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A Comparative Analysis
of the Financing of
HIV/AIDS Programmes
in Botswana, Lesotho, Mozambique,
South Africa, Swaziland and Zimbabwe
OCTOBER 2003
Prepared for the Social Aspects of HIV/AIDS and
Health Research Programme of the
Human Sciences Research Council
by Dr H. Gayle Martin
Funded by the WK Kellogg Foundation
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Contents
Executive Summary vii
Acknowledgements xi
Abbreviations xii
Introduction 1
Methodology 3
Definition of HIV/AIDS Expenditures 3
Data Collection 4
Limitations and Challenges 5
Botswana 7
Level of Expenditure 7
Functional Classification of HIV/AIDS Expenditures 11
Sources of Financing 11
Financing Mechanisms 11
Lesotho 15
Level of Expenditure 15
Sources of Financing 18
Financing Mechanisms 18
Mozambique 21
Level of Expenditure 21
Functional Classification of HIV/AIDS Expenditures 25
Sources of Financing 25
Financing Mechanisms 26
South Africa 27
Level of Expenditure 27
Sources of Financing 28
Financing Mechanisms 29
Swaziland 33
Level of Expenditure 33
Functional Classification of HIV/AIDS Expenditures 37
Sources of Financing 37
Financing Mechanisms 38
Zimbabwe 41
Level of Expenditure 41
Sources of Financing 42
Financing Mechanisms 42
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Comparative Analysis 43
Health Expenditure 43
Government Expenditure on HIV/AIDS 45
Expenditure on HIV/AIDS by External Sources 47
Total Expenditure on HIV/AIDS 49
Conclusion 51
Special Resource Mobilisation Strategies 51
Do Increased Resources mean Increased Inefficiency? 51
Sustainability 51
Appendices 53
Appendix A: Selected Indicators by Country 53
Appendix B: HIV/AIDS Indicators by Country 57
Appendix C: Terms of Reference 58
Bibliography 59
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Tables
Table 1: Total and Public Health Expenditure in Botswana (1990–2000) 8
Table 2: Core Expenditure on HIV/AIDS Programs in Botswana (1999/01–2002/03, in
current US$) 9
Table 3: Sources of Funding for HIV/AIDS programmes in Botswana (2000) 10
Table 4: Expenditure on HIV/AIDS in Botswana (2001/02) 10
Table 5: Functional Classification of Government of Botswana HIV/AIDS Expenditure
(2002/03) by Financing Mechanism 13
Table 6: Global Fund Award to Botswana 13
Table 7: Total and Public Health Expenditure in Lesotho (1990–2000) 15
Table 8: Government of Lesotho funding for HIV/AIDS, Tuberculosis and Malaria in
(2001/02) 16
Table 9: Expenditure on HIV/AIDS in Lesotho (2001/02) 16
Table 10: External Sources of Funding for HIV/AIDS programmes in Lesotho (2000) 17
Table 11: Global Fund Award to Lesotho 19
Table 12: Total and Public Health Expenditure in Mozambique (1990–2000) 21
Table 13: Government of Mozambique funding for HIV/AIDS, Tuberculosis
and Malaria (2001) 22
Table 14: External Sources of Funding for HIV/AIDS programmes in Mozambique
(2000) 23
Table 15: Expenditure on HIV/AIDS in Mozambique (2001) 25
Table 16: Sources of Government Revenue in Mozambique (1999–2000) 26
Table 17: Global Fund Award to Mozambique 26
Table 18: Public Health Expenditure in South Africa (constant US$, 1999/00) 27
Table 19: Expenditure on HIV/AIDS in South Africa (2001/02) 28
Table 20: Breakdown of Conditional Grant for National Integrated Plan Funds by
Department and Function in South Africa (in current US$) 30
Table 21: Summary of the Goals and Objectives of HIV/AIDS Control in the
Departments of Health, Social Development and Education in
South Africa 31
Table 22: Global Fund Award to South Africa 32
Table 23: Total and Public Health Expenditure in Swaziland (1990–2000) 33
Table 24: Government of Swaziland funding for HIV/AIDS, Tuberculosis and Malaria
(2001/02) 34
Table 25: Government of Swaziland Non-Health Sector Funding to Government
Institutions for HIV/AIDS-related Interventions (2001/02) 34
Table 26: Swaziland NGOs involved in AIDS Interventions by
Funding Status (2001/02) 35
Table 27: External Sources of Funding for HIV/AIDS for Swaziland (2001) 36
Table 28: Expenditure on HIV/AIDS in Swaziland (2001/02) 37
