1. HIV/AIDS AND THE BUDGET IN NAMIBIA Presented by Hopolang Phororo John Ashipala NEPRU Funding the Fight Seminar September 20, 2004 Benoni, South Africa

2. 2 HIV/AIDS Epidemic National adult prevalence steadily increased – 4.2% (1992) to 23.3% (2002) National adult prevalence steadily increased – 4.2% (1992) to 23.3% (2002) Most critical public health problem Most critical public health problem HIV prevalence among pregnant women ranged from 9% to 43% in 2002 HIV prevalence among pregnant women ranged from 9% to 43% in 2002 Women are worse affected - 56% of all reported new HIV infections Women are worse affected - 56% of all reported new HIV infections Number of orphans rising – 87,587 lost one parent and 9,590 lost both Number of orphans rising – 87,587 lost one parent and 9,590 lost both

3. 3 HIV-related hospital admissions as % of total admissions quadrupled from 1.2% in 1995 to 4.5% in 2000 HIV-related hospital admissions as % of total admissions quadrupled from 1.2% in 1995 to 4.5% in 2000 AIDS-related deaths as a % of total deaths more than doubled from 9.8% in 1995 to 22.4% in 2001 AIDS-related deaths as a % of total deaths more than doubled from 9.8% in 1995 to 22.4% in 2001 In some hospitals, 50% of the beds occupied by AIDS-related patients In some hospitals, 50% of the beds occupied by AIDS-related patients Strain is placed on health services Strain is placed on health services Burden placed on families and communities Burden placed on families and communities

4. 4 Government responses to HIV/AIDS POLICIES AND PLANS Namibian constitution Namibian constitution Namibian HIV/AIDS Charter of Rights – 2000 Namibian HIV/AIDS Charter of Rights – 2000 In NDP2, HIV/AIDS is a separate chapter In NDP2, HIV/AIDS is a separate chapter HIV/AIDS is central to Vision 2030 HIV/AIDS is central to Vision 2030 1987 – AIDS Advisory Committee 1987 – AIDS Advisory Committee 1990 – National AIDS Coordination Programme launched 1990 – National AIDS Coordination Programme launched

5. 5 Short-Term Plan developed and implemented (1990-1992) Short-Term Plan developed and implemented (1990-1992) Medium-Term Plan (MTPI) – 1992-1998 Medium-Term Plan (MTPI) – 1992-1998 1996 – External & intersectoral team assess implementation of MTPI 1996 – External & intersectoral team assess implementation of MTPI MTPII covering 1999-2004 - 5 broad areas addressed, role of Ministries and other sectors MTPII covering 1999-2004 - 5 broad areas addressed, role of Ministries and other sectors National Policy on HIV/AIDS for Education Sector enacted National Policy on HIV/AIDS for Education Sector enacted 2003 - External mid-term review of MTPII 2003 - External mid-term review of MTPII 2003 – ARV programme launched 2003 – ARV programme launched

6. 6 NACOP managed by different structures – three committees at central level NACOP managed by different structures – three committees at central level National AIDS Committee (NAC) National AIDS Committee (NAC) National Multisectoral AIDS Coordination Committee (NAMACOC) National Multisectoral AIDS Coordination Committee (NAMACOC) National AIDS Executive Committee (NAEC) National AIDS Executive Committee (NAEC) Regional AIDS Coordination Committees (RACOCs) – regional level Regional AIDS Coordination Committees (RACOCs) – regional level Public-private partnerships – NCCI and then NABCOA launched in 2003, NANASO umbrella welfare body of HIV/AIDS NGOs, churches Public-private partnerships – NCCI and then NABCOA launched in 2003, NANASO umbrella welfare body of HIV/AIDS NGOs, churches Structures and Institutions

7. 7 Structure and Degree of decentralisation 1997, policy of decentralisation slowly being implemented – public service delivery and economic development 1997, policy of decentralisation slowly being implemented – public service delivery and economic development MoHSS realigned its organisational structure MoHSS realigned its organisational structure Regional management team manages 13 regions Regional management team manages 13 regions 34 public health districts providing a package of essential services 34 public health districts providing a package of essential services 3 main providers of health services – the government (88%), church missions (7%), private sector (5%) 3 main providers of health services – the government (88%), church missions (7%), private sector (5%) Over 80% of the population live within 10km of the nearest health facility Over 80% of the population live within 10km of the nearest health facility Health care is financed by government Health care is financed by government Fees collected from patients go to central government Fees collected from patients go to central government

