michael chaitkin, teresa guthrie, neetu hariharan, adeel ... · neetu hariharan, adeel ishtiaq,...

Michael Chaitkin, Teresa Guthrie,

Neetu Hariharan, Adeel Ishtiaq,

Aparna Kamath, Nathan Blanchet,

and Robert Hecht

IAEN Pre-conference

16 July 2016

Durban, South Africa

Results for Development Institute (R4D) with

support from the UNAIDS/World Bank HIV

Economics Reference Group

What is HIV financing integration?

“The process of moving toward national health financing

systems where funds for HIV & AIDS are collected, pooled,

and used to pay for health services together with funds for

other health services rather than through separate

financing and payment structures.”

From R4D’s earlier work (Blanchet, Ishtiaq, & Ooman 2014):

2 | R4D.org

Source: Blanchet, N. J., Ishtiaq, A., & Ooman, N. (2014). Integration of HIV Financing into Health Financing

Systems in Low- and Middle-Income Countries: Conceptual Framework and Preliminary Findings. Report for the

UNAIDS-World Bank Economic Reference Group’s Technical Working Group on Sustainable Financing). Geneva:

UNAIDS.

http://hiv-erg.org/publications/sf/integration_financing.pdf

UNAIDS undertook feasibility analysis in South Africa as input to

government discussions and to inform the global discourse

3 | R4D.orgImages: (left) cover of the South African HIV and TB Investment Case Phase 1 (March 2016) and (right)

cover of the NHI White Paper, Department of Health, South Africa (Dec 2015)

http://sanac.org.za/2016/03/22/summary-report/

http://www.mm3admin.co.za/documents/docmanager/f447b607-3c8f-4eb7-8da4-11bca747079f/00090702.pdf

4 | R4D.org

SDG 3 targets include:

3.3: End the AIDS epidemic by 2030

3.8: Achieve universal health coverage

Images: (left) cover of the South African HIV and TB Investment Case Phase 1 (March 2016) and (right)

cover of the NHI White Paper, Department of Health, South Africa (Dec 2015)

UNAIDS undertook feasibility analysis in South Africa as input to

government discussions and to inform the global discourse

http://sanac.org.za/2016/03/22/summary-report/

http://www.mm3admin.co.za/documents/docmanager/f447b607-3c8f-4eb7-8da4-11bca747079f/00090702.pdf

Our method – a thought experiment – emphasized

consultative scenario development and assessment

5 | R4D.org

Note: UNAIDS refrains from endorsing one scenario over the others. The study

focuses on highlighting the pros and cons of each scenario relative to the

status quo and other options and is meant to support government deliberations

on HIV financing integration.

Characterize status quo

Develop scenarios

Assess scenarios

Stimulate discussion

Key data sources:

• Desk review of literature and gov’t documents and data

• Consultations and interviews with gov’t officials and experts

Government’s HIV response is financed differently from

(most of) the rest of the publicly financed health system

6 | R4D.org

Estimated allocations for FY 2016/17 based on analysis of National Treasury’s projections of provincial expenditure.


Develop scenarios

Assess scenarios


The HIV budget is large and growing faster than the rest of

the primary health care and overall DOH budgets

7 | R4D.org

1.01.6 2.1

2.73.5

4.35.6

6.77.7

8.9

10.7

12.6

14.1

15.9

18.2

20.6

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

0

5

10

15

20

25

DO

H f

un

din

g fo

r H

IV (

R b

illio

ns,

no

min

al) HIV share of PHC spending

HIV share of all DOH spending

Consolidated provincial and national health HIV/AIDS expenditure (outcomes 2003/4 - 2013/14; estimates 2014/15 - 2019/19).

Sources: Ndlovu et al., 2015; National Treasury (FYs 2004/05–2015/16 documents): Estimates of Provincial Expenditure; Estimates of

National Expenditure; Medium Term Budget Policy Statements; Budget Reviews; Division of Revenue Bills/Acts; and data provided to

R4D by NDOH and NT.


Develop scenarios

Assess scenarios


8 | R4D.org

Degree of national sphere’s influence over use of HIV funds

Le

ve

l o

f in

teg

ratio

n in

th

e p

oo

ling

an

d m

an

ag

em

ent

of fu

nds for

HIV

and o

ther

health s

erv

ices

Five scenarios indicative of the government’s choice set

along two dimensions: integration and nat’l influence


Develop scenarios

Assess scenarios


9 | R4D.org


S. Africa today

(HIV)

S. Africa today

(PES)1

Sustained HIV

conditionality

Le

ve

l o

f in

teg

ratio

n in

th

e p

oo

ling

an

d m

an

ag

em

ent

of fu

nds for

HIV

and o

ther

health s

erv

ices




Develop scenarios

Assess scenarios


10 | R4D.org


S. Africa today

(HIV)

S. Africa today

(PES)

White Paper vision:

single NHIF

1

Sustained HIV

conditionality

Le

ve

l o

f in

teg

ratio

n in

th

e p

oo

ling

an

d m

an

ag

em

ent

of fu

nds for

HIV

and o

ther

health s

erv

ices




Develop scenarios

Assess scenarios


11 | R4D.org


S. Africa today

(HIV)

S. Africa today

(PES)1

Sustained HIV

conditionality

3

Unconditional

integration

4

Ring-fenced

PHC integration

5

National PHC Fund

2

National HIV Fund

Le

ve

l o

f in

teg

ratio

n in

th

e p

oo

ling

an

d m

an

ag

em

ent

of fu

nds for

HIV

and o

ther

health s

erv

ices



White Paper vision:

single NHIF


Develop scenarios

Assess scenarios


12 | R4D.org


S. Africa today

(HIV)

