The Financial Gap Analysis Report 2012
Analysis of the financial commitments in addressing the National Strategic Plan for the Elimination of Mother-to-
Child Transmission of HIV and Paediatric Care and Treatment 2011/12-2015/16
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Acknowledgements
The Ministry of Health (MOH) wishes to acknowledge the Elizabeth Glaser Pediatric AIDS Foundation (EGPAF) and the United Stated Agency for International Development (USAID) for the technical support which they provided during this analysis.
Completion of the analysis would not be complete without the inputs of Government and its HIV services implementing partners. The Ministry would sincerely like to extend their gratitude toward WHO, WFP, UNICEF, UNFPA, Baylor College of Medicine, ICAP, Clinton Foundation, EGPAF, MSF, MSH, PIH, LPPA, LENASO, mothers2mothers, PSI and Riders for Health for their participation in this exercise.
Finally, the Ministry acknowledges the wide range of staff members within the Family Health Division, STI/HIV/AIDS Directorate and Disease Control who were committed to the process.
Photo: Horse-rider Potso Seoete rides through a pass in the Maluti mountains on the journey to the Molika-liko health clinic in the Mokhotlong district, Lesotho, 01 September 2010. Credit: Jon Hrusa/EPA.
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Executive Summary
BackgroundAfter Lesotho's launch of the Strategic Plan for Elimination of Mother-to-Child Transmission of HIV and for Pediatric HIV Care and Treatment, the question arose whether Lesotho had adequate resources to meet the costs associated with reaching elimination of mother-to-child HIV transmission (EMTCT). This prompted the Ministry of Health (MOH) to task the Elizabeth Glaser Pediatric AIDS Foundation (EGPAF)-Lesotho program with leading a financial gap analysis.
MethodologyThe study was a cross-sectional quantitative analysis to capture available funds needed to implement activities outlined in the EMTCT strategic plan between 2012 and 2015. The gaps were identified based on areas described in the strategic plan; the four prongs of PMTCT, increasing access to pediatric HIV treatment, care and support among infected children and adolescents, integration of HIV with other health services, health systems strengthening and coordination between government and stakeholders. Costs taken into account included laboratory, pharmaceutical and clinical commodities, staff, logistics and infrastructure support costs. The EGPAF research team developed a structured questionnaire to capture activities delineated in the strategic plan and funding allocated to each activity between 2012 and 2015. Twenty-four questionnaires were sent to seven MOH departments and 17 organisations via email in May 2012. An Excel electronic database was developed by the team in which variables from the questionnaire were entered. Descriptive analyses of the variables were carried out in November 2012 by the EGPAF-Lesotho research team.
Key FindingsQuestionnaires had an 83% response rate and 25% of the surveyed organizations and departments provided supporting financial documents. The total funding committed to the strategic plan from 2012 to 2015 was US $80 million. Prong 1 had a funding gap of US $14 million; Prong 3, a gap of US $7.8 million; Prong 4 had a funding gap of US $33.5 million; and the integration of HIV into other health services had a US $9 million funding gap. Prong 2, access to pediatric HIV treatment, care and support; health systems strengthening and coordination had excess funding available of US $5 million, US $0.8, US$7 million and US $3.8 million, respectively. Of note, the highest funding deficit was prong 4 with a gap of US $33.5 million; this gap is likely due to unmet funding needs for laboratory systems improvements and pharmaceutical procurements for tuberculosis and opportunistic infections.
ConclusionThere was an overall funding gap of more than 50% of the required amount for elimination in Lesotho. This financial gap analysis is being used for resource mobilization efforts and reallocation of funds according to real need. It is important that all funding agencies and stakeholders come together to regularly reassess financial commitment as we move toward elimination of new pediatric infections.
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Key recommendations A resource mobilization strategy should be drafted in order to address the financial gaps
identified in the gap analysis. It is important that all relevant stakeholders remain abreast of the progress of the Strategic Plan
for the Elimination of MTCT of HIV and Paediatric Care and Treatment in order to align their own goals to those planned strategies.
Since under or overspending will determine the funding allocated to organizations, it is advised that implementing departments within any organization make an effort to become knowledgeable of the financial resources at their disposal.
Each organisation must thrive to reach maximum absorption rate of the funding that it receives by carrying out all activities effectively and in a timely manner. This action will affect the allocation they receive when they request more funding as donors look at efficient absorption of funding as a determining factor in allocating funding.
It is recommended that organisations participate in strategic planning and integrate strategic plan interventions for which they are responsible into their existing activities and budgets.
Organisations should also be proactive to apply for “bridge funding” from funding partners or explore other funding mechanisms when caught in between funding cycles so that service delivery is not delayed;
Offering staff renewable contracts or long-term contracts will serve as an incentive for staff at facility level and thereby reduce a proportion of the staff turnover. When staff are secured, programs can be implemented with fewer interruptions.
An efficient and effective supply chain management for pharmaceuticals and laboratory supplies should be maintained so that the relevant tools are available to complement the staff effort at all levels.
The gap analysis should be used as a tool to advocate for investment in human resources at district level.
To avoid further human resource challenges, trainings and refresher trainings should be adhered to as stipulated in the EMTCT plan so that the staff is well capacitated to carry out these interventions especially when the necessary financing is available.
Integration efforts among different stakeholders must be made in order to experience cost savings when delivering services. With this in mind, coordination efforts will need to be strengthened in order to experience the highest returns for collaboration.
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Contents
Acknowledgements.................................................................................................................................2
Executive Summary.....................................................................................................................................3
Background..........................................................................................................................................3
Methodology.......................................................................................................................................3
Key Findings.........................................................................................................................................3
Conclusion...........................................................................................................................................3
Key recommendations.........................................................................................................................3
Acronyms.................................................................................................................................................7
Chapter 1: Introduction...............................................................................................................................9
Status of PMTCT in Lesotho.....................................................................................................................9
HIV/AIDS Funding....................................................................................................................................9
Chapter 2 Costing of the EMTCT Plan........................................................................................................10
Classification by programmatic themes.................................................................................................14
Human Resources (HR)......................................................................................................................14
Trainings............................................................................................................................................14
Community Sensitization and Outreach............................................................................................14
Procurement (Vehicles, commodities, equipment and infrastructure).............................................14
Laboratory.........................................................................................................................................15
Pharmaceuticals................................................................................................................................15
Classification by capital and recurrent costs..........................................................................................16
Cost per Capita..................................................................................................................................17
Chapter 3: How the Financial Gap Analysis was Developed (Methodology).............................................17
Limitations.........................................................................................................................................18
Chapter 4: Results of Funding Commitments toward the EMTCT Plan......................................................19
Funding by Constituents........................................................................................................................19
Funding by Year.....................................................................................................................................20
Funding Gap by Strategic Area..............................................................................................................21
Excluded Funding...................................................................................................................................23
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Chapter 5: Financial Commitments Made to Support Prevention of HIV Infections among HIV Uninfected Women and Men of Reproductive Age (Strategic Area 1).........................................................................23
Chapter 6: Financial Commitments Made to Support the Prevention of Unintended Pregnancies in Women Infected with HIV (Strategic Area 2).............................................................................................24
Chapter 7: Financial Commitments to PMTCT (Strategic area 3)...............................................................25
Chapter 8: Financial commitments to support the increase in access to quality treatment, care, and support for HIV infected women, their male partners, and their families (Strategic Area 4)....................26
Chapter 9: Financial Commitments Made to Promote Access to Quality Paediatric HIV Treatment, Care and Support for all HIV-infected Infants, Children and Adolescents Support Coordination and Collaboration (Strategic Area 5)................................................................................................................28
Chapter 10: Financial Commitments Made to Support Integration between HIV, MNCH and Related Services (Strategic area 6).........................................................................................................................29
Chapter 11: Financial Commitments Made to Support Health System Strengthening (HSS) (Strategic Area 7)...............................................................................................................................................................31
Chapter 12: Financial Commitments to Support Coordination and Collaboration between Government and all Relevant Organisations (Strategic area 8)......................................................................................32
Chapter 13: Challenges and Opportunities................................................................................................33
Human Resources..................................................................................................................................34
Supply Chain Management....................................................................................................................34
Assessment of Infrastructural Developments........................................................................................34
Community linkages..............................................................................................................................34
Competing versus complementary priorities.........................................................................................34
Financial Gap Analysis Challenges and Opportunities...........................................................................35
Chapter 14: Recommendations.................................................................................................................35
Chapter 15: Financial Implications of Option B+........................................................................................37
Summary of Findings.............................................................................................................................38
Differences in Cost between Option A and Option B+...........................................................................39
References.................................................................................................................................................40
Appendix 1: Questionnaire........................................................................................................................42
Appendix 2: List of Key Informants............................................................................................................49
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AcronymsANC Antenatal clinicsART Antiretroviral therapyARV AntiretroviralCDC U.S. Centers for Disease Control and PreventionCHAL Christian Health Association of LesothoCTA Call to ActionDFID Department for Foreign International DevelopmentEGPAF Elizabeth Glaser Paediatric AIDS FoundationEID Early infant diagnosiseMTCT plan National Strategic Plan for Elimination of Mother to Child Transmission of HIV and
for Paediatric HIV Care and Treatment 2011/12-2015/16EU European UnionFGA Financial gap analysisFP Family planningGDP Gross Domestic ProductGTZ German Technical CooperationHCW Healthcare workerHIV Human immunodeficiency virusHR Human resourcesHSS Health system strengtheningICAP International Centre for AIDS Care and Treatment ProgramsIMAM Integrated management of acute malnutrition programINH IsoniazidIPT Isoniazid preventive therapyJICA Japanese International Cooperation AgencyLENASO Lesotho Network of AIDS Services OrganisationsLPPA Lesotho Planned Parenthood AssociationM&E Monitoring and evaluationMBP Mother baby packMCA Millennium Challenge AccountMM Mentor mothersMNCH Maternal, neonatal, and child healthMOH Ministry of HealthMSF Medecins San FrontièresMSH Management Sciences for HealthMTCT Mother-to-child transmissionNACS Nutrition, assessment, and counselling servicesNDSO National Drug Supply OrganizationNGO Non-governmental organisationOI Opportunistic infectionPEPFAR President's Emergency Plan for AIDS ReliefPIH Partners in HealthPMTCT Prevention of mother to child transmissionPSI Population Services International
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RHZE Rifampicin + isoniazid + pyrazinamide + ethambutolRNA PCR Reverse transcription polymerase chain reactionTB TuberculosisTWG Technical Working GroupUN United NationsUNAIDS Joint United Nations Programme on HIV/AIDSUNFPA United Nations Population FundUNICEF United Nations Children’s FundVHW Village Health WorkerWFP World Food ProgramWHO World Health Organisation
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Chapter 1: Introduction
Status of PMTCT in Lesotho The fight against mother-to-child transmission of HIV in Lesotho began in 2003 and has made remarkable progress in the last decade1. Signaling the increased investment in PMTCT, in 2004, MOH collaborated with USAID and EGPAF on a five year USD 4.7milion Call to Action (CTA) project in Lesotho, which supported the scale-up of services for PMTCT2 As a result, Lesotho successfully scaled up PMTCT provision to 100% of eligible sites. Paediatric treatment services started in July 2005(1,3) . In 2006/7, a PMTCT and paediatric HIV care and treatment scale-up plan was launched to facilitate the roll-out of antenatal services within health centres to provide relevant services to all women (HIV-positive and negative)3. Between 2008 and 2009, there were approximately 4,000 new paediatric infections globally, as opposed to the projected 5,400 new infections in the absence of any PMTCT interventions4,5,6. As of December 2010, there were 198 sites providing PMTCT services in Lesotho, and 91.8% of pregnant women attended antenatal clinic (ANC) at least once during the course of their pregnancy2,3. It is estimated that 27.7% of pregnant women attending ANC were HIV-infected1.
