analyze the trends and the gapsas compared with OECD and Kaiser Family Foundationaggregate data.

3. Results

In this section, we show the data that we havecomprehensively collected and estimated on Japaneseinternational financial assistance for HIV/AIDS control,although we will discuss the difficulties in data collectionand limitations on the data in the next section.

56 K. Mori et al. / Health Policy 94 (2010) 54–60

Table 1Relevant data on Japanese International Financial Assistance for HIV/AIDS control.

Category Sub-category Data item

Bilateral aid Free financial aid (ODA grants) General grantsEmergency grantsGrassroots human security grant aid

Technical cooperation (JICA) Trainee acceptanceExpert dispatchEquipment suppliesProject technical cooperationJapan overseas cooperation volunteer (JOCV) dispatchDevelopment researchExpert training and securementAid efficiency promotion projectsDevelopment and welfare assistance projectsDevelopment partners assistance projects

Loan aid JBIC

Other bilateral aid AssessmentsNGO projects subsidyGrant assistance for Japanese NGO projectsCommissioned researchMEXT teacher trainingsJICWELS

Multilateral aid (earmarked) UN organizations and World Bank UNAIDSWHOUNESCOUN trust fund for human securityWorld Bank (PHRD)World Bank (JSDF)

Other multilateral organizations GFATMAsian Development Bank (JSF)Asian Development Bank (JFPR)IPPF

Total

Table 2Japanese international assistance exclusively for HIV/AIDS control.

Thousand USD $

2003 2004 2005 2006 2007

Bilateral aid 13,184 17,147 18,301 19,080 22,341Free financial aid (ODA grants) 5,213 2,836 2,972 3,514 7,086

General grants 4,680 2,482 2,832 3,072 6,181Emergency grants 0 0 0 0 0Grassroots human security grant aid 533 355 140 441 905

Technical cooperation (JICA) 7,086 13,921 14,236 15,049 13,765Trainee acceptance 1,331 2,302 1,299 1,710 1,032Expert dispatch 250 340 216 260 410Equipment supplies 1,119 898 646 411 241Project technical cooperation 3,858 6,297 6,493 8,503 8,198Japan overseas cooperation volunteer (JOCV) dispatch 41 3,244 4,434 3,095 3,233Development research 9 0 0 0 0Expert training and securement 0 130 158 213 122Aid efficiency promotion projects 400 452 565 326 339Development and welfare assistance projects 0 0 0 0 0Development partners assistance projects 78 258 426 531 189

Loan aid 0 0 0 110 –Other bilateral aid 884 389 1,093 408 1,490

Multilateral aid 63,107 63,214 70,013 86,472 118,918UN organizations and World Bank 14,233 11,398 9,711 9,815 4,430Other multilateral organizations 48,874 51,816 60,302 76,657 114,488

GFATM 45,596 48,231 57,000 75,486 113,464

Total 76,291 80,361 88,314 105,551 141,259

K. Mori et al. / Health Policy 94 (2010) 54–60 57

Table 3Japanese international assistance not exclusively for HIV/AIDS control.

Thousand USD $

2003 2004 2005 2006 2007

Bilateral aid 50,582 110 107 111 12,946Free financial aid (ODA grants) 50,417 110 107 111 12,802

General grants 122 110 107 111 12,802Emergency grants 50,295 0 0 0 0Grassroots human security grant aid 0 0 0 0 0

Technical cooperation (JICA) 0 0 0 0 0Loan aid 0 0 0 0 0Other bilateral aid 165 0 0 0 144

Multilateral aid 711 1,031 9,797 2,725 1,5001

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UN organizations and World Bank 711Other multilateral organizations 0

Total 51,293

Table 2 shows the data on expenditures exclusively forIV/AIDS control during 2003–2007. The data from 2007

s the newest available. Table 3 shows the data on expen-itures “not” exclusively for HIV/AIDS control. Based onable 3, expenditures “not” exclusively for HIV/AIDS con-rol are not so large except for 2003, in which a largeDA emergency grant including HIV/AIDS control was

mplemented. Thus, we focus on data on expendituresxclusively for HIV/AIDS control. The total expendituren 2007 is 141,259 thousand United States dollars (USD).here is an obvious increasing trend in total expenditure,lthough we observe nominal values. It has increased bypproximately 87% for the most recent 5 years. In partic-lar, the Japanese contribution to GFATM in 2007 is morehan doubled as compared with that in 2003.

