1. BUDGETING FOR HIV/AIDS Namibia, Aug 2003. Teresa Guthrie Research Unit on AIDS & Public Finance Budget Information Service

2. Regional Experience HIV/AIDS Budgeting 1. Key Themes and Trends 2. Case Study: South Africa

3. Research Unit on AIDS and Public Finance ~ Idasa ~ Namibia, 12-14 Aug 2003 3 International Comparative HIV/AIDS Budget Analysis Results from an Initial 5 country study: –Uganda, Botswana, Thailand, Brazil, South Africa Current expanded 10 country study: –Africa: Namibia, Botswana, Kenya, South Africa, Mozambique –Latin America: Nicaragua, Mexico, Chile, Ecuador, Argentina First stage of report preparation - unfortunately results not ready to present here.

4. Research Unit on AIDS and Public Finance ~ Idasa ~ Namibia, 12-14 Aug 2003 4 Regional Comparative Review: Key themes 1.Location of HIV/AIDS policy and coordination political will 2.Creating an inter-sectoral response 3.Decentralisation 4.Channeling donor funds 5.Suitable funding channels

5. 5 1.Location of HIV/AIDS policy and coordination and political will Botswana: Immediate response ‘86 (STP), MTP1, revised National HIV/AIDS policy 1993, NDP8 (“national emergency”), MTPII. National AIDS Council (NACA) - President’s Office - President as Chair & his commitment to issue. All funds channeled through NACA - better co-ordinated Incorporated HIV/AIDS into national development plan (5yr period). Prevention, treatment, care, awareness, research. 2001 “the most serious challenge facing our nation, and a threat to our continued existence as a people” (President, Budget Speech 2001). 2002 - Universal free access to ARVs!

6. 6 Namibia: Presidential commitment. HIV/AIDS Medium Term Plan II. Component in NDP2 & for each Ministry. Central to emerging Vision 2030 document. National AIDS Co-ord. programme in MoHSS. Funds to MoH - no specific HIV/AIDS budget - difficult to track. 1.Location of HIV/AIDS policy and coordination and political will

7. 7 Uganda AIDS Commission Established 1992 by statute of Parliament to coordinate and actualize multi-sectoral policy. Membership: Govt ministries, legislature, NGO, PLWA. Located in President’s Office. Responsible for advocacy, joint planning, monitoring, and evaluation. Full time secretariat—headed by the Director General. 1.Location of HIV/AIDS policy and coordination and political will

8. 8 Mozambique: National Aids Council (NAC) chaired by PM. Nat. Strat.Plan to Combat HIV/AIDS & STDs. South Africa: 1998 - National co-ordinating body was ‘established’…. With the Deputy President as the Chair (SANAC). However, limited activities... Developed National Strategic Plan 2000-2005. Involved departments: DoH, DoE, DoSD - co- ordinated by DoH. Lack of political commitment & will.

9. Research Unit on AIDS and Public Finance ~ Idasa ~ Namibia, Aug 2003 9 Often intersectoralism remains in the realm of politics, policy and planning unless it is backed up with budgets and implementation structures which give it flesh. How can budgeting processes and financial relations reinforce this extension beyond Health? 2.Creating an multi-sectoral response

10. 10 2.Creating an multi-sectoral response Namibia - multi-sectoral National Development Plan II - each sector has specific obligations. Also active involvement and support of community level activities. Mozambique - multi-sectoral response, not viewed as public health problem only. NAC comprised of Ministries of Health, Planning and Finance, Foreign Affairs, Education, Social Welfare and Youth and Sport, and reps of civil society. MoH and NAC are lead agencies in implementation of the National Strategy.