In 2010, with high prevalence rates in mind, The Global Plan Towards The Elimination Of New HIV Infections Among Children By 2015 And Keeping Their Mothers Alive: 2011-2015 was introduced by the Joint United Nations Programme on HIV/AIDS4. Within a year of this introduction, in December 2011, Lesotho officially launched its costed National Strategic Plan for Elimination of Mother to Child Transmission of HIV and for Paediatric HIV Care and Treatment 2011/12-2015/16 (eMTCT plan)3 The strategy plan and costs associated with it were largely based around implementation of the 2010 WHO guidelines and a spectrum of activities related to the four PMTCT prongs which were underscored by the Option A regimen. The total operational cost for implementing this plan was greater than 1 billion Maloti3..
In April 2012, the World Health Organization (WHO) released a programmatic update on the Use of Antiretroviral Drugs for Treating Pregnant Women and Preventing HIV Infection in Infants which recommended lifelong antiretroviral therapy (ART) for HIV-infected pregnant and lactating women7,8. This recommendation would push Lesotho even closer toward its goal of eliminating new pediatric infections by 2015]. The 2010 WHO guidelines, implemented in Lesotho under Option A, called for use of CD4 tests to determine ART eligibility 1.Option B+ stresses that all HIV-infected pregnant women, regardless of CD4 counts, are eligible for lifelong ART. Under Option B+, the preferred regimen for HIV-infected pregnant women is TDF/3TC/EFV7,8.Lesotho began efforts to update the national PMTCT guidelines, evaluate the practicability of the changes needed to implement Option B+ and to weigh the financial considerations of implementing these guidelines in September 2012). Lesotho began the switch from Option A to Option B+ in April 2013.
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HIV/AIDS Funding Global funding for HIV/AIDS has significantly increased in the last twenty years. In 2011 and 2012, US$16.8 billion and US$18.9billion were spent on HIV and AIDS, globally6. This is a long way from the US$300 million invested in 1996 to counter the epidemic 4. The most recent UNAIDS report showed that at least 75% of HIV related spending in lower middle income countries and lower income countries came from international sources6.
Lesotho is a lower middle income country with a GDP of 1,193USD per capita9.By 2009, the funding envelope toward HIV/AIDS, outside of the Government of Lesotho, was increasingly geared toward prevention activities with the introduction and uptake of PMTCT services and the health sector policy on HIV prevention10. Lesotho has key development partners with respect to funding HIV/AIDS activities, namely- United States Government through U.S. Centers for Disease Control (CDC) and U.S. President’s Emergency Fund for AIDS Relief (PEPFAR), UN Agencies, Millennium Challenge Account (MCA), World Bank, European Union, Irish AID, German Technical Cooperation (GTZ), Department for Foreign International Development (DFID), Japanese International Cooperation Agency (JICA). In 2009, the international expenditure (268million Maloti) toward HIV/AIDS was 7% higher than the public expenditure (233million Maloti)10,11.
The Millennium Challenge Account was launched in 2007 for a period of five years12 The MCA investment of approximately USD 122 million was made toward the renewal of the country-wide health care infrastructure, across the central, district and local levels which included renovations and equipping of health centres in order to better facilitate health care services which included HIV and TB treatment; establishment of ART clinics in hospital outpatient departments and overall health system strengthening12. According to the Global Fund report, their disbursement of HIV grants by end of September 2011 was approximately USD 48milion and expenditure was USD 45 million while the disbursement for tuberculosis (TB) was approximately USD5.6 million and expenditure stood at USD 4.6 million13,14. Lesotho also received about USD 91.7 million toward comprehensive HIV/AIDS prevention, treatment and care programs from FY 2009 to FY 2011 from USAID2.
In order to determine the financial availability for the implementation of the EMTCT; a financial gap analysis was conducted and this financial gap analysis report was produced. This report serves as a supplement to the costed National Strategic Plan for EMTCT of HIV and for Paediatric HIV Care and Treatment (EMTCT plan) that was launched in December 2011.
Chapter 2 Costing of the EMTCT Plan
The EMTCT plan was developed by the MOH PMTCT Technical Working Group in 2011. It was successfully launched on December 1, 2011 at the annual World AIDS Day Celebration. The cornerstone of the EMTCT plan was WHO 2010 Option A PMTCT regimen which stipulated that:
An HIV-infected pregnant woman with CD4>350 receives Zidovudine (AZT) starting at 14 weeks and AZT, Lamivudine (3TC), and Nevirapine (NVP) during labor, and that the infant receives Nevirapine suspension until one week post-cessation of breastfeeding; while
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An HIV-infected pregnant woman with a CD4<350 is initiated on antiretroviral therapy (ART)1
The EMTCT plan detailed the targets that must be met to achieve elimination; the strategies and broad activities that will be performed in order to meet these targets; monitoring and evaluation (M&E) framework; and the estimated costs per activity which will be incurred to reduce the risk of HIV transmission from mothers to children to less than 5% .
The targets that would guide the implementation of the EMTCT plan are shown in Table 1 below.
Table 1 Key Targets to achieve the EMTCT plan
Targets Baseline 2012 2013 2014 2015 2016% 1st ANC Attendance 91.8% 93% 95% 96% 97% 98%% Women attending ANC with known HIV status during pregnancy - 93% 95% 96% 97% 100%% HIV infected pregnant women with known status receiving prophylaxis or antiretroviral therapy (ART) 81% 85% 90% 94% 97% 100%
% breastfeeding at 6 months of age (HIV infected women) 87.6% 89% 90.5% 92% 93.5% 95%% HIV exposed infants who receive 1st DNA PCR by 2 months of age 30% 50% 70% 80% 90% 95%% HIV exposed infants who receive confirmatory test for HIV within 18 months of birth 16.9% 40% 50% 70% 80% 95%
MTCT rate at end of breastfeeding 13.1% 12.3% 10% 8.5% 7.1% 4.6%Source: EMTCT plan (2011) 3
The key strategic areas of the eMTCT plan are shown in the table below:
Table 2 Strategic areas for EMTCT plan
Strategic Area 1 Prevention of HIV infections among HIV uninfected women and men of reproductive ageStrategic Area 2 Prevention of unintended pregnancies in women infected with HIVStrategic Area 3 Prevention of transmission of HIV from women infected with HIV to their childrenStrategic Area 4 Increase access to quality treatment, care and support for HIV infected women, their male partners and
their familiesStrategic Area 5 Promote access to quality paediatric HIV treatment, care and support for all HIV infected infants, children
and adolescentsStrategic Area 6 Integration between HIV, MNCH and other related servicesStrategic Area 7 Health system strengthening (HSS)Strategic Area 8 Coordination and collaboration between government and all relevant organisationsSource: EMTCT plan (2011)3
Strategic areas 1-4 are synonymous with the four PMTCT prongs. In order to reach virtual elimination targets, the MOH has to provide a comprehensive approach which includes reducing new HIV infections among women of reproductive age (Prong 1 of the WHO’s PMTCT strategy) and meeting unmet family planning (FP) needs (Prong 2), in addition to preventing HIV transmission from women living with HIV to their infants (Prong 3) and the provision of appropriate treatment, care, and support to mothers living with HIV and their children and families (Prong 4)16.
The first strategic area is drawn from Prong 1 and includes men and women so that “the cascade of events leading to new paediatric HIV infections will be halted”16. According to statistics, the adult population (15-49 years of age) totals approximately 1,402,285 and the HIV prevalence of women and
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men of this age is 23%; this population is targeted in this strategic area16. The activities under this area are directed toward improvement of effective behaviour change communication on safe sexual behaviour in communities, promoting HIV testing and counselling to encourage an individual’s awareness of their status and promoting biomedical interventions for HIV prevention such as male circumcision, use of microbicides etc. 3,16. Previous research indicates that HIV counselling and testing enhances awareness of one’s status protects the individual and others from infection; early detection improves medical efficacy and psychosocial support and it also promotes behaviour change17. Farnham et al. (2010) measured the value of HIV prevention efforts in the United States (US) and the findings revealed estimated medical savings from infections averted by U.S. prevention programs from 1991-2006 to be $129.9 billion with 361,878 HIV infections averted18.
There are several advantages to integrating prevention of unintended pregnancies with HIV prevention, care and treatment (Prong 2). One study shows that cost savings ranging 62 to 82 million dollars were made in 14 countries by integrating FP to HIV patients19. Integrating FP services empowers women to decide if and when to have children and to avoid unintended pregnancies, and prevent sexually transmitted infections19.It also allows them to reduce any economic losses that may be experienced while making several trips or spending more time at a facility to receive services19. Prevention of transmission of HIV from women infected with HIV to their children (Prong 3) and Increase access to quality treatment, care and support for HIV infected women, their male partners and their families (Prong 4) are discussed in the previous section. The remaining strategies relate to demand creation of services, promoting uptake of services, the six pillars of health system strengthening and coordination and collaboration among the government and stakeholders.
The EMTCT plan was costed in order to facilitate planning, budgeting, and implementation processes. The costing component encouraged the developers and implementers of the plan to thoroughly consider each proposed activity, as each activity was intensively explored based on inputs and costs.
The costs were estimated using a top-down ingredients approach, meaning that each “broad activity” was broken down into activities and then further into its “ingredients,” which are the necessary line items to achieve the strategies. The basic formula for calculating cost for any ingredient used in an intervention is unit cost of resource required for intervention multiplied by the expected quantity.
