Financing HIV/Aids in South Africa and role of major donors

Meeting to inform Council for Foreign Relations

January 2010Mark Blecher National Treasury

Keith Cloete WC DOH

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Scale of problem

• SA has largest number of HIV infected persons in world >5m• Largest number of persons on treatment• Number of persons on treatment growing rapidly – will exceed

400 000 pa in 10/11• Soon to exceed 1 mil on treatment but this will grow to over 3

million• 400 000 new infections pa with prevention programmes not

sufficiently effective• Highest spending of any country on HIV ….but this will need to

triple over time• Huge implications for struggling health services

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HIV costing

• NSP costing suggested scenarios of R11b-R13b per annum by 2011

• New draft costing by aids2031 suggest costs could reach R40 billion by 2030

• This includes other sectors and private – but amounts are huge – could rise from 18% to 40% of health budget

• And these don’t fully factor costs of lower treatment threshold of cd4 350

• Need to continue to strive to reduce unit costs

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NSP: Summarized total costs for the low cost scenarios (million

Rands, 2005/06 prices)Year

Priority area Goal intervention 2007 2008 2009 2010 2011 % TotalPrevention 643 792 951 1,098 1,247 12%

Reduce sexual transmission 642 790 949 1,097 1,245 12%Behavioural change interventions 300 400 500 600 700 6%Condom provision 145 152 172 180 188 2%Life skills 158 168 177 186 195 2%PEP for sexual assault 10 10 11 11 12 0%STI management 30 60 90 120 150 1%

Reduce transmission through occupational exposure 1 1 1 1 1 0%PEP for occupational exposure 1 1 1 1 1 0%

Care, support and health system strengthening 4,042 5,612 6,960 8,474 10,012 88%Scale-up access to VCT 260 420 423 426 428 5%

HIV testing 260 420 423 426 428 5%Maintain health of HIV-infected adults 2,495 3,365 4,250 5,301 6,360 55%

Antiretroviral treatment for adults 1,588 2,296 3,115 4,036 5,014 40%Food support for adults 521 586 652 782 912 9%Home and Community Based Care 386 483 483 483 435 6%

Address the special needs of mothers and children 1,007 1,267 1,447 1,627 1,823 18%Antiretroviral treatment for children 245 359 488 635 791 6%OVC 452 561 589 618 649 7%PMTCT dual therapy and infant testing 310 348 370 374 383 4%

Strengthen the health system 280 560 840 1,120 1,400 11%Strengthen TB programme management 30 60 90 120 150 1%Increase CHC coverage 250 500 750 1,000 1,250 9%

Grand Total 4,685 6,404 7,910 9,572 11,259 100%

Aids 2031 Draft scenario

Aids 2031 Draft scenario

Projected growth in number of ART patients if 80% target is met (Dorrington)

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Financing

• Both graphs (cost and number of arvs) level off• Once level off govt can fully carry costs• However period from 2010 to 2015 is one of v rapid

scale-up• Esp given lower treatment thresholds, move to 80%

coverage, improved prevention …..and many other health sector issues and priorities

• Require >R2bil new funds annually during scale-up• Difficult to sustain this level of scale-up and

simultaneously replace existing donor funding

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Some major financing streams 09/10 approximate

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R million 09/10HIV and AIDS conditional grant 4,376Provincial own contributions 1,077National Department of Health (core) 500Health: CG+prov own+nat own 5,053Education CG 177Social Development 678Subtotal 6,631PEPFAR 4,314Global fund and other donors 1,000Provinces - hospital and PHC care 5,000Total 17,631

Two broad positions of donors

1) Middle income countries must look after themselves or

2) Very high burden of disease middle income countries merit support

• We support second option. SA has little need for donors beyond HIV, but the HIV problem is very large and difficult

• Sustainable as govt will take over funding as treatment numbers start stabilising

• Govt has sought partnership with major donors eg PEPFAR and Global Fund

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Major donors

• Pepfar and Global Fund have played major role in SA

• Especially helped to build capacity through supporting govt treatment points

• Supported large numbers of worthy projects• Amounts are large and partnership is valuable• Donors potentially bring technical expertise,

flexibility, support

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Problem areas

• Value for money huge amounts being spent – are we getting best value – we may have sufficient funds if we optimally used the combined pool

• Weak coordination between provincial and donor funded services

• Fragmentation between large numbers of organisations poorly coordinated

• Difficulty aligning services and funding coming via multiple routes

• Difficulty allocating tasks and funding around a common plan

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Potential improvements

• Build shared commitment around common plan and agreement on division of work –responsibilities, services and funding

• Funding on budget (WC Global Fund) worked v well• Would be good to develop a five year plan and clear

partnership (there is huge amount to do – scale up to 3 m on Rx)

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Western Cape case study

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2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

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New Stage IV - public sector estimate

Actual provision

Roundtable scenario

National model for policy change to CD4 350

Current trajectory following roundtable scenario

Scenarios for uptake of ART in the Western Cape Province

(assuming guideline change for ART eligibility to 350 cells/µl)

Current financial year

Background

• The Current (Expiring) Western Cape GF Grant Programme– Round 3 (originally 5-year grant)– Sub-CCM: Western Cape Provincial AIDS Council

• Title: Strengthening & Expanding the Western Cape HIV/AIDS Prevention, Treatment & Care Programme

• Four Objectives in the Grant Programme1. ARV treatment services2. Peer education HIV prevention intervention in selected secondary schools3. Palliative care services4. Community Based Response (small grants programme to local CBOs/NGOs)

• Special circumstances of Western Cape Phase 2 Grant Programme– 4-year Phase 2 period in respect of Objectives 1 & 3 in order to provide for a

Grant exit strategy (funding ends June 2010)

– 3-year Phase 2 period in respect of Objectives 2 & 4 (funding ended June 2009)

ARV Treatment Services – Western Cape

• Costing Model

– Revised normative staffing model for medical, nursing, pharmacy, clerical & adherence support (NGO) staff

• Task shifting/sharing• First year’s treatment norms vs norms for subsequent years• 2009 public service salary scales + 7% inflator p.a.

– Revised model for patients on first & second line ARV treatment• All patients start on first line• Average of 0.2% per month changed to second line

– Average ARV medicine cost/patient• In 2009: First line: R215 p.m.; Second line: R642 p.m.• Constant unit cost/patient over RCC period

– Lab tests (NHLS): CD4 Count & Viral Load• 6 monthly tests per patient (ART Protocol)• Average 5% p.a. inflator over RCC period

W CAPE RCC PROPOSAL DEVELOPMENT

• Addressing Long Term Financial Sustainability

– Government’s ability to meet the funding requirements of the Western Cape HIV/AIDS Programme (from own revenue sources) has been seriously affected by the global economic downturn since 2008.

– Problem is likely to persist over the coming MTEF period, followed by economic & fiscal recovery.

– RCC Proposal is therefore structured in order to:• Request maximum possible Grant funding for Years 7 – 9• Followed by incremental transfer of Grant Programme activities to

government funding sources in Years 10 – 12

Conclusion

• HIV treatment and prevention will need to scale up massively over next 5 -10 years

• This has huge cost implications – spending doubling to tripling• However ultimately sustainable as numbers and costs level off• Partnership and support will be valuable during this period of

rapid scale-up• There are many advantages to developing an improved

partnership arrangement over next 5+ years• We value support that has been given and would hope to see

an ongoing and strengthened partnership for next 5 years

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