1. PEPFAR Technical Assistance Support for Health Financing in the Caribbean 1 Elaine Baruwa, PhD Health Systems 20/20 Caribbean Project Abt Associates Inc. May 2013

2. HIV, health systems strengthening, and financial sustainability Financial sustainability of HIV programs linked with overall health system financial sustainability Need for health system financial planning: Cost escalation? Rising out-of-pocket spending? Increasing prevalence of NCDs? Global recession? Decreased tax revenues? Need HIV program sustainability planning, given decline in external funding: What public and private domestic resources can be leveraged? 2

3. Leveraging USG resources for health systems strengthening PEPFAR II has emphasized health systems strengthening to improve financial sustainability U.S.-Caribbean PEPFAR Partnership Framework aims to increase HIV program sustainability by: Supporting health system and health financing reforms Strengthening and expanding partnerships among public and private entities 3

4. U.S.-Caribbean PEPFAR Partnership Framework 6 U.S.G. Agencies: CDC, Dept. of Defense, Peace Corps, HRSA, State Department, USAID 12 countries: Antigua & Barbuda Dominica Grenada St. Kitts & Nevis Saint Lucia St. Vincent & the Grenadines 4 Bahamas Barbados Belize Jamaica Suriname Trinidad & Tobago

5. USAID-funded projects working on sustainability in the Caribbean Health Systems 20/20 Caribbean Strengthening Health Outcomes through the Private Sector (SHOPS) Health Policy Project MEASURE Evaluation Caribbean HIV/AIDS Alliance (CHAA) PANCAP 5

6. Information needs for financial sustainability planning QuestionApproachExample How much have public and private entities spent on health overall? Is spending allocated to the “right” things? National Health Accounts (NHA) St. Kitts & Nevis, Dominica How much have public and private entities spent on HIV and AIDS? NHA subaccounts for HIV and AIDS St. Kitts & Nevis, Dominica What do HIV prevention and treatment services currently cost? Costing studies (unit cost estimation) Antigua, Grenada Are services being provided more efficiently in some facilities or programs than others? Efficiency analysisHaiti What resources will be needed to support HIV programs adequately in the future? Financial projections and gap analysis (such as HAPSAT) Guyana 6

7. Information needs for financial sustainability planning QuestionApproachExample How much have public and private entities spent on health overall? Is spending allocated to the “right” things? National Health Accounts (NHA) St. Kitts & Nevis, Dominica How much have public and private entities spent on HIV and AIDS? NHA subaccounts for HIV and AIDS St. Kitts & Nevis, Dominica What do HIV prevention and treatment services currently cost? Costing studies (unit cost estimation) Antigua, Grenada Are services being provided more efficiently in some facilities or programs than others? Efficiency analysisHaiti What resources will be needed to support HIV programs adequately in the future? Financial projections and gap analysis (such as HAPSAT) Guyana 7

8. NHA quantifies health spending and tracks every health dollar from the original source through the funds manager, to the provider, and finally to the type of health service where it is spent Financing Source Funds Managers Providers Functions Focus example: NHA & HIV Subaccounts

9. Focus example: NHA in the OECS NHA health spending information is urgently needed to: Understand current health care use and spending patterns for evidence-based planning Design national health insurance schemes Plan for reduced donor HIV funding St. Kitts & Nevis and Dominica are the first in the OECS to collect NHA data and HIV Subaccounts 9

10. Focus example: NHA in the OECS Household and HIV expenditure surveys in the field now  dissemination in September 2013 What are PLHIV spending “out-of-pocket” on HIV care?? What are governments spending on HIV programs?? HS20/20 collaboration with UWI-HEU: Building regional capacity to conduct future rounds of NHA

11. Information needs for financial sustainability planning QuestionApproachExample How much are public and private entities spending on health overall? Is spending allocated to the “right” things? National Health Accounts (NHA) St. Kitts & Nevis, Dominica How much are public and private entities spending on HIV/AIDS? NHA subaccounts for HIV/AIDS St. Kitts & Nevis, Dominica What do HIV prevention and treatment services currently cost? Costing studies (unit cost estimation) Antigua, Grenada Are services being provided more efficiently in some facilities or programs than others? Efficiency analysisHaiti What resources will be needed to support HIV programs adequately in the future? Financial projections and gap analysis (such as HAPSAT) Guyana 11