The costs were classified into the strategic areas, programmatic themes and into capital and recurrent costs. The information pertaining to the activities was drawn through consultative meetings with key persons and supplemented by data and document reviews. The cost data for the line items was obtained through a market price survey, financial and programmatic document reviews, and through consultations with key persons. Assumptions that guided the costing included:
An inflation rate of 5.5% per annum; An exchange rate of 1US$ to 7.5 Maloti (May 2010 prices); A wage inflation rate of 8% per annum; and And a constant HIV prevalence among ANC attendees of 27.7%.
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The total cost to achieve EMTCT in Lesotho was 1,089,163,083 Maloti (US$145,221,744). The strategic areas, objectives and costs which the nation of Lesotho are obliged to meet in order to achieve elimination are shown in Table 2 below.
Table 3 Total cost per strategic area
Strategic Area Total Cost (Maloti)Strategic Area 1 Prevention of HIV infections among HIV uninfected women and men of
reproductive age 182,783,487
Strategic Area 2 Prevention of unintended pregnancies in women infected with HIV 6,905,745Strategic Area 3 Prevention of transmission of HIV from women infected with HIV to their
children201,772,517
Strategic Area 4 Increase access to quality treatment, care and support for HIV infected women, their male partners and their families 414,361,994
Strategic Area 5 Promote access to quality paediatric HIV treatment, care and support for all HIV infected infants, children and adolescents 53,110,706
Strategic Area 6 Integration between HIV, MNCH and other related services 85,624,360Strategic Area 7 Health system strengthening (HSS) 141,270,949Strategic Area 8 Coordination and collaboration between government and all relevant
organisations 3,333,325
Total Cost 1,089,163,083Source: EMTCT plan (2011)3
The distribution of costs varied greatly by each strategic area. The strategic area with the largest outlay of financial resources was increasing access to quality HIV treatment, care, and support for HIV infected women, their male partners and their families (strategic area 4). Implementing costs were expected to be at their highest in the first two years as a result of initial procurement of equipment, but were expected to decline steadily thereafter. Upon further analyses of the costing of the EMTCT plan, an annual breakdown of costs was drawn in addition to classification of the costs into programmatic areas and cost categories which are discussed further in this section. The annual cost breakdown of the EMTCT plan is shown in Table 3.
Table 4 Annual breakdown of costs of EMTCT plan per strategic area from 2011/12-2015/16
Year/Maloti 2011/2012 2012/2013 2013/2014 2014/2015 2015/2016Total
estimated cost per
strategic areaStrategic Area 1 27,805,600 32,065,640 34,110,329 41,493,953 47,307,964 182,783,487Strategic Area 2 2,385,669 2,581,010 451,442 1,126,444 361,179 6,905,745Strategic Area 3 39,573,975 44,745,558 42,528,965 39,201,497 35,722,522 201,772,517Strategic Area 4 67,338,021 89,799,946 85,208,480 85,658,748 86,356,799 414,361,994Strategic Area 5 14,107,866 18,101,555 14,281,630 5,140,016 1,479,640 53,110,706Strategic Area 6 29,890,000 28,544,000 26,092,000 286,000 812,360 85,624,360Strategic Area 7 48,172,212 24,834,201 20,916,852 24,537,164 22,810,521 141,270,949Strategic Area 8 2,287,465 263,465 263,465 263,465 255,465 3,333,325Total estimated cost per year 231,560,808 240,935,375 223,853,163 197,707,287 195,106,450 1,089,163,083
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Classification by programmatic themesThe eMTCT plan included a spectrum of programmatic areas that were implicit to the strategic areas such as trainings, community mobilization, pharmaceuticals, construction, human resource (HR) recruitment, infrastructure, equipment and machinery.
Human Resources (HR). A quick gap analysis of the relevant cadres that would be required to successfully implement the EMTCT plan was conducted and the missing cadres were identified. At the time of preparing the EMTCT plan, the MOH staff complement was inadequate and plagued with concerns about recurring staff rotation within the districts and staff attrition. The estimated costs for these staff were restricted to basic salaries only for a 13-month period for each year. It was assumed that wages would increase by 8% per year while using the 2011 salaries as a baseline. Other employee benefits were not costed.
Trainings. There were thirty-one trainings were costed for the entire EMTCT plan. Trainings were directed toward different cadres such as village health workers (VHWs), community-based distributors, peer educators, professional healthcare workers (HCWs), mentors, and practitioners. The duration per training varied from 2 to 7 days, and the number of participants ranged from 180 to a maximum of 500 participants across the districts. The inputs of each training included: the number of participants and facilitators; allowances for accommodation and meals; cost of the venue; transport costs (fuel); and stationery, materials, and other supplies (e.g., certificates, folders and compact discs for storage of information for the participants).
Mentorship and Supportive Supervision. This cost was attached to all activities relating to mentorship and supportive supervision of healthcare workers at all facilities. These visits are intended to reinforce the trainings that are held.
Community Sensitization and Outreach. There were 32 community sensitization activities included in the costing for the EMTCT plan. Community sensitizations included production of information, education and communication (IEC) materials (such as posters, pamphlets, audio cassettes, and radio and mobile phone messages), newspaper advertisements, and sponsored sporting events per district. Costs associated with these outreach activities were estimated. Each community sensitization activity was proposed in the EMTCT plan. Community outreach activities refer to outreach activities at schools, hosting community testing campaigns and general increase in utilization of mobile clinics.
Procurement (Vehicles, commodities, equipment and infrastructure). This category involves the purchase of vehicles, medical commodities (i.e. male and female condoms) and equipment and construction. Equipment included materials and machinery necessary for neonatal resuscitation and emergency obstetric interventions and mobile clinics for outreach purposes. Nutrition commodities and equipment were also included for the establishment and maintenance of nutrition corners The cost of constructing new infrastructure or partitioning of facilities to accommodate maternal, neonatal and
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child health (MNCH) services at hospitals and health centres was calculated as a proportion of the total cost of the construction that was being carried out at health centres at the time. The relative sizes of the proposed construction and renovations were unknown and, for that reason, it was assumed that the construction costs were for a maximum of 18 hospitals since construction was already being carried out at the health centres. As contingency, if any infrastructure developmental needs arose at the health centre, the expenses could be shifted to these health centres. The estimated costs for procurement of medical, commodities and equipment were obtained from the vendors themselves. Historical data was obtained from the MOH procurement office, and a 5.5% inflation rate was used. The vendors were asked to provide the best price.
The national PMTCT Technical Working Group (TWG) decided the proportion of microbicides, HIV testing kits, and condoms which could be reasonably supplied through ANC. The costs were drawn from current prices and subjected to the annual increases as well. Since the quantities were relatively similar each year, economies of scale were not assumed.
Laboratory The laboratory activities refer to procurement and distribution of POC technologies, supply of laboratory commodities, installation and improvement of health information system and new laboratory equipment.
Pharmaceuticals1. ARVs and Prophylaxis. The following assumptions guided the costing for ARVs and prophylaxis:
All HIV-infected clients who attended ANC would receive some form of pharmaceutical intervention:
50% of all eligible clients were already on ART by the time they came to ANC; Prevalence of HIV in ANC was 27.7%; Estimates of ANC population were drawn from Bureau of Statistic; Attendance to ANC was based on the targets were set by the TWG; There was a buffer stock of about 20%; It was assumed that women were looked after for an average of 19 months in ANC and
postnatal care It was assumed that 30% of existing patients on ART were on tenofovir (TDF), while 32%
converted to TDF during pregnancy as a result of low haemoglobin or other reasons.
2. TB formulations-treatment and prophylaxis. The targeted population requiring TB formulations were a proportion of all HIV-infected clients in ANC plus a proportion of HIV-negative clients would receive TB rifampicin + isoniazid + pyrazinamide + ethambutol (RHZE) treatment and isoniazid (INH) prophylaxis. Infant formulations were equal to 10% of the adult population on treatment. An average dose was assumed instead of ordering by body weight. Costs of drugs increase by 5.5% per year. A 100% buffer stock was recommended.
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3. Opportunistic infection (OI) formulations. A quick gap analysis of the OI medications which were not readily available within the country conducted by the pharmaceutical department of the MOH informed the actual formulations required. The number of clients on ART was used as the proxy for the number of people who needed OI treatment medications, except Albendazole which was prescribed to all infants. Maximum dosage for each formulation is assumed. Costs included freight costs and value added tax (VAT). A 33% buffer stock was recommended.
4. Supplements. All ANC clients would receive supplements at the required dosage over a one-year period. There would be a 25% buffer stock for procurement of supplements.
Other. This section refers to costs incurred for meetings, assessments, evaluations, surveys and other document development. At least thirty-nine activities were dedicated to these areas.
Table 5 Annual cost breakdown of EMTCT plan by activity for 2011/12-2015/16
In Maloti 2011/2012 2012/2013 2013/2014 2014/2015 2015/2016 Total cost per activity
Human Resources 16,346,760 15,623,090 16,871,538 18,219,862 19,676,053 86,737,303Laboratory 31,859,995 51,296,873 52,035,799 49,510,363 50,163,745 234,866,775 Procurement (vehicles, equipment, commodities buildings)
110,671,625 90,329,937 87,922,593 46,257,296 45,273,735 380,455,186
Training 6,931,113 23,488,537 6,920,976 20,040,500 5,160,313 62,541,439Mentorship and Supportive Supervision
2,898,350 3,873,350 3,873,350 3,873,350 3,873,350 18,391,750
Community 6,441,291 7,384,273 7,193,935 7,200,476 7,252,665 35,472,640Other 18,049,021 9,892,254 6,314,328 4,054,286 6,081,561 44,391,449Pharmaceutical 37,599,381 39,046,895 42,845,053 48,698,833 58,116,378 226,306,541Total cost per year 230,797,536 240,935,209 223,977,572 197,854,966 195,597,800 1,089,163,083
*In Table 6, other costs refer to costs incurred for meetings, assessments, evaluations, surveys and other document development.
Classification by capital and recurrent costsIn this paper, we refer to capital as all investments which tend to be one-time expenses, are incurred on the purchase of land, buildings, construction, equipment and training used in the production of goods and services. Training is considered as capital as it has future benefits to the programme20. These services are expected to last more than one year. Meanwhile, recurrent costs refer to costs incurred more regularly and repeatedly such as materials, supplies, personnel salaries and travel allowances.
Table 6 Annual costs by capital and recurrent expenditure
Maloti in millions 2011/2012 2012/2013 2013/2014 2014/2015 2015/2016 %
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Capital 108,896,169 103,012,495 84,754,531 48,636,157 32,887,536 35%
Recurrent 126,974,946 133,034,293 139,315,620 149,311,389 162,339,945 65%
35% of the 1.089 billion Maloti is for the capital costs and 65% for recurrent component. Investment in capital goods is frontloaded and is at the highest in the first year of the plan and decrease thereafter. By the end of the plan; they would have decreased to less than 50%. This is mainly because the capital costs are also synonymous with set-up costs for emergency and obstetric care equipment, vehicles, construction of waiting mothers’ homes and regional hospice care centres, renovation of adolescent corners and laboratory information systems. These activities are critical and need to be in place for the implementation of the rest of the plan.