Table 29: Functional Classification of Ministry of Health and Social Welfare HIV/AIDS
Expenditures in Swaziland (2001/02) 38
Table 30: Global Fund Award to Swaziland 39
Table 31: Total and Public Health Expenditure in Zimbabwe (1990–2000) 41
Table 32: Global Fund Award to Zimbabwe 42
Table 33: Summary of Expenditure on HIV/AIDS by Country (2000/01, US$) 46
Table 34: Summary of Expenditure on HIV/AIDS by Country
(2000/01, International $) 47
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Figures
Figure 1: Total health expenditure (US$) per capita) in the six countries vii
Figure 2: Health expenditure in the six countries as a percentage of government
expenditure (2001/02) viii
Figure 3: Total HIV/AIDS expenditure (US$ millions) ix
Figure 4: Total HIV/AIDS expenditure (US$) ix
Figure 5: Change in Life Expectancy in Botswana (1970–2000) 7
Figure 6: Financial Flows for HIV/AIDS Expenditure in Botswana 12
Figure 7: Financial Flows for HIV/AIDS Expenditure in Lesotho 19
Figure 8: Sources of Health Financing in Mozambique (1997) 22
Figure 9: The Flow of Resources for HIV/AIDS to the Provincial Level in
South Africa 29
Figure 10: Total Health Expenditure (A) as a Percentage of GDP and (B) Per Capita
(US$) for 1990–2000 By Country 44
Figure 11: Health Expenditure as a percentage of government expenditure
by Country 45
Figure 12: Government expenditure on HIV/AIDS per capita and per PLWHA (2001) 47
Figure 13: Expenditure on HIV/AIDS as a percentage of GDP (2001) 48
Figure 14: Expenditure on HIV/AIDS (2001/02, current US$) 48
Figure 15: Share of Government and External Sources of HIV/AIDS Financing 49
Figure 16: Infant Mortality Rate per 1,000 live births (1970–2000) 53
Figure 17: Maternal Mortality Ratio per million live births (1994–2000) 53
Figure 18: Life Expectancy (1970–2000) 54
Figure 19: Population Growth (1970–2000) 54
Figure 20: Gross National Product (per capita, current US$) 55
Figure 21: Economic Growth (per capita) 55
Figure 22: Human Development Index (1975–2001) 56
Figure 23: HIV Infection rates for Adults and Children 57
Figure 24: People Living with HIV/AIDS 57
vi
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Executive Summary
In April 2001 in Abuja, African leaders committed to take all necessary measures to
mobilise the required resources for HIV/AIDS. The pledge was made to allocate at least
15 per cent of government expenditure to the improvement of the health sector. This
commitment was endorsed by world leaders at the Special Session of the United Nations
General Assembly on HIV/AIDS in June 2001. At this Special Session, developed countries
committed to assist African leaders in their efforts to realise the funding targets set in the
Abuja Declaration.
Botswana, Lesotho, Mozambique, South Africa, Swaziland and Zimbabwe comprise 12 per
cent of the population in the sub-Saharan African region and account for 33 per cent of
the total HIV/AIDS burden in the region. Among these six countries, four have adult HIV
infection rates of above 30 per cent and all but one have rates above 20 per cent.
Mozambique has the lowest adult HIV prevalence – 12 per cent. Because of the relatively
large population sizes in South Africa and Zimbabwe, these two countries account for
eighty per cent of the infected adults in these six countries.
It is within the context of this HIV/AIDS burden that this comparative analysis aims to
assess the readiness and ability of the countries to respond to the HIV/AIDS epidemic.
The key issues that are addressed in this analysis are:
• Is the allocation to health, as a per cent of total government expenditure, sufficient?
• Is enough allocated to deal with HIV/AIDS, given the magnitude of the problem?
Data limitations made it nearly
impossible to evaluate HIV/AIDS
expenditure allocation – in terms of
economic classification (capital and
recurrent) or functional classification
(prevention, care and support, and
treatment). The allocation of HIV/AIDS
funds by activity is therefore, generally,
not addressed in the report.
Another data limitation was the paucity
of information on household (and
business) expenditure on HIV/AIDS.
