Andrew Fearon: afearon.consulting@gmail.com

Challenges and Opportunities for

Sustainable Actions to Address HIV

among Special Populations in the

Caribbean

National AIDS Spending

Assessments in the Caribbean

Total HIV Expenditure 2002-

2009 Trinidad & Tobago

0

20

40

60

80

100

120

140

2002 2003 2004 2005 2006 2007 2008 2009

TT$m

Presentation Outline

1. BACKGROUND

- Why Track HIV Expenditures

- Why Track HIV Prevention Expenditures on MARPs

- HIV Prevalence in the Caribbean (Gen Pop, MSM, FSW)

2. METHODS

- National AIDS Spending Assessment (NASA)

- National Health Accounts (NHA)

- UNGASS Reporting on National HIV Spending

3. RESULTS

4. DISCUSSION

5. CONCLUSIONS AND RECOMMENDATIONS

Background

Since 2001 there has been an unprecedented level in external financial and technical assistance from mechanisms like the UN Joint Team, PEPFAR, the GF, World Bank and other donors in the region

While this surge in funding is a welcome development, perhaps more critical than the amount invested is how those funds are spent and whether or not they are meeting intended targets i.e. more efficiency and with greater impact – or are they targeted at all?

Tracking HIV expenditures can measure the extent of government / donor commitment over time—towards a sustainable national and regional response

The Global Economic Crisis has forced all partners to do more to meet unmet needs with finite resources.

1. Why Track HIV Expenditures

Three of the largest Anglophone Caribbean countries

(Jamaica, Trinidad and Tobago, and Guyana) report an

HIV prevalence of 20 percent or more among MSM.

(UNAIDS 2008).

For many other countries, it is not clear if MARPs are

the drivers of the Epidemic

Preventing HIV transmission among MARPS benefits

society as a whole because they can serve as a bridge

to spread HIV to the wider population

Why Track HIV Prevention Expenditure

on Most At Risk Populations

Comparing Adult HIV Prevalence

with HIV Prevalence in MSM (2005-2008)

0%

5%

10%

15%

20%

25%

30%

35%

DOR T&T JAM SUR GUY BAH

1.1% 1.5% 1.6%2.4% 2.5% 3%

6%

20%

31.8%

7%

21%

8.2%

Adult HIV Prevalance

MSM Prevalance

Comparing Adult HIV Prevalence

with HIV Prevalence in FSWs (2008-2009)

0%

5%

10%

15%

20%

25%

30%

DOR JAM SUR GUY

1.1% 1.6%2.4% 2.5%3%

9%

21%

27%

Adult HIV Prevalance

SW Prevalance

Methods

Study Methods

Data collected from the (UNAIDS) National AIDS Spending Assessment (NASA), (WHO) National Health Accounts (SHA) and UNGASS Indicator 1 on Four countries in the Caribbean was utilized for this study. Using data collected from this study we conducted the following analysis:

1. Described the trends in HIV expenditures related to GDP

2. Compare contributions of domestic and international financing sources for HIV

3. Compared HIV expenditures on MARPS with overall prevention expenditures.

4. Based on current HIV expenditure on MARPs, discuss utility of expenditure tracking surveys for making resource allocation and mobilization decisions with a view to sustainability for MARPs programming

National AIDS Spending Assessment

(NASA) Developed by UNAIDS to track all financial flows relating to HIV and

AIDS

Designed to give decision makers critical financial information to enable improved decision making on sustained and efficient allocation of resources.

NASA is a globally recognized methodology, linked to the SHA that reveals sources of funds, expenditure by provider, expenditure by activity, expenditure by beneficiary population.

Can point to greater efficiencies in resource utilization – Visualize Resource Gaps

Tracking trends in expenditure in HIV & AIDS performance can be benchmarked against the priorities and objectives as outlined in the NSP and facilitate a better understanding of needs and identify gaps in programs

11

NASA Methodology

Financing Source Financing Agent Provider

AIDS Spending

Categories (ASCs)