Cost per CapitaThe cost analysis further revealed that it would cost an estimated 2,128 Maloti (US$266) per HIV infected mother-baby pair seeking ANC services for a total of 19 months (i.e. 7 months for mother only, and 12 months postpartum for both mother and infant) based on the EMTCT plan. This amount is below GDP per capita threshold and should be affordable given that GDP is distributed equitably in Lesotho.
Chapter 3: How the Financial Gap Analysis was Developed (Methodology)One of the questions generated by the EMTCT plan is whether Lesotho had adequate resources to meet the costs forecasted to achieve elimination of paediatric HIV by 2016. This prompted the MOH to lead a gap analysis in order to: i) establish the availability of funds within Lesotho to meet these forecasted costs; ii) estimate the additional resources required to meet elimination by 2016; and iii) make recommendations on the way forward. The specific objectives of this report are to:
Update organisations of the available funding sources within Lesotho with respect to each of the eight strategic areas;
Inform the relevant organisations on the variation between the available funding and the projected costs per activity determined in the eMTCT plan; and
Inform organisations on the opportunities and challenges which may exist with regards to financing the intended activities.
The research question which led the analysis was: What is the difference between the available and actual funds required to carry out the EMTCT plan in Lesotho by 2016?
The financial gap analysis began approximately five months after the EMTCT plan had been launched in Lesotho. Development of the protocol ran concurrently to the development of the implementation plan
17
for the strategic plan. The analysis was designed as a cross-sectional quantitative analysis which would capture the relevant activities and the respective funding that each stakeholder was contributing as part of the goal to contribute to the achievement of the targets in the strategic plan. The criteria for selecting stakeholders were (i) all implementing partners whose Memorandum of Understanding with the government of Lesotho was to directly support the MOH Family Health Division; (ii) any organisations whose support was indicated during the construction of the eMTCT plan and (ii) finally any organisations, although not specifically linked to FHD but whose participation in the health system contribute to the success of eliminating paediatric HIV infections and providing care, treatment and support to their families. Other organisations which contributed toward national health system but whose contribution could not easily be streamlined to the EMTCT plan activities were excluded. The list of participating organizations is shown in Appendix 2.
The analysis was carried out using structured questionnaires (see Appendix 1). The questionnaires were administered to partners and MOH departments directly supporting PMTCT and HIV care and treatment. The questionnaires were reviewed and, along with the protocol, were submitted to the MOH Ethics and Research Committee for approval. Twenty-four questionnaires were sent out and each questionnaire was supplemented with either a sensitization visit or a phone call to address any queries that the respondents would have pertaining to completion of the questionnaire. The questionnaire sought to capture the type of organization, the services that the organization provided that were relevant to the EMTCT plan and the funding available for the aforementioned services. The questionnaire also allowed participants to provide insight on any financial or practical challenges and opportunities that were anticipated with respect to the implementation of the EMTCT plan. These sensitization meetings took place between May-August 2012. The team that conducted the research received ethical training and technical support. Eighty-three percent (83%) of the organisations responded, of which 79% were via written responses and the other 4% responded via a structured interview. The analysis was performed in Excel for the available data. To avoid double-counting; we focused on the financial expenditure from implementing partners. Supporting documents were also requested in order to complement the information. Twenty-five percent (25%) of the surveyed organisations and departments provided supporting financial documents. The information collected from the questionnaires was kept in a database. The data was cross-checked with documentation from the organisations and verified by the MOH.
LimitationsSome of the data input sheets developed for this study were not used because the funding commitments could not be broken down to that level of detail where capital costs could be separated from operational costs, nor programmatic themes as outlined in the eMTCT costing unless a budget was made available. In 86% of the cases, the funding information provided was for a period less than the five years projected in the plan, which means there will be a degree of underestimation in the amount of funding that will be available to implement the plan in the subsequent years. One of the effects is that the funding available significantly declines in the last 3 years of the plan. However, since data from the first year of the plan was the most comprehensive and complete data, it can also be used as a more accurate picture of the funding sources and funding availability of the latter years.
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Chapter 4: Results of Funding Commitments toward the EMTCT Plan
Funding by Constituents 67% of funding commitments toward the EMTCT plan is derived from international NGOs. Government departments within the MOH contribute 15% while local NGOs have the least representation at 7%. Figure 1 shows the expected total expenditure from all constituencies over the 5-year period (2011/12-2015/16
Organization0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
GOL Multilateral International NGOs Local NGOs
Figure 1 Distribution of funding per constituency
Since some organizations did not provide expected funding for the last three years of the plan such that the total funding depicted in Figure 1 may not be a true representation of the expenditure contribution for the organizations throughout the five year plan. We went further to examine the annual contribution for each organization. Upon further examination shown in figure 2; data from 2011/12 showed that GOL and multilateral agencies contribute a higher amount during the initial year of the plan compared to the later years of the plan. This analysis also showed that international NGOs continue to contribute a larger proportion of funding for the EMTCT activities for all the years. International NGOs contributed 49% and local NGOs contributed 10%.
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2011/12 2012/13 2013/14 2014/15 2015/16 -
50,000,000
100,000,000
150,000,000
200,000,000
250,000,000
300,000,000
GOL Multilateral International NGOs Local NGOs
Figure 2 Funding contributions per constituency per year
Based on the findings, it shows that international NGOs are expected to contribute minimally to strategic area 6 which refers to integration between HIV, MNCH and other services. This is likely due to the injections toward capital that are required to better facilitate integration of services. Currently, HCWs within MNCH provide a ‘supermarket approach’ to women who visit MNCH.
Strategic Area 1
Strategic Area 2
Strategic Area 3
Strategic Area 4
Strategic Area 5
Strategic Area 6
Strategic Area 7
Strategic Area 8
-
50,000,000
100,000,000
150,000,000
200,000,000
250,000,000
Government (line ministries) MultilateralInternational NGOs Local NGOs
Figure 3 Funding available per organization per strategic area
Funding by YearThe total funding committed within the country, among the selected organisations (bilateral/other agencies, local and international NGOs, and government ministries) was 684 million maloti. The distribution of the funding commitments per year is shown in the graph below.
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2011/ 2012 2012/ 2013 2013/ 2014 2014/ 2015 2015/ 2016 -
50,000,000
100,000,000
150,000,000
200,000,000
250,000,000
300,000,000
Mal
oti in
mill
ions
Figure 4 Comparison of annual estimated cost per year against annual funding committed from 2011/12-2015/16
The funding gap was 405 million Maloti. The initial year of the plan was the only year with a funding surplus. The funding gap in the last three years averages 121 million Maloti.
2011/ 2012 2012/ 2013 2013/ 2014 2014/ 2015 2015/ 2016
(140,000,000) (120,000,000) (100,000,000)
(80,000,000) (60,000,000) (40,000,000) (20,000,000)
- 20,000,000 40,000,000
Mal
oti in
mill
ions
Figure 5 Annual funding gap from 2011/12-2015/16
Funding Gap by Strategic AreaOverall, strategic areas pertaining to prevention of unintended pregnancies in women infected with HIV (strategic area 2); promoting access to quality paediatric HIV treatment, care and support for all HIV infected infants, children and adolescents (Strategic area 5); HSS (strategic area 7); and coordination and collaboration between Government and all relevant stakeholders (strategic area 8) had funding surpluses while strategic areas 1,3,4 and 6 had funding deficits. The strategic area with the highest financial deficit was in increasing access to quality treatment, care and support for HIV infected women, their male partners and families (291.7million maloti) followed by prevention of HIV infections among HIV uninfected women and men of reproductive age (122.5 million maloti).
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Strategic Area 1
Strategic Area 2
Strategic Area 3
Strategic Area 4
Strategic Area 5
Strategic Area 6
Strategic Area 7
Strategic Area 8
(350,000,000)
(300,000,000)
(250,000,000)
(200,000,000)
(150,000,000)
(100,000,000)
(50,000,000)
-
50,000,000
100,000,000
Figure 6 Annual funding gap per strategic area from 2011/12-2015/16
In the first year, four out of the eight strategic areas had funding surpluses. From the second year, the financial contribution toward PMTCT (strategic area 3 ) falls below the origin. Only three areas have surpluses; these become smaller as the years progress. The negative funding gap for strategic area 4 is growing over the five year period while the funding gap for integration of services (strategic area 6) is more visible in the first three years.
Table 7 Annual funding gap by strategic area for 2011/12-2015/16
Funding gap 2011/ 2012 2012/ 2013 2013/ 2014 2014/ 2015 2015/ 2016 Total gap Strategic Area 1 (6,161,895) (12,153,240) (26,148,721) (34,556,537) (40,533,580) (119,
553,973) Strategic Area 2 9,263,876 22,820,144 3,945,518 3,020,804 3,892,181
42,942,522 Strategic Area 3 41,255,316 (27,159,378) (27,876,997) (27,642,825) (24,188,290) (
65,612,173) Strategic Area 4 (29,732,051) (53,585,377) (61,046,701) (70,013,396) (70,266,111) (2
84,643,637)
Strategic Area 5 (753,212) 414,471 (430,308) 2,178,494 6,048,088 7,457,534
Strategic Area 6 (26,525,913) (25,400,528) (25,922,856) (109,944) (728,696) (78,687,937)
Strategic Area 7 27,899,852 25,629,834 9,202,295 (2,480,020) 53,343 60,305,303
Strategic Area 8 5,785,434 7,760,910 7,499,351 7,511,286 4,224,535 32,781,516
Total estimated cost per year 21,031,408 (61,673,165)
(120,778,419)
(122,092,138)
(121,498,530)
(405,010,844)
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Excluded FundingThere is an additional 12.6 million maloti which is pending due to delayed disbursements of funding for strategic area 3. This amount is targeted toward increasing access to laboratory screening for all suspected cases and follow-ups at health centre level. Another funding contribution of approximately 2 billion maloti was not included in the analysis because it was not linked exclusively to the EMTCT plan, although it would have a positive impact on implementation of EMTCT activities - the grant toward Christian Health Association of Lesotho (CHAL) and other facilities. It is also not included to avoid duplication of funding commitments, since some of these organisations would have already submitted information for this study. An in-depth analysis at site level would be necessary to determine the extent to which these sub-grantees carry out their activities with respect to the EMTCT plan.
It is important to note that some organizations were unable to provide their funding commitment for the greater part of the exercise and their commitments may be largely underestimated. Further detail on the specific strategic areas is provided in the following chapters.