Estimates from Latin American and
Caribbean countries found that average
annual expenditure by people living
with HIV/AIDS (PLWHA) was US$1,000,
while an assessment in Rwanda reported US$25 per PLWHA. Even at the latter level, it is
clear that significant amounts of household resources are devoted to HIV/AIDS, resulting
in a combination of transient and permanent impacts on household welfare. One
particular outcome is an increase in the number of households falling below the poverty
line. While not addressed in this report, this household-level outcome has several
secondary consequences that also need to be considered – for example, increasing the
demand for government assistance in the form of poverty alleviation.
vii
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US$
300
250
200
150
100
50
0
Botswana Lesotho Mozambique South Swaziland Zimbabwe
Africa
$191
$255
$56
$43
$28
$9
Figure 1: Total health expenditure (US$)
per capita in the six countries
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The financing of HIV/AIDS programmes
Among the six countries, total health expenditure ranges from a high of US$255 per
capita in South Africa to a low of US$9 per capita in Mozambique. During the 1990s total
health expenditure increased in all these countries except for South Africa. The largest
increase was in Botswana where total health expenditure increased by 115 per cent
between 1990 and 2000. Estimates of the minimum level of spending on essential or basic
health services range from a low of US$12 (in the World Development Report 1993) to
US$34 (by the Macroeconomic Commission on Health in 2001). Four of the six countries
have expenditures in excess of these levels, although two countries, Lesotho and
Mozambique, have per capita expenditures of well below US$34, and in the case of
Mozambique, below US$12.
Is the allocation to health, as a per cent
of total government expenditure,
sufficient? Except for South Africa and
Zimbabwe, none of the countries fulfilled
their commitment made in Abuja in April
2001 to allocate 15 per cent of
government expenditure to health.
Botswana comes closest among the
remaining countries, spending ten per
cent of government expenditure on
health. The other countries spend about
half of the 15 per cent target. It should
however be noted that this data is for the
years 2001 and 2002. When viewed
against the background of increasing
allocations to the health sector over time, it is likely that Botswana and Swaziland will
meet the target. However, the constrained macroeconomic environment in Mozambique
and Lesotho suggests less optimism for reaching the targeted 15 per cent.
Aggregate government expenditure on HIV/AIDS in these southern African countries is
nearly US$70 million annually. There is great variation in the level of expenditure on
HIV/AIDS by individual countries. Government expenditure on HIV/AIDS ranges from a
high of US$33 million in South Africa to a low of US$0.8 million in Lesotho. Per capita
expenditure on HIV/AIDS shows similar variation – on the high end is Botswana with
US$30 per capita, which is almost 30 times the level of expenditure in the other countries.
All the other countries fall below US$1.50 per capita. The median per capita HIV/AIDS
expenditure for the six countries is US$1. If one considers only the HIV infected
population, then Botswana spends $51 per PLWHA. The HIV/AIDS expenditure in
Botswana is also the highest when measured as a percentage of GDP – the government
of Botswana spends one per cent of GDP on HIV/AIDS.
External sources – bilateral donors, multilateral donors (including the UN agencies),
business and NGOs – account for a total of US$180 million expenditure on HIV/AIDS in
these six countries. This translates into a per capita expenditure of US$2 and expenditure
of US$19 per PLWHA. The highest level of donor assistance, in absolute terms, is in
Botswana where US$96 million was spent in 2001. This is equal to US$60 per capita and
US$291 per PLWHA. With the exception of South Africa, expenditures on HIV/AIDS in
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20
15
10
5
0
Percentage
Botswana Lesotho Mozambique South Swaziland Zimbabwe
Africa
10.4
15.4
7.4
15.8
7.4
8.8
Figure 2: Health expenditure in the six countries
as a percentage of government expenditure
(2001/02)
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Executive summary
these countries are financed mainly by
external sources. In Mozambique, Lesotho
and Swaziland more than eighty per cent
of total HIV/AIDS spending is funded by
external sources. The allocations from the
Global Fund to Fight AIDS, Tuberculosis
and Malaria to these countries will add an
additional US$479 million over the total
period of the allocations, and US$192 over
the first two years of each award.
Total spending in these countries
(government- and donor-financed but
excluding household out-of-pocket
spending and the Global Fund allocations)
amounts to approximately US$250 million
for the year 2001, or to US$3 per capita
and US$27 per PLWHA. In the literature,
the reported HIV/AIDS spending per capita
(excluding out-of-pocket spending) for
sub-Saharan Africa is US$0.3 per capita and
US$8 per PLWHA. Regardless of the
measure, total expenditure on HIV/AIDS in
these six countries is higher than the
regional average. Specifically, per capita
HIV/AIDS expenditure is ten times higher
and expenditure per PLWHA is more than
three times higher than in the sub-Saharan
Africa region. This is consistent with the
higher burden of HIV/AIDS in Botswana,
Lesotho, Mozambique, South Africa,
Swaziland and Zimbabwe. These countries
account for a third of PLWHA in sub-
Saharan Africa compared to a tenth of the
region’s population.
