1 Resources for HIV/AIDS prevention and care Marjorie Opuni, Stefano Bertozzi a , José-Antonio Izazola b , Juan-Pablo Gutierrez, William McGreevey c From the Division of Health Economics and Policy, National Institute of Public Health, Cuernavaca, Mexico; a the Division of Health Economics and Policy, National Institute of Public Health, Cuernavaca, Mexico and the University of California, San Francisco, Institute for Global Health, San Francisco, USA; b the Regional AIDS Initiative for Latin America and the Caribbean (SIDALAC), Mexico, DF, Mexico; and c the Futures Group International, Washington, DC, USA. Correspondence should be addressed to: Marjorie Opuni, Division of Health Economics and Policy, National Institute of Public Health, Av. Universidad 655, 62508 Cuernavaca, Mexico. E-mail: [email protected]Running head: Resources for HIV/AIDS
To plan and implement effective responses to the epidemic, policymakers require data on
resources for HIV/AIDS prevention and care. Without a complete picture of both public
and private spending on the epidemic, governments are unable to track and assess the
impact of their response to HIV/AIDS. Without some estimate of the scope of potential
resource needs to address the epidemic adequately, they are unable to plan strategically
for the future. However, only limited HIV/AIDS financing data are available for low-
and middle-income countries, with most advances in data compilation limited to data for
Latin America countries. Current data collection efforts with all of their limitations show
that with approximately US$ 600 million in official development assistance to HIV/AIDS
for 2000, the flow of HIV/AIDS funding from high-income countries to developing
countries has increased substantially. They also show that an average of US$ 1000 per
person living with HIV/AIDS was spent in Latin American countries in 2000. This is
significantly more than estimates for sub-Saharan Africa approximated around US$ 25
and substantially less than estimates for the United States approximated over US$ 30,000.
Moreover, the level of current expenditures in Latin America compared with estimated
resource needs for the future highlight significant inefficiencies especially in commodity
procurement in the region.
Key wordsHIV, AIDS, financing, economics
3
Introduction
In the last two years political commitment to respond to the HIV/AIDS pandemic has
increased substantially. The UN General Assembly Special Session on AIDS in 2001
and the recent creation of the Global Fund to Fight AIDS, Tuberculosis and Malaria are
two indicators of this commitment at the global level. At the regional level, HIV/AIDS
has been an issue on the agenda of the Inter-American Development Bank, the Asian
Development Bank, the Organization of African Unity and the African Development
Forum, to name but a few institutions. And at the national level, low- and middle-income
countries, home to over 95 percent of people living with HIV/AIDS, have made
important progress in HIV/AIDS planning and program development [1, 2].
In this policy environment, the importance of information on resources for HIV/AIDS
prevention and care has increased. More and more, policy makers are looking for data on
the level and flow of current allocations to HIV/AIDS. They want to know where money
for HIV/AIDS prevention and care is coming from, the services and commodities that are
purchased with these funds and the population coverage of implemented interventions.
At the same time, in order to identify gaps between what is and what should be and plan
strategically, they are seeking information on the scale of resources required to prevent
the further spread of HIV and to provide adequate care for those people living with
HIV/AIDS.
4
Because the pandemic is so concentrated in low- and middle-income countries,
estimating HIV/AIDS resource allocations and requirements in these countries is key to
responding effectively to HIV/AIDS worldwide. It is also in these countries that this task
is most complicated. To monitor resource flows, program data, ideally produced by
national health information systems, are required. In many of these countries, however,
such systems are weak or nonfunctioning. Similarly, to derive estimates on resource
needs, one requires a range of demographic, economic, and health data that are scarce or
nonexistent in many developing countries.
Notwithstanding these obstacles, significant progress was made during the last year in
both monitoring the level and flow of current allocations to HIV/AIDS and estimating
HIV/AIDS resource requirements in developing countries. This article reviews the latest
data and examines their policy implications. It identifies the gaps and limitations of
current research. And it discusses future directions to strengthen the quality of data on
resources for HIV/AIDS prevention and care.
Resources allocated to HIV/AIDS
Few countries, whether low-, middle- or high-income, regularly monitor resource flows
to the HIV prevention activities conducted by government and non-governmental
institutions within their territory. And to date, no country has developed a system that
regularly tracks expenditures on HIV/AIDS care.