Chapter 5: Financial Commitments Made to Support Prevention of HIV Infections among HIV Uninfected Women and Men of Reproductive Age (Strategic Area 1)Overall, 14 respondents indicated that they carry out activities relating to the first strategic area. The total funding gap for Strategic Area 1 is 119.5 million maloti.
2011 / 12 2012 / 13 2013/ 14 2014/ 15 2015 / 16 -
5,000,000
10,000,000
15,000,000
20,000,000
25,000,000
30,000,000
35,000,000
40,000,000
45,000,000
50,000,000
Amou
nt in
Mal
oti
Figure 7 Difference between cost and funding for prevention of HIV infections among HIV uninfected women and men of reproductive age
The interventions in this strategic area were those interventions related to adolescents (1/5), testing and counselling services (1/5), and community sensitization. The highest funding commitment of approximately 9 million maloti is a cross-cutting package of interventions which is aimed at prevention activities for at-risk groups. The development and implementation of a national campaign through mass
23
and mid-media channels, to provide women and couples with correct information on PMTCT and FP is second highest funded activity and is allocated 5.4 million maloti. Financing for male circumcision is given a 270,000 maloti allocation.
Further analysis showed that the outstanding financing needs were those linked to “introduction of microbicides” and activities related to serodiscordant couples which total approximately 27 million maloti in the strategic plan. Financial commitments for “assessments and evaluations” and development of tools or packages were one million maloti.
One possible reason for this gap is that the targeted population for this strategic area could have been too broad. It is not limited to women in either antenatal or postnatal care or their infants but is extended to all those people of reproductive age. Another reason for this gap could have stemmed from the economic recession which saw reduction in funding allocations toward certain program areas. In such circumstances, financial responsibility of implementing some activities was shifted to the MOH or private donors by at least 7% of the organisations. Fourteen percent of these respondents indicated that their program had reached the end of the cycle and were awaiting disbursement of the new funding pending approval of the budget.
As of 2013, the National guidelines for PMTCT of HIV indicate that Lesotho has since adapted Option B+ as a measure to tackle MTCT of HIV. Option B+ proposes that all pregnant HIV-infected women, regardless of their CD4 cell counts will be counselled and initiated on antiretroviral therapy and this considerably reduces sexual transmission to a serodiscordant (uninfected) partner8]. Due to this development, at least a proportion of serodiscordant couples’ counselling and pharmaceutical needs will be met under the forthcoming budget drawn up to match the updated guidelines.
Chapter 6: Financial Commitments Made to Support the Prevention of Unintended Pregnancies in Women Infected with HIV (Strategic Area 2)Forty one percent (41%) of respondents contributed to “prevention of unintended pregnancies in women infected with HIV”. The total funding commitments for strategic area 2 were 49.8million maloti. There was a funding surplus of 42.9 million maloti. In the first two years, a sizeable difference between estimated costs and the funding committed is indicated. The estimated funding for 2011/12 and 2012/13 immediately fell to 9.6million maloti and 12.8million maloti respectively.
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2011 / 12 2012 / 13 2013/ 14 2014/ 15 2015 / 16 -
5,000,000
10,000,000
15,000,000
20,000,000
25,000,000
30,000,000 Am
ount
in M
aloti
Figure 8 Differences between cost and funding for prevention of unintended pregnancies in women infected with HIV
One area which remained unexplored and without any financial commitment was the “provision of free surgical methods of FP to women and men of reproductive age who want them in public sector health facilities,” which was estimated to cost a humble 430,000 maloti for a population of approximately 40 male and female clients per government hospital per year.
All FP commodities and relevant training costs in the FP program were actually not included in the EMTCT plan costing in order to avoid duplication of efforts. However, as the gap analysis was being conducted, it was not possible to streamline the funding contributions to the EMTCT plan alone. Therefore, the entire financial subvention toward the FP was included in this study.
There was, however, apprehensiveness among some respondents regarding the targeted population of the interventions as they indicated that they did not categorize this population in terms of HIV status. This was resolved by seeking all inclusive information from the respondents. Another assertion that was made was that the nature of condoms use served “dual protection” needs and that their provision could not be limited to a single strategic area. Needless to say, the nature of the activities was examined and discussed further and the activities were logged into relevant areas.
Chapter 7: Financial Commitments to PMTCT (Strategic area 3)Strategic area 3 comprises interventions that facilitate the “prevention of transmission of HIV from women infected with HIV to their children.” Sixty five percent (65%) of the respondents indicated that they were conducting activities under this area. The type of support ranged from technical assistance, trainings, mentorship and supportive supervision. Strategic area 3 costs are quite consistent given that the average estimated cost per year is 40.3 million maloti while the range is between 35.7-44.7 million maloti. The overall funding deficit for strategic area 3 was 65 million maloti.
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2011 / 12 2012 / 13 2013/ 14 2014/ 15 2015 / 16 -
10,000,000
20,000,000
30,000,000
40,000,000
50,000,000
60,000,000
70,000,000
80,000,000
90,000,000 Am
ount
in M
aloti
Figure 9 Difference between cost and funding for PMTCT
The highest financial commitment was 50 million maloti which was geared toward nutrition interventions. The funding committed to pharmaceutical provision falls short of the estimated costs across the board except for the first year of implementation of nine million maloti. The total costs estimated for mother baby packs (MBPs) ranged from 9-11 million maloti for the provision and preparation of the packages. Pharmaceutical supplies for MBPs were costed separately in strategic area 4.
There was substantial funding available toward provision of nutrition assessments, counselling and support within MNCH and ANC settings. The funding commitment for pharmaceuticals was not provided for the remaining four years as those budgets were not readily available from the respective stakeholders. Pharmaceuticals are largely financed by the government of Lesotho and the Global Fund within Lesotho. The MOH and the supporting partners are very supportive of the MBPs and funding is consistently allocated to ensure their provision annually.
Chapter 8: Financial commitments to support the increase in access to quality treatment, care, and support for HIV infected women, their male partners, and their families (Strategic Area 4)Strategic area 4 has the highest estimated costs in the strategic plan mainly due to the high costs of the interventions included under area. The interventions included salaries of psychologists (2 million maloti per year), expanding wellness clinics (5 million maloti per year), provision of supplements (2 million maloti per year), cotrimoxazole (10.5 million maloti per year) and TB formulations (16 million maloti per year); providing RNA PCR in-country which would require new equipment, supplies and commodities (10 million maloti per year) and improvement on laboratory costs (132 million maloti in total).
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Fifty percent (50%) of the respondents indicated that they carry out activities related to strategic area 4. The overall funding gap is 284 million maloti. The highest funding commitment is in the first year and relates to psychosocial support and health education to mothers.
2011 / 12 2012 / 13 2013/ 14 2014/ 15 2015 / 16 -
10,000,000
20,000,000
30,000,000
40,000,000
50,000,000
60,000,000
70,000,000
80,000,000
90,000,000
100,000,000
Amou
nt in
Mal
oti
Figure 10 Difference between cost and funding for increasing access to quality treatment, care and support for HIV-infected women, their male partners and their families
On further analysis the outlay of funding against expected costs showed that there are gaps in all programmatic themes except commodities, supplies, and technical support and community activities. The largest funding gap was toward the procurement of equipment and machinery.
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Gap
(350,000,000)
(300,000,000)
(250,000,000)
(200,000,000)
(150,000,000)
(100,000,000)
(50,000,000)
-
50,000,000
100,000,000
Commodities
Capital (equipment, machinery etc)
HR (new hires)
Advocacy/ meetings
Research
Technical support
Capacity Building
Community
PharmaceuticalsFunding Gap
Figure 11 Funding gap per key area in strategic area 4 for 2011/12 to 2015/16
These strategic areas also require large procurement of equipment and supplies or infrastructural development and laboratory system development. The purchase of ARV pharmaceuticals represents only 7% of the estimated cost and is therefore not considered a high cost burden. However, the inclusion of all OI formulations, TB prevention and treatment interventions, and antibiotics for HIV-infected women with caesareans increases the cost burden (112 million maloti) of pharmaceuticals in the EMTCT plan. In the financial gap analysis, it appears that only 16% of pharmaceutical costs remain uncovered.
Chapter 9: Financial Commitments Made to Promote Access to Quality Paediatric HIV Treatment, Care and Support for all HIV-infected Infants, Children and Adolescents Support Coordination and Collaboration (Strategic Area 5)Strategic area 5 consisted of two main construction activities: adolescent corners in hospitals and filter clinics and regional hospices for palliative care services for HIV infected children and their families. The total estimated cost for these two activities was approximately 40 million maloti. The overall cost for strategic area 5 was 53.1million maloti.
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Forty five percent of respondents indicated that they carried out strategic area 5. Strategic area 5 had a surplus of funding of approximately seven million maloti. Most of this funding was toward TB/HIV integration, paediatric HIV care and treatment, and support of Ariel and teen clubs.
No funding commitments toward these projects had been secured from the interviewed organizations.
2011 / 12 2012 / 13 2013/ 14 2014/ 15 2015 / 16 -
2,000,000
4,000,000
6,000,000
8,000,000
10,000,000
12,000,000
14,000,000
16,000,000
18,000,000
20,000,000
Amou
nt in
Mal
oti
Figure 12 Differences between costs and funding to promote access to quality paediatric HIV treatment, care and support for all HIV infected infants, children and adolescents support coordination and collaboration
The highest funding commitments of about 40 million maloti spanning over five years of the plan were directed toward included early infant diagnosis (EID), cotrimoxazole provision, TB screening, and treatment for HIV-infected children at facility level. Over 12 million maloti was pledged for paediatric HIV care and treatment for the five year period.
Not all funding is matched to the expected expenditure for example, the EMTCT plan had not costed for paediatric care and treatment with respect to pharmaceuticals. The highest variance between estimated costs and financial commitments can be noted in the last two years of the plan. There are fewer cost intensive strategies in the last two years; less procurement and construction are expected and the other relevant costs are well-covered in other strategic areas.
Chapter 10: Financial Commitments Made to Support Integration between HIV, MNCH and Related Services (Strategic area 6)While integration of health service delivery services falls under a spectrum of definitions, it is clear that the benefits of integration of MNCH and related services will create a more favourable environment to implement the similarly extensive continuum of activities proposed in the plan. According to WHO integration can be defined as “the management and delivery of health services so that clients receive a
29
continuum of preventive and curative services, according to their needs over time and across different levels of the health system. 21”
The expectations under strategic area 6 are to define a policy; establish an integrated system and provide an environment with appropriate infrastructure and capacitated staff which will allow successful and sustainable integration of health services in MNCH in order to meet the elimination targets. These activities include reorganizing service delivery areas to allow provision of the services, establishing referral systems to enable tracking patients as they move through the system, relevant training of staff, periodic assessments and evaluations of the process. Reinforcement of the outreach component is also included in this scope of activities so that these services may be offered to the community as a comprehensive package even during outreach excursions. Construction to reorganize service delivery areas was estimated to cost about 25 million maloti each year in the first three years.