S. Africa today

(PES)

White Paper vision:

single NHIFAlternate vision:

9 PHIFs

1

Sustained HIV

conditionality

3

Unconditional

integration

4

Ring-fenced

PHC integration

5

National PHC Fund

2

National HIV Fund

Le

ve

l o

f in

teg

ratio

n in

th

e p

oo

ling

an

d m

an

ag

em

ent

of fu

nds for

HIV

and o

ther

health s

erv

ices




Develop scenarios

Assess scenarios


Descriptive and evaluative frameworks tailored to the priority

considerations raised by policymakers and experts

13 | R4D.org

Evaluation criteria

Impact

On HIV response

On PHC services

On efficiency

Feasibility

Legal

Political

Technical

Descriptive features

Financing mechanism

Rationale

Potential pools of funds

Governance

HIV spending

HIV budget planning

HIV target setting

Each is elaborated in detail for all five scenarios,

mindful of the three to five year time horizon.


Develop scenarios

Assess scenarios


14 | R4D.orgCharacterize status quo

Develop scenarios

Assess scenarios


85.8 85.8 85.2 85.8 87.6

39.8 39.855.7

18.7 18.6

18.7

18.7 18.6

13.6

53.3

15.3

1.8

55.0

0

25

50

75

100

125

150

175

1. Sustained HIVconditionality

2. National HIVFund

3. Unconditionalintegration

4. Ring-fenced PHCintegration

5. National PHCFund

Pro

ject

ed b

ud

get –

PD

OH

s (R

bill

ion

)

Illustrative allocations for Scenarios 1-5 for FY 2016/17 (R billion)

HIV or PHC-HIV CG

NHIF

Other health CGs

Health PES (PHC)

Health PES (non-PHC)

Comparing potential pools of funds makes very tangible the

scenarios’ implications for resource allocation

Evaluative scorecard highlights risks, opportunities, and

trade-offs

15 | R4D.org

Scenario

Impact

on HIV

response

Impact

on PHC

services

Impact on

efficiency

Legal

feasibility

Political

feasibility

Technical

feasibility

1. Sustained HIV

conditionalityReference scenario High High High

2. National HIV Fund ? / - Ø ? / -Low-

mediumMedium

Low-

medium

3. Unconditional

integration- - - ? / + Ø / - High Low High

4. Ring-fenced PHC

integrationØ ++ ? / + Medium Medium Medium

5. National PHC Fund ? / - + ?Low-

mediumMedium Low

Note: These ratings are indicative and are intended to

animate discussion within the government.


Develop scenarios

Assess scenarios



trade-offs

16 | R4D.org

Scenario

Impact

on HIV

response

Impact

on PHC

services

Impact on

efficiency

Legal

feasibility

Political

feasibility

Technical

feasibility

1. Sustained HIV



mediumMedium

Low-

medium

3. Unconditional


4. Ring-fenced PHC



mediumMedium Low




Develop scenarios

Assess scenarios



trade-offs

17 | R4D.org

Scenario

Impact

on HIV

response

Impact

on PHC

services

Impact on

efficiency

Legal

feasibility

Political

feasibility

Technical

feasibility

1. Sustained HIV



mediumMedium

Low-

medium

3. Unconditional


4. Ring-fenced PHC



mediumMedium Low




Develop scenarios

Assess scenarios


There are several lessons for policy design and future

analysis of HIV (and perhaps other) financing integration

Key policy design lessons include:

Don’t lose sight of non-personal HIV services.

HIV program strengths could support broader UHC efforts, but

dilution of program management is also a risk.

As NHI systems evolve, strategic purchasing may have greatest

potential within financing policy to boost efficiency.


Develop scenarios

Assess scenarios




Lessons for further applied research on integration include:

Unpacking financing integration is valuable, perhaps essential.

Developing multiple options in consultation with government officials

stimulates useful debate (and simple visuals help!).

Retaining neutrality and focusing on feasibility, risks, and trade-offs

helps to ease concerns about “radical” options.


Develop scenarios

Assess scenarios





Develop scenarios

Assess scenarios




Lessons for further applied research on integration include:

Unpacking financing integration is valuable, perhaps essential.

Developing multiple options in consultation with government officials

stimulates useful debate (and simple visuals help!).

Retaining neutrality and focusing on feasibility, risks, and trade-offs

helps to ease concerns about “radical” options.


Develop scenarios

Assess scenarios


Thank you

22 | R4D.org

Michael Chaitkin

[email protected]

@mchaitkin

Results for Development Institute (R4D)

@results4dev

Thank you (and a plug for our satellite)

23 | R4D.org

Financing South Africa’s HIV Response

Date

Tuesday 19 July

Time

18:30 – 20:30

Venue

ICC Session Room 12

Featured speakers

Aaron Motsoaledi, Minister of Health, S. Africa

Pravin Gordhan, Minister of Finance, S. Africa

Michel Sidibe, Executive Director, UNAIDS

Deborah Birx, U.S. Global AIDS Coordinator

Mark Dybul, Executive Director, Global Fund

Robert Hecht, Results for Development Institute

Moderated by

Mia Malan, Mail & Guardian

Organized by the South African Government, UNAIDS, and R4D

Sponsored by the UNAIDS/World Bank HIV Economics Reference Group

Michael Chaitkin

[email protected]

@mchaitkin

Results for Development Institute (R4D)

@results4dev

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