5
The most well established data collection activities documenting resource allocations to
HIV/AIDS in developing countries are international initiatives. Each year, donors report
their official development assistance (ODA) to HIV/AIDS and other sexually transmitted
diseases (STI) to the OECD Development Assistance Committee [3]. Similarly, donors
respond to the annual surveys of the Netherlands Interdisciplinary Demographic Institute
(NIDI), UNFPA, and UNAIDS, on their HIV/AIDS/STI expenditures while developing
countries respond to similar surveys every other year. But the most detailed information
on resource allocations to HIV/AIDS in developing countries comes from in-depth
country studies conducted on an ad hoc basis. Most recently, the Regional AIDS
Initiative for Latin America and the Caribbean (SIDALAC) and the Partnerships for
Health Reform (PHR) have investigated HIV/AIDS financing in several countries using
the National Health Accounts framework [4]. This section discusses the latest data from
these sources.
Table 1 presents the 2000 HIV/AIDS/STI ODA data reported to NIDI and the OECD
DAC. A total of US$ 396 million were reported to NIDI while a total of US$ 521 million
were reported to the OECD DAC. In part this discrepancy exists because some
differences in the donors reporting to the two institutions in a given year. In addition,
however, there are important variations across countries between data reported to both
institutions. Since both institutions collect project-by-project expenditure data on
HIV/AIDS/STI activities, these discrepancies illustrate the difficulties encountered in
reporting even by institutions with relatively well-developed financial monitoring
systems.
6
Despite their limitations, the figures do provide some important insight. Taking what
appear to be the most complete country reports, total HIV/AIDS/STI ODA for 2000, can
be assumed to total almost US$ 600 million. Almost all (99.6 percent) of total ODA
disbursed by DAC member countries in 2000 came from these 21 countries and all
available data suggest that they also provide most of the official development assistance
disbursed for HIV/AIDS/STI activities in 2000. Figure 1 illustrates that similar imputing
with NIDI and OECD DAC data from 1998 and 1999 shows a significant increase in
HIV/AIDS/STI ODA provided by these donors over the last three years …
What is revealed by these data and past surveys on HIV/AIDS/STI ODA [5-7] is that
surveys provide reasonable information on these expenditures, albeit varying in
comprehensiveness and accuracy. Past global surveys have also illustrated that
questionnaires can provide relatively good data on HIV/AIDS resource allocations that
flow into developing countries from the UN system and non-governmental institutions in
high-income nations. Although as there are more multisectoral projects implemented to
address HIV/AIDS in tandem with a wider set of sectoral issues, funds supporting
activities relevant to HIV/AIDS are becoming more difficult to track even among these
international institutions.
In terms of data on domestic resource allocations to HIV/AIDS within developing
countries, however, questionnaires usually sent to national HIV/AIDS coordinating
institutions are much less efficient tools. In part, this is because regularly updated
7
information systems do not exist and it is difficult for coordinating institutions to gather
expenditure data from the many organizations implementing HIV/AIDS interventions in
a country. In addition, for large portions of HIV/AIDS expenditure, data must be
estimated with special studies. To estimate domestic expenditure on HIV/AIDS care, for
example, studies costing selected services must be undertaken. Likewise, to capture how
much individuals themselves spend on HIV/AIDS services (out-of-pocket spending),
which in many countries constitutes the majority share of overall AIDS spending,
requires household or clinic-based studies of people living with HIV/AIDS.
It is these information gaps that in-depth country studies using the National Health
Accounts (NHA) framework aim to fill. These studies attempt to account for all
expenditures by looking not only at public sector financing, but also at spending within
the private sector, including spending by individuals. They collect the data that are
available and conduct special studies such as household surveys, as necessary.
Most of the studies on HIV/AIDS resource allocations using the NHA framework have
been carried out in Latin American and the Caribbean [8]. Referred to as National
HIV/AIDS Accounts, they were first carried out in Brazil, Guatemala, Mexico and
Uruguay in 1997/1998 [9-12] with substantial scaling up of efforts occurring in the last
year with SIDALAC completing studies in 12 countries (Argentina, Bolivia, Brazil,
Chile, El Salvador, Guatemala, Mexico, Nicaragua, Panama, Paraguay, Peru, and
Uruguay) and three additional countries underway (Costa Rica, Dominican Republic and
Honduras).
