Transcript Rapid scale-up - Results for Development Institute

The long term costs and financing of AIDS
in low and middle income countries –where is the world heading?
Third Symposium on HIV/AIDS Prevention, Care, and Treatment
14 December 2010
Phnom Penh, Cambodia
Robert Hecht, Managing Director
Agenda
1. What are the biggest AIDS financing the challenges we
face today – and why does long-term thinking matter?
2. What is aids2031?
3. What are our global findings?
4. What are the policy implications for governments and
donors?
5. What is the significance of aids2031-Cambodia?
What are the AIDS financing challenges today, and why
does long term thinking matter?
1.
We have entered a major crisis in the financing of AIDS
2.
We cannot stay the current course – this will mean 3X spending, 3-4X people on
ART, and too little reduction in infections
3.
We need to move out of short-run emergency mode and take a long-run view of
AIDS costs/financing if we are to do the right things today
4.
If we take sound actions now, we will have better results in the long run

Radically reduced new infections

All HIV infected in need on treatment

More manageable costs

More sustainable financing
5.
The “right actions” actions involve (a) spending smarter and (b) mobilizing
additional resources – the current crisis is also an opportunity
6.
National leaders and external funders need to be equipped to weigh the options
and make sound choices
The global AIDS financing context
 Annual spending in developing countries has grown from $400 million a
decade ago to $15 billion today
 But there is still enormous unmet demand – and it is growing
 ..and the “supply momentum” is accelerating
 ..but available funding is becoming tighter, in low and middle income
countries and in donor countries alike
It is critical that LMIC governments and external funders find ways to
spend smarter and more efficiently, and mobilize resources better, if AIDS
programs are to be extended and sustained over the next two decades.
Why is wrong with the way we have been
approaching AIDS financing issues?
1. Too short term and emergency oriented




