Increasing Domestic Investment in AIDS, Tuberculosis and Malaria: Global Fund Resource Mobilization in Implementing Countries
Among other things, we will discuss:
-New Global Fund policies that promote implementing country investments
-Financing leveraged to date and expectations for additional increases
-On-the-ground examples of domestic resource mobilization
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4. Welcome & Introductions
Deb Derrick
President
Friends of the Global Fight
Johannes Hunger
Head of Strategic Information
The Global Fund
George Korah
Senior Specialist in Health Financing
The Global Fund
5. Background
• Current landscape:
• Increased funding requirements to sustain/scale-up
programs
• Plateauing donor resources globally
• Global Fund’s new funding model prioritizes leveraging
domestic resources for AIDS, TB & malaria
Increased domestic resource mobilization is key to transition from
emergency response to sustainable health programs.
6. 6
Opportunity: Resources for HIV in LICs & MICs
The UN General Assembly 2011 Political Declaration on HIV and AIDS set
a target of USD 22bn–24bn by 2015
Source: UNAIDS estimates
Resources available for HIV in low- and middle-income countries, 2002–2012 and
2015 target [USD bn]
7. Scale Up of Domestic Resources Needed to
Sustain Programs
0
20
40
60
80
100
120
140
160
180
2011 2012 2013 2014 2015 2016 2017
USDMillions
Vietnam: Available Funding
and Gap for HIV/AIDS (2011-17)
Global Fund Other Donors Government Gap
0
10
20
30
40
50
60
2012 2013 2014 2015 2016 2017
USDMillions
Bangladesh: Available Funding
and Gap for HIV/AIDS (2012-17)
Global Fund Other Donors Government Gap
8. Counterpart Financing
• All Global Fund supported programs must meet a minimum threshold
of domestic public investment known as counterpart financing.
• Low Income 5%
• Lower-Lower Middle Income 20%
• Upper-Lower Middle Income 40%
• Upper Middle Income 60%
• “Willingness-to-pay” incentive added in 2014
• 15% of Global Fund allocation contingent on additional government
investments:
• Beyond current level of government spending and not less than already planned
spending
• Over minimum threshold requirements
• Targeted to priority areas of national strategic plans
9. Country Engagement Process
Portfolio Review Update and Clarification from Country Stakeholders
Existing commitments are sufficient and reasonable
to meet WTP requirements based on country context
Assessment of Government Commitments
Commitments are not sufficient to meet
WTP requirements or not known
Country
Dialogue
Engagement to
formalize commitments
Engagement to increase and
formalize commitments
CCM Submission of Commitments
Secretariat Review
Grant Making and Agreement
Grant Implementation
Communication to Country on Allocation and Requirements
10. Counterpart Financing:
Role of Country Team & Country Dialogue
• Country team:
• Clarifies counterpart financing issues identified by portfolio analysis
• Engages with country stakeholders on additional governmental
investments & actions
• Country dialogue ensures a clear understanding of:
• Government financing mechanisms
• Extent of funding & interventions supported
• Timing of government investments
• Tracking & reporting mechanism
• Development/implementation of financial stability plans for countries
no longer eligible for Global Fund support
12. Your responsibility to invest with the Global Fund
To overcome the three diseases, governments and the Global Fund must invest together in
solutions. To establish the basis for future sustainability of national disease programs, the Global
Fund requires governments to do more to support its own programs. See below for the
requirements that apply to Botswana.
Counterpart financing requirements
Access to new funding is contingent on compliance with the Global Fund’s counterpart financing
policy. It requires the demonstration of:
1. Minimum threshold government contribution to disease programs supported by the Global
Fund (60 percent for upper- middle income countries);
2. Increasing government contribution over time to the (a) disease programs supported by the
Global Fund, and (b) health sector; and
3. Reliable disease and health expenditure data to measure and monitor compliance with the
requirements of government spending.