12. Focus example: Costing for Improved Policy and Planning in Antigua & Barbuda MOH and HS20/20 estimated unit costs of: Primary health care services HIV and AIDS outpatient clinical services, including for Opportunistic Infections (OIs) Inpatient care including inpatient HIV and AIDS services 12

13. Antigua & Barbuda costing: Process and findings Process: Collaboration has built capacity of MOH, National AIDS Program, and Mount St. John’s Medical Centre staff Selected findings: Data gaps inhibit understanding of costs Incremental cost for decentralizing VCT services to Health Centers estimated at US$30 per person counseled & tested/yr Per person average annual cost for PLHIV on ART estimated at US$1,658 73% is cost of ARV drugs 13

14. Information needs for financial sustainability planning QuestionApproachExample How much are public and private entities spending on health overall? Is spending allocated to the “right” things? National Health Accounts (NHA) St. Kitts & Nevis, Dominica How much are public and private entities spending on HIV/AIDS? NHA subaccounts for HIV/AIDS St. Kitts & Nevis, Dominica What do HIV prevention and treatment services currently cost? Costing studies (unit cost estimation) Antigua, Grenada Are services being provided more efficiently in some facilities or programs than others? Efficiency analysisHaiti What resources will be needed to support HIV programs adequately in the future? Financial projections and gap analysis (such as HAPSAT) Guyana 14

15. Focus example: Haiti OVC program cost analysis Analysis of OVC program sustainability Questions What are we spending on what? What exactly is being provided to how many OVC? Is there variation? – efficient, inefficient or just variable? What will it cost to meet Haitian OVC needs? 15

16. Unit cost per service per OVC, Haiti 16

17. Implications of findings What exactly is being provided to how many OVC? Few <5 reached, not much health services, cost depends on the age of the child Is there variation? – efficient, inefficient or just variable Wide variation! In what programs are delivering …. education $10-$255, nutrition $60-452, health $5-14 What will it cost to meet Haitian OVC needs? 50% coverage $37m IF variation is addressed by packaging 17

18. Information needs for financial sustainability planning QuestionApproachExample How much are public and private entities spending on health overall? Is spending allocated to the “right” things? National Health Accounts (NHA) St. Kitts & Nevis, Dominica How much are public and private entities spending on HIV/AIDS? NHA subaccounts for HIV/AIDS St. Kitts & Nevis, Dominica What do HIV prevention and treatment services currently cost? Costing studies (unit cost estimation) Antigua, Grenada Are services being provided more efficiently in some facilities or programs than others? Efficiency analysisHaiti What resources will be needed to support HIV programs adequately in the future? Financial projections and gap analysis (such as HAPSAT) Guyana 18

19. Focus example: HAPSAT HIV/AIDS Program Sustainability Analysis Tool Flexible, user-friendly software for quantifying the financial and human resources required for a set of HIV program scenarios Gap analysis: Assess current funding resources Assess financial and human resources required to maintain and scale-up HIV services Planning resource generation/innovative financing 19

20. HAPSAT in Guyana Stakeholders’ top priority for HIV program: Shortage of HRH HAPSAT analysis quantified HRH needs Result: Gaps are relatively small if current health workers can be utilized more efficiently Stakeholders’ decisions: Establish appointment system Adjust clinic hours to better fit client needs Review number of HIV counselors 20

21. Options for increasing financial sustainability of HIV programs (1) Resource mobilization Experiment with innovative taxes (“sin” taxes, airline levies) Increase public sector allocations to health Increase the proportion of health budgets allocated to HIV Leverage additional resources from private sources Incentivize enrollment in private health insurance plans and mandate that HIV benefits be included Prioritization Reallocate budgets to more cost-effective services (e.g. investments in prevention programs to reduce long-term health costs) Contract with private providers when it is more efficient 21

22. Options for increasing financial sustainability of HIV programs (2) Increase efficiency of health programs -- stretch health budgets further Service integration (one-stop shopping) Primary care model for routine services Provider payment mechanisms to incentivize cost-efficient service provision Better quality assurance to make best use of health resources 22

23. Thank you! Elaine Baruwa, Health Economist Elaine_Baruwa@abtassoc.com Laurel Hatt, Project Director, HS2020 Caribbean Laurel_Hatt@abtassoc.com Rene Brathwaite, USAID HIV Officer rbrathwaite@usaid.gov William Conn, PEPFAR Regional Coordinator wconn@usaid.gov 23