Yet AIDS is a long term phenomenon
Those on ART today will need to be supported for a decade or more
Yesterday’s infections will be tomorrow’s ART cases
Some actions required to stem the epidemic will take years to
implement, e.g., legal and social norm changes
2. Most financial analysis has focused on the costs of scale up,
without considering epi impact – little integrated modeling
3. Most costing has been done for advocacy (or budgeting),
quantifying ambitious maximum scenarios, rather than
considering how to spend wisely in constrained environments
Costs and
Financing
aids2031
An international
consortium of
partners from
academia, industry,
government, and
NGOs who have
come together to
improve the longterm AIDS response
by promoting
actions today that
positively impact
the future of the
epidemic.
David de Ferranti
Science and
Technology
Callisto Madavo
Chris Elias
Robert Hecht
Modelling
Geoff Garnett
Michael Merson
Communication
Social Drivers
Secretariat
Geeta Rao Gupta
Denise Gray-Felder
Peter Piot
Stef Bertozzi
Heidi Larson
William Fisher
HyperEndemic Areas
Programmatic
Response
Achmat Dangor
Leonardo Simão
Paul DeLay
Sigrun Møgedal
Leadership
Zackie Achmat
As Sy
Countries in
Rapid
Economic
Transition
Myung-Hwan Cho
Prasada Rao
Malekgapuru
Makgoba
Key issues in financing the global AIDS response -–
the raison d’etre for aids2031
1. How much financing will be required to combat AIDS over the next
two decades in developing countries, under different scenarios?
2. Under these possible scale-up scenarios, what health impacts will
be generated?
3. What can be done to improve efficiency, by spending on the
“right things” and spending in the “right ways” on them?
4. Who will pay the future price tag for AIDS? What is the fairest and
most sustainable way to do this?
Methods and data
 aids2031 Costs and Financing Working Group modelled long term
financial requirements for AIDS scale up
 Needs estimated under four scenarios, shaped by assumptions on
political will, resources, and approach
 Best available demographic, epidemiological, and financial data
employed (UN Pop Div, WHO, LMIC country reports and studies)
 Modelling tools from Spectrum software suite (GOALS, GRNE)
 Projections of country and donor fiscal space using IMF/WB GDP and
growth projections and OECD donor database
 Elasticities of revenue and health spending built upon van de Gaag’s
work (Brookings/R4D)
aids2031: Financial requirements and health impact
Total annual financial needs, 2008-31
New HIV infections among adults 15-49 annually
aids2031: Key results of global modeling
Scenario
Cumulative
funding
required, US$
billions
(2009-2031)
Cumulative
adult HIV
infections,
millions
(2009-31)
Number of
new HIV
infections,
millions
(2031)
Number of
people on
ART, millions
(2015)
Cumulative
life years
gained,
millions
Current Trends
490
47.5
2.1
8.8
148
Rapid Scale-up
722
33.3
1.3
11.6
235
Hard Choices
for Prevention
397
39.4
1.7
11.3
232
How much will AIDS cost, and who will pay?
(AIDS spending requirements as a share of GDP, 2015)
= Group I
= Group II
One reality: High burden low income countries
Projected HIV prevalence and AIDS expenditure, 2008-31
2008
2015
Prevalence
GDP per
capita
(US$)c
AIDS
exp per
capita
(US$)
AIDS
exp as
% of
THEd
AIDS
exp as
% of
GDP
Cameroon
5·0
782
6
15·8
Kenya
7·0
513
11
Mozambique
12·6
336
Nigeria
3·1
South Africa
2030
Prevalence
GDP per
capita
(US$)c
AIDS
exp per
capita
(US$)
AIDS exp
as % of
THEd
AIDS
exp as
% of
GDP
0·8
3·8
898
17
36·0
52·0
2·2
5·7
627
23
12
86·3
3·5
12·2
493
522
4
19·0
0·7
2·6
18·3
3,946
32
9·8
0·8
Uganda
5·5
294
8
42·3
Zambia
15·2
401
24
111·5
Country
Sources:
Prevalence
GDP
per
capita
(US$)c
AIDS
exp per
capita
(US$)
AIDS
exp as
% of
THEd
AIDS
exp as %
of GDP
1·9
1·9
1,234
15
22·6
1·2
84·6
3·6
3·2
921
23
57·3
2·5
30
145·1
6·0
8·0
1,198
30
57·8
2·5
674
11
44·0
1·6
1·5
1,137
11
25·3
1·0
19·3
5,194
58
13·4
1·1
17·9
8,992
64
8·4
0·7
2·8
3·8
353
14
59·7
4·0
1·6
550
12
31·8
2·2
6·0
13·1
530
34
118·9
6·4
7·9
915
33
64·5
3·6
Unless otherwise indicated, all numbers are the authors’ own calculations.
c Based on World Bank GDP estimates.
d THE stands for total health expenditure.
AIDS spending will absorb
large share of health
expenditure ...
...and GDP (2-6%)
….and will remain
stubbornly high
over the next two decades
Another reality: Low burden middle income countries
Projected HIV prevalence and AIDS expenditure, 2008-31
2008
2015
Prevalence
GDP per
capita
(US$)c
AIDS
exp per
capita
(US$)
AIDS
exp as
% of
THEd
AIDS
exp as
% of
GDP
Brazil
0·6
4,010
4
1·1
Cambodia
0·9
512
3
China
0·1
1,930
India
0·3
Mexico
2030
Prevalence
GDP per
capita
(US$)c
AIDS
exp per
capita
(US$)
AIDS exp
as % of
THEd
AIDS
exp as
% of
GDP
0·1
0·6
4,566
4
1·1
11·0
0·6
0·6
814
5
0
0·5
0·0
0·2
3,277
727
1
1·7
0·1
0·2
0·3
6,320
7
1·8
0·1
Thailand
1·4
2,779
4
1.2
Ukraine
1·6
1,172
2
Vietnam
0·5
661
1
Country
Sources:
Prevalence
GDP
per
capita
(US$)c
AIDS
exp per
capita
(US$)
AIDS
exp as
% of
THEd
AIDS
exp as %
of GDP
0·1
0·5
5,650
4
0·9
0·1
10·7
0·6
0·2
1,903
5
4·2
0·3
3
2·4
0·1
0·2
9,002
3
0·8
0·0
1,090
2
4·2
0·2
0·1
2,388
2
1·8
0·1
0·3
7,009
9
2·1
0·1
0·3
8,018
8
1·6
0·1
0·1
1·1
3,489
4
3·2
0·1
0·6
5,179
3
1·6
0·1
2·2
0·1
1·6
1,817
6
4·8
0·3
1·8
4,332
6
1·9
0·1
2·3
0·1
0·5
963
3
5·7
0·3
0·6
1,822
3
3·0
0·2
Unless otherwise indicated, all numbers are the authors’ own calculations.
c Based on World Bank GDP estimates.
d THE stands for total health expenditure.
AIDS spending will consume
smaller share of health
expenditure (<10%)
...and a smaller
fraction of GDP
With low prevalence, AIDS
spending stable or declining
to 2031
What are the global policy implications?
1. Concentrate on expanded, smarter prevention
2. Make ART more efficient – drugs, tests, personnel, delivery
models
3. Continue investing in game-changing AIDS prevention tools
4. Launch “social movement” for prevention in generalized
settings
5. Encourage middle income countries (and those with
concentrated epidemics) to pay more; pursue donor
“transition” strategies
6. Sustain support for high burden low income countries, but
linked to greater domestic funding (“ownership”) and
commitments to target-based prevention
What is the significance of aids2031-Cambodia?
Selected by our task force to explore the cost and financing options
for a low burden, low income country
1. Cambodia can be an important global leader in targeted
prevention.
2. Cambodia can show how strong prevention helps to alleviate longterm treatment costs.
3. Cambodia can be a global leader in setting a long-term financing
framework to reduce donor dependency.
4. Cambodia can show others how a national team can master an
integrated program/cost/impact modeling approach.
5. Cambodia can show others how a team of epidemiologists and
economists can work together effectively.
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