8
Total HIV/AIDS spending in the 12 countries in Latin America studied (representing 75
percent of the population of the region) [13] in 2000 was estimated at US $1.04 billion.
This represents an average of US$ 2.70 per capita for the 12 countries with individual
country per capita expenditure ranging from US$ 0.30 and US$ 0.60 in Bolivia and El
Salvador to US$5.60 and US$ 4.90 in Uruguay and Argentina (Table 2). In terms of
average expenditure per person living with HIV/AIDS (PLWHA) in the 12 countries, this
translates into a little over US$ 1,000, with over US$ 3,000 spent per PLWHA in
Uruguay and only US$ 175 per PLWHA spent in Guatemala.
Overall, the majority of HIV/AIDS resources in the 12 countries was spent on care with
US$ 753 million (73 percent) while US$ 283 million (27 percent) were spent on
prevention. This trend was true across countries with the exception of Bolivia and
Nicaragua where only 34 percent and 36 percent of HIV/AIDS resources were spent on
care (Table 3). Almost 72 percent of the resources spent on HIV/AIDS care in the 12
countries were spent on drugs with the vast majority – almost 90 percent of drug
expenditure – spent on antiretroviral drugs (ARVs). Of course social pressure for access
to ARVs in the region is high and three of the 12 countries - Argentina, Brazil and
Uruguay provide universal access to these drugs. However, this estimate does appear to
be extremely high and may represent a bias since drug expenditure is often easier to
monitor than other components.
9
With 60 percent of prevention expenditure on condoms and 14 percent on mass media
campaigns, most of the prevention expenditure in the 12 countries was spent on
interventions targeting the general population. This is notable in countries where HIV
prevalence is concentrated among specific population groups [1]. In Mexico, Nicaragua
and most of the Andean region, sex between men is the most prominent route of HIV
transmission. Similarly, in Argentina, Chile, and Uruguay injecting drug use is the main
route of transmission. Given the epidemiology of the epidemic in the region, one would
expect, therefore, that significant proportions of HIV prevention expenditures would be
allocated to interventions targeting these population groups key to the expansion of the
epidemic. However, only limited funds in the region (7 percent of prevention
expenditure) were allocated to such interventions.
The major sources of HIV/AIDS funds also varied across countries. In Argentina, Brazil,
Chile, El Salvador, Guatemala, Mexico and Panama, the public sector and primarily the
health sector was the primary source of resources allocated to HIV/AIDS. In Paraguay,
Peru, and Uruguay private funds including enterprise, non-governmental organizations
and households were the primary sources of resources allocated to HIV/AIDS while
international resources were the primary source of HIV/AIDS in Bolivia and Nicaragua.
Even though studies using the National Health Accounts framework provide the most
detailed estimates on resource flows in countries, they remain estimates that vary in
completeness and accuracy. And it is likely that these estimates also under represent the
full scale of HIV/AIDS expenditures in countries. Though the studies attempt to account
10
for all expenditures, the quality of the estimates depends on the availability and quality of
financial and accounting data within relevant government and non-governmental
institutions and the capacity of personnel within these organizations to formulate
estimates where data are not available. It is likely, that as mentioned above, certain
portions of expenditure including spending on information, education and communication
interventions are underestimated because they are more difficult to track than expenditure
on commodities such as drugs and condoms. It is also likely that expenditure by non-
governmental organizations, especially those that are community based is underreported
since donated goods and services may not always be captured accurately. Likewise, it is
probable that in decentralized governments, with weak financial tracking at lower
administrative levels, funds are missed or alternatively, double counting occurs with
funds reported at higher administrative levels.
In order to estimate the expenditure on HIV/AIDS prevention and care for all countries in
Latin America and the Caribbean, a regression was run to extrapolate the estimates for
these 12 countries to the region. The result is an estimate of US$1.4 billion for all
countries in Latin America and the Caribbean.
The only country outside of Latin America and the Caribbean where the National Health
Accounts framework has also been used to estimate expenditures on HIV/AIDS is
Rwanda. A study conducted for 1998 concluded that a total of US$ 10 million or
US$ 1.27 per capita were spent on HIV/AIDS during that year [14]. This represents a
11
total of US$ 25 per person living with HIV/AIDS compared to the average of US$ 1,000
per PLWHA in the 12 countries in Latin America discussed above.
