Improving Funding Allocation within HIV/AIDS Programs in Developing Countries

1.“One reason new infections have not decreased may be that funding is allocated sub optimally. The amount of spending on HIV treatment and control is $15-$17 billion per year. This is an adequate amount of funding to have more impact on both prevention and treatment than has occurred to date. However, the money is allocated very inefficiently.” Conversation with Anil Soni on October 18, 2012

2.“While all acknowledge that behavioral interventions to prevent HIV are important, few trials have yielded evidence on high impact interventions. The exception is male circumcision which remains very under-financed and limited in scope. It is possible that some other spending is also ineffective since many programs have not been evaluated, such as abstinence education. A bigger problem is that it is unknown whether certain interventions have any effect, such as targeted communications and some community-based projects.” Conversation with Amanda Glassman on December 13, 2013

3.“WHO and UNAIDS recommended the intervention be added in countries with high HIV prevalence, generalized heterosexual HIV epidemics, and low levels of male circumcision where the intervention is likely to have the greatest public health impact. Fourteen priority countries with this profile are striving to scale up voluntary medical male circumcision: Botswana, Ethiopia, Kenya, Lesotho, Malawi, Mozambique, Namibia, Rwanda, South Africa, Swaziland, Tanzania, Uganda, Zambia and Zimbabwe.

Medical male circumcision for HIV prevention offers excellent value for money. Recent modelling studies found that reaching 80% coverage among men 15 – 49 years old in the priority countries – by performing approximately 20 million circumcisions – would cost US$1.5 billion and would result in net savings of US$16.5 billion by 2025 due to averted treatment and care costs. Achieving, and maintaining, 80% coverage through 2025 would avert 3.4 million new HIV infections.” WHO voluntary medical male circumcision for HIV prevention fact sheet.

4.“As of December 2012, 3.2 million African men had been circumcised through specific services for voluntary medical male circumcision. The cumulative number of men circumcised almost doubled in 2012, rising from 1.5 million as of December 2011.” UNAIDS report on the global AIDS epidemic 2013, pg 18.

5.“If the objective of these monies is to maximize impact on HIV incidence, a specific example of non-optimally allocated funds is that funders are buying second line medications for HIV to deal with resistant cases while about half of people who are eligible for the more affordable first line treatment are not receiving it (something similar occurs for tuberculosis as well). There is a plausible argument for funding second or third line treatments while first line demands are still partially unmet: a health infrastructure has already been built in some places, and the patients in those places need second and third line treatments. It’s easier to continue working in existing locations, and it’s difficult to say no to existing patients. However, a tradeoff is being made in the decision not to move to new locations.
While it is hard to move to the necessary new places and may require strengthening capacity, it is not a case of a last-mile problem where those new places will be extremely difficult and expensive; rather, half of the population is currently uncovered. This is a tradeoff between two medical interventions that are known to work. Expanding to new areas in order to expand first line treatment may be more costly in the short term than switching existing patients to second or third line treatment, but is better value in terms of disease control in the long run, and likely more equitable as well. This information is in the report from the Center for Global Development’s Value for Money Working Group. [Of course, many funders –governments and donors- take other considerations besides value for money into account when allocating resources. Ethical considerations, for example.]” Conversation with Amanda Glassman on December 13, 2013

“Further, there are still opportunities to scale up the most cost-effective interventions in the pursuit of disease-control objectives. For example, first-line regimens are more cost-effective than second and third-line regimens. In countries that have not fully scaled up the coverage and quality of first-line treatment to the entire eligible population, investing in second- and third-line treatment is not likely the most cost-effective intervention.13 However, the Global Fund subsidizes second- and third-line antiretroviral (ARV) and tuberculosis medications in several low-income countries where first-line coverage and, perhaps, quality remains low. In the last round of commodity spending reported to the Price and Quality Reporting (PQR) system, spending on second- and third-line ARV and tuberculosis medications represented the majority of total medication spending.i Spending on second- and third-line treatment is likely to increase as more patients fail first-line treatment, which may imply tradeoffs in reaching the Global Fund’s expressed disease goals and in achieving equitable access or (still implicit) disease goals specific to drug-resistant strains.ii The Global Fund likely offers second- and third-line regimes for reasons of “gap-filling” role as countries take on (though incompletely) raising coverage and quality of first-line treatment. Or because patients failing on first-line treatment that stay on first-line can develop resistant strains of the virus. Or for ethical reasons of continuing treatment for those already being treated,14 though there are also reasons for doing otherwise—for example, based on the “fair innings” principle.15 Ethical arguments on equitable access aside, the Global Fund risks pursuing an ad hoc approach with an unclear disease-control objective without a systematic policy to tackle the spread of drug resistance and subsequently the use of second- and third-line or other newer treatment regimens.” Center for Global Development More Health for the Money Report, pg 13