We compare the trend in the expenditure for HIV/AIDSith that in ODA net total expenditure. ODA is financial

unding for developing countries directly and indirectlyhrough international organizations. This is to enable themo develop their society and economy and improve socialelfare. A part of Japanese international assistance forIV/AIDS is included in ODA: general grants, emergency

rants, and grassroots human security grant aids. Fig. 1hows their trends respectively with the expenditures in003 set to be equal to 100. Obviously total expenditure forIV/AIDS indicates an increasing trend whereas ODA net

ig. 1. Comparison with changes in Japanese ODA net expenditure.ource: Ministry of Foreign Affairs of Japan. ODA White paper.

,031 9,797 2,725 1,5000 0 0 0

,141 9,904 2,836 14,446

total expenditure does not. Between 2003 and 2007, totalexpenditure for HIV/AIDS increased by 85.2% whereas ODAnet total expenditure decreased by 14.4%. Japanese inter-national assistance for HIV/AIDS has recently taken priorityover the other fields.

Let us conduct a comparative analysis on the collecteddata with OECD aggregate data. The OECD Creditor Report-ing System (CRS) Activity online database provides the dataon Japanese expenditures for HIV/AIDS control [2]. We havecollected relevant data from the OECD database using twopurpose codes: 13040 (HIV/AIDS control) and 16064 (socialmitigation of HIV/AIDS). Before we conduct a comparativeanalysis, several important features on OECD data shouldbe noted.

First, OECD data provide data on commitments and dis-bursements. There are noticeable discrepancies betweenthem. For example, the figure on commitment is muchlarger than that on disbursement in 2003, whereas thedisbursement value is more than double that of the com-mitment value in 2004. However, the reason is unknown.Second, OECD data include only data on expenditures for‘bilateral’ aids. OECD data do not include any data on thecontributions through international organizations (multi-lateral aids) such as GFATM, UN Trust Fund for HumanSecurity, Joint United Nations Programme on HIV/AIDS(UNAIDS), and the World Bank. Third, JICA’s activities forHIV/AIDS control (“technical cooperation”) have not beenrecorded in OECD data since 2003 because JICA was pri-vatized in that year. The rules for JICA’s reporting forOECD changed because of its privatization. However, JICAdata are collected only in 2007, although they may notbe completely included in OECD data. Fourth, OECD datado not include information on Grassroots Human Secu-rity Grant Aid, Loan Aid (JBIC), and NGO Projects Subsidyor Grant Assistance for Japanese non-governmental orga-nization (NGO) Projects for 2003–2007. Therefore, OECDdata do not contain sufficient information on the Japanesecontribution in terms of HIV/AIDS control, although OECDdata are considered to be official international data. Fig. 2

shows the comparison between our data on only bilat-eral aid exclusively for HIV/AIDS control and OECD data oncommitments and disbursements, respectively. A large gapbetween them is observed mainly because the importantdata item “technical cooperation (JICA)” is not included in

58 K. Mori et al. / Health Policy 94 (2010) 54–60

should be selected as a relevant project for HIV/AIDS con-

Fig. 2. Comparison with OECD data. Source: OECD CRS Aid Activity onlinedatabase

OECD data. We are therefore faced with serious underes-timation of Japanese international financial assistance forHIV/AIDS control based on OECD data.

Next, let us conduct a comparative analysis with KaiserFamily Foundation aggregate data. The Kaiser FamilyFoundation is a non-profit, private operating foundationdedicated to providing information and analysis on healthcare issues including HIV/AIDS. Kaiser Family Report pro-vides data on the international assistance for HIV/AIDScontrol during 2004–2007 [3]. A few features of Kaiser datashould be noted before the comparison.

First, the total contribution is composed of two parts:bilateral aid and global fund. Bilateral aid relies on the OECDCRS database, but Kaiser recognizes that OECD data do notinclude several funding sources. Thus, they have collecteddata directly from relevant organizations. The data do notinclude funding for international research on HIV/AIDSbecause it is not considered in estimates of resource needsfor service delivery of HIV-related activities, although thevalue in this category concerning the Japanese contribu-tion is not large. Second, the most important point toconsider is that Japan data are preliminary. They includeseveral imprecise estimates based on previous data andcommitment data. Third, as for the global fund, interna-tional funding is considered to be disbursement, althoughthe fund is not directly and immediately used in the sameyear. In general, they do not distinguish between commit-ment and disbursement about the global fund. However,we also treat data of the global fund (GFATM) in the samemanner.