8. 8 The budget Budget presented in 2 parts: Budget presented in 2 parts: Recurrent or operational budget (Estimates of Revenue and Expenditure) - MoF Recurrent or operational budget (Estimates of Revenue and Expenditure) - MoF Development budget – NPC Development budget – NPC MoF introduced three-year rolling development budget MoF introduced three-year rolling development budget Medium-term expenditure framework Medium-term expenditure framework Performance & Effectiveness Management Programme (PEMP) being implemented Performance & Effectiveness Management Programme (PEMP) being implemented

9. 9 The budget process

10. 10 Intergovernmental fiscal transfers for HIV/AIDS Funds planned for utilisation under MTPII – 20% at national level, 20% at regional level, 60% at constituency level Funds planned for utilisation under MTPII – 20% at national level, 20% at regional level, 60% at constituency level NACOP receives funding through 2 channels – MoHSS (recurrent budget) and receives funds from the development budget (through NPC) NACOP receives funding through 2 channels – MoHSS (recurrent budget) and receives funds from the development budget (through NPC) Individual ministries budget for HIV/AIDS activities in recurrent budgets Individual ministries budget for HIV/AIDS activities in recurrent budgets There is monitoring and accountability to the NPC of the development budget funds only There is monitoring and accountability to the NPC of the development budget funds only

11. 11 Donor Funds for HIV/AIDS NPC – coordinates donor funding (only through dev budget) NPC – coordinates donor funding (only through dev budget) Allocations published in the three-year rolling Development Budget Allocations published in the three-year rolling Development Budget Information on HIV/AIDS is not always specified by line item for each Ministry - problematic Information on HIV/AIDS is not always specified by line item for each Ministry - problematic Donor community plays a major role in HIV/AIDS programmes Donor community plays a major role in HIV/AIDS programmes No detailed database available on all donor funding going to HIV/AIDS No detailed database available on all donor funding going to HIV/AIDS High reliance upon donor aid for HIV/AIDS (outside SRF = 80% by 2005/06) High reliance upon donor aid for HIV/AIDS (outside SRF = 80% by 2005/06) GFATM – 27% of requested amount was approved – none had been disbursed to date. GFATM – 27% of requested amount was approved – none had been disbursed to date.

12. 12 Health Spending MoHSS – pivotal role in HIV/AIDS MoHSS – pivotal role in HIV/AIDS 2001/02 – 2004/05, total expenditure has annual growth rate of 7.8% (nominal terms) 2001/02 – 2004/05, total expenditure has annual growth rate of 7.8% (nominal terms) Remains at 13% of total recurrent budget Remains at 13% of total recurrent budget Health- specific expenditure = 9.4% of the total recurrent budget Health- specific expenditure = 9.4% of the total recurrent budget

13. 13 Health Spending as proportion of total government recurrent budget 0% 2% 4% 6% 8% 10% 12% 14% 16% 2001/022002/03 2003/042004/05 Share of Total SRF Expenditure MOHSS budget as share of total expenditure Total Health- Specific Expenditure/ Total Expenditure Sources: Republic of Namibia, Estimates of Revenue & Expenditure, 2001/02–2003/04.

14. 14 Grants and Welfare Spending MWCW – Social allowances and welfare programmes Division caters for grants – 56% of the Ministry’s total budget MWCW – Social allowances and welfare programmes Division caters for grants – 56% of the Ministry’s total budget 2000/01 to 2001/02 budget increased by 133.54%, 2001/02 to 2002/03, budget increased by 206.47% - cater for AIDS orphans and responsibility shifted to the Ministry from MoHSS 2000/01 to 2001/02 budget increased by 133.54%, 2001/02 to 2002/03, budget increased by 206.47% - cater for AIDS orphans and responsibility shifted to the Ministry from MoHSS MWCW accounted for 0.88% of recurrent budget MWCW accounted for 0.88% of recurrent budget

15. 15 HIV/AIDS allocations under recurrent budget not included HIV/AIDS allocations under recurrent budget not included No specific budget line for HIV/AIDS expenditure No specific budget line for HIV/AIDS expenditure Such expenditures are lumped together with other costs under Health and Social Services budget vote e.g. salaries of NACOP staff, training and condom supplies Such expenditures are lumped together with other costs under Health and Social Services budget vote e.g. salaries of NACOP staff, training and condom supplies Therefore can only present allocations in the development budget and therefore figures are an underestimation of total HIV/AIDS spending Therefore can only present allocations in the development budget and therefore figures are an underestimation of total HIV/AIDS spending HIV/AIDS allocations in the Namibian Budget