While spending in Latin America is large compared to spending in Rwanda – and
presumably other countries in sub-Saharan Africa – even this expenditure is very small
compared to expenditure by high-income countries such as the United States. The United
States Federal Government spent US$ 10,800 million on HIV/AIDS in the year 2000
[15]. If this amount is raised by the same proportion as that which prevails between
public and total spending on health in the United States, then total HIV/AIDS spending
can be estimated just below US$ 25 billion in 2000 [16, 17]. This amount translates into
nearly US$ 90.00 per capita or just over US$ 30,000 per PLWHA. A check on the
credibility of this seemingly high level of spending is provided by an analysis of spending
on Medicaid-covered AIDS patients that projected that expenditure would average almost
US$36,000 per patient [18].
Resource needs for HIV/AIDS
Similar progress was made in the area of estimating resource needs for HIV/AIDS over
the last year. Two major studies of resource requirements estimates were published. The
first, undertaken for the Commission on Macroeconomics and Health (CMH), estimated
resources needed to scale up a package of core interventions to address HIV/AIDS and
other priority illnesses in 83 low- and middle-income countries (including all of sub-
Saharan Africa) by 2007 and 2015 [19, 20]. The second, carried out in preparation for
12
the UN General Assembly Special Session (UNGASS), estimated the cost of HIV/AIDS
prevention and care needs in 135 low- and middle- income countries in 2005 [21].
These two studies built on prior work on estimating resource needs for HIV/AIDS and
used similar methodologies [22, 23]. The methodologies used have been detailed
elsewhere [19-21]. In summary, both studies included a selection of interventions that
were costed based on published and unpublished project assessments (Table 4).
Estimates were then made intervention-by-intervention and country-by-country using
demographic, economic and epidemiological data to adjust the estimates to different
country contexts. The main difference in methodology between the two studies was the
inclusion in the CMH study of the costs for infrastructure strengthening necessary for
scaling up. In addition there were differences in assumptions, with the most important
being differences in target population coverage rates for the different interventions.
The UNGASS study called for the spending of US$ 9.2 billion on HIV/AIDS prevention
and care in low- and middle-income countries by the year 2005. The CMH study
concluded that depending on coverage assumptions and price estimates, between
US$ 13.6 billion and US$ 15.4 billion should be spent on HIV/AIDS prevention and care
(including necessary infrastructure strengthening) in selected low-and middle income
countries by the year 2007 in addition to what is already being spent and this should
increase to between US$ 20.6 billion and US$ 24.9 billion by 2015.
13
The ranges of the results within and across studies underline the fact that these are
estimates with limitations. They underscore the data gap in low- and middle-income
countries and the many assumptions required while building each model to derive
parameter estimates for which no data exist. As discussed further below, they should
therefore be interpreted with caution and be seen as works in process that can be refined
as new information becomes available on cost data, current intervention coverage
estimates and country capacity to expand services.
Nonetheless, sensitivity analysis conducted on UNGASS estimates confirm that study
results provide a consistent estimate of the scale of resources needed. A probabilistic
analysis conducted changing assumptions on intervention coverage, costs and country
capacity to expand services showed that results are most likely to fall within the same
order of magnitude as model estimates.
So, in short, UNGASS and CMH estimates provide policy makers with consistent
information on the scale of the resources needed. But it would be inappropriate to use
them to guide resource allocations at the global or national level. Though these two
studies did differentiate across regions and countries whenever possible, data limitations
did not allow them to pay significant attention to individual country or even regional
characteristics and the way in which those may affect overall costs.
In order to improve the estimates so as to have them serve as tools for global and country
strategic planning, both study teams recognized that additional country-level work would
14
be necessary. And this process has begun with individual country validations of the
UNGASS estimates for the Latin America and Caribbean region. The ten countries to
participate in a first phase of this effort were Brazil, Chile, Dominican Republic,
Ecuador, El Salvador, Guatemala, Honduras, Jamaica, Mexico, and Trinidad and Tobago
[24].
These countries increased the estimated resource requirement for HIV prevention by 15
percent and the estimated care requirements by 27 percent. The main differences in
prevention estimates are accounted for by an increase in estimated resource needs for the
social marketing of condoms and prevention of mother-to-child transmission. The main
differences in care estimates were due to important differences in the expected costs for
HAART. Total expected resource needs for HAART increased by 45 percent compared
to UNGASS estimates.