6.“Even within the same categories of medication, shifting resources to more cost-effective formulations can yield health gains and savings. For example, research in South Africa found that the most commonly used first-line ARV combination (stavudine, lamivudine, and nevirapine) was among the least cost-effective and efficacious.16 Shifting to another World Health Organization (WHO)–approved first-line regimen would thus be a win-win, both in improving patient outcomes and in saving money. The extent of these potential gains will likely increase in the coming years due to the growing need for second-line treatment.17” Center for Global Development More Health for the Money Report, pg 13-14

7.“HIV interventions are not always clearly or appropriately targeted to high-risk groups. In a sample of grant agreements from five countries with varying epidemiologic profiles (Ethiopia, India, Nigeria, the Philippines, and South Africa), most funding over 2002–12 was either earmarked for the general population, or did not indicate a specified target group.12 While this finding does not necessarily imply that the Global Fund itself did not tailor interventions to specific populations, it suggests that other funders such as PEPFAR are unlikely to know what populations Global Fund grants reach, and to respond accordingly.” Center for Global Development More Health for the Money Report, pg 13

“Much HIV funding is likely spent inefficiently. Clear examples of this include the fact that interventions often are not targeted to critical groups, such as to concentrated epidemics in key populations, and the fact that much spending goes to a variety of non-treatment programs, especially the spending of The Global Fund to Fight AIDS, Tuberculosis and Malaria…
[In some forthcoming research from a colleague, we are finding that low governance countries lose about half the expected effectiveness of the ARV that they receive from all sources. This suggests that both PEPFAR and Global Fund should take governance of recipient countries into account in their allocation formulae – something thus far resisted by Global Fund, for example.]” Conversation with Amanda Glassman on December 13, 2013

8.“The program [PEPFAR] may lose money through their reliance on high-cost US contractors to deliver services, which is a problem the organization acknowledges, and so it is trying to move towards working with country-based organizations. It will be important for that move to be monitored to determine whether the work becomes more efficient and effective.” Conversation with Amanda Glassman on December 13, 2013

9.More from our Conversation with Amanda Glassman on December 13, 2013:

“It is not possible to track spending on HIV treatment and prevention by intervention, since large organizations working on HIV don’t collect or share sufficient information and the field has poor reporting standards. For instance, the President’s Emergency Plan for AIDS Relief (PEPFAR) doesn’t have good data on the characteristics of the people that have enrolled in treatment, and the retention rate and quality of their treatment program.”

“[I]t is unknown whether certain interventions have any effect, such as targeted communications and some community-based projects. Such programs are relatively common, but it isn’t possible to identify how much funding they have.”

“PEPFAR collects lots of data that it doesn’t share with the public.”

“There is limited information in the public domain on how PEPFAR funding is spent, and, consequently, the effectiveness and efficiency of that spending (Biesma et al. 2009; Oomman et al. 2008). Historically, PEPFAR has made public only very limited data on the unit costs or cost-effectiveness of its programs, specifically two reports on the cost of ARV treatment (OGAC 2010; OGAC 2012a) and a related journal article (Menzies et al. 2011). Most recently, PEPFAR has published preliminary findings from its Expenditure Analysis Initiative (OGAC 2012b), which connects expenditure data to outputs in order to “determine the expenditure per beneficiary reached for a wide variety of services” (Holmes et al. 2012). However, the pilot report is limited in scope and does not include the underlying data, but instead “provides a curated sample” of findings, “which makes it difficult to draw any concrete conclusions from the data” (Fan et al. 2012b).” Center for Global Development Financial Flows of PEPFAR report, pg 1-2

10.“PEPFAR is committed to restricting funding to interventions that are effective against AIDS, but it isn’t currently possible to see that that happens in practice. It remains to be seen whether the new leadership of the organization will put money behind performance verification. PEPFAR collects lots of data that it doesn’t share with the public.
The program may lose money through their reliance on high-cost US contractors to deliver services, which is a problem the organization acknowledges, and so it is trying to move towards working with country-based organizations. It will be important for that move to be monitored to determine whether the work becomes more efficient and effective.

