Making the money work harder: the new reality of HIV scale-up

Potential effects of the economic crisis on AIDS programming

The ongoing economic crisis will demand greater attention to programme efficiency and effectiveness to justify current levels of funding, but should not be used as an excuse to ignore the needs of the developing world or condemn it to second-rate treatment, the HIV Implementers’ meeting heard earlier this month.

“It could get ugly but we can do more with what we have,” Dr Stefano Bertozzi, chair of the UNAIDS Reference Group on Economics told the HIV Implementers’ Meeting earlier this month, referring to the current global financial crisis and its implications for HIV/AIDS funding and programmes. 

Getting more money for AIDS has been the focus of global efforts up until now, with less attention paid to getting less AIDS for the money. In 1987 less than $1 million was being spent on the pandemic.  The involvement of the World Bank and subsequently PEPFAR and the Global Fund represented an extraordinary response: by 2008 a total of $13 billion had been invested in treatment, prevention and care.  

Two strategies present themselves in the face of the current situation in which the probability of funding decreases is highly likely, said Bertozzi:  1) continue on the same path and seek to maintain increases in funding levels and 2) take advantage of the opportunity the crisis presents to improve efficiency.   

Calls for more efficient use of available resources, coordination and harmonisation and ‘knowing your epidemic’ echoed throughout the conference.   

“We need to improve the efficiency of our programmes. Yes, we need new and better drugs, diagnostics and tools, but we can do a much better job with the ones available,” said the Namibian Minister of Health and Social Services, Dr. Richard Nchabi Kamwi, MP, speaking at the closing ceremony. “It is imperative that we make wise investments of the scarce resources put at our disposal, including and starting from domestic resources. Evidence-driven and cost-effective interventions should be the top priority of our plans and programmes. ‘Knowing your epidemic’ - there is no way we can make wise investments if we do not know our epidemic.”

WHO HIV head Dr Kevin De Cock noted that “despite emphasis on ‘knowing your epidemic’ it remains difficult to answer the simple, essential questions – of the last 1000 infections, in whom did they occur, how were they acquired, where and from whom?”

Where are we now?

Despite 25 years of prevention, Dr. Bertozzi noted that while HIV is arguably an easily preventable disease there were 2.7 million new infections in 2007 with close to 4 million on treatment. Twice as many are dying as are starting new treatment and twice as many may become infected as those who start on treatment. The treatment gap is not even close to a break even point, he said. 

AIDS funding to date has seen dramatic increases bilaterally, multilaterally and domestically. The biggest increase, of 616% from 1987 to 2008, from bilateral donors such as the UK, Netherlands, Germany and the Scandanavian countries, is the most vulnerable. Prior financial crises have prompted dramatic decreases in international development assistance (IDA).  For example, 10% and 44 % decreases in IDA were experienced with the Nordic and Japanese banking crises, in the early 2000s and the early 1990s respectively. 

The World Bank in collaboration with UNAIDS and WHO did an informal survey of staff working in 71 countries and asked about the current and future impact of the crisis on HIV prevention, treatment and care. Close to 50 % of respondents, representing countries with 75 percent of people with HIV worldwide, expect prevention programmes for people most at risk to be affected by the crisis.   

Treatment for most of those already on ARVs appears secure for the time being, yet eleven percent noted that the crisis was already having an adverse impact on treatment programmes.  Staff responding in 22 countries, where 61 % of those on treatment live, expect an impact on treatment this year. Concern was expressed that planned treatment scale-up for the two-thirds currently in need would not occur. Respondents also reported concern due to budget cuts, uncertainty about future funding, job losses and decreased household incomes as well as increased cost of antiretroviral drugs due to weakened local currencies.

The economic crisis will mean that countries largely dependent  on commodities for revenue will be particularly vulnerable to fluctuations in aid.  Botswana has seen diamond exports which represent 40 % of the Gross Domestic Product (GDP) drop by 89 %. In Zambia copper prices have fallen by 60%. These outcomes together with cuts in external aid will disproportionately affect the most vulnerable.  It is highly probable that short-term staff positions (for example, adherence counsellors) will be cut directly affecting quality of services. Services to most at risk populations (MARPs) will most likely be eliminated.  Such cuts would generate little or no political backlash, Dr. Bertozzi suggested. 

Worst case scenarios as a result of programme interruption 

• Increased morbidity and mortality
• Increased transmission risks
• Increased treatment interruption leading to
• Increased  ART resistance leading to
• Increased burden on health systems and a reversal of economic and social gains

Opportunity in crisis

Dr. Bertozzi suggested that in times of relative financial stability it is easy to be sloppy and readily see improvements even when they are nowhere near meeting desired outcomes.  When there is less money strategic decision-making is a necessity. Interventions will focus on providing the maximum benefit not only in terms of service delivery but in their integration with other services (for example, family planning and TB), as well as ensuring a continuum of care, for example linking VCT to treatment and care. 

