1. Domestic Financing for Health in Africa: The Road of Sustainability and
Ownership
Prof Alan Whiteside
The Global Fund Satellite Meeting
Cape Town
7 December 2013

2. Outline
1. Where we are: AIDS, TB and Malaria in epidemiological terms:
• Global burden of disease
• A Southern African example
• AIDS and malaria a major issue
2. What we need for 2014 – 2016
3. Two tipping points
• The economic transition theory
• The epidemiological and advocacy transition theory
• Real data
4. This meeting

3. Years of life lost (women) by cause: Global, 2010
0-1
1-4 5-14 15-24
25-49
Age
50 – 80 +
Source: 2010 Global Burden of
Diseases Study
http://www.healthmetricsandevaluation.
org/

4. Years of life lost (women): Western Europe 2010
Maternal
Neonatal
HIV & TB
0-1
1-4 5-14 15-24
25-49
50 – 80 +
Source: 2010 Global Burden of Diseases Study
http://www.healthmetricsandevaluation.org/

5. Years of life lost (women): Western Africa, 2010
Maternal
Neonatal
HIV & TB
0-1
1-4 5-14 15-24
25-49
50 – 80 +
Source: 2010 Global Burden of Diseases Study
http://www.healthmetricsandevaluation.org/

6. Years of life lost (women): Central Africa, 2010
Maternal
Neonatal
HIV & TB
0-1
1-4 5-14 15-24
25-49
50 – 80 +
Source: 2010 Global Burden of Diseases Study
http://www.healthmetricsandevaluation.org/

7. Years of life lost (women): Eastern Africa, 2010
Maternal
Neonatal
HIV & TB
0-1
1-4 5-14 15-24
25-49
Age
50 – 80 +
Source: 2010 Global Burden of Diseases Study
http://www.healthmetricsandevaluation.org/

8. Years of life lost (women): Southern Africa, 2010
Maternal
Neonatal
HIV & TB
0-1
1-4 5-14 15-24
25-49
Age
50 – 80 +
Source: 2010 Global Burden of Diseases Study
http://www.healthmetricsandevaluation.org/

9. Ante-natal prevalence South Africa
1990-2011

10. HIV Prevalence Among Pregnant
Women: Botswana
40%
37.4%
33.4%
35%
32.4%
33.7%
2005
2006
2007
31.8%
30.4%
2009
2011
30%
25%
20%
15%
10%
5%
0%
2003

12. What is needed for ATM 2014- 2016
• Estimated funding required $87 billion
• Available estimated funding $76 billion or 87%
– Domestic $23 billion certain
– Global Fund $12 billion: pledging 2- 4th December
– Domestic $14 billion potential
– International $10 billion very likely $24 billion
hoped for
• Mind the gap: $13 to $39 billion

13. International Funding Uncertain

14. Global Priorities Changing: Post 2015 MDG
High Level Panel Report

15. How to sustain an HIV/AIDS Response?
1. Increase donor support: getting more from
existing donors or involving new donors
2. Increase government support
3. Decrease the cost of the current response by
improving efficiencies in existing programs
But prevent new infections!

16. Criteria for Investment in Health and ATM
• Level of national income, GDP or GNI. An approximation of
resources available within a country
• Degree to which the Government is able to raise revenue through
taxes, levies, domestic borrowing, or other means.
•
Proportion of Government budget devoted to debt
• Pre-existing pattern of disbursement to different sectors. For health
if historical allocations have been low, infrastructure may be poor
reducing the short-run capacity to absorb rapid increases and convert to
service delivery.

17. Plan for Analysing “Fiscal Space”
• Macroeconomic analysis
– Evaluating potential resource needs and resource
availability, identifying future resource gaps and
potential ways of eliminating such financial gaps.
• Microeconomic analysis
– Assessing potential opportunities to make the 3
largest interventions efficient:
• ART
• PMTCT
• OVC

18. Understanding Curves: New Infections and
Deaths
Deaths of HIV Positive People
Number of people
New Infections
Time

19. Treatment Requirements
Treatment needed
Number of people
People Requiring
Treatment
Time

20. Economic Transition
Deaths of HIV Positive People
Economic Transition
Credit Mead Over
Number of people
New Infections
Time

21. Data from South Africa
7000000
HIV
infections
6000000
5000000
4000000
AIDS cases
3000000
2000000
AIDS deaths
1000000
0
1985
1990
1995
2000
2005
2010
2015
2020
2025

22. Data from South Africa
700000
600000
No Economic Transition
on the horizon
500000
New infections
(Incidence)
400000
300000
200000
AIDS deaths
100000
0
1985
1990
1995
2000
2005
2010
2015
2020
2025

23. Epidemiologic Transition
New Infections
Treatment
Deaths of HIV Posive People
New people needing treatment
Number of people
An Advocacy and
Epidemiological Transition
Time

24. Epidemiologic Transition
Deaths of HIV Posive People
New people needing treatment
Number of people
New Infections
Treatment
Time

25. Table 1: Domestic Investment 2011: % of
total government expenditure
Rwanda
Togo
Botswana
Malawi
Zambia
Nigeria
Kenya
Tanzania
23.7%
15.4%
8.7%
18.5%
16.0%
7.5%
5.9%
11.1%
Source: UNAIDS, Oxford Policy Management and Authors own
calculations

26. Summary of three diseases
Source
US $ billions
75% of an alcohol levy
3.9
Contributions from high-revenue enterprises
2.4
Airline levy by all African countries
1.7
2% of public sector budgets earmarked for AIDS 2.4
Mobile phone levy
2.0
1% income tax levy earmarked for AIDS
3.1

27. Recommendations 1
•
Need for better data. We are not clear on who is spending what. This is true of
both domestic and international funding. Data needs to be improved and accessible.
•
Political leadership is critical, and we need to develop advocacy messages to
ensure that health continues to be a priority.
•
Revisit the economic arguments for health, including the macro-economic ones.
•
Address rigid budgeting practices making it hard to reallocate revenues toward
health.
•
Empowered Health officials to talk to finance and finance to understand health
•
Address the perception that “donors will take care of the AIDS program”.

28. Recommendations 2
•
Recognized and improved the role of civil society .
•
The core question: it is possible to define the “right” mix of domestic and
international investment in any country. Initial thoughts this will vary country by country.
•
We should establish on a country by country basis an acceptable “benchmark” for
countries to invest from their own resources.
•
The Global Fund should work with other key donors as a „thought leader‟. In
particular it should look to providing data and information.
• This is a complex political question not just an economic one

29. Conclusions
1. Treatment is crucial




Medical
Moral
Ethical
Economic
2. Prevention is essential

We have to turn off the tap

30. This meeting is about
how do we find
innovative ways of
mobilising more
resources?

31. Thank You