In this report, the authors assess the potential of results-based approaches to deliver long-term and sustainable results by measuring the performance of different initiatives against widely agreed aid effectiveness principles. They found that, in general, results-based approaches are not particularly good at supporting aid effectiveness principles but broader approaches do appear to be better aligned with the principles. Ownership tends to be higher when the responsibility for designing programmes falls on recipient governments. This does not mean that funder-led approaches cannot achieve significant degrees of ownership, but results are likely to be less consistent, have higher costs and impose a significant burden on host governments and civil society. Results-based approaches tend to reinforce accountability to external funders and in doing so, undermine mutual accountability. In general, the problem is less acute with country-wide initiatives and it is most pressing when working through third party service providers. In addition, the level of harmonisation of results-based approaches is low because of their widespread use of parallel structures. Eligibility and public financial management criteria demanded by funders can further influence and limit the type of country systems that recipient countries can implement.
Resource allocation and health financing
South African Health Minister, Aaron Motsoaledi cautioned those attending the International AIDS conference, held in Vienna, Austria, from 19–27 July 2010, that backtracking on funding for HIV could threaten treatment success rates. In his speech to the Conference, he outlined success stories in the fight against HIV and AIDS in South Africa, such as integrating HIV and tuberculosis services and committing an additional US$400 million to expand anti-retroviral therapy. He noted that African civil society organisations have a key role to play in holding all stakeholders accountable. He also called for increased funding, full replenishment of the Global Fund to Fight HIV/AIDS, Malaria and Tuberculosis and long-term term partnerships between international funders and recipient countries.
This paper focuses on elicitation of contact information, notification and testing of sex partners of HIV infected patients (aPS). Using study data and time motion studies, the authors constructed an Excel-based tool to estimate costs and the budget impact of aPS in selected facilities in Kisumu County. The authors report the annual total and unit costs of HTS, incremental total and unit costs for aPS, and the budget impact of scaling up aPS over a 5-year horizon. The average unit costs for HIV testing among HIV-infected index clients was US$ 25.36 per client and US$ 17.86 per client using nurses and CHWs, respectively. The average incremental costs for providing enhanced aPS in Kisumu County were US$ 1 092 161 and US$ 753 547 per year, using nurses and CHWs, respectively. The average incremental cost of scaling up aPS over a five period was 45% higher when using nurses compared to using CHWs. Over the five years, the upper-bound budget impact of nurse-model was US$ 1,8mn, 63% and 35% of which were accounted for by aPS costs and ART costs, respectively. The CHW model incurred an upper-bound incremental cost of US$ 1,3mn which was 71% lower than the nurse-based model. The budget impact was sensitive to the level of aPS coverage and ranged from US$ 28 547 for 30% coverage using CHWs in 2014 to US$ 1,3mn for 80% coverage using nurses in 2018. Scaling aPS using nurses has minimal budget impact but not cost-saving over a five-year period. Targeting aPS to newly-diagnosed index cases and task-shifting to community health workers is recommended by the authors.
The authors of this paper oppose the view put forward by some analysts that economic evaluations of antiretroviral therapy (ART) may be used to evaluate HIV treatment as prevention (TasP) programmes. ART outcomes and costs assessed in currently existing programmes are unlikely to be generalisable to TasP programmes programmes for several fundamental reasons, the authors argue. First, to achieve frequent, widespread HIV testing and high uptake of ART immediately following an HIV diagnosis, TasP programmes will require components that are not present in current ART programmes and whose costs are not included in current estimates. Second, the early initiation of ART under TasP will change not only patients' disease courses and treatment experiences - which can affect behaviours that determine clinical treatment success, such as ART adherence and retention - but also quality of life and economic outcomes for HIV-infected individuals. Third, the preventive effects of TasP are likely to alter the composition of the HIV-infected population over time, changing its biological and behavioural characteristics and leading to different costs and outcomes for ART.
