Using data and tools to inform resource allocation for the HIV response. Dr. Sarah Alkenbrack & Dr. Suneeta Sharma Futures Group

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1 Using data and tools to inform resource allocation for the HIV response Dr. Sarah Alkenbrack & Dr. Suneeta Sharma Futures Group Second Global Symposium on Health Systems Research, Beijing October 31, 2012

2 What we hope to achieve Have fun while learning something about resource allocation choices Discuss the past, present and future of resource allocation for HIV/AIDS Give an overview of tools that can be used to improve resource allocation decision-making for HIV/AIDS Hear about examples of how these tools are working in various countries

3 What we will learn How tools developed in the fight against HIV/AIDS can help to influence the way in which resources are allocated

4 Outline of session Part 1: Overview of HIV/AIDS resource allocation at a global level: past, present and future Part 2: Strategic planning at the national level: tools for guiding the process Part 3: Using tools to know your epidemic, response, context and costs and impacts Closing discussion

5 But first.hiv/aids resource allocation and UHC: how are they linked? Health systems agenda striving towards UHC HIV/AIDS agenda striving for universal access for those in need but somewhat separate dialogue Should HIV/AIDS agenda be better integrated with movement towards UHC? There are challenges: community-based service delivery is optimal disagreement on prevention needs, due to cultural and religious differences, e.g., free distribution of condoms, circumcision, abstinence?

6 HIV/AIDS Resource Allocation and UHC Evidencebased planning Increasing value for money More resources to reach people in need UHC

7 Part 1. Overview of Resource Allocation for HIV/AIDS at a global level: past, present & future Sarah Alkenbrack, PhD Futures Group Health Policy Initiative Costing Task Order

8 US$ million Resource Availability for HIV/AIDS, ,000 $16,8 16,000 14,000 $13,7 12,000 $11,3 10,000 8,000 $7,91 $8,83 6,000 4,000 2, Domestic (Public and Private)*** Multilateral ODA* Bilateral ODA* Philanthropic sector**

9 Why such rapid growth in spending for HIV/AIDS? Can be partially explained by: Launch of UNAIDS in 1996 Introduction of the World Bank MAP program and the Bill and Melinda Gates Foundation in 2000 UN General Assembly Special Session on HIV & AIDS (UNGASS) in 2001 Start of the Global Fund in 2002 Launch of PEPFAR in 2003 G8 Summit in 2005 and the corresponding commitment to universal access Push to achieve Millennium Development Goals (MDG 6)

10 International assistance disbursed to low- and middle-income countries for HIV in 2011 US PEPFAR 18% 2% 4% 6% 1% 21% 48% European governments Other OECD-DAC governments Global Fund Other multilateral agencies Philanthropics Data from UNAIDS, 2012 Brazil, Russia, India, China, S. Africa, & non-oecd DAC govs

11 Has money for HIV/AIDS been well spent? Discussion among participants

12 Strengths and weaknesses of past HIV/AIDS resource allocation Strengths Saved millions of lives Strong advocacy has resulted in increased funding Multisectoral collaboration Strong leadership Valuable lessons for other sectors/health areas Weaknesses Other priorities neglected? Fragmented: focus on discrete interventions Not enough focus on evidence Not successful in changing behaviors Not enough focus on value for money? Health system strengthening?

13 Current challenges Competing priorities Financial crisis Lack of sustainability: can domestic programs support as donor funding declines? Parallel systems: how to integrate service delivery and program planning? National health services/ primary care Strategies for RH, MCH, TB, harm reduction, poverty reduction, etc. Other?

14 How can we do better? The Investment Framework UNAIDS via Schwartlander & others in Lancet (2011)

15 The Investment Framework, The Lancet, June, 2011

16 Resources required for the investment framework (billions of US$) Universal coverage in 2015

17 The Investment Framework: expected outcomes Implementation of the new investment framework would: Avert 12 2 million new HIV infections between 2011 and 2020 Avert 7 4 million deaths from AIDS Result in 29 4 million life-years gained The framework is cost effective at $1060 per lifeyear gained The additional investment proposed would be largely offset from savings in treatment costs alone

18 Resource allocation at a global level: Summary Emergency response to HIV/AIDS resulted in unprecedented funding to global epidemic Resource allocation process has not been entirely evidence-based The Investment Framework, the result of a modeling exercise, justifies a new approach that focuses on the evidence, as well as enabling factors and synergies with other sectors Focus on value for money will save more lives and get closer to the goal of universal coverage

19 Part 2: Strategic planning for HIV/AIDS at the national level: tools for guiding the process Suneeta Sharma, PhD Futures Group, India

20 Resources: A Key Theme Revise National Strategic and Operational Plan Evaluate Changes in Outcomes Analyze situation Implementation & process monitoring (indicators, resource tracking) Select activities Resource Needs, Funding Identify Key National Outcomes & Priorities Select strategic approaches

21 Key Questions in Resource Allocation 1. What is an optimal allocation of resources? 2. Why is it important to know your epidemic when allocating resources? 3. Where are current resources being spent and who is providing those resources? 4. Where will future resources come from? 5. How effective are the interventions which are being funded?