Dr. Bertozzi, referring to a cost-effectiveness analysis of Information, Education and Communication (IEC) tools undertaken by himself and colleagues for UNAIDS in 2006, noted that there were no cost-effectiveness data for condoms and social marketing. 

Implementation of large-scale interventions without measuring their effectiveness was not acceptable. He requested that in the rollout of interventions to reduce concurrent multiple partnerships prospective, rigorous evaluations be initiated so that changes can to be measured from the outset. Or, as Dr. Kevin De Cock of WHO put it in his plenary talk, “more than ever we need interventions to be based on evidence, not magical thinking."

Citing Russia as an example of mismatched interventions where IDUs represent 75% of those at risk yet only 20% are targeted, Dr. Bertozzi stressed the importance of targeted interventions for increased effectiveness.

Implementation efficiency can be improved.  He noted the example of the variability of cost per client for pre- and post-test counselling, ranging from approximately $7 per client in Russia to close to $700 in Mexico.  He asked whether  the cost per patient on treatment for example, was known by national governments, across PEPFAR programmes, in World Bank-funded programmes or in Global Fund  programmes.  If there is extreme variability in costs it affords the opportunity to identify savings, he noted. 

Twenty-seven years into the epidemic the focus remains on short-term results to deal with a long-term problem, resulting in a failure to give sufficient emphasis to long-term structural changes such as training more health care workers, empowering women or changing social norms. Evaluation of programme impact was also being given second place in emergency responses to getting programmes up and running, Dr Bertozzi argued. 

Elizabeth Lule of the World Bank concurred and reiterated that the current crisis provides an opportunity to do better. She suggested questions that Ministers of Finance would ask as they review their budgets. Was there a decrease in mortality with people on treatment? Was there an increase in their productivity as a result? Did children return to school? 

There is a need to convince the Minister of Finance that by investing in the social sector and in HIV that there would be huge payoffs: for example, an improvement in life expectancy and education. 

Dr. Lule stressed the importance of governance and accountability: civil society and government bear mutual responsibility to ensure that the monies reach those who need it, she argued 

She underscored the importance of measuring the impact of programmes and highlighted an absence of baseline data, a necessity for future sustainability. Such data are needed not only for the health system but also for procurement as well as fiduciary responsibility. She stressed that even if a government system is not working it cannot be ignored. Surveillance data are largely missing. While it is weak for all diseases it is particularly so for HIV, but surveillance is particularly critical for proper targeting  

Coordination and harmonization, Dr. Lule noted, is not just for donors.  It is also important between and among countries and regions. Regional integration will promote economies of scale for procurement and enable negotiation for scale-up.

How to reduce the risk of programme interruptions in the event of a funding shortfall

At the national level, planning to minimise the risks of programme interruption will include:

1.  The development and implementation of National Strategic Plans (NSPs) and Operating Plans (OPs)
2. Good governance (e.g. transparency and elimination of corruption), and
3. Improved effectiveness and efficiency of programme delivery

The World Bank hosts the AIDS Strategy and Action Plan Program (ASAP) on behalf of UNAIDS and has created a specific Financial Crisis Impact Assessment Tool for HIV/AIDS (FinCIAT)  to assist National Governments, notably Ministers of Finance, as they consider how to allocate emergency funding being put in place by the international community to respond to this financial crisis.   

The Financial Crisis Impact Assessment Tool for HIV/AIDS (FinCIAT) has been designed specifically to help countries assess the impact of the crisis on their HIV/AIDS programmes.  It is a flexible short-term tool with a simple 6-step approach allowing for identification of trade-offs among changes in programme activities.  It can be as general or as detailed as necessary adaptable to different country conditions.  With a focus on evidence and prioritization its aim is to enable identification of priority interventions that have to be maintained in this time of limited resources.  Long-term use is also suggested to improve programme efficiency and effectiveness. 

The current tool (dated May 28, 2009) is in draft form available for comment from users.  www.worldbank.org/asap   Comments on this draft may be sent to Jonathan Brown at the World Bank jbrown3@worldbank.org

The steps include:

1. Evaluation of the current funding status enabling identification of gaps
2. Estimating the vulnerability of funding commitments
3. The funding status of programme activities
4. Reprioritisation and reallocation
5. Implementation of changes and negotiation
6. Monitoring, evaluation and revision – the identification of changes and their impact on programme outputs.

Stagnation is likely necessitating increased  strategic and operational planning, better integration of HIV into other health and social programmes, increased efficiency of programmes more like the private sector and ultimately planning for success in the long-term.