Willingness-to-pay
To encourage countries to increase national funding beyond the minimum counterpart financing
requirements, 15 percent of the total allocation is contingent upon Botswana meeting
‘willingness-to-pay’ commitments. These commitments represent government’s willingness to
increase spending on health and the three diseases and will be a point of discussion with your
Fund Portfolio Manager (FPM) and Country Team. Willingness-to-pay commitments will be
discussed during country dialogue and confirmed when the CCM decides how it wants to split its
funds across diseases and HSS activities
Example of Language in Allocation Letter
13. Example of Commitments from Ministries of Health/Finance
HIVProgram/ProgramAreas ActualFY2011/2012 ActualFY2012/2013 BudgetFY2013/2014 BudgetFY2014/2015 BudgetFY2015/2016 BudgetFY2016/2017
AntiretroviralTherapy(ARVs) 84,922,273 129,245,857 158,731,285 193,000,000 202,650,000 212,782,500
LabConsumablesandReagents 10,061,675 18,166,221 25,897,930 29,268,910 30,640,197 31,775,238
PersonnelCosts 48,918,387 60,941,924 68,177,648 76,271,067 82,505,433 86,630,705
PlanningandAdministration/OperatingCosts 50,286,986 70,642,750 69,955,170 79,060,822 82,764,925 85,830,884
Communication 1,036,353 1,812,550 3,897,082 4,404,342 4,610,691 4,781,491
Conferences,Workshops&Trainings 540,883 416,417 721,187 815,060 853,246 884,854
TotalGovernmentHIVExpenditures 195,766,557 281,225,718 327,380,301 382,820,201 404,024,493 422,685,672
“Please find attached a document that shows funding
from the Swaziland Government. It captures Government
spending or expenditures for the financial years
2011/12, 2012/13 and the budget for 2013/14. Also
included is the commitments for subsequent years”
14. 38% 44% 8% 4% 6%
Strongly Agree Agree Disagree Strongly Disagree Do not know
Applicant Feedback from 2014 NFM Waves
“The Global Fund's increased focus on counterpart financing encouraged
greater government commitments in my country”
“This will help our country to take charge and not to rely on donation alone”
“My country is already meeting its counterpart financing requirements, and has
(and is) demonstrating additional willingness-to-pay. Global Fund’s increased
focus on counterpart financing and willingness-to-pay played no real role.”
17. Mozambique
0
10
20
30
40
50
60
70
2012 2013 2014 2015 2016 2017
USDMillions
Government Spending and
Commitments for HIV, TB and Malaria
HIV Tuberculosis Malaria
• Additional $28 million to
Global Fund-supported
programs in 2015
• Will be maintained/
increased over time
• Commitments = additional
$118 million for 2015-17
• >130% increase from 2012-
14
18. Papua New Guinea
0
5
10
15
20
25
30
35
40
2012 2013 2014 2015 2016 2017
US$Million
Earmarked Budget Spending and
Allocation for HIV, TB and Malaria
HIV Malaria TB
• Additional gov’t contribution of
$48 million
• 78% increase from 2012-14
• Full financing of TB drugs &
supplies
• Support for malaria drugs &
diagnostics
• Procurement of ARVs
• Transitioning donor funded
positions to government payroll
19. Philippines
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
0
5
10
15
20
25
30
ShareofGovernmentinTotalHIVSpending
USDMillion
Government HIV Spending and
Commitments
Share of Government in Total HIV Spending
• 85% of “sin tax” revenue
earmarked for health
• 58% increase in Department of
Health appropriation from 2013
to 2014
• Gov’t contributes to 84% of
funding for HIV in 2015-17,
compared to 18% in 2009
• Gov’t resources will cover:
• >80 percent of treatment costs
treatment for PLHIV
• 100% of prevention among sex
workers
• 100% of treatment for sexually
transmitted infection for key
populations
20. Other Domestic Resource Mobilization Efforts
• Domestic Financing Strategy for Health
• Advocacy through global & regional platforms
• High level engagement, advocacy & technical support in priority countries (e.g.
Ethiopia, Kenya, Malawi, Nigeria, Senegal & Tanzania)
• Special initiative for value for money & sustainability
• Technical support for costing, priority setting, sustainability planning &
operationalization of sustainability initiatives
• Support for institutionalization of National Health Accounts
• Support for mobilizing domestic resources through OECD Senior Budget
Officials regional networks
• Debt2Health & private sector initiatives allow contributions to be
channeled towards Unfunded Quality Demand
23. Counterpart Financing Related Grant Conditions
In accordance with the Global Fund Board Decision Point GF/B28/DP4: Evolving the Funding Model (Part
Two), the commitment and disbursement of 15% of aggregate allocation of approximately USD 184.6
million, which is equal to approximately USD 27.7 million, is subject to compliance with the Global Fund
willingness to pay requirement (the “WTP Requirement”). In order to meet the WTP Requirement, by 31
December of each calendar year, the Grantee shall ensure and deliver evidence of compliance with each
applicable program-specific requirement set forth below:
• On or before 31 December 2015, the government shall budget funding for substitution maintenance
therapy (the “SMT”) program and implement the SMT program for the duration of 2016, in
accordance with the target of the NAP 2014-18;
• On or before 31 December 2016, the government shall budget funding for the SMT program and
implement the SMT program for the duration of 2017, and provide evidence that domestic funding
for 2016 has been effectively provided in accordance with the target of the NAP 2014-18;
• On or before 31 December 2016, the government shall budget funding for the HIV and TB
prevention packages for key populations, including for the harm reduction component, TB active
case finding, adherence and implementation of activities for the duration of 2017 and 2018, in
accordance with the targets of the NAP 2014-18; and
• On or before 31 December 2016, the government shall budget funding for the ARV treatment to
transfer all HIV patients from the Grant Funds to the state program, in accordance with the target of
the NAP 2014-18, ensuring treatment continuation.
