1. Domestic Financing for Health in Africa
Prof Alan Whiteside
Meeting of Ministers of Health and Finance on Domestic Financing for Health
Addis Ababa, Ethiopia
Global Fund and African Development Bank
11-12 November 2013

2. Outline
1. Where we are: AIDS, TB and Malaria in epidemiological terms:
• Global burden of disease
• A Southern African example
• AIDS and malaria a major issue
2. What we need for 2014 – 2016
3. Where it is coming from
4. Mobilising Domestic resources
5. Where are we going?

3. Years of life lost (women) by cause: Global, 2010
0-1
1-4 5-14 15-24
25-49
Age
50 – 80 +
Source: 2010 Global Burden of
Diseases Study
http://www.healthmetricsandevaluation.
org/

4. Years of life lost (women): Western Europe 2010
Maternal
Neonatal
HIV & TB
0-1
1-4 5-14 15-24
25-49
50 – 80 +
Source: 2010 Global Burden of Diseases Study
http://www.healthmetricsandevaluation.org/

5. Years of life lost (women): Western Africa, 2010
Maternal
Neonatal
HIV & TB
0-1
1-4 5-14 15-24
25-49
50 – 80 +
Source: 2010 Global Burden of Diseases Study
http://www.healthmetricsandevaluation.org/

6. Years of life lost (women): Central Africa, 2010
Maternal
Neonatal
HIV & TB
0-1
1-4 5-14 15-24
25-49
50 – 80 +
Source: 2010 Global Burden of Diseases Study
http://www.healthmetricsandevaluation.org/

7. Years of life lost (women): Eastern Africa, 2010
Maternal
Neonatal
HIV & TB
0-1
1-4 5-14 15-24
25-49
Age
50 – 80 +
Source: 2010 Global Burden of Diseases Study
http://www.healthmetricsandevaluation.org/

8. Years of life lost (women): Southern Africa, 2010
Maternal
Neonatal
HIV & TB
0-1
1-4 5-14 15-24
25-49
Age
50 – 80 +
Source: 2010 Global Burden of Diseases Study
http://www.healthmetricsandevaluation.org/

9. Ante-natal prevalence South Africa
1990-2011

10. HIV Prevalence Among Pregnant
Women: Botswana
40%
37.4%
33.4%
35%
32.4%
33.7%
2006
2007
31.8%
30.4%
2009
2011
30%
25%
20%
15%
10%
5%
0%
2003
2005

12. What is needed for ATM 2014- 2016
• Estimated funding required $87 billion
• Available estimated funding $76 billion or 87%
– Domestic $23 billion certain
– Domestic $14 billion potential
– International $24 billion potential
– Global Fund $15 billion potential

13. How to sustain an ATM and HSS Response?
1. Increase donor support: getting more from
existing donors or involving new donors
2. Increase domestic financing
– Public or government
– Private sector
– Out of pocket
3. Decrease the cost of the current response by
improving efficiencies in existing programs
But prevent new infections!

14. International Funding Uncertain

15. Global Priorities Changing: Post 2015 MDG
High Level Panel Report

16. International versus Domestic Agendas
• Donors have their own
agendas
• Countries adjust their
plans based donor
goals
• This may be „ants in
the sugar bowl‟
Image Credit:
http://cdn.backyardchickens.com/0/0b/0b999fa8_2_ants.jpeg

17. Africa has made commitments
• Abuja Declaration on HIV/AIDS, Tuberculosis and Other
Related Infectious Diseases, 2001: Heads of State commit to
spend at least 15 % of budgets on Health.
• Addis Ababa, African Union roadmap on shared responsibility
and global solidarity for AIDS, TB and malaria response, 2012
Endorsed Roadmap on Shared Responsibility and Global
Solidarity for HIV, TB and Malaria, Pharmaceutical
Manufacturing Plan
• Tunis Declaration on value for money, sustainability and
accountability in the health sector, 2012 Enhance value for
money, increase accountability improve sustainability of health
resources.

18. Domestic Investment 2011: % of total
government expenditure
Rwanda
Malawi
Zambia
Togo
Tanzania
South Africa
Botswana
Nigeria
Kenya
Source:
23.7%
18.5%
16.0%
15.4%
11.1%
10.0%
8.7%
7.5%
5.9%
UNAIDS, Oxford Policy Management, R4D and Authors
own calculations

19. What should the domestic commitment
to health and ATM be?
•
•
•
•
•
•
According to minimum standard? ($44)
What is affordable?
What is cost effective?
Fair share between domestic and donors?
UNAIDS developed Domestic Index of Priority
More money for health or more health for money?
This is a political decision at national and
international levels.

20. Criteria for Investment
• Level of national income, GDP or GNI. An approximation of
resources available within a country
• Degree to which the Government is able to raise revenue through
taxes, levies, domestic borrowing, or other means.
•
Proportion of Government budget devoted to debt
• Pre-existing pattern of disbursement to different sectors. In health if
historical allocations were low, poor infrastructure reducing capacity to
absorb rapid increases and convert to service delivery.

21. Plan for Analysing “Fiscal Space”
• Macroeconomic analysis
– Evaluating potential resource needs and resource
availability, identifying future resource gaps and
potential ways of eliminating such financial gaps.
• Microeconomic analysis
– Assessing potential opportunities to make the 3
largest interventions efficient:
• ART
• PMTCT
• OVC

22. Innovative Ways of raising money
Source
US $ billions
75% of an alcohol levy
3.9
Contributions from high-revenue enterprises
2.4
Airline levy by all African countries
1.7
2% of public sector budgets earmarked for AIDS 2.4
Mobile phone levy
2.0
1% income tax levy earmarked for AIDS
3.1
But how to 1. sell and 2. ring fence

23. Increased Domestic Funding
• Economic trends
• Abuja Declaration at least 15 % of budgets on Health.
• Economic trends plus DALY
Even then there will be a gap

24. Recommendations 1
•
Need for better data. We are not clear on who is spending what. This is true of
both domestic and international funding. Data needs to be improved and accessible.
•
Political leadership is critical, and we need to develop advocacy messages to
ensure that health continues to be a priority.
•
Revisit the economic arguments for health, including the macro-economic ones.
•
Address rigid budgeting practices making it hard to reallocate revenues toward
health.
•
Empowered Health officials to talk to finance and finance to understand health
•
Address the perception that “donors will take care of the AIDS program”.

25. Recommendations 2
•
Recognized and improved the role of civil society .
•
The core question: it is possible to define the “right” mix of domestic and
international investment in any country. Initial thoughts this will vary country by country.
•
We should establish on a country by country basis an acceptable “benchmark” for
countries to invest from their own resources.
•
The Global Fund should work with other key donors as a „thought leader‟. In
particular it should look to providing data and information.
• This is a complex political question not just an economic one

26. Understanding Curves: New Infections
and Deaths
Deaths of HIV Positive People
Number of people
New Infections
Time

27. Treatment Requirements
Col 1
Number of people
People Requiring
Treatment
Time

28. Economic Transition
Deaths of HIV Positive People
Economic Transition
Credit Mead Over
Number of people
New Infections
Time

29. Economic Transition Occurs
when new infections fall below deaths of HIV positive people
HIV
positive
deaths
New
New
infectio
infections
ns

30. Epidemiologic Transition
Deaths of HIV Posive People
Treatment
An Advocacy and
Epidemiological Transition
Number of people
New Infections
Time

31. Epidemiologic Transition
Deaths of HIV Posive People
Number of people
New Infections
Time
Treatment

32. Thank You