Twenty seven percent (27%, or 6/22) respondents supported this strategic area. Strategic area 6 had a funding deficit of 78.7 million maloti with the largest deficits in the first three years.
2011 / 12 2012 / 13 2013/ 14 2014/ 15 2015 / 16 -
5,000,000
10,000,000
15,000,000
20,000,000
25,000,000
30,000,000
35,000,000
Amou
nt in
Mal
oti
Figure 13 Difference between estimated cost and funding to support integration between HIV, MNCH and related services
During the development of the strategic plan, it was determined that separate construction was required to insure full integration of services and the costs were estimated. However, upon inquiry on the subject, there was neither a department nor any organization that provided data indicating their financial commitment to this area that would narrow this gap. Whether such a huge construction undertaking will be carried out soon after the recent health facility renovations under the Millennium Challenge Account, is yet to be seen.
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Chapter 11: Financial Commitments Made to Support Health System Strengthening (HSS) (Strategic Area 7)Strategic area 7 looks at HSS interventions. HSS focuses on ensuring that the six health system blocks are functioning at their most effective capacity22,23. These core components of the health system refer to health services, health workforce, health information system, medical products, vaccines and technologies, health financing system, and leadership and governance. The strategies that are proposed in strategic area 7 are expected to advance the overall Lesotho health system even though they are also drawn from the perspective of achieving elimination targets by 2015.
The high expenditure areas are increasing the human resource capacity within the health facilities; capital expenditures such as procurement of emergency units for hospitals in all districts; standard neonatal resuscitation and emergency and obstetric equipment in MNCH and maternity sections at hospitals. The staff required to meet the overall staffing complement in Lesotho included pharmacy technicians, pharmacists, nursing assistants, laboratory technologists, senior nurse assistants, and nursing officers and was expected to cost 71 million maloti. Furthermore, the procurement summed up to 17 million maloti.
2011 / 12 2012 / 13 2013/ 14 2014/ 15 2015 / 16 -
10,000,000
20,000,000
30,000,000
40,000,000
50,000,000
60,000,000
70,000,000
80,000,000
Amou
nt in
Mal
oti
Figure 13: Difference between estimated costs and funding commitments to support HSS
Approximately 55% of respondents facilitate the implementation of HSS interventions. The total financing available is 201.6 million maloti Strategic area 7 has a budgeted surplus of 60 million maloti. The funding surplus is associated with the first three years of the plan. The outlay of funding relevant to each HSS component is shown in Table 7 and Figure 13.
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Table 8 Funding Resources per HSS component for 2011/12-2015/16
HSS elements Total available in Maloti
Service delivery 89,328,726
Health workforce 11,511,520
Health Information Systems 5,972,184
Medical products, vaccines and technologies 89,551,876
Health financing 2,526,816
Leadership and governance 2,685,125
Total 201,576,247
Investments in medical products, vaccines and technologies (89.5 million maloti) and service delivery (89.3million maloti) receive the highest pledges. There was a proposed government procurement of vaccines which totalled about 35 million maloti. However, these vaccines would be used across many programs within the health system and were not just limited to strategic area 7.The subventions toward the largest outlay were dedicated toward procurement of POC technologies, vaccines, TB screening and treatment services. Service delivery referred to increasing the number of staff at the point of delivery of services. It was not clear which staff complement is supported by this amount. Although service delivery is quite high, it also includes aspects of health workforce but the exact proportions were not easily differentiable.
Chapter 12: Financial Commitments to Support Coordination and Collaboration between Government and all Relevant Organisations (Strategic area 8)The EMTCT plan from which this FGA stems successfully shows how the government and its relevant partners can collaborate their efforts, although dissimilar in process, and still contribute to the same health agenda of EMTCT of HIV and for paediatric HIV care, treatment and support. In order to exploit the benefits of an efficient, effective, and equitable health system derived from coordinating players within the health system, the EMTCT plan outlays strategies for establishing forums to encourage regular interaction among MOH Central and key stakeholders: sexual and reproductive health, paediatric HIV, nutrition, M&E, pharmaceutical, laboratory, TB, health education, and community programs at central, district, and facility levels.
This strategic area has a high funding surplus of nearly 20 million maloti. The funding commitments range from 4-8 million maloti. They obscure the eMTCT plan estimates, which range from 255,000 to two million maloti.
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The areas which are covered are the support of quarterly review meetings (320,000 maloti); coordination and collaboration (22 million maloti for the five year period); compiling and disseminating annual joint review report (172,405 maloti), and contribution to the supply chain management TWG (576,000 maloti).
2011 / 12 2012 / 13 2013/ 14 2014/ 15 2015 / 16 -
1,000,000
2,000,000
3,000,000
4,000,000
5,000,000
6,000,000
Amou
nt in
Mal
oti
Figure 14 Difference between cost and funding for coordination and collaboration between Government and all relevant organisations
The estimated costs for this strategic area were conservative as this was a relatively new scope of activities that the MOH Family Health Division was proposing to undertake. Fortunately, it seemed that pursuing these activities was a priority for the stakeholders involved as they have made a sizeable financial commitment to the achievement of coordinating and collaborative endeavours.
A further analysis post-implementation of the EMTCT plan may be conducted to ascertain the real cost of coordination. In order to facilitate coordination of development partners, at least six weekly meetings with development partners are recommended but the meetings had been discontinued and the MOH planning department is organizing to revive them. Stakeholders participate in the national and districts symposia to facilitate for communication at all levels.
Chapter 13: Challenges and Opportunities As much as full funding is required to implement strategic activities, it was important to establish some challenges that the organisations were facing or anticipated that would prevent them from successfully implementing the activities. In addition to challenges, there were also asked to discuss opportunities that could be exploited in order to enhance, improve and support the MOH with achieving the EMTCT plan. The key areas were human resource capacity and availability; the status of decentralization of
33
decision-making to lower levels and delays in financial disbursement and willingness of stakeholders to participate in national priorities.
Human Resources A task shifting, nurse-driven initiative within Lesotho was immediately recognized as an added advantage to the national program. For successful implementation of the plan, any amount of funding must be coupled with an adequate staff complement at implementation level. At least 35% of the respondents noted that previously, most activities had been hindered by staff turnover of all cadres of health workers and “poor attitudes” of staff at facility-level. At the time; the respondents suggested that unavailability of staff stemmed from staff attrition as qualified health workers sought higher wages across the borders. Upon further inquiry; ‘staff attitudes’ referred to an ‘overwhelmed staff’ who responded ‘sluggishly’ to any new policies, guidelines and tools that were introduced. On further examination, the key reasons for this behaviour were (i) unavailability of resources to perform the tasks at hand due to stock outs of relevant commodities; (ii) inadequate staff complement (discussed above) and (iii) inadequate capacity building of new and previously trained health workers prior to deployment. Respondents emphasized that, going forward, they planned to expand human resource capacity to improve supply chain management and better equip workers through trainings and increased mentorship programs at facility level
Supply Chain ManagementIn order to ensure the provision of drugs to adults and children, the forecasting and procurement of drugs must remain accurate and timely. This requires addressing the need for continued staff development in supply chain management. There is also a growing need to expand the capacity of the storage facilities for drugs and commodities.
Assessment of Infrastructural DevelopmentsThe recent infrastructural development conducted under MCA needs to be thoroughly assessed in order to determine suitability for implementation of EMTCT plan activities such as renovating waiting mothers’ homes and extent to which MNCH is integrated physically as well as technically for example.
Community linkagesSome valuable opportunities have arisen as a result of the recognition of peer support groups in the health system and the revitalization of VHWs. The process of establishing male and mother-in-law groups and defaulter tracking was expected to improve over the coming years.
Competing versus complementary prioritiesOne prevalent reason for non-completion and delays of activities prior to the EMTCT plan was the competing priorities at central and organizational level. Lack of coordination costs the health system through inefficiency transport unavailability, duplication of efforts, poor linkages along the continuum of care compromise the quality of service delivery. Fortunately, it is anticipated that the combined multidisciplinary trainings, supportive supervision and mentorship visits highlighted in the plan would reduce coordination costs, streamline priorities and encourage complementary rather than competitive approaches to the work.
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Respondents indicated that the health funding landscape in Lesotho, although not regularly tracked had been quite stable and this was assuring and boosted staff confidence. However, there had been unanticipated delays with disbursements as a result of the global economic crisis. As a result some activities had been absorbed by other organisations, delayed or reprogrammed. In the future, it will be important to how Lesotho may improve their ability to generate financial resources in-country to avoid such occurrences.
Financial Gap Analysis Challenges and OpportunitiesThere was a general appreciation of the EMTCT plan among respondents. There was a general consensus to program their activities to answer the objectives of the plan. They also recognized the strong political will on HIV/AIDS issues and partnerships coupled with donor commitment which were apparent in Lesotho. However, there was a lack of in-depth knowledge of all the activities within the EMTCT plan by some of the respondents which affected quality of financial data provided and may affect coordination or tracking of these activities over time. This was resolved by sending the questionnaire with a soft copy of the EMTCT plan and discussing the plan with respondents in the sensitization meetings.
Most of the activities that are carried out in the organisations are crosscutting and translate to a target population broader than just people living with HIV who are in the topic of the questionnaires (see Annex 2). Therefore, it proved difficult for respondents to categorize their activities and divide the funding accordingly. This led to an overestimation of the actual funding available in those areas. To circumvent this problem, the report presents two estimations: one includes the obvious estimations, while the other excludes them.
Chapter 14: RecommendationsIn view of the findings, some recommendations have been made in order to improve and remain abreast of the funding portfolio with respect to the EMTCT plan, and are listed below:
A resource mobilization strategy should be drafted in order to address the financial gaps identified in the gap analysis.
It is important that all relevant stakeholders remain abreast of the progress of the Strategic Plan for the Elimination of MTCT of HIV and Paediatric Care and Treatment in order to align their own goals to those planned strategies.
Since under or overspending will determine the funding allocated to organizations, it is advised that implementing departments within any organization make an effort to become knowledgeable of the financial resources at their disposal.
Each organisation must thrive to reach maximum absorption rate of the funding that it receives by carrying out all activities effectively and in a timely manner. This action will affect the allocation they receive when they request more funding as donors look at efficient absorption of funding as a determining factor in allocating funding.
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It is recommended that organisations participate in strategic planning and integrate strategic plan interventions for which they are responsible into their existing activities and budgets.
Organisations should also be proactive to apply for “bridge funding” from funding partners or explore other funding mechanisms when caught in between funding cycles so that service delivery is not delayed;
Offering staff renewable contracts or long-term contracts will serve as an incentive for staff at facility level and thereby reduce a proportion of the staff turnover. When staff are secured, programs can be implemented with fewer interruptions.