The high level of financing in Botswana, from domestic and external sources, makes this
country somewhat of an outlier. Botswana spends US$71 per capita and US$343 per
PLWHA. However, despite this relatively high level of financing, the total spending on
HIV/AIDS is substantially lower than the average HIV/AIDS expenditure in countries of
the Latin American and Caribbean region.
Is enough allocated to deal with HIV/AIDS given the magnitude of the problem? In the
literature it has been estimated that sub-Saharan Africa requires US$4.6 billion annually for
prevention, care and support, and treatment (including anti-retroviral therapy). Given that
these six countries account for a third of the HIV/AIDS burden in the region, it can be
argued that a third of this estimate are the required annual resources for HIV/AIDS
interventions. This figure exceeds the current total HIV/AIDS expenditure that is at one
quarter of US$1 billion.
ix
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Figure 3: Total HIV/AIDS expenditure (US$ millions)
Total: $249 million
Government
$69,28%
External
$180,72%
Per capita Per PLWHA
30
25
20
15
10
5
0
$1
$8
$2
$19
External
Government
Figure 4: Total per capita HIV/AIDS expenditure
(US$)
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The financing of HIV/AIDS programmes
The gravity of the HIV/AIDS situation in these six countries calls for prioritisation,
protection and targeting of HIV/AIDS spending. What is the appropriate institutional
funding mechanism for responding to this call? A detailed assessment of the experiences
of, for example, Zimbabwe (with the earmarking of three per cent wage tax for HIV/AIDS
expenditures), Lesotho (with the allocation of two per cent of all sectoral budgets to
HIV/AIDS) and South Africa (with the introduction of a conditional grant for HIV/AIDS),
is required in order to make specific recommendations. However, preliminary evidence
suggests that the experiences of Zimbabwe and South Africa have generally been positive,
although Lesotho has had less success. Some of these experiences are shared in the
report.
A further important resource mobilisation strategy is the Global Fund. It will be important
to share lessons and experiences before and after countries embark on the Global Fund
process. The seriousness of the HIV/AIDS situation does not allow for each country to
replicate the learning curves. It is, furthermore, important that the increased allocations
which the various international resource mobilisation initiatives aim to effect, are not
accompanied by increased inefficiency in budget management and budget execution. This
would be a tragic outcome given the unprecedented level of commitment and focus on
resource mobilisation for HIV/AIDS.
Extensive planning and consultation processes have preceded the Global Fund
allocations. HIV/AIDS has stressed the capacity of the health sectors in the six countries.
The ability to absorb the vastly increased resources will be a critical determinant of
whether the increased resources will be translated into increased outputs and, ultimately,
into improved outcomes. Importantly, as the experience in Botswana has demonstrated,
human resource capacity constraints may severely limit the response to HIV/AIDS in spite
of high level of financial resources.
The Abuja Declaration showed developing countries’ commitment to making their own
resources available to meet the enormous challenge posed by HIV/AIDS. It is important
that the gains made by the commitment in Abuja are not reversed by the nearly US$500
million Global Fund allocations made to these six countries. This will be an important
issue to monitor – specifically, to what extent does the Global Fund crowd-out
government expenditure, displacing rather than adding to the resources for health and
HIV/AIDS.
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This report is the product of contributions from various research teams. I would like to
acknowledge them and their contributions to making this monograph possible. The data
collection was completed because of the joint efforts of research teams in Botswana,
Lesotho, Mozambique, South Africa, Swaziland and Zimbabwe. The team leaders were:
•Professor Sheila Tlou – Botswana
•Dr Ron Cadribo – Lesotho
•Mr Joel Gudo – Mozambique
•Efua Dorkenoo – South Africa
• Rudolph Maziya – Swaziland
•Brian Chandiwana – Zimbabwe
The Departments of Treasury/Finance and the Departments of Health in the six countries
played an important role in the provision of information, without which this report would
not have been possible. We sincerely appreciate their collaboration.
The role of Dr Gayle Martin in analysing the data, synthesizing information, often
augmenting this with insights gleaned from other sources, and then writing it all up, is
much appreciated.