Fig. 3 shows comparison of the total expenditurebetween our data and Kaiser data. The data in 2006 areconsistent with each other, while we find gaps betweenthem in the other years. Mysteriously, there is an obviousincreasing trend in our data whereas we find a decreas-ing trend in Kaiser data. The main cause of this gap isin the difference in exchange rates and preliminary esti-mates included in Kaiser Family Reports. In particular, itis quite normal that disbursements will be different fromcommitments due to changes in real conditions and the

time lags between them. Another reason is that Kaiserdata do not seem to include all the expenditure for inter-national organizations as un-earmarked multilateral aidsexcept for the global fund, although Kaiser data categorizes

Fig. 3. Comparison with Kaiser data. Source: Kaiser Family Foundation.Financing the response to AIDS in low- and middle-income countries:International assistance from the G8, European Commission and otherdonor Governments, 2007.

earmarked multilateral aids into bilateral aids. Moreover,we find a big difference in the Japanese contribution to theglobal fund (GFATM) between them in 2007. Kaiser datashow 75,500 thousand USD for the global fund while ourdata show 113,464 thousand USD. Kaiser data may assumethat the identical contribution in 2006 would be imple-mented in 2007, because the data were unavailable whenthe Kaiser Family Report was published. There is a clearincreasing trend in the Japanese contribution to the globalfund. It has increased from 75,486 thousand USD in 2006to 113,464 thousand USD in 2007. The gap between Kaiserdata and our data is 37,964 thousand USD in the globalfund in 2007. Considering this, Kaiser data and our dataare approximately compatible with each other in 2006 and2007. Nonetheless, we run the risk of underestimating theJapanese international contribution to HIV/AIDS control in2007 on the basis of Kaiser data unless we are aware of theabove-mentioned problems with the data.

4. Discussion

We discuss the limitations of the collected data andthe difficulties in collecting relevant data on Japaneseinternational financial assistance for HIV/AIDS control.We are repeatedly confronted with difficulties in collect-ing appropriate data. Let us discuss several importantpoints.

First, many data are unpublished and politically sensi-tive. We cannot access data unless we directly ask relevantorganizations. The data are not systematically adminis-trated in many cases. In several cases, IDI data from MOFAdo not coincide with data from individual organizations.Information of individual projects is often insufficient evenif we can obtain the list of individual projects related toHIV/AIDS. In this case, we have difficulty judging if they

trol. HIV/AIDS is such an important infectious disease thatwe need an organization that systematically and compre-hensively manages to record relevant data and informationin the context of international assistance.

K. Mori et al. / Health Policy 94 (2010) 54–60 59

Table 4Comparison of exchange rates.

Year Shishutsukan ratea Exchange rate based on PPPb Asian Development Bank exchange ratec FRB (USA) annual averaged

2003 122.00 138.47 107.00 115.942004 110.00 133.10 102.76 108.152005 107.00 127.52 117.70 110.112006 111.00 124.50 119.07 116.312007 116.00 – 112.29 117.76

a Ministry of Finance.

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b OECD.c Asian Development Bank.d Federal Reserve Bank (USA).

Second, many international organizations deal with theroblem of HIV/AIDS control, but they do not specialize

n projects of HIV/AIDS control except for UNAIDS. Underhis situation, it is difficult to separate the data related toIV/AIDS control from the others especially in the case ofomprehensive projects. For example, GFATM is one of theost important international organizations for HIV/AIDS

ontrol, but they deal with the problem of tuberculosis andalaria in addition to HIV/AIDS. As for GFATM, we must

stimate expenditures for HIV/AIDS control on a pro rataasis. We carry out the same procedure of estimation foreveral data items. Such a situation is inevitable as long asIV/AIDS is a serious infectious disease that is controlled

trategically and internationally, but the data are not neces-arily precise. The mechanism by which we get an accuraterasp of all the projects related to HIV/AIDS internationallyay need to be reconsidered. We would expect UNAIDS in

ooperation with other UN organizations and internationalanks to help if this is the case.