22 What is an Optimal Allocation of Resources?

23 Country A: Ideal vs. Actual Allocation Optimal Allocation Strategy Actual Allocation IDU Sex Workers General Pop. Condoms Blood Tx/Care

24 Country B: Ideal vs. Actual Allocation Optimal Allocation Strategy Actual Allocation IDU Sex Workers General Pop. Condoms Blood Tx/Care

25 Why is it Important to Know Your Epidemic?

26 HIV Infection in..? Sex workers 6% Soldiers 2% General Population 92%

27 HIV Infection in..? Hetero 5% Maternal 2% MSM 1% IDU 92%

28 How are current resources being spent?

29 Reported HIV/AIDS Expenditures < 2% Source: Report on the Global AIDS Epidemic, UNAIDS, 2008.

30 Resource Allocation in Strategic Plans

31 Gambia DRC Mali Burkina Faso Mauritius Ghana Rwanda Togo Congo Cote d'ivoire Uganda Gabon Tanzania Malawi Mozambique Zambia Lesotho Botswana Swaziland Allocation of Prevention Resources in Sub-Saharan Africa 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% PMTCT Condoms MARPs VCT BCC Source: Report on the Global AIDS Epidemic, UNAIDS, 2008.

32 Expenditures on prevention for MSM (%) vs. MSM HIV cases as a % of all cases % Expenditures on MSM Cases of MSM HIV

33 Conclusions The first step in knowing the best allocation of resources involves knowing your epidemic Next, its critical to know how resources are being spent and who is providing them Finally, its critical to allocate resources in order to achieve the greatest possible impact.

34 Current Strategic Plans Goals Objectives Activities Budgets are not linked to goals! Budgets

35 Problem Most countries now have strategic plans, but the costing is done after the plan is developed. There is no strategic analysis of funding and goals. There is no exploration of the effects of alternate patterns of resource allocation. There is little understanding of the cost to achieve specific coverage of key services.

36 How to Improve Future Resource Allocation? Better understand your epidemic Better understand your response and context Better understand the costs of interventions Integrate resource allocation into the planning process; not as an afterthought Think about financial sustainability (what happens if? )

37 Purpose of Goals Model To improve resource allocation for HIV/AIDS programs by showing: The funding required to reach goals The impact of different scenarios on infections averted and deaths averted The expected effect of alternate resource allocation patterns

38 Approach Goals is intended to be a tool to assist interactive discussions among all stakeholders.

39 Goals Model Treatment Pop Group Behavior Low Risk Med Risk High Risk MSM IDU Num partners Acts/partner Condom use Etc. Probability of Transmission New HIV Infections Coverage Effectiveness Behavior Change Outreach Education Communication Technology Condoms STI Tx MC PrEP Microbicdes Vaccines

40 Goals 3.0% HIV Prevalence/Incidence % 2.5% 0.25% 2.0% 0.20% 1.5% 0.15% 1.0% 0.10% 0.5% 0.05% 0.0% %

41 Uses of Goals National Strategic Plans 17 country applications (including China) Global impact Global impact of scaling-up HIV/AIDS prevention programs Expanded response: can we reverse the epidemic? The impact of an AIDS vaccine in developing countries aids2031 projections UNAIDS Investment Framework

42 Goals application in Ukraine, Ukraine spent US$55 million per year in 2011 on HIV and AIDS. Goal of country was to achieve universal access to ART and to increase coverage of drug-substitution for IDUs Goals exercise was conducted and indicated that Ukraine would require US$307 million in 2013 to achieve universal access How did Ukraine prioritize its plan to achieve the greatest possible impact?

43 Scenarios Scenario 1: Constant funding Scenario 2: Universal access Scenario 3: 50% coverage of prevention; universal access to treatment Scenario 4: Universal access to prevention; 50% access to treatment Scenario 5: Limited funding by government ($244 million)

44 Which scenario to choose? # Scenario Cost in 2015 Coverage (ART) Coverage (IDU) Prevalence (2015) 1. Constant funding $118 million 2. Universal access $307 million 16% 1% 2.24% 80% 60% 2.26% 3. Emphasis on prevention 4. Emphasis on treatment $242 million $270 million 44% 60% 2.18% 80% 31% 2.32% 5. Limited funding $244 million 80% 33% 2.26%

45 Why don t countries allocate resources based on evidence? Lack of data; limited relevance of specific studies Multisectoral response results in watered-down approach Political will Poor planning Lack of control over process

46 Part 3: Using tools to know your epidemic, response, context, and costs and impacts Suneeta Sharma and Sarah Alkenbrack

47 Key message Models and tools can be used to know your epidemic, context, response, and costs, as well as impacts. Models and tools can be used to engage decisionmakers and influence resource allocation patterns for HIV/AIDS programs.