ASC1

Production

Factors1

Beneficiary

Populations1

ASC2

Production

Factors2

Beneficiary

Populations2

Results Trinidad & Tobago

2002-2009

Results: Trinidad and Tobago 2002-2009

0

10

20

30

40

50

60

2002 2003 2004 2005 2006 2007 2008 2009

TT

$m

Expenditure by Priority Area

Prevention

Treatment

A & HR

S & R

Programme Mgmt

Results: Trinidad and Tobago

2002-2009

0

2

4

6

8

10

12

14

16

18

20

2002 2003 2004 2005 2006 2007 2008 2009

TT$m

Prevention Expenditure

General Population

MARP

PMTCT and VCT

Results: Trinidad and Tobago

2002-2009

0%

10%

20%

30%

40%

50%

60%

70%

2002 2003 2004 2005 2006 2007 2008 2009

HIV Expenditure Targeting Beneficiary Populations 2002-20009

PLWHA

MARP

General Population

Results: Trinidad and Tobago

2002-2009

$0

$5

$10

$15

$20

$25

2002 2003 2004 2005 2006 2007 2008 2009

TT

$

Sources of Funding for Prevention 2002-2009Health

NACC

Other Gov't

International

Private

Results: Caribbean

HIV Expenditure % Share of GDP and

Total HIV Expenditure USD. 2008 2009 2010

0.00%

0.20%

0.40%

0.60%

0.80%

1.00%

1.20%

A B C D

2008

2009

2010

-

0.01

0.01

0.02

0.02

0.03

A B C D

2008

2009

2010

Total HIV Expenditure per

Capita USD 2008 2009 2010

-

5.00

10.00

15.00

20.00

25.00

30.00

35.00

A B C D

2008

2009

2010

HIV Expenditure by Priority

Country A 2008 2009

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

40.0%

45.0%

50.0%

Prevention Treatment OVC Programme Managment

Human Resources

Social Protection

Enabling Enviroment

Research

2008

2009

HIV Expenditure by Priority

Country B 2008 2009

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

40.0%

45.0%

50.0%

Prevention Treatment OVC Programme Managment

Human Resources

Social Protection

Enabling Enviroment

Research

2008

2009

HIV Expenditure by Priority

Country C 2009 2010

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

35.00%

40.00%

45.00%

Prevention Treatment OVC Programme Managment

Human Resources

Social Protection

Enabling Enviroment

Research

2009

2010

HIV Expenditure by Priority

Country D 2008

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

35.00%

40.00%

45.00%

Prevention Treatment OVC Programme Managment

Human Resources

Social Protection

Enabling Enviroment

Research

2008

2008

Percentage Share HIV

Expenditure Prevention: Sex

Workers 2008 2009 2010

0.00%

0.50%

1.00%

1.50%

2.00%

2.50%

3.00%

3.50%

4.00%

A B C D

2008

2009

2010

Percentage Share HIV

Expenditure Prevention: MSM

2008 2009 2010

0.00%

0.50%

1.00%

1.50%

2.00%

2.50%

3.00%

3.50%

A B C D

2008

2009

2010

Percentage Share HIV

Expenditure Prevention: Drug

Users 2008 2009 2010

0

0.005

0.01

0.015

0.02

0.025

0.03

0.035

A B C D

2008

2009

2010

Percentage Share HIV

Expenditure Prevention: General

Population 2008 2009 2010

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

A B C D

2008

2009

2010

Percentage Share HIV

Expenditure Stigma &

Discrimination 2008 2009 2010

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

7.0%

8.0%

A B C D

2009

2009

2010

Percentage Share HIV

Expenditure Civil Societies 2008

2009 2010

0%

5%

10%

15%

20%

25%

30%

35%

40%

A B C D

2008

2009

2010

Measurement Challenges

Inaccessibility and unavailability of expenditure data

Unavailability and limited recognition of the need for

expenditure to be disaggregated by activity and by

beneficiary population.

Lack of financial coordination between funding agents -

donors and governments – varying

budgeting, accounting and financial reporting

Donors financial plans are not harmonised with Country

National HIV Strategic Plans

Not all National Strategic Plans are costed –

comparison of expenditure against the budgets..

31

Measurement Challenges

Lack of an Agenda. Expenditure analysis is seen as a

donor led activity with limited country buy-in

Piecemeal implementation reduces the value of the

expenditure analysis for decision making

Challenges

Lack of Institutionalisation of expenditure tracking – UNGASS Indicator 1 findings: Little emphasis on data collection

Confusion between Budgets and Expenditure

Confusion between Objectives and Activities

Technical Capacity – emphasis on data production, not translation into policy

Lack of transfer of capacity to local staff

Lack of Dissemination of expenditure reports

Lack of understanding between Expenditure Analysis and Auditing

Recommendations

Governance –

expenditure assessments should be

incorporated into the strategic planning

cycle,

International agencies should promote

capacity building in financial policy making,

CSO need to ensure that financial

commitments are maintained by

Governments and Donors

Recommendations

Human Resources– Commitment to Learn by doing

Support by external consultants should focus on capacity building rather than data collection.

Training in financial capacity building –government, international and CSO sector

Financial Information Develop systems that can link financial

information to activity based budgeting

Integrate expenditure analysis into the country planning and budgeting process

Recommendations For

Sustainability Align external support to national Strategic Plans

which are costed.

Recognise where the funding is currently flowing from and where it is flowing to.

Identify current challenges in funding

Recognise what funding (Technical Support as well as cash transfer) the government already provide

Examine areas that can gradually be incorporated into government annual plans and commitments

Develop a domestic sustainable funding strategy

Conclusions

Expenditure on HIV prevention programs for MSM and CSW is very low relative to overall prevention expenditure—despite the proportion of HIV transmission attributed to sex between men.

The evidence, both on the magnitude of the issue and the effectiveness of MSM interventions, demands that countries increase resource allocations for MSM programming.

Government policymakers and program planners will require more evidence of the cost-effectiveness of MSM interventions so that they understand the value of investing in programs for most-at-risk groups—this needs to be part of future research agendas

Post Script – International

Agencies Commitment PANCAP Caribbean Based Resource Mapping Project

Resource Mapping in the British Overseas Territories

World Bank. The Global Strategic Action Plan for the Promotion of National Health Accounts

UNAIDS. The National AIDS Spending Assessment

OECD, World Bank, WHO and USAID. Where is the money and what are we doing with it? Creating an Evidence Base for Better Health Financing and Greater Accountability