Third, we should be careful about exchange rates. Ineneral, international financial data have been recordedn USD, but projects in an individual country do notecessarily plan expenditures in USD. They often use

ocal currencies. In this case, we convert the mone-ary unit into USD using an exchange rate. The amountf expenditures is therefore affected by exchange rates.he Japanese governments use a specific exchange ratealled “shishutsukan rate”, which is completely differentrom the annual average spot exchange rate and thexchange rate on the basis of purchasing power parity (PPP)Table 4).

Fourth, disbursement data are better to evaluate thenternational contribution to HIV/AIDS control than plan-ased data such as commitment, budget and pledge. Theap between disbursement and plan-based data is oftenarge. This is partly because all the plans were not executednd mainly because there is time lag between plans andheir implementation. Thus, we have collected disburse-

ent data as long as they are available. We collect theisbursement data in all the data items except for the Min-

stry of Education, Culture, Sports, Science and TechnologyMEXT) teacher trainings. Nonetheless, the problem is that

he disbursement data are available only in 2007, whichre too old for current political decisions. Current data (ort least data for the previous 18 months or 12 months)ust be known because the diffusion of HIV/AIDS is

ynamic.

Finally, the accounting year is different among orga-nizations. The Japanese government and governmentalorganizations use the Japanese fiscal year (starts from Aprilof 1 year until March of the next year), whereas many inter-national organizations use the calendar year (January toDecember of the same year). The World Bank uses a dis-tant fiscal year (begins from July of the previous year untilJune of the present year). The fiscal year used by the WorldBank is irrelevant because we obtain data on the WorldBank from MOFA, which uses the Japanese fiscal year. Nev-ertheless, the data of aggregate values are inconsistent interms of the period of 1 year.

5. Conclusion

We have comprehensively collected and estimated dataon Japanese international financial assistance for HIV/AIDScontrol, while systematic and total data has not beenpublished in this area previously. This is a major contri-bution from the viewpoint of international health policyon HIV/AIDS. We also conduct a comparative analysis withOECD and Kaiser aggregate data, and show the possibilityof underestimating Japanese international contribution onthe basis of these data sources. Finally, we discuss severalimportant problems and limitations associated with datacollection. Similar problems may arise in other countries,so our discussion may be helpful for future studies in othercountries.

International comparison of financial assistance forHIV/AIDS among countries is urgently needed. The KaiserFamily Report has attempted it, but it is insufficient in thatthe data of individual countries cannot necessarily be com-pared. Data definitions are quite ambiguous. Whether thedata of individual countries include all common financialexpenditures is unknown. After we clearly define, calculateand show the data of international financial assistance forHIV/AIDS in individual countries, we should compare andadjust the data items that should be evaluated in the inter-national comparison. Then, we should discuss internationalcooperation and coordination of health policies, based onwell-defined data.

Up-to-date data on international financial assistance for

HIV/AIDS control is needed for international political coop-eration in the context of international health policy, whichis crucial for preventing the prevalence of HIV. We insistthat UNAIDS and individual national governments shouldcooperatively play an important role in this objective.

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60 K. Mori et al. / Hea

Acknowledgements

We would like to give many thanks to the followingorganizations: Ministry of Foreign Affairs of Japan (MOFA),Ministry of Finance of Japan (MOF), Ministry of Health,Labour and Welfare of Japan (MHLW), Ministry of Edu-cation, Culture, Sports, Science and Technology of Japan(MEXT), Japan International Cooperation Agency (JICA),

Japan Bank for International Cooperation (JBIC), WorldBank (JSDF and PHRD), Asian Development Bank (ADB,JSF and JFPR), Plaza for International Cooperation, JapanInternational Corporation of Welfare Services (JICWELS),Organization for Economic Co-operation and Development

y 94 (2010) 54–60

(OECD), and Joint United Nations Programme on HIV/AIDS(UNAIDS). Without their cooperation, we could not haveobtained the relevant information and data. In addition, wereally appreciate anonymous reviewers’ helpful comments.

References

[1] UNAIDS. 2008 Report on the global AIDS epidemic. Geneva, Switzer-

land. www.unaids.org; 2008.

[2] OECD CRS Aid Activity online database. http://stats.oecd.org/WBOS/.[3] Kaiser Family Foundation. Financing the response to AIDS in low-

and middle-income countries: International assistance from the G8,European Commission and other donor Governments, 2007. USA.www.kff.org; 2008.