In order to estimate the HIV/AIDS prevention and care needs for all countries in Latin
America and the Caribbean, estimates for these 10 countries regressions were run to these
figures to the region. The revised UNGASS model called for US$ 1.1 billion with
US$ 550 million for prevention and US$ 550 million for care and support1. Country
revisions increased this by US$ 160 million to almost US$ 1.3 billion with US$ 480
million for prevention and US$ 780 million for care and support.
1 Global prevention numbers were refined following the Science publication of the model estimateslowering estimate for Latin America and the Caribbean from US$ 590 million.
15
Since the discrepancy between the UNGASS estimates and those of the ten specialists is
reasonably small, these preliminary estimates provide further support for the consistency
of the results.
Discussion
To plan and implement effective responses to the epidemic, policymakers require data on
resources for HIV/AIDS prevention and care. Without a complete picture of both public
and private spending on the epidemic, governments are unable to track and assess the
impact of their response to HIV/AIDS. Without some estimate of the scope of potential
resource needs to address the epidemic adequately, they are unable to plan strategically
for the future. Yet, most policymakers in low- and middle-income countries – those
countries that need this information most urgently – do not have these data for their
countries.
Limited data are available on the annual official development assistance allocations to
HIV/AIDS by high-income countries. But other than that, with one exception, it is only
in Latin American that significant progress has been made in estimating the flow of
resources to HIV/AIDS in the past year. Likewise, though several global models have
been developed to estimate resource needs to address the epidemic it is only in Latin
America and the Caribbean that countries have checked and refined country-specific
estimates of resource needs.
16
Comparing the results of the UNGASS resource needs model for Latin America and the
Caribbean (almost US$ 1.3 billion for 2005) to those of the National HIV/AIDS
Accounts studies expanded to the region (US$ 1.4 billion for 2000) both underscores the
imprecision of current data estimating efforts and at the same time illustrates some of the
important policy implications that are raised by this type of data.
The higher estimates of current expenditure are due in part because the two estimates do
not attempt to measure the allocations and the needs of identical packages of
interventions. As importantly, this discrepancy could be caused by one or more of the
assumptions on costing data, estimates of current intervention coverage, and country
capacity to expand services continue to be inadequate and underestimate needs – when
extrapolated to the whole region. However, for the most part, the difference lies in the
global estimates of resource needs assuming country efficiency in procuring commodities
such as ARVs, condoms, and HIV test kits and technical or management efficiency in the
implementation of HIV interventions. The fact that estimates of current expenditure are
higher than those for future resource needs in part reflects many countries in the region
continuing to pay high prices for condoms and ARVs, for example.
Necessary next steps include the institutionalization of National HIV/AIDS Account
studies or similar studies in Latin America and the Caribbean and other regions. Any
future steps undertaken in this are must be linked to the future of the National Health
Accounts promoted by WHO and the OECD. But SIDALAC has demonstrated that the
process is feasible. Conducting National AIDS Accounts in LAC has cost between US$
17
25,000 and US$ 55,000 per year per country depending on country size and existing
capacity demonstrating that limits in financial resources need not be a barrier to the
execution of a fairly complete system of resource flows.
At the same time, country level resource needs estimates should be compiled for low- and
middle-income countries in other sub-Saharan Africa, Asia and Eastern Europe.
Finally, one important component regarding HIV/AIDS prevention and care resources in
developing countries is still missing. Ideally, country resource needs estimates should go
a step further approximating not only resource needs but also the benefits provided by the
resources spent. Focusing on the benefits provided with invested resources would
provide data critical to policy makers deciding on the distribution of resources within and
across countries and sectors.
18
Acknowledgements
The authors acknowledge the contributions of the SIDALAC country consultants from
Argentina, Bolivia, Brazil, Chile, El Salvador, Guatemala, Mexico, Nicaragua, Panama,
Paraguay, Peru, and Uruguay who collected the data on the National HIV/AIDS
Accounts. They thank Nicolas Noriega of SIDALAC for his assistance with the
compilation of the National HIV/AIDS Accounts data. And they are grateful to Eric Lief
and Lisa Regis of UNAIDS for providing access to and compiling the
UNAIDS/UNFPA/NIDI official development assistance data.
19
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