BUDGETING FOR HIV/AIDS - Costing the ‘Indirect Impact’ on the Health Sector Namibia, Aug 2003....

BUDGETING FOR HIV/AIDS - Costing the ‘Indirect Impact’ on

the Health SectorNamibia, Aug 2003.

Teresa Guthrie

Research Unit on AIDS & Public Finance

Budget Information Service

Research Unit on AIDS and Public Finance ~ Idasa ~ 12 Aug 2003

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Measuring the ‘Indirect Impact’ of HIV/AIDS on the Health System

The HIV/AIDS pandemic has become the greatest challenge not only to health in Southern Africa,

but to development in general.

Various socio-economic impact studies have been done, projections of costs of specific HIV interventions (prevention, treatment, support etc.), public, private & personal costs

Direct expenditureon HIV/AIDS programmes

e.g. condoms, PMTCT, public awareness campaigns

Indirect expenditureas result of impact

of HIV/AIDSe.g. increased demand for social security grants, higher hospital bed occupancy,

medicine for OIs

Usually requires unconditional transfers

or general budget support

On recurrent or operation budget

(State Revenue Fund)

Best addressed using earmarked/ring-fenced funds

On development budget (partially

covered by donors)


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Quantifying those ‘indirect costs’...

• That is, the extra ‘burden’ on existing health services due to the increased demand for treatment and care of OIs, LRTIs, TB, STDs etc

• More difficult to quantify the less direct costs and losses, to individuals, families, communities and the state.

• How much should govt. allocate to enable the over-stretched health services to continue ot provide quality care?

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Challenges of Costing the Indirect Impact

Notifiability and Identification

• HIV infection is not a notifiable disease in many African countries.

• Many countries do not conduct routine voluntary HIV testing on patients.

• Confidentiality of HIV status must be respected

• Thus, it is almost impossible to identify HIV+ patients attending health facilities, to quantify the cost of their services and to compare these costs with those of HIV- patients.

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Challenges of Costing the Indirect Impact (2)

Stages of the Syndrome • HIV infection presents as a syndrome of many

infections, illnesses.• In the earlier stages of the illness, OIs, STDs, TB are

common, but cannot be directly attributed to HIV without test results.

• Thus surveillance usually only captures patients once they reach stage 3 or 4 of the illness, when more symptomatic.

• At same time, mainstreaming efforts would not wish to distinguish HIV-specific services from non-HIV.


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Varying costs

• Obviously the costs in the later stages are greater than in the earlier stages.

• But costs of earlier stages difficult to separate from general health service costs - little info.

• Many studies use these infections as ‘proxies’ to identify HIV+ patients - this is not ideal/accurate.


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Data Limitations

• Inaccuracies of prevalence data/ projections - can’t accurately calculate how many people are currently infected and at which stage, can’t quantify and cost their need for services.

• Limited availability, quality, validity & reliability of data on which to base costings.

• Lack of sophisticated information systems and trained personnel to use them.

• Even less data at district level, where the services are delivered and the greatest impact felt….

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Limitations of Existing ‘Indirect’ Costing Studies

• Many studies use ‘proxies’ forf HIV status.

• Most single studies (‘snap-shot’ vs longitudinal), over a short specific time - therefore do not capture the frequency of visits as patient becomes more ill.

• Usually single site, problematic to extrapolate to national costs.

• Most limited to financial costs to the service-provider, do not measure economic impact to all role-players, such as costs to family (financial, time, energy etc).


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Other considerations...• The background burden and demand for

services (non-HIV related) remains.

• Increasing HIV+ patients at health facilities may decrease the access for patients with other chronic conditions.

• Rationing - anecdotal evidence that HIV+ patients are being turned away from health services, due to high demand for services and a sense of not being able to ‘do anything’.


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Importance of Estimating the Indirect Costs….

• In order to allocate sufficient funds to service-delivery, for infra-structural and capacity development to accommodate the greater demand due to HIV.

• “The important message is that there is still much to be done to help policy makers plan and manage this epidemic so that it has as minimal impact as possible on the health system”(Franklin, Desmond, Manning, 2001)

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Overview of Available Literature• Few African studies.• Some infection-specific costings eg. TB (but can’t

assume that all are HIV-related).• No. of visits, length of stay, cost per visit (vs non-

HIV), bed occupancy, no. of admissions.• Costs to families (some looking at funeral costs).• Level of service differences, rural/urban differences.• Little/ none out-patient care/ primary health care.• Some HBC costs but not compared to hospital costs.• Little on child health needs and costs.

Country Studies

Refer to Article


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Namibia Inpatient ServicesYEAR HIV-related

AdmissionsAIDS related

deaths1995 1.2% 9.8%1996 1.6% 15.1%1997 2.3% 18.6%1998 3.3% 22.2%1999 4.4% 26.0%2000 4.5% 26.7%2001 3.6% 22.4%

Source: Republic of Namibia 2002.

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Burkino Faso: Impacts of HIV/AIDS on the Health-Care Sector for Various Scenarios

2005 2010 1997

Base

Year Best-case

scenario

Worst-case

scenario

Best-case

scenario

Worst-case

scenario

Spending on hospitalization linked to

AIDS (billions of CFAF)11.18 13.48 19.23 14.63 23.61

Percentage of health-care budget

allocated for hospitalization due to

AIDS** 64.6% 58.7% 83.8% 63.7% 102.8%

Days at the hospital and hospital beds

required (millions)

1.68 2.03 2.89 2.2 3.55

Percentage of hospital beds required 198.7% 239,6% 341.9% 260.1% 419.7%

** As a percentage of the 1999 budget.Source: Boily, Larivière, Martin at the IDEA International Institute


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Recurrent Expenditure

Development expenditure

0

20,000,000,000

40,000,000,000

60,000,000,000

80,000,000,000

100,000,000,000

120,000,000,000

2000/01 ActualExpenditure

2001/02 ApprovedEstimates

2002/03 Estimates

TANZANIA : Recurrent and development health expenditure

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South Africa: Estimates of public health (indirect) expenditure on

HIV/AIDS• DOH estimates very significant expenditure incurred by public health system: Combined national and provincial expenditure on HIV/AIDS = R4.4448 bn or 15.0% of 2001/2 consolidated public health expenditure

• In 2000, estimated 628 000 admissions to public hospitals for AIDS-related illnesses, or 24% of all public hospital admissions (DoH, Abt)

• Cost of hospitalising AIDS patients (public facilities) = R3.6 billion in 2001/2 = 12.5% of total public health budget


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Recommendations (1)

• Improve systems :

– data collection and information management

– budgeting and planning

– accounting and tracking

– capacity building to manage these systems


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Recommendations (2)• Public Health Facilities Improvement:

– Allocate funds to improve services for the prevention and treatment of OIs, TBs, STDs, RTIs, diarrhoea, etc.

– Funds for general improvement of health services, personnel, infrastructural development etc

– Funds for ‘step-down’ facilities for last stages of illness


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Recommendations (3)

• Funding Mechanisms

– Conditional grants to ensure delivery of specific programmes

– Non-conditional transfers to regions for general improvement of health services

– Co-ordination of donor funds

Thank you

For more information, contact:

Teresa Guthrie

Research Unit on AIDS & Public Finance,

Budget Information Service

Idasa

[email protected]

BUDGETING FOR HIV/AIDS - Costing the ‘Indirect Impact’ on the Health Sector Namibia, Aug 2003....

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