An efficient and effective supply chain management for pharmaceuticals and laboratory supplies should be maintained so that the relevant tools are available to complement the staff effort at all levels.
The gap analysis should be used as a tool to advocate for investment in human resources at district level.
To avoid further human resource challenges, trainings and refresher trainings should be adhered to as stipulated in the EMTCT plan so that the staff is well capacitated to carry out these interventions especially when the necessary financing is available.
Integration efforts among different stakeholders must be made in order to experience cost savings when delivering services. With this in mind, coordination efforts will need to be strengthened in order to experience the highest returns for collaboration.
Since there are some strategic areas (Strategic areas 1, 3 and 4) which have a higher financial burden than other areas, funding that is in excess in one strategic area should be reallocated to another in order to ensure efficient and effective expenditure of the funding allocations.
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Chapter 15: Financial Implications of Option B+The costing was carried out from the providers’ perspective (i.e. the MOH of Lesotho). A generic costing model from EGPAF-Lesotho was used. A similar model was used on another occasion to assist the MOH of Lesotho in the costing of the most recent “National Strategic Plan for Elimination of MTCT of HIV and for Paediatric HIV Care and Treatment” 2011/2012-2015/2016.” It was divided into direct drug costs and non-drug direct and indirect costs, such as laboratory, human resources, and community costs. The list of undertakings that were critical to the successful switch of moving from Option A to Option B+ were informed by the PMTCT Technical Advisory Committee, a review of the newly proposed PMTCT guidelines and further discussions with various members of the PMTCT TWG. The costing focused on near-term costs such as the incremental cost of paying for Option B+ from Option A. The scope did not include long term aggregated costs and benefits accrued under Option B+ compared to Option A. The cost implications on the strategic plan were also explored. More details on the methodology are available in The Option B+ costing report 201324.
At first glance, Option B+ seems to be the more costly option of treatment as it involves scaling up treatment to a wider population. However, the advantages cited under Option B+ could outweigh the increase in costs if, further country specific cost-benefit analyses are conducted. Initiating HIV-infected women on ART for life is an advantageous approach because:
Table 8 Advantages of Option B+Source: WHO. (2011).PMTCT Programmatic Update8
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Summary of FindingsThe annual cost of switching from Option A to Option B+ is 74,594,628 million maloti (US$8.78million using 2011 exchange rate) which implies an annual cost of US$338 per mother-baby pair.
The total cost for pharmaceuticals required in this transitory period is US$5 million. Based on this plan, the annual weighted cost of ARV therapy per HIV-infected woman is US$183. The annual cost of nevirapine per HIV-exposed infant is US$1 since the period of time which exposed infants must take nevirapine has become shorter under the new guidelines. The drug costs take into account the costs of acquiring single tablets of lamivudine (3TC) and nevirapine (NVP) in order to make use of the zidovudine (AZT) that was previously being used as a prophylaxis for HIV-infected pregnant women whose CD4 cell count was greater than 350. An additional US$237,000 was required and included in the total pharmaceutical costs. Another anomaly which had transitory cost implications was that the lactating HIV infected women who were initiated on prophylaxis during their ANC visits and returned to ANC for post-partum visits would also need to be initiated on ART for life. Coverage of this population required US$1.3 million which was included in the total pharmaceutical costs.
There are seven laboratory tests which are important for the successful implementation of Option B+, namely: HIV testing for adults and infants, creatinine tests, Hb testing, CD4 testing, liver function test, and DNA PCR. The number of laboratory tests required per person is stipulated in the new guidelines. The total laboratory costs are US$24.2 million. It was assumed that the laboratory-related additional
38
staff, maintenance of machinery, administration or transport costs would be absorbed into the existing MOH laboratory budget and would not be considered as a separate Option B+ cost. Some of these costs were also accounted for in the EMTCT plan costing.
The indirect non-drug costs are those costs that are not directly linked to care of the individual patients but essential to successful implementation of Option B+. These costs refer to the cost incurred for community sensitization, M&E, supportive supervision and training.
There were several community awareness approaches that were proposed in the strategic plan and only a few deviated from these approaches in the implementation of Option B+. The activities were mainly geared toward community preparedness and improving adherence and retention rates of HIV infected women who will be on lifelong ART. These additional methods were costed and resulted in US$460,715 for the first year of implementation. M&E costs were mainly associated with the revision of registers, summary forms, tally sheets, and SOP sand were costed at approximately US$6,000. Part of successfully implementing new guidelines comes from having effective and efficient HCWs. As a result, regional and district trainings were budgeted for as well as mentorship and supportive supervision. The overall cost for capacitating the health workers in order to confidently execute the guidelines is about US$400,000.
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Differences in Cost between Option A and Option B+The total additional cost from Option A to Option B+ is 119.7 million maloti. The differences in cost are realized from 2013 onward. The graph below shows the differences in costs for each strategic area from 2013/14 to 2015/16. Strategic area 3 rises as a result of increased expenditure on pharmaceuticals while the HSS strategic area 7 increases by a small proportion as a result of laboratory and M&E adjustments. Additional pharmaceutical costs were included for the remaining three years of the plan, while assuming the population to be constant in order to give an indication of the additional costs that will be experienced as lifelong ART is used in MNCH.
Strategic Area 1
Strategic Area 2
Strategic Area 3
Strategic Area 4
Strategic Area 5
Strategic Area 6
Strategic Area 7
Strategic Area 8
-
50,000,000
100,000,000
150,000,000
200,000,000
250,000,000
300,000,000
122,912,246 117,452,984
257,224,027
68,264,537
122,449,348
1,939,066
209,509,031
261,140,100
20,901,286 27,190,360
92,492,867
782,395
Amou
nt in
Mal
oti
Figure 15 Comparison between Option A and Option B+ costs by strategic area for Y3-Y5
2011/12 2012/13 2013/14 2014/15 2015/16 -
50,000,000
100,000,000
150,000,000
200,000,000
250,000,000
300,000,000
350,000,000
Amou
nt in
Mal
oti
Figure 16 Comparison between Option A and Option B+ costs by year
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References
1. Ministry of Health and Social Welfare. (2010). National Guidelines for the Prevention of Mother to Child Transmission of HIV. Second Edition. Ministry of Health and Social Welfare.
2. MOH,USAID, EGPAF (2010) Ground-breaking Program to Prevent Mother -to-Child Transmission of HIV.Foundation is Awarded Expanded HIV and AIDS Project to Reach New Targets by 2011. Accessed in March 2014. Press Release http://www.gov.ls/documents/press/Lesotho%20CTA%20Press%20Release.pdf
3. Ministry of Health and Social Welfare. (2011). National Strategic Plan for the Elimination of Mother to Child Transmission of HIV and Paediatric Care and Treatment: 2011/12-2015/16. Ministry of Health and Social Welfare.
4. UNAIDS. (2011). Global Plan Towards The Elimination Of New HIV Infections Among Children By 2015 And Keeping Their Mothers Alive.
5. UNAIDS. (2012). Global AIDS Response Country Progress Report Towards Zero new infections, Zero AIDS related deaths and zero discrimination January 2010-December 2011. Accessed from http://www.unaids.org/en/dataanalysis/knowyourresponse/countryprogressreports/2012countries/ce_LS_Narrative_Report%5B1%5D.pdf. Accessed on 6/6/2013.
6. UNAIDS (2013). Global Report: UNAIDS report on the Global AIDS epidemic 2013. Accessed from http://www.unaids.org/en/media/unaids/contentassets/documents/epidemiology/2013/gr2013/unaids_global_report_2013_en.pdf Accessed 6/6/2014.
7. World Health Organization. (2011).PMTCT Programmatic Update .8. World Health Organization. (2012) Programmatic Update: Use of Antiretroviral Drugs for Treating Pregnant Women and
Preventing HIV Infection in Infants. WHO. 9. The World Bank Group. (2014). GDP per capita. Accessed from http://data.worldbank.org/indicator/NY.GDP.PCAP.CD?
order=wbapi_data_value_2012+wbapi_data_value+wbapi_data_value-last&sort=desc10. Ministry of Health. (2012). Lesotho UNGASS Country Report 2010-2011 (Draft)11. Ministry of Health. (2012).Lesotho Global AIDS Response Country Progress Report: Status of the National HIV and AIDS
Response 2011. Accessed from http://www.unaids.org/en/dataanalysis/knowyourresponse/countryprogressreports/2012countries/ce_LS_Narrative_Report%5B1%5D.pdf. Accessed on 22/5/2014.
12. Millenium Challnge Corporation. General Brochure: Millenium Chalenge Acccount Program in Lesotho. Accessed from http://www.finance.gov.ls. Accessed on June 2014.
13. Ministry Of Finance And Development Planning. (2012). Annual Report For Global Fund Support In Lesotho October 2010-September 2011. Accessed from http://www.gfcu.org.ls/documents/Annual%20report%20%20for%20ALL%20Grants%202010-11finalized%20%2020-07-2012.pdf. Accessed on 7/6/2014.
14. Ministry Of Finance And Development Planning. (2013). Annual Report For Global Fund Support In Lesotho October 2011-September 2012. Accessed from http://www.gfcu.org.ls/documents/Annual%20Report%202011_2012%20%20FINAL%20FOR%20PRINTING%2019082013%20Final%20OK%20Edited%20Friday%20the%2013th%202013%20Complete.pdf. Accessed on 7/6/2014.
15. Mahy, M., Stover J., Kiragu, K., Hayashi C., Akwara, P., Luo, C., Stanecki, K., Ekpini R., Shaffer, N. (2010). What will it take to achieve virtual elimination of mother-to-child transmission of HIV? An assessment of current progress and future needs. Sex Transm Infect, 86, pp 48-55.
16. Ministry of Health and Social Welfare. (2013). National Guidelines for the Prevention of Mother to Child Transmission of HIV. Third Edition. Ministry of Health and Social Welfare
17. Sweat M, Gregorich S, Sangiwa G, Furlonge C, Balmer D, Kamenga C et al. (2000). Cost-effectiveness of voluntary HIV-1 counselling and testing in reducing sexual transmission of HIV-1 in Kenya and Tanzania. Lancet; 356(9224):113-121.