The editorial and production work of HSRC Publishers will not go unnoticed. They
worked under extreme time pressure and managed to get the report completed within the
given time frame.
Finally, the financial contribution of the WK Kellogg Foundation, and the support of
Bishop Malusi Mpumlwana and Mrs Vuyo Mahlati, who offered constant encouragement
and support throughout the project, is highly valued.
The Social Aspects of HIV/AIDS and Health Research Programme of the Human Sciences
Research Council takes responsibility for the content of this report because it was
responsible for conceiving the idea and ensuring that it was successfully carried out and
completed.
Dr Olive Shisana
Executive Director, Social Aspects of HIV/AIDS and Health Research Programme,
Human Sciences Research Council
Acknowledgements
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[...]... of funds for HIV/AIDS interventions that are available to the Ministry of Finance/National Treasury These sources have been dis-aggregated as far as the data would allow The purpose of the study was, however, not to scrutinise the allocation criteria but to quantify the allocation for health and HIV/AIDS Free download from www.hsrcpublishers.ac.za None of the countries studied have undertaken a ‘National... preventing and coping with the impact of the disease • Measure impact of HIV/AIDS on population Education Address HIV/AIDS issues in the education system • Implement life-skills, train master trainers to train teachers, and train lay counsellors and peer educators Source: National Treasury, 2001 31 ©HSRC 2003 The financing of HIV/AIDS programmes Most of the National Integrated Programme funds are made available... programme The rest of the funds are allocated to the National Departments for co-ordination of the National Integrated Programme strategy The allocation of funds for the first three years of the National Integrated Programme strategy is shown in Table 20 Each department receives funds from one of the programmes as seen fit by the National Integrated Programme Steering Committee Presently, the Department... flow of resources for HIV/AIDS to the provincial level in South Africa National Treasury Vertical allocation to national departments Top slice NIP allocation Free download from www.hsrcpublishers.ac.za National department(s) HIV/AIDS Directorate (Education, Health and Social Welfare) National vertical allocation and NIP allocation Provincial equitable share Provincial HIV/AIDS unit (Education, Health and... followed by a comparative analysis of the financial dimension of HIV/AIDS programs and interventions across the six countries The report concludes with some of the critical issues and implications of the findings of the comparative analysis For reference, selected health and economic indicators for the six countries are presented in Appendix A In Appendix B the HIV/AIDS indicators for these countries are listed... and other sectoral departments • the HIV/AIDS allocation as part of the Equitable Share grant to provincial governments • the conditional grant for the National Integrated Programme (NIP) These mechanisms are demonstrated in Figure 9 and are discussed separately Some effort has been made to give an indication of the functional classification of expenditures under each financing mechanism Figure 9: The. .. was an increase in external finance to the health sector over the period 1997–2001 External finance takes the form of grants or loans These are provided and managed through different financial mechanisms Sector loans are managed by the sector, and are usually provided by the multilateral agencies and by the development banks There has been an overall expansion of government expenditure during the late... Department of Health receives all VCT programme funds as well as some of the funds in the life skills and HBC programmes The Department of Education receives most of the funds for the life skills programmes Both the Departments of Health and Social Development receive funds for communitybased home-based care programmes Although most of the National Integrated Programme activities are based around the Department... Social Welfare departments) HIV/AIDS Allocation in the Departmental Budgets The other sources of funds for the provincial and local government HIV/AIDS units include the vertical allocations from the national departments’ budgets – especially in the health, education and social development sectors The most significant source is the budgetary allocation to the National AIDS Chief Directorate by the National... Declaration, made by African leaders in April 2001 stated: ‘We commit ourselves to take all necessary measures to ensure that the needed resources are made available from all sources, and that they are efficiently and effectively utilised We pledge to set a target of allocating at least 15 per cent of our annual budget to the improvement of the health sector We undertake to mobilise all the human, material . A Comparative Analysis of the Financing of HIV/ AIDS Programmes in Botswana, Lesotho, Mozambique, South Africa, Swaziland and Zimbabwe OCTOBER 2003 Prepared for the Social Aspects of HIV/ AIDS. sources and mechanisms of financing of healthcare and HIV/ AIDS expenditures. This is followed by a comparative analysis of the financial dimension of HIV/ AIDS programs and interventions across the. for HIV/ AIDS interventions that are available to the Ministry of Finance/National Treasury. These sources have been dis-aggregated as far as the data would allow. The purpose of the study was,
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