Efficiency, Effectiveness, and Financial Sustainability: The Importance of Country Ownership Dr Bernhard Schwartländer UNAIDS

2011 Political Declaration on HIV/AIDS: resources for the HIV response  Programmes must become more cost-effective and evidence-based and deliver better value for money  Break the upward trajectory of costs through the efficient utilization of resources (simplification and integration)  Close the global resource gap by 2015 (USD 24 billion by 2015)  Support and strengthen existing financial mechanisms  Expand voluntary and additional innovative financing mechanisms

Total funding for AIDS in sub-Saharan Africa is slowing after many years of growth Source: UNAIDS AIDS investment in sub-Saharan Africa US$ billions

Treatment programmes are highly aid-dependent International share (%)

A new investment approach We are gradually doing better – examples for incresed effectiveness and efficiency Sustainable financing – a new global compact for shared responsibility Overview

But we can do better Scale up to date guided by a “commodity approach”  Unsystematic prioritisation and investment with limited basis in country epidemiology and context  Resources spread thinly across many parallel interventions  Focus on discrete interventions rather than overall results leading to a fragmented response We have done a lot…  Unprecedented scale up of HIV prevention, treatment, care and support  Decline in rate of new HIV infections in many countries  More than 6.6 million people on ART  Millions of orphans receiving basic education, health, social protection

AIDS: a new Investment Framework SYNERGIES WITH DEVELOPMENT SECTORS CRITICAL ENABLERS Care & treatment Male circumcision Keeping people alive Key populations OBJECTIVES Stopping new infections BASIC PROGRAMME ACTIVITIES Social enablers Laws & policies Community mobilization Stigma reduction Programme enablers Community-centered design & delivery Management & incentives Production & distribution Research & innovation Social protection; Education; Legal Reform; Gender equality; Poverty reduction; Gender-based violence; Health systems (incl. treatment of STIs, blood safety); Community systems; Employer practices.

Three investment scenarios Impact on the epidemic USD (Billions) New HIV Infections (millions) Business as usual

USD (Billions) Business as usual Investment framework New HIV Infections (millions) Three investment scenarios Impact on the epidemic

USD (Billions) Rapid scale up previous projections Business as usual Investment framework New HIV Infections (millions) Three investment scenarios Impact on the epidemic

Anew investment approach We are gradually doing better – examples for incresed effectiveness and efficiency Sustainable financing – a new global compact for shared responsibility Overview

Resources available for HIV in low and middle income countries, globally,

ARV costs in South Africa

Reduction in ART unit costs in Ethiopia and Zambia US$

Above facility costs can be reduced Facility Level Cost National Programme Cost ART costs per patient at the facility and program level

Integrated services are more efficient The example of VCT: Costs per client Stand-alone VCT clinics Integrated into SRH services

Times of austericy – a new investment approach We are gradually doing better – examples for incresed effectiveness and efficiency Sustainable financing – a new global compact for shared responsibility Overview

OECD countries can afford more 2010 overseas development assistance as a share of Gross National Income

Economic growth in Africa, 1970–2010 Third-fastest growing region in the World

Domestic AIDS spending needs to match the burden of disease Domestic AIDS spending as a share of health spending Burden of disease caused by AIDS Median % across countries Burden of disease from AIDS vs spending on AIDS

Measuring national commitment to AIDS: the Domestic Investment Priority Index

Options for increasing domestic HIV investment in Africa Source: UNAIDS Domestic public AIDS investment in sub-Saharan Africa

Examples of innovative country-level approaches to HIV financing  Taxes on tobacco and alcohol are common to finance health initiatives  Zimbabwe’s ‘AIDS levy’ earmarks a part of individual and corporate income tax for the AIDS response  Kenya and Zambia are considering an AIDS trust fund  Several African countries collect a tax on airline flights to finance UNITAID’s efforts on AIDS, tuberculosis and malaria; own airline tax in Niger  Levy on mobile telephone air time: being explored in Gabon, Kenya, Burkina Faso  Leverage or tax remittance flows

A new global compact on shared responsibility: Domestic financing potential and international investment needs in sub-Saharan Africa

Conclusions  The leveling off in international resources is a threat – but also an opportunity  We need the experience and innovation of the practitioners of the global South  AIDS can lead the way – as it has done before  Country ownership is essential – but has accountability at its core  We can break the back of the epidemic  Within a new global compact on shared responsibility we can generate the resources we need