1. 6/21/20161 Challenges in Donor Funding in Zambia: the Example of HIV/AIDS Funding Preliminary observations 27 May 2008

2. 6/21/20162 Outline of the Presentation A) Health Care Financing:  1. Main Sources of Health Financing.  2. Health Financing Modalities.  3. Recent changes to the Funding Modalities.  4. Donor funding to health. B) Challenges of HIV/AIDS funding for the health sector:  5. Overall  6. Procurement  7. Management information systems HR: talked about elsewhere…???? [Sylvia, you may have to include a few slides on this during the workshop; you decide]

3. 6/21/20163 1. Main Sources of Health Financing MOFNP – taxes (and small? medical levy) Households – OOP, inc. user fees*; and (community) pre-payments. External/donor funds – foreign taxes and other external funds (through GIs). Other sources:  Medical saving scheme (mining companies);  private health insurance,  other e.g., fuel contribution by Total  potentially SHI, etc

4. 6/21/20164 2. Health Financing Modalities SWAp = GBS through MOFNP. SWAp = direct funding of expanded basket.  SWAp is strongly preferred by MOH. Vertical funding  GAVI, GF, etc. earmarked to specific interventions in health and is on-budget. Parallel funding: e.g., PEPFAR, which is earmarked to specific interventions in health and is off-budget. Facility and community level financing:  User fees (now in urban areas only).  Pre-payment schemes???  Other income generating activities Sylvia, maybe provide a few examples verbally during presentation (look in PETS report if you need ideas)

5. 6/21/20165 3. Changes to the Funding Modalities Zambia Aids Policy (2005) & Joint Assistance Strategy for Zambia (JASZ)  defining Wider Harmonization in Practice (WHIP). WHIP has involved:  Movements from project to GBS.  Interim movements were observed: Movement to GBS e.g., EU, DfID, etc. Movement away from health to other sectors e.g., DANIDA initially moved to education. Some stayed in Health e.g., Sida, DfID (replacement fund in 2005/06) but are intending to move.

6. 6/21/20166 4. Donor Funding: Average Shares of Total Health Expenditure in 2004 (Source: NHA) update with NHA 2007/08, if that is available…

7. 6/21/20167 B) Challenges of HIV/AIDS funding for the health sector: Recall:  5. Overall Size of the funds Planning difficulties Emerging difficulties in implementation  6. Procurement New systems and implication  7. Management information systems New systems and implication  Add “8. Human resource” if you included some slides on HR

8. 6/21/20168 5. Overall Challenges of HIV/AIDS Funding ( Size of the funds)

9. 6/21/20169 5. Overall Size of HIV/AIDS F unding – cont’d

10. 6/21/201610 5. Overall Size of HIV/AIDS F unding – cont’d

11. 6/21/201611 5. Overall Challenges of HIV/AIDS Funding – Cont’d Implication of the size…:  National stewardship is potentially weakened.  Preferred SWAp (all the systems, processes, structures, tools, etc) is potentially undermined.  Reporting allegiances are potentially formed with funders.  Mutual accountability is potentially weakened.  Potential health systems distortions / destabilization…

12. 6/21/201612 5. Overall Challenges of HIV/AIDS Funding – Cont’d Potential health systems distortions / destabilization:  Planning cycle mismatches make coordination difficult.  Unplanned HIV/AIDS spending that shows up in health facilities at district level make it hard for MOH to request for supplementary budgets from MOFNP.  HR and other resource deflections (time, attention, etc) goes to well funded programme  HIV/AIDS Specific health system effects  Procurement in health  Management information systems

13. 6/21/201613 6. Procurement in Health New systems: HIV Procurement.xls, andHIV Procurement.xls How involving is HIV procurement?

14. 6/21/201614 6. Procurement in Health – cont’d Implication of new procurement systems and demands:  (+) More efficient HIV procurement systems, e.g., less stock-outs.  (-) Coordinator difficulties, e.g., with transportation/distribution schedules.  (-) Limited externalities  LMU has limited spill- over to general health procurement (PSU).  (-) Further limitation of MOH stewardship (not adequately involved in HIV procurement planning).

15. 6/21/201615 7. Management Information Systems HIS: HIV & Health Info Systems.xls, andHIV & Health Info Systems.xls How is health information generated and collected?

16. 6/21/201616 7. Health information systems – cont’d Implication of new HISs and demands:  (+) Much more information generated. Note: HMIS has had its own weaknesses, but with HIV…  (-) Disproportionately more information for HIV/AIDS is generated – resource deflection: ARTIS is information heavy (combination of multiple systems that previous existed)  extra burden for HWs; & it has been unable to integrate with HMIS. SMARTCare was originally for overall patient records/HMIS, but to date ART, ANC-PMTCT & VCT are the only automated services.  (-) Limited feedback to lower levels, does not improve with HIV/AIDS focus info. systems.

17. 6/21/201617 Recommendation for Global Partners MOH point of view: Increased commitment/support to national health systems and programmes; buy into SWAp (joint planning, joint procurements, integrated financing / accounting / information / reporting / etc. systems, etc.). Improve information sharing about funding amounts and timings, towards improving predictability and fostering national planning/priority setting. Full subscription by all partners to principle of mutual accountability.

18. 6/21/201618 Conclusion Point of view of the series of studies: A lot has not been covered here (further research is required…) From preliminary observations:  Government systems require attention.  Government is not sufficiently honouring Aduja declaration & may be sending negative signal.  Partners are not unified: in their willingness to lose some amount of identity; & in buying into government systems. Long road ahead in building HS, which will require dialogue and like mindedness.

19. 6/21/201619 Thank you for your attention, enjoy Livingstone