In this study, the authors reviewed the available literature on modelled estimates of the cost of providing antiretroviral therapy (ART) to different populations around the world, and they suggest alternative methods of characterising cost when modelling several decades into the future. In past economic analyses of ART provision, costs were often assumed to vary by disease stage and treatment regimen, but for treatment as prevention, in particular, most analyses assume a uniform cost per patient. This approach disregards variables that can affect unit cost, the authors note, such as differences in factor prices (i.e., the prices of supplies and services) and the scale and scope of operations (i.e., the sizes and types of facilities providing ART). They go on to discuss several of these variables, and then present a worked example of a flexible cost function used to determine the effect of scale on the cost of a proposed scale-up of treatment as prevention in South Africa. Adjusting previously estimated costs of universal testing and treatment in South Africa for diseconomies of small scale, i.e., more patients being treated in smaller facilities, adds 42% to the expected future cost of the intervention.
The HIV/AIDS pandemic has spurred significant advances in reproductive health policies across Africa, however, governments do not allocate sufficient legal and financial resources to ensure that the policies are effective, according to a report launched by advocates from seven African countries: Ethiopia, Ghana, Kenya, Nigeria, Tanzania, South Africa, and Zimbabwe, and the U.S.-based Center for Reproductive Law and Policy (CRLP). The report is based on two years of collaborative research and analysis of laws and policies related to women's reproductive lives.
Hailed as a "quantum leap" in the fight against the HIV/AIDS pandemic, the Global Fund to Fight AIDS, Tuberculosis and Malaria has become a focal point for funding efforts to bring the epidemic to heal. But a year after issuing its first call for funding proposals, the Fund remains seriously under-resourced, and concern is mounting over its sustainability. UN Secretary-General Kofi Annan estimated in 2001 that US $7-10 billion a year was needed to fight the HIV/AIDS epidemic. "At the end of the year (2002), we [Global Fund] had received US $2.1 billion in pledges and approximately US $800-850 million was available," Global Fund spokeswoman Mariangela Bavicchi told PlusNews.
According to this article, Africa needs to innovatively diversify the way in which it raises finances for development, arguing that diaspora bonds are one way of doing this. World Bank and International Monetary Fund figures have put remittances from Africans abroad to the continent at between US$25 billion and US$34 billion a year. Unrecorded informal flows of remittances were most probably at least a third of this amount. The authors recommend that Africa should leverage this African diaspora money more aggressively and innovatively for development. The idea of issuing diaspora bonds should be considered as a viable alternative to raise finance for Africa’s development. Some of these remittances from Africans abroad could be channeled into buying such diaspora bonds, which can be specifically used to finance Africa’s development in terms of infrastructure or health. Diaspora bonds are long-term sources of finance and therefore less volatile and they may also allow Africa to circumvent the conditionalities that accompany development and investment finance from both old industrial and new emerging powers. However, poor governance and lack of democracy in some African governments could mean potential African diaspora investors may be wary. The article considers India and Israel, two countries where diaspora bonds have been used successfully as model examples of how Africa could proceed.
In recent years, new global initiatives responding to the AIDS crisis have dramatically affected how developing countries procure, distribute, and manage pharmaceuticals. A number of developments related to treatment scale-up, initially focused on AIDS-related products, have created frameworks for widening access to medicines for other diseases that disproportionally impact countries with limited resources and for strengthening health systems overall. Examples of such systems strengthening have come in the areas of drug development and pricing; policy and regulation; pharmaceutical procurement, distribution, and use; and management systems, such as for health information and human resources. For example, a hospital in South Africa developed new tools to decentralise provision of antiretroviral therapy to local clinics-bringing treatment closer to patients and shifting responsibility from scarce pharmacists to lower level pharmacy staff. Successful, the system was expanded to patients with other chronic conditions, such as mental illness. Health experts can likely take these achievements further to maximise their expansion into the wider health system.
Emeritus Professor Diane McIntyre presents her chapter on: 'How best we can achieve a universal health system: a public conversation'. The chapter was published in the recent South African Health Review. She calls for a broadening of the national discourse on universal health coverage and proposes that the term is replaced with the term 'universal health system' which she suggests is less open to misinterpretation.