A comparison of national HIV/AIDS health expenditures in Kenya, Malawi, Rwanda, Tanzania, and Zambia -- before and after the donor influx

Presenter: Susna De, Abt Associates

Abstract

RATIONALE: In recent years, there have been unprecedented increases in external assistance for HIV/AIDS from mechanisms like the US President's Emergency Plan for AIDS Relief, Global Fund to fight AIDS, TB, and Malaria, and the World Bank’s Multicountry HIV/AIDS Program. While this surge in funding is a welcome development, perhaps more critical than the amount invested is how those funds are spent and whether or not they are meeting intended targets. Without this information, stakeholders of recipient countries are poorly equipped to make resource allocation decisions and track the impact of received funds. Recognizing this need, many countries are using a standard resource tracking tool called National Health Accounts to produce focused expenditure reviews, or ‘subaccounts,’ on HIV/AIDS.

OBJECTIVE: Drawing from country subaccount data, this paper aims to describe changes in national HIV financing patterns for Kenya, Malawi, Rwanda, Tanzania, and Zambia - before and after the influx of external financing for HIV/AIDS.

METHODS: The study compares subaccount data from Kenya (2002, 2006), Malawi (2003, 2004, 2005), Rwanda (2000, 2002, 2006), Tanzania (2003, 2006), and Zambia (2002, 2006). With the influx of funds arriving in countries approximately in 2004, the ‘pre-influx period’ occurs before 2004 and the ‘post-influx period’ after 2004. Each country subaccount describes the flow of HIV resources from their sources (public, private and donor) to their end uses.

FINDINGS: The donor HIV influx is largely intended to be supplemental to local investment; however, in three of the five countries, namely Kenya, Malawi, and Zambia, government HIV contributions decreased by 65%, 10%, and 34% respectively compared to pre-influx levels. Domestic private company investments in HIV/AIDS also decreased in 4 of the 5 countries, in some cases by over 50% of pre-influx levels (Kenya, Rwanda Zambia). In comparing the average out-of-pocket expenditure on health by a person who is living with HIV to that of someone in the general pop, PLHIV do spend more for health care; however, this gap has been narrowing substantially since the donor influx. For example in Rwanda in the year 2000, the average expenditure by a person living with HIV was 349% higher than that incurred by someone without HIV and just 28% higher in the post-influx period of 2006. Finally, in all countries studied there is a shift from spending in the informal sector to increased resource consumption at hospitals, health centres, and clinics. For example when compared to pre-influx levels, spending at traditional healers dropped by 47% in Kenya, 20% in Malawi, 33% in Tanzania, and 55% in Zambia.

SIGNIFICANCE OF FINDINGS: In countries experiencing both a drop in government and private company investment, the findings raise concern about the sustainability of HIV financing should external resources wane -- an implication made more poignant when considering the global economic crisis and its potential affect on future donor support. In terms of positive findings, the burden of financing by PLHIV to pay for health care has lessened considerably since the donor influx, and fewer people are seeking care in the informal sector.