48 What tools are available and how do they fit together? Surveillance Data Census/UN Pop Division Estimates UNAIDS model epidemic patterns National AIDS Accounts Costing and coverage data Existing effectiveness data What is HIV prevalence? What riskbehaviors? What are the demographics? What is being spent? By whom? What does it cost? What resources are required? How should we allocate resources? EPP/AEM Spectrum NASA/ NHA HIV subaccounts Resource Needs Model Goals

49 Surveillance Data Census/UN Pop Division Estimates UNAIDS model epidemic patterns Know your response What is HIV prevalence? What riskbehaviors? What are the demographics? EPP/AEM Spectrum National AIDS Accounts Costing and coverage data Existing effectiveness data What is being spent? By whom? What does it cost? What resources are required? How should we allocate resources? NASA/ NHA HIV subaccounts Resource Needs Model Goals

50 Resource Tracking: NASA and NHA sub-accounts - Methodologies to measure and track resources of the national responses to HIV. It is used to estimate HIV expenditure in terms of amounts and sources. - Compared with Resource Needs reflects possible financing Gaps

51 What is being spent? Past Future NASA and NHA HIV/AIDS sub-accounts Resources consumed (Past) Resource Needs Model (RNM) Resources requirements (Future)

52 Who is financing Vietnam s response? Source: Data from HS2020 Project, Abt Associates

53 Surveillance Data Census/UN Pop Division Estimates UNAIDS model epidemic patterns National AIDS Accounts Costing and coverage data Existing effectiveness data Know your context What is HIV prevalence? What riskbehaviors? Critical enablers What (e.g., are stigma, the poor health literacy, demographics? punitive policies and laws) What is being spent? By whom? Synergies with other development sectors (e.g., strengthening What does it cost? health What resources systems, gender equality, are required? social protection, etc.) How should we allocate resources? EPP/AEM Spectrum NASA/ NHA HIV subaccounts Resource Needs Model Goals

54 Prevention Expenditures on MSM and % of Cases Related to MSM % Expenditures on MSM Cases of MSM AIDS

55 An enabling environment? Financing MSM interventions may have limited impact in the absence of a favorable policy environment % of countries reporting non-discrimination laws or regulations for specific populations Source: UNAIDS, Together we will end AIDS.

56 An enabling environment? Financing MSM interventions may have limited impact in the absence of stigma-reduction efforts Source: UNAIDS, Together we will end AIDS.

57 Surveillance Data Census/UN Pop Division Estimates UNAIDS model epidemic patterns Know your costs What is HIV prevalence? What riskbehaviors? What are the demographics? EPP/AEM Spectrum National AIDS Accounts Costing and coverage data Existing effectiveness data What is being spent? By whom? What does it cost? What resources are required? How should we allocate resources? NASA/ NHA HIV subaccounts Costing models/ Resource Needs Model Goals

58 US$ Average Unit Costs The unit cost of VCT programs in 5 countries unit costs vary by scale, context, efficiency, etc. 1, ,000 10, ,000 Annual clients receiving VCT Mexico Uganda Russia India South Africa

59 What would it cost to scale-up prevention interventions in country X by 2017?

60 Resource Needs Model (RNM): How Does it Work? For each intervention: # people in target population for intervention % coverage to be achieved # of people to be reached with the intervention cost of intervention per person reached Cost of intervention

61 RNM: Prevention interventions Interventions with Priority Populations Youth Sex Workers MSM Workers Injecting Drug Users Communities Other Vulnerable Populations (e.g., prisoners, mobile populations, uniformed services, etc.) Service Delivery Condom provision STI Management VCT Male Circumcision PMTCT Mass Media Health Care Blood Safety Post-Exposure Prophylaxis Safe Injection Universal Precautions

62 Vulnerable population: sex-workers Population Coverage Unit costs = Results Is defined by default as a percentage of the adult female population Range: 0.2% - 7.4% of women age Default: 1% of women age % of sex workers currently covered Desired coverage Cost per sex worker reached Number of sex workers reached Resources for reaching sex workers by year