The Global Fund and PEPFAR are interested in more closely tracking the costs of interventions, and are starting to do so. Ideally they will prioritize products that are the best value for money rather than the cheapest. That said, there hasn’t been much progress on increased performance verification, which may be the most important thing, nor has there been much progress on making budgets more transparent so that it is possible to identify how much is allocated to each intervention.” Conversation with Amanda Glassman on December 13, 2013

“The Global Fund board is currently prioritizing improved allocation of funds as part of its five-year strategy and new funding model.” Conversation with Anil Soni on October 18, 2012

11.“The United Nations Programme on HIV/AIDS (UNAIDS) founded an economic reference group with money from the Gates Foundation that is supposed to focus on allocative efficiency, sustainability and costing.” Conversation with Amanda Glassman on December 13, 2013

12.“The American Foundation for AIDS Research did a study examining the issue of population targeting for HIV interventions.
There are a handful of HIV civic groups that watch what’s happening with HIV treatment within African countries, including South Africa. Here is a short list: itpcglobal.org ; aidspan.org ; aidsaccountability.org (South Africa)
The World Bank also does some related work on public expenditure tracking surveys, although does not focus specifically on AIDS. It conducts surveys and identifies bottlenecks in spending, normally for the public sector rather than for non-governmental organizations. The surveys for the expenditure tracking are put out by the World Bank’s Poverty Reduction and Economic Management team, and their use in different sectors depends on each in-country team. There is also an interesting initiative on measuring and mapping service delivery, which could include greater work on HIV-related issues.
The International Budget Partnership project at the Center for Budget and Policy Priorities, based in DC with some in-country affiliates, does some budget watching and creates report cards for frontline service providers. However, it does not have a particular focus on HIV. It largely focuses instead on maternal health, mainly because maternal health doesn’t receive much funding.
The Institute for Health Metrics and Evaluation has done some work on the efficiency frontier of health spending.” Conversation with Amanda Glassman on December 13, 2013

13.“Academics who have worked on efficiency issues in AIDS spending:

• Stefano Bertozzi, UC Berkeley
• Tim Hallett, Imperial College London
• Paul Revill, University of York
• Gesine Meyer-Rath, Boston University (based in South Africa)
• Nicolas Menzies, Harvard
• Josh Salomon, Harvard
• Alan Whiteside, University of KwaZulu-Natal
• Mike Hammond, IHME
• Markus Haacker, London School of Hygiene and Tropical Medicine
• Robert Greener, Oxford
• Damian Walker, Gates Foundation”

Conversation with Amanda Glassman on December 13, 2013

14.From our Conversation with Amanda Glassman on December 13, 2013:

“Outside organizations could take a couple of approaches to change the state of HIV funding:

• • Support open government and budget watchdog groups on the ground, such as civil society groups or groups doing data audits, to follow intervention coverage and quality.
  • Pressure the organizations involved, possibly by donating enough to secure a seat on the board of e.g. the Global Fund, to measure their results and prepare budgets which connect money to interventions and track the results.
  • Improve epidemiological data to know where people are affected geographically so that the interventions which are known to work can be targeted more effectively.
  • Promoting specific interventions that are well-supported by evidence. A possible example is male circumcision, which may be underinvested in relative to its evidence base because of low donor interest, cultural objections, and the difficulty in extending the intervention to adult men. PEPFAR has become interested in male circumcision recently.
  • Pressure the HIV community via the Center for Global Development. The Center has had some success in pushing the World Bank and the Global Fund to do results-based funding.”

From our Conversation with Anil Soni on October 18, 2012: “Because the limiting factor in HIV control is inefficient allocation of funding rather than insufficient funding, one of the best uses of donations to improve HIV treatment would be to fund efforts to influence large funders, such as the Global Fund, to use their HIV money more efficiently. The Global Fund board is currently prioritizing improved allocation of funds as part of its five-year strategy and new funding model. The Gates Foundation is also prioritizing “efficiency and effectiveness” in its grant-making. Still, more investment in this area is justified.

Other approaches to improving the funding situation might include:

Working with countries so that they can better allocate funding they receive from major funders such as the Global Fund. For example, the Clinton Health Access Initiative worked with the Rwandan government to help them get a comprehensive picture of what HIV interventions are being funded in their country and how they can reallocate HIV resources optimally. One approach to improving allocation of HIV funding would be to sponsor similar projects in other countries. The ELMA Philanthropies and the Joint United Nations Programme on HIV/AIDS (UNAIDS) have some interest in doing so.

One could try to draw focus to the most cost-effective interventions HIV interventions by running large scale trials and publishing the results in an article or series of articles in the Lancet if it turns out that certain clusters of interventions do much better than others. This might influence funders because they would want to fund interventions with the strongest evidence bases.

15.“Rwanda and Ethiopia have seen great strides in global health relative to other countries. This can largely be attributed to the managerial strength of their heads of states, ministers of health and program managers. Increasing talent is a worthy target for external investment to replicate their success in other settings, and to make the most of available funding from other donors.” Conversation with Anil Soni on October 18, 2012