16. 16 HIV/AIDS in the Three-Year Rolling Development Budgets Development budget organised by projects under each vote Development budget organised by projects under each vote Projects are funded either ‘inside SRF’ or ‘outside SRF’ Projects are funded either ‘inside SRF’ or ‘outside SRF’ HIV/AIDS-related projects fall under Vote 13: Health and Social Services HIV/AIDS-related projects fall under Vote 13: Health and Social Services HIV/AIDS accounts for almost 4% of total development expenditure HIV/AIDS accounts for almost 4% of total development expenditure HIV/AIDS projects first coded in a separate HIV/AIDS sector in 2003/04-2005/06 HIV/AIDS projects first coded in a separate HIV/AIDS sector in 2003/04-2005/06

17. 17 Increasing HIV/AIDS projects in the development budget Namibian Development HIV/AIDS Budget (1998/99-2005/06) Nominal N$'000 0 10,000 20,000 30,000 40,000 50,000 60,000 70,000 80,000 90,000 2000/012001/022002/032003/042004/052005/06 N$'000 Outside SRF Inside SRF Sources: Namibian Rolling Development Budgets (2000/01, 2001/02-2003/04, 2003/04-2005/06)

18. 18 HIV/AIDS allocations as share of total Health & Social Services dev. budget 0% 5% 10% 15% 20% 25% 30% 35% 40% 2000/012001/022002/032003/042004/052005/06 Percentage Share Sources: Namibian Rolling Development Budgets (2000/01, 2001/02-2003/04, 2003/04-2005/06)

19. 19 Composition of HIV/AIDS spending NDP2 gives indications/ guidelines of government intentions – (estimates but not actual budget allocations) NDP2 gives indications/ guidelines of government intentions – (estimates but not actual budget allocations) Four focus areas: IEC, condom promotion, care and support, sector organisation and management Four focus areas: IEC, condom promotion, care and support, sector organisation and management Care and support was to absorb almost the whole budget in 2001 Care and support was to absorb almost the whole budget in 2001 More funds should go towards recent ARV programme More funds should go towards recent ARV programme Global Fund submission, emphasis is on prevention and education programmes, support and capacity building Global Fund submission, emphasis is on prevention and education programmes, support and capacity building

20. 20 Key sources of data Estimates of Revenue and Expenditure (ERE) Estimates of Revenue and Expenditure (ERE) Development Budgets Development Budgets NDP2 covering 2001/02-2005/06 NDP2 covering 2001/02-2005/06 MoHSS MoHSS MoF MoF National Planning Commission National Planning Commission MWACW MWACW

21. 21 Key difficulties faced No comprehensive database on nationally sourced funds or donor funding No comprehensive database on nationally sourced funds or donor funding Recurrent Budget documents do not provide disaggregation of HIV/AIDS programmes Recurrent Budget documents do not provide disaggregation of HIV/AIDS programmes No clear data on actual expenditure nor on the processes for devolution to the regions No clear data on actual expenditure nor on the processes for devolution to the regions Difficult to study adequacy and efficiency of HIV/AIDS spending Difficult to study adequacy and efficiency of HIV/AIDS spending

22. 22 Conclusions and Key Recommendations Government is committed to policy interventions Government is committed to policy interventions Partners from private sector are involved Partners from private sector are involved The lack of data impedes the monitoring and evaluation of financial commitment The lack of data impedes the monitoring and evaluation of financial commitment NACOP should administer HIV/AIDS budgeting at the national level NACOP should administer HIV/AIDS budgeting at the national level HIV/AIDS activities must be better coordinated and administered at national level HIV/AIDS activities must be better coordinated and administered at national level

23. 23 THANK YOU Authors of the report Hopolang Phororo (ILO) - phororo_ADD@ilo.org phororo_ADD@ilo.org Rosa Endjala (NEPRU) Ndeutalala Haimbodi (NEPRU) - NdeutalalaH@nepru.org.na NdeutalalaH@nepru.org.na Teresa Guthrie (IDASA) – teresa@idasact.org.za teresa@idasact.org.za