63 PMTCT Prevention of Mother-to-Child Transmission Population x Coverage x Unit Costs = Results Click to add text Pregnant women who received prenatal care Women who are tested for HIV and found positive % receiving ANC % that receive HIV testing % HIV+ treated with ART % receiving formula % receiving supplements % receiving CTX (?) % receiving PCR (?) Cost per - Woman tested - Woman receiving prenatal ART -Formula -CTXX per child - PCR Test # women receiving testing and counseling # receiving PMTCT # receiving formula # receiving CTX # receiving PCR Resource requirements

64 Millions of US$ Country X: Resource Requirements Testing UP Injection PEP Blood Mass media MTCT VCT STIs #REF! Pub/Priv condoms MSM IDU Workplace CSWs Youth

65 Surveillance Data Census/UN Pop Division Estimates UNAIDS model epidemic patterns Know your impacts What is HIV prevalence? What riskbehaviors? What are the demographics? EPP/AEM Spectrum National AIDS Accounts Costing and coverage data Existing effectiveness data What is being spent? By whom? What does it cost? What resources are required? How should we allocate resources? NASA/ NHA HIV subaccounts Resource Needs Model Goals

66 Male Circumcision: A game changer for the HIV epidemic?

67 The Impact of Male Circumcision on the epidemic Goal: To reach and maintain 80% coverage for MC programs in 13 countries by 2015 Tool: The Male Circumcision (MC) Decisionmakers Tool Excel-based model that estimates the impact and cost of scaling-up male circumcision services as an HIV prevention intervention Considers: Target populations Rates of scale-up Costs of service delivery

68 Step 1. How many MCs are needed to scale-up coverage between 2011 and 2015? 20.4 million circumcisions needed to reach 80% coverage in 5 years 5,000,000 4,500,000 4,000,000 3,500,000 4,333,134 4,245,184 3,000,000 2,500,000 2,000,000 1,500,000 1,000, , ,244 40, , ,788 2,101,566 1,059, ,218 1,746, ,450 1,373,271 1,949,292 1,912,595

69 Step 2. How much will it cost to scale-up MC? $1.5 billion between 2011 and 2015 to achieve 80% coverage in all 13 countries An additional $5 billion to maintain coverage in all 13 countries $16.5 billion net savings from due to averted treatment and care costs

70 Number of HIV infections averted Percent of infections averted by MMC Step 3. How many new infections and AIDS-related deaths can be averted? Scaling up to 80% would avert 3.36 million new HIV infections and 386,000 AIDS deaths through ,200,000 1,000, , , , , % 40.0% 35.0% 30.0% 25.0% 20.0% 15.0% 10.0% 5.0% 0.0%

71 HPI Costing TO: Male Circumcision Publications

72 Follow-on questions: MC analysis Which mode of service delivery for MC is most efficient? (country-specific studies) What are the cost-drivers of MC programs? (6 countries) Can the use of a device increase efficiency? Improve access?

73 Modeling the implications of new policies: some examples

74 What are the costs and impacts of implementing Option B+ for PMTCT? Option B+ would put all HIV-positive women accessing prenatal services on ART immediately for life, regardless of CD4 count. Goal of analysis: To help countries assess the cost implications and impact (infections averted) of implementing Option B+, relative to Option A Analysis conducted in 6 countries (Malawi, Mozambique, Nigeria, South Africa, Tanzania, Uganda).

75 Other relevant policy questions What does it cost to provide prevention programs for most-at-risk populations in the Eastern Caribbean? How can HIV programs make better use of resources in the face of donor phase-out/declines? What would be the impact of changing ART eligibility criteria from CD4<250 to CD4<350? What would happen if ART treatment were interrupted? (e.g., as a result of war, supply-chain problems, or funding constraints)

76 We ask the audience.... Does your country of interest have an optimal resource allocation pattern? Why? Why not? How has HIV/AIDS funding in your country contributed to health systems strengthening? Synergies with other sectors? Are critical enablers being considered? What are some of the ways your country could improve its use of evidence to increase value for money?

77 Summary of session Past resource allocation patterns for HIV show that decisions have not always been evidence-based The investment framework suggests that HIV financing be focused on: 1) what works; 2) enabling factors; 3) synergies with other health areas/sectors Resource allocation tools (e.g., NASA, NHA subaccounts, and Spectrum models) can be used to better understand the 5 Knows and encourage more optimal resource allocations More optimal resource allocation increases value for money and is key to sustaining the response and moving towards universal coverage

78 HIV/AIDS Resource Allocation and UHC Evidencebased planning Increasing value for money More resources to reach people in need UHC

79 Thank you! Contact information: For more information about the HPI Costing Task Order visit: For more information about Futures Group and the Spectrum models visit:

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