11. Research Unit on AIDS and Public Finance ~ Idasa ~ Namibia, Aug 2003 11 Uganda - defines HIV/AIDS as poverty-related issue - mainstreamed into Poverty Eradication Action Plan (PEAP). Each Ministry has to develop Sectoral Budget Frameworks. National Strategic Framework 1998-2002 –HIV/AIDS should be integrated into all aspects of development work, service provision, planning and implementation by line ministries, local government, religious and cultural organizations, private sector and NGOs and CBOS. 2.Creating an multi-sectoral response

12. Research Unit on AIDS and Public Finance ~ Idasa ~ Namibia, Aug 2003 12 2.Creating an multi-sectoral response South Africa - only DoH, DoE & DoSD specifically - lead by DoH. Limited alignment between 3 depts. In theory other Depts are meant to address the issue, but no co-ordination or monitoring. Difficulty transferring funds between levels and co- ordinating effectively. DoH Co-ordinators struggle to get reports and collaboration from other depts.

13. Research Unit on AIDS and Public Finance ~ Idasa ~ Namibia, Aug 2003 13 2.Creating an multi-sectoral response Botswana 1993 revised National Policy beyond Health. Co-ordinated response in sectors through NACA (2000), within development framework - also involves district level, NGOs & civil society.

14. 14 Botswana’s Multisectoral Budgeting Botswana HIV/AIDS Budget, 2002/03 (approx. USD 45mill)

15. 15 3.Decentralisation Namibia - Decentralization Implementation Plan (DIP). Botswana - NACA co-ordinates all levels of govt. District level key involvement: –Since 1993 decentralisation of activities to district and then to village levels - multi-sectoral AIDS Committees (but few at district level - little training and capacity building?) –Public health services, run by Local Govt are virtually free of charge –Management & Information services at national and district levels. Uganda - national responsible for policy, districts for implementation - District Response Initiative & sub- county AIDS co-ordinating committee’s (SACC’s). South Africa - limited decentralisation.

16. 16 4.Suitable funding channels Botswana - government budget votes are general. Do not ‘unpack’ line-items. Difficult to track HIV/AIDS specific funds. ART & HBC funds channeled mainly through MoH. Funds also to other ministries HIV/AIDS co-ordinators and NGOs. South Africa - uses conditional grants and equitable share (further detail follows....) Namibia - very specific and detailed HIV/AIDS targets and performance indicators in the NDPII. Allocations in MTP/PEMP. What funding mechanisms are used?

17. Research Unit on AIDS and Public Finance ~ Idasa ~ Namibia, Aug 2003 17 5.Effectively channeling donor funds Namibia - ‘outside SRF’ donor funds recorded in the Development Budget. However, not all are captured there. Botswana - NACCA controls all donor funds. South Africa - Mostly off budget, so difficult to track and assess impact. Uganda - AIDS Commission oversees donor & local funds through same budgeting system.

18. Research Unit on AIDS and Public Finance ~ Idasa ~ Namibia, Aug 2003 18 5.Effectively channeling donor funds Channeling funds to NGOs : Recognition of importance in delivering services. National vs provincial allocation & monitoring? Option of CG to provinces to select approp. NGOs, disburse, financial control & monitoring. South Africa - National Development Agency now channeling all funds to NGOs - many organisations negatively effected, funding ceased.

19. Research Unit on AIDS and Public Finance ~ Idasa ~ Namibia, Aug 2003 19 CASE STUDY SOUTH AFRICA HIV/AIDS BUDGET

20. 20 South Africa’s HIV/AIDS Policy The HIV/AIDS & STD Strategic Plan 2000-2005 Multi sectoral plan implemented by departments of health, education and social development. Components: Prevention, Treatment, care and support, Human and legal rights, and Monitoring, research and surveillance.