18. Farnham, P. G., Holtgrave, D. R., Sansom, S. L., Hall, H. I., (2010). Medical Costs Averted by HIV Prevention Efforts in the United States, 1991–2006. Journal of Acquired Immune Deficiency Syndromes: 54(5):565-567
19. Population Action International. (2012). The benefits of integrating HIV and family planning programs. <http://populationaction.org/wp-content/uploads/2012/07/FPHIV_Integration_FINAL.pdf> Accessed on 2/5/2013
20. Weld L.G. and.Wink .G. B (1997). Taxes: Expense or capitalize training costs? Management Accounting. Ed.Curatola A. http://faculty.lebow.drexel.edu/CuratolaA/management%20accounting%20199705.pdf
21. World Health Organization. (2008). Integrated health services – What and Why? Technical Brief No.122. World Health Organization. (2010). Monitoring the building blocks of health systems: a handbook of indicators and their
measurement strategies. Accessed from http://www.who.int/healthinfo/systems/monitoring/en/. Accessed on 6.6.201323. Action for Global Health. (2012). Action for Global Health Call for International Development Select Committee Inquiry Into
Health Systems Strengthening. Accessed from www.worldvision.org.uk/index.php/download_file/view/222/958/. Accessed on 6.6.2013
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24. Ministry of Health. (2014). The Option B+ Costing Report. Draft.25. IATT. (2013) Costing Tool: Considerations in Costing a Transition to Option B/B+.. IATT Toolkit, Expanding and Simplifying
Treatment for Pregnant Women Living With HIV: Managing the Transition to Option B/B+.Accessed from www.emtct-iatt.org26. Elizabeth Glaser Paediatric AIDS Foundation. (2011). Donor/Funding Landscape Tool. 27. Kalk, E, Slogrove A, Speert, D P, Bettinger, J A et al. (2013) HIV sero-conversion during late pregnancy – when to retest.
Southern African Journal of HIV Medicine 14 (2).28. Global Plan Towards the Elimination of New HIV Infections Among Children by 2015 and Keeping Their Mothers Alive, Joint
United Nations Programme on HIV/AIDS (UNAIDS), 201129. Malaria Consortium. 2008. GAMBIA RBM Needs Assessment. 30. Ministry of Health and Social Welfare. (2007). Prevention of Mother to Child Transmission of HIV and Paediatric HIV Care
and Treatment Scale up Plan 2007/08-2010/11. 31. Ministry of Health and Social Welfare. (2009). Lesotho Demographic and Health Survey. Ministry of Health and Social
Welfare.32. Public Eye. (2013). Article. Cut and Dry. Accessed from http://publiceye.co.ls/?p=2332 Accessed on 7/6/2014. 33. Stenberg, K, Johns. B, Scherpbier, R.W and Edejer, T.T. 2007. A financial road map to scaling up essential child health
interventions in 75 countries. Bulletin of the World Health Organization, 85.34. The Partnership for Maternal, Newborn & Child Health. 2011. Analysing Commitments to Advance the Global Strategy for
Women’s and Children’s Health. The PMNCH 2011 Report. Geneva, Switzerland: PMNCH.35. UNICEF. (2011). Children and AIDS: Fifth Stocktaking Report 2010, Summary. Accessed from:
http://www.unicef.org.uk/Documents/Publications/stocktaking10.pdf. Accessed on 6/9/2011.
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Appendix 1: QuestionnaireIntroduction
The aim of the study is to conduct a Financial Gap Analysis (FGA) between the cost of achieving the strategies that fall under the Strategic Plan for the Elimination of Paediatric HIV and Paediatric Care and Treatment: 2011/12-2015/16 in Lesotho. The Strategic Plan is a comprehensive and integrated response to the call for elimination of new HIV infections through mother to child transmission.
The cost of achieving the Strategic Plan has already been estimated. At this stage, the MOH would like to:
1. Establish the financial landscape among stakeholders with respect to achieving the Elimination Plan in Lesotho between 2012 and 2016.
2. Determine the size of the overall funding gap that may hinder achievement of the strategic plan.
You have been identified as a key stakeholder to participate in this FGA. We are convinced that the information you will share is key in the detection of the overall funding gap. The information you provide will be used solely for the purposes of conducting the FGA.
May all persons within your organization who participate in responding to the questionnaire list their details below:
First name and surname Position of respondent
Mobile Number Email Address
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1. Establish what role the organization plays in the financing of MOH activities
1. Put X next to relevant description.Multilateral funder Bilateral funder Implementing partnerInternational NGO Local NGO Government Private sectorUS based Canadian based *Europe based (specify)
*If European-based organization, please be more specific regarding the origin of the funding i.e. EU, Irish Embassy, DFID etc.
2. Establish awareness and the priority areas of the organization toward the National Strategic Plan for the Elimination of Paediatric HIV and paediatric Care and Treatment
2.1 Tick in the box if you have read the Strategic Plan for the Elimination of Mother to Child Transmission of HIV and Paediatric Care and Treatment
2.2 Provide a description of the activities you carry out in relation to the Strategic Plan (Example is shown in the grey table below)Column 2.2.A & Column 2.2.B: Highlight the activities in which your organization is involvedColumn 2.2.C: Detail the approach you use to carry out this activity. In your description of the activity, detail the core activities that you carry out to fulfil the obligations i.e. the number and cadre of staff predominantly carrying out this activity, the size of the targeted population for the particular intervention in terms of number, districts, health facilities (public/private/CHAL).Column 2.2.D: Indicate when the activity is planned forColumn 2.2 E. Indicate when the activity will endColumn 2.2.F. Indicate any irregularities that may accelerate/ impede the implementation of the activity under the relevant columnIf the space is insufficient, please type on a separate WORD document.
2.2.A Strategic Area
2.2.B Broad Strategy
2.2.C Description of activity
2.2.D Start-date
2.2.E End date
2.2.F Comments
Accelerators ImpedimentsPrevention HIV infections in
women, men of reproductive health
Human resources- 5 counsellors who provide PITC
12 June 2011 11 June 2012
Although the counsellors’ contracts end in June 2012, we expect to renew their contracts for two more years
Unintended pregnancies (HIV infected women)
3 senior advisors to conduct 5 on-site trainings on family planning services for HIV infected women for 50
12 May 2012 16 December 2012
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health workers from Leribe at Motebang Hospital (Public) and Tsepong Hospital (Private) in Maseru
2.2.A Strategic Area
2.2.B Broad Strategy 2.2.C Description of activity
2.2.DStart-date
2.2.EEnd-date
2.2.F Comments
Accelerators Impediments
Prevention Primary prevention of HIV infection in women and men of reproductive agePrevention of unintended pregnancies in HIV infected womenPrevention of Mother to Child Transmission of HIV (PMTCT)
Care and treatment
Adult treatment, care and support
Paediatric HIV treatment, care and support
Integration of HIV and MNCH
HIV, MNCH and other related services
Health Systems Strengthening
Service Delivery
Health workforceInformationMedical products, vaccines & technologiesFinancingLeadership and governance
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Coordination and collaboration between government and all relevant stakeholders
2.3 May you provide any documentation that supports the details of your commitments? (I.e. strategic work-plan, implementation plan etc.)
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3. Establish and understand the financial nature of the stakeholders’ commitment to Elimination of Paediatric HIV, paediatric care and treatment
3.1 Provide information on the amount of funding available for each strategic areaColumn 3.1.A & Column 3.1.B Highlight the activities in which your organization is involvedColumn 3.1.C Align the amount of funding you receive per each activity you have described above to the relevant year. If the funding covers more than one year, include it in all the appropriate boxes. However if the funding continues beyond the final stipulated year i.e. 2015/16, indicate in parenthesis how long the funding is for (e.g. 1,000,000USD(2017/18)Column 3D, indicate the source of the funding you have mentioned in Column 3C.
3.1.A. Strategic Area
3.1.B. Broad Strategy
3.1.C. Size of Funding 3.1.D. Source of funding2011/12 2012/13 2013/14 2014/15 2015/16
Prevention Primary prevention of HIV infection in women and men of reproductive agePrevention of unintended pregnancies in HIV infected womenPrevention of Mother to Child Transmission of HIV (PMTCT)
Care and treatment Adult treatment, care and supportPaediatric HIV treatment, care and support
Integration HIV, MNCH and other related services
Health Systems Strengthening
Service deliveryHealth workforceInformationMedical products, vaccines & technologiesFinancing
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Leadership and governance:
Coordination and collaboration between government and all relevant stakeholders
3.2 May you provide any documents that support the details of your financial commitments? (annual report, FY report, expenditure report)
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4. Establish any inconsistencies regarding expected financing
4.1 How much additional funding are you expecting to receive/apply for from 2012-2016 with respect to the above activities?
4.2 Detail any delays/anomalies that have occurred/may occur with respect to receiving/dispatching funding?
4.3 What are the plans to resolve these issues?
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Appendix 2: List of Key InformantsOrganization Name Position
1. UNFPA Dr Thabelo Ramapatleng UNFPA Consultant
2. UNICEF
Dr Magan Country RepresentativeM’e Blandinah Motaung Health Officer (PMTCT)
Nasseem Awl UNICEF Specialist, Adolescent Development & HIV Prevention
3. WHO Professor Jacob Mufunda Country RepresentativeMe Mantsana Tsoloane-Bophelo FHP Officer
4. WFP Rui Possolo Head of Programme and LogisticsKekeletso Mabeleng Senior Programme Assistant
5. Baylor Dr Lineo Thahane Associate Clinical Director6. CHAI Heather Awsumb Acting Country Director
7. EGPAFDr Leopold Buhendwa Country DirectorManthethe Monethi Associate Director of OperationsAllan Ahimbisibwe Technical Advisor
8. PSI
Dennis Walto Country RepresentativeBrian Pedersen Technical Services AdvisorPalesa Malebo Deputy Country Rep, Corporate ServicesMankhala Lerotholi Deputy Country Rep, programs
9. PIH Dr H Satti Country DirectorThaothe Bosiu Finance Manager
10. MOH Dept. of Disease Control Ntate John Nkoanyana Director of Disease Control11. MOH Finance Mr Sekoli Director of Finance
12. MOH Health Planning Me Majoele Makhakhe Director of Health Planning and StatisticsNtoetse Mofoka SEP
13. MOH Human Resources Me Gladys Moeketsi Director of Human Resources
14. m2m‘M’e Patose, Country ManagerSean Brown Program Support ManagerMasebo Koto M&E coordinator
15. ICAPMe Blanche Pitt Country DirectorDr Koen Frederix Clinical Team LeaderSebueng Manki Finance and Administration Director
16. LENASO
‘M’e Mamello Makoae Country DirectorMalefane Wall Data ClerkTseliso Ncheke District Community CoordinatorMakhamise Letsoara Field Operations OfficerMamokupo Tsepane Finance Manager
17. MSF Denis Penoy Field CoordinatorMarleen Dermaut SRH officer
18. MSH Me Hoohlokhotle Country Project Director19. LPPA Me Mphana Program Director20. Riders for Health Mahali Hlasa, Country Director
21. MOH Family Health Division Florence M Mohai Acting Head of Family Health DivisionMatsepeli Nchephe, PMTCT Programme Manager
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