1. BUDGETING FOR HIV/AIDS - Costing the ‘Indirect Impact’ on the Health Sector Namibia, Aug 2003. Teresa Guthrie Research Unit on AIDS & Public Finance Budget Information Service

2. Research Unit on AIDS and Public Finance ~ Idasa ~ 12 Aug 2003 2 Measuring the ‘Indirect Impact’ of HIV/AIDS on the Health System The HIV/AIDS pandemic has become the greatest challenge not only to health in Southern Africa, but to development in general. Various socio-economic impact studies have been done, projections of costs of specific HIV interventions (prevention, treatment, support etc.), public, private & personal costs

3. Direct expenditure on HIV/AIDS programmes e.g. condoms, PMTCT, public awareness campaigns Indirect expenditure as result of impact of HIV/AIDS e.g. increased demand for social security grants, higher hospital bed occupancy, medicine for OIs Usually requires unconditional transfers or general budget support On recurrent or operation budget (State Revenue Fund) Best addressed using earmarked/ring-fenced funds On development budget (partially covered by donors)

4. Research Unit on AIDS and Public Finance ~ Idasa ~ 12 Aug 2003 4 Quantifying those ‘indirect costs’... That is, the extra ‘burden’ on existing health services due to the increased demand for treatment and care of OIs, LRTIs, TB, STDs etc More difficult to quantify the less direct costs and losses, to individuals, families, communities and the state. How much should govt. allocate to enable the over-stretched health services to continue ot provide quality care?

5. 5 Challenges of Costing the Indirect Impact Notifiability and Identification HIV infection is not a notifiable disease in many African countries. Many countries do not conduct routine voluntary HIV testing on patients. Confidentiality of HIV status must be respected Thus, it is almost impossible to identify HIV+ patients attending health facilities, to quantify the cost of their services and to compare these costs with those of HIV- patients.

6. 6 Challenges of Costing the Indirect Impact (2) Stages of the Syndrome HIV infection presents as a syndrome of many infections, illnesses. In the earlier stages of the illness, OIs, STDs, TB are common, but cannot be directly attributed to HIV without test results. Thus surveillance usually only captures patients once they reach stage 3 or 4 of the illness, when more symptomatic. At same time, mainstreaming efforts would not wish to distinguish HIV-specific services from non-HIV.

7. Research Unit on AIDS and Public Finance ~ Idasa ~ 12 Aug 2003 7 Challenges of Costing the Indirect Impact (3) Varying costs Obviously the costs in the later stages are greater than in the earlier stages. But costs of earlier stages difficult to separate from general health service costs - little info. Many studies use these infections as ‘proxies’ to identify HIV+ patients - this is not ideal/accurate.

8. Research Unit on AIDS and Public Finance ~ Idasa ~ 12 Aug 2003 8 Challenges of Costing the Indirect Impact (4) Data Limitations Inaccuracies of prevalence data/ projections - can’t accurately calculate how many people are currently infected and at which stage, can’t quantify and cost their need for services. Limited availability, quality, validity & reliability of data on which to base costings. Lack of sophisticated information systems and trained personnel to use them. Even less data at district level, where the services are delivered and the greatest impact felt….

9. 9 Limitations of Existing ‘Indirect’ Costing Studies Many studies use ‘proxies’ forf HIV status. Most single studies (‘snap-shot’ vs longitudinal), over a short specific time - therefore do not capture the frequency of visits as patient becomes more ill. Usually single site, problematic to extrapolate to national costs. Most limited to financial costs to the service- provider, do not measure economic impact to all role-players, such as costs to family (financial, time, energy etc).

10. Research Unit on AIDS and Public Finance ~ Idasa ~ 12 Aug 2003 10 Other considerations... The background burden and demand for services (non-HIV related) remains. Increasing HIV+ patients at health facilities may decrease the access for patients with other chronic conditions. Rationing - anecdotal evidence that HIV+ patients are being turned away from health services, due to high demand for services and a sense of not being able to ‘do anything’.

11. Research Unit on AIDS and Public Finance ~ Idasa ~ 12 Aug 2003 11 Importance of Estimating the Indirect Costs…. In order to allocate sufficient funds to service- delivery, for infra-structural and capacity development to accommodate the greater demand due to HIV. “The important message is that there is still much to be done to help policy makers plan and manage this epidemic so that it has as minimal impact as possible on the health system” (Franklin, Desmond, Manning, 2001)

12. 12 Overview of Available Literature Few African studies. Some infection-specific costings eg. TB (but can’t assume that all are HIV-related). No. of visits, length of stay, cost per visit (vs non- HIV), bed occupancy, no. of admissions. Costs to families (some looking at funeral costs). Level of service differences, rural/urban differences. Little/ none out-patient care/ primary health care. Some HBC costs but not compared to hospital costs. Little on child health needs and costs.

13. Country Studies Refer to Article

14. Research Unit on AIDS and Public Finance ~ Idasa ~ 12 Aug 2003 14 Namibia Inpatient Services

15. 15 Burkino Faso: Impacts of HIV/AIDS on the Health-Care Sector for Various Scenarios ** As a percentage of the 1999 budget. Source: Boily, Larivière, Martin at the IDEA International Institute

16. Research Unit on AIDS and Public Finance ~ Idasa ~ 12 Aug 2003 16 TANZANIA : Recurrent and development health expenditure

17. 17 South Africa: Estimates of public health (indirect) expenditure on HIV/AIDS DOH estimates very significant expenditure incurred by public health system: Combined national and provincial expenditure on HIV/AIDS = R4.4448 bn or 15.0% of 2001/2 consolidated public health expenditure In 2000, estimated 628 000 admissions to public hospitals for AIDS-related illnesses, or 24% of all public hospital admissions (DoH, Abt) Cost of hospitalising AIDS patients (public facilities) = R3.6 billion in 2001/2 = 12.5% of total public health budget

18. Research Unit on AIDS and Public Finance ~ Idasa ~ 12 Aug 2003 18 Recommendations (1) Improve systems : –data collection and information management –budgeting and planning –accounting and tracking –capacity building to manage these systems

19. Research Unit on AIDS and Public Finance ~ Idasa ~ 12 Aug 2003 19 Recommendations (2) Public Health Facilities Improvement: –Allocate funds to improve services for the prevention and treatment of OIs, TBs, STDs, RTIs, diarrhoea, etc. – Funds for general improvement of health services, personnel, infrastructural development etc –Funds for ‘step-down’ facilities for last stages of illness

20. Research Unit on AIDS and Public Finance ~ Idasa ~ 12 Aug 2003 20 Recommendations (3) Funding Mechanisms –Conditional grants to ensure delivery of specific programmes –Non-conditional transfers to regions for general improvement of health services –Co-ordination of donor funds

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