21. Research Unit on AIDS and Public Finance ~ Idasa ~ Namibia, Aug 2003 21 South Africa’s HIV/AIDS Funding Channels 2 primary vehicles to transfer funds to provinces from national: conditional grants (CGs) & equitable share (ES) 98% of provincial budgets come from national Approximately 85% from ES; rest from CGs Utilises CGs to fund 3 programmes in Strat Plan Also new funding approach through the Equitable Share gives provinces more freedom to allocate resources and implement programmes as determined by provinces

22. 22 Appropriate funding mechanisms for HIV/AIDS interventions? South Africa National govt relying heavily on block grants: R1.1 billion of R1.952 billion set aside for HIV in this budget is sent to provinces via equitable share. Two main purposes of ES funds: 1. To ensure health services strengthened generally 2. To allow provinces to fund care and treatment including ARVS, ‘as policy develops’ Unconditional transfers allow provinces discretion: * to make different political choices (outside natl policy) * to allocate funds to most cost-effective programmes

23. What is government spending on HIV/AIDS? Allocations for general strengthening of health sector (non-specific HIV spending) + Total government is spending on HIV/AIDS Conditional grants to provinces (ring fenced funds) HIV/AIDS specific allocations/programmes by provinces themselves (from own budgets) HIV/AIDS-specific allocations HIV/AIDS Directorate in national Department of Health Other programmes: nutrition, poverty alleviation, social security, Funds added to provinces equitable share grant--for purposes of HIV/AIDS Conditional grants administered by national depts (DoH, DoE, DSD) On regular budget of DoH (as programme)

24. Research Unit on AIDS and Public Finance ~ Idasa ~ Namibia, Aug 2003 24  Abuja Declaration 2001—15% target Health share of the South African budget

25. Research Unit on AIDS and Public Finance ~ Idasa ~ Namibia, Aug 2003 25 Funds set aside for HIV/AIDS interventions in national budget: How much is specifically targeted for HIV/AIDS interventions?

26. Research Unit on AIDS and Public Finance ~ Idasa ~ Namibia, Aug 2003 26 How much is specifically targeted for SA HIV/AIDS interventions?

27. Research Unit on AIDS and Public Finance ~ Idasa ~ Namibia, Aug 2003 27

28. 28 HIV/AIDS programmes in provincial health depts totaled R680 m in 2003/4--this is over 90% real increase from last year. HIV/AIDS Provincial Health Expenditure as Proportion of Total Provincial Health Expenditure

29. Research Unit on AIDS and Public Finance ~ Idasa ~ Namibia, Aug 2003 29

30. Research Unit on AIDS and Public Finance ~ Idasa ~ Namibia, Aug 2003 30

31. Research Unit on AIDS and Public Finance ~ Idasa ~ Namibia, Aug 2003 31 Actual expenditure of health HIV/AIDS condtl grants

32. 32 Issues for consideration….. Location of the HIV/AIDS policy and co- ordination - Presidential level and mainstreaming? –However must have authority to truly facilitate multi-sectoral collaboration. Political support - acknowledgement of the problem, within broader development framework, commitment of HIV specific allocations & general support to sectors.

33. 33 More issues for consideration….. Enhancing multi-sectoral collaboration - each Ministry with HIV/AIDS line-item, allocations and accountability. Decentralisation requires: –Capacity building - Infrastructure, personnel, resources. –Support for local & civil society involvement. –Support for NGO activities. Strengthen provincial & local financial management, planning, & accountability mechanisms - improve M&E. Improved general health service delivery. Funding channels - targeted ear-marked/ ring-fenced grants and/or unconditional transfers? Co-ordination and monitoring of donor funds. Mechanisms to track GF??

34. Thank you For more information, contact: Alison Hickey or Teresa Guthrie Research Unit on AIDS & Public Finance, Budget Information Service, Idasa teresa@idasact.org.za

35. Appendices

36. Research Unit on AIDS and Public Finance ~ Idasa ~ Namibia, Aug 2003 36 South Africa: funds in budget specifically targeted to HIV/AIDS

37. Research Unit on AIDS and Public Finance ~ Idasa ~ Namibia, Aug 2003 37 Provincial HIV/AIDS Health Budgets

38. Research Unit on AIDS and Public Finance ~ Idasa ~ Namibia, Aug 2003 38 Overview of actual spending on HIV/AIDS conditional grants - South Africa