Johannes
Leveraging domestic resources for Global Fund supported programs core to the New Funding Model; necessitated by
Increasing funding requirements to scale-up and sustain programs
Plateauing of donor resources for HIV, TB and malaria at the global level
Shift in the business model to
A country owned sustainable response to the epidemics; from a project based emergency response
Predictable financing through an allocation model based on programmatic and funding needs, differentiated by country circumstances
Performance based financing that is focussed on
impact and outcomes at the program level rather than outputs and processes
national targets and their performance rather than grant specific targets and performance
Johannes
Johannes
George
Global Fund Eligibility Requirements of Counterpart Financing
Minimum threshold government contribution to disease program
Low Income 5%
Lower-Lower Middle Income 20%
Upper-Lower Middle Income 40%
Upper Middle Income 60%
Increasing government contribution to disease program over time in the context of overall increases to the health sector
Reliable data for tracking government spending
Incentive for Additional Counterpart Financing (Willingness to Pay)
15% of Global Fund allocation is contingent on additional investments that are:
Beyond current level of government spending
Over minimum counterpart threshold
Targeted to priority areas of national strategic plans
Exemptions to Counterpart Financing Requirements
Non-CCM, regional and multi-country concept note submissions;
Extenuating circumstances that are approved by the Head, Grant Management
George
George
The Country Team clarifies counterpart financing issues identified by the portfolio analysis and engages with country stakeholders on additional governmental investments and sustainability actions
The country dialogue process to ensure a clear understanding of:
Mechanisms through which government will finance the disease program (central/regional/local government revenues, loans, debt relief and/or social health insurance);
Current and planned additional government financing of disease programs in terms of extent of funding and interventions supported;
Timing or annual calendar of government investments;
Mechanism by which government spending will be tracked and reported
A key focus of country dialogue in countries no longer eligible for Global Fund support, middle income countries, and low income countries that are likely to transition to higher income categories in the near future will be on development and implementation of a ‘financial sustainability plan’
2012-14 Government Funding vs. 2015-17 Commitments by Income- 117 Programs of First Four Waves of Concept Note Submission (US$ millions)
George
Example of counterpart financing and willingness to pay language in allocation letter.
George
Example of implementing country commitments. T
George
N=381
Low income country that is heavily dependent on donor resources to finance its health sector including its HIV, TB and malaria programs.
Historically, government contributions to Global Fund supported programs were limited to facility and other overhead costs of program implementation
In the context of increasing funding needs and plateauing donor support, government contributions to the three programs was a major focus of the country dialogue.
Demonstration of strong commitment by providing additional budget support of about USD 28 million to the programs supported by the Global Fund in 2015; which will be maintained and incrementally increased over time.
These commitments translate into an additional US$ 118 million for the three programs in the 2015-17 period compared to 2012-14, an increase of over 130%.
Additional government contribution to the three programs in 2015-17 is US$ 48 million- a 78% increase compared to 2012-14
Additional contributions will support
Full financing of requirements for drugs and supplies for TB
Absorbing entire Global Fund support for malaria drugs and diagnostics
Absorbing donor funded positions to the government payroll
Strong political support for health with the launch of President Aquino’s Health Agenda (AHA) for ‘Universal Health Care’.
Additional revenues of US$ 6 billion over five years is anticipated from the ‘Sin tax’ on cigarettes and alcohol, effective from 1st January 2013- 85% of which is earmarked for health
In 2014, Department of Health (DOH) budget recorded a massive 58% increase in appropriation compared to 2013
Government commitments for HIV in the next phase (2015-2017) account for 84 percent of total available resources – a significant increase from about 18 percent in 2009.
Government resources will cover
Over 80 percent of costs for PLHIV treatment
Fully finance prevention among Sex Workers and STI treatment for all key populations
Domestic Financing Strategy for Health
Advocacy through global and regional platforms (UN General Assembly, ASEAN, African Union, APEC Summit, Parliamentarians Forum)
High level engagement, advocacy and technical support in priority countries (Initially Ethiopia, Kenya, Malawi, Nigeria, Tanzania and Senegal)
Special Initiative for Value for Money and Sustainability sanctioned by the Board to work with partners
Technical support for costing, priority setting through use of allocative efficiency tools, sustainability planning and operationalization of sustainability initiatives
Support for institutionalization of National Health Accounts (NHA)
Supporting Ministry of Finance officials to engage in mobilizing domestic resources for the three diseases through the OECD ‘Senior Budget Officials (SBO) regional networks
Debt2 Health and Domestic Private Sector Initiatives
New Earmarking Policy, that allows contributions by the Private Sector and Debt2Health to be channeled towards the country’s Unfunded Quality Demand
A new Friends report, Innovation for Greater Impact, highlights ways in which Global Fund implementing countries are increasing domestic investments in health. The report illustrates how, through a variety of approaches – such as innovative financing and results based financing - African governments are mobilizing additional resources to fight HIV/AIDS, tuberculosis and malaria.
