In 1998, there was no… • PEPFAR • Global Fund for AIDS, TB, and Malaria • Life Initiative • Bill & Melinda Gates Foundation • World Bank Multi-Country HIV/AIDS Program (MAP)
Global Spending on HIV/AIDS Various sources
What is a Strategic Plan? • “A strategy is nothing more than a series of steps designed to move from one situation towards another.” • - UNAIDS, 1998
Types of Strategic Plans • A general framework which sets fundamental principles, broad strategies, and the institutional framework • A general framework plus more detailed strategies and intermediate steps to reach stated objectives • A general framework plus detailed strategies plus detailed alternatives for each strategy to overcome potential obstacles.
Key Elements of a Strategic Plan • Clear and measurable goals and targets • Clear and justified priorities • A monitoring and evaluation plan • Clearly defined responsibilities for those to carry out the strategic plan • Cost estimates with clear plans for resource mobilization
“The complexities of HIV sometimes have led governments to attempt planning for all eventualities….A more strategic approach concentrates on planning in priority areas, through identifying the epidemic’s most important determinants.” - UNAIDS, 2000
Ways to Prioritize: Wish List Approach: • Identify all possible interventions that donors might support • Distribute resources evenly across interventions • Let others make the priorities Strategic Approach: • Determine criteria for prioritizing • Apply the criteria to possible interventions • Fully fund high priority interventions first
Distribution of National HIV/AIDS Plans Source: Review of National HIV/AIDS Strategies for Countries Participating in the World Bank’s Africa Multi-Country AIDS Program (MAP), World Bank, 2005.
Kenya’s 1999-2004 HIV/AIDS Strategic Plan • Current Strategic Plan: 156 “priority interventions” costing $31 million over 6 years • Top financed interventions: • STI drugs: $4.9 million • Female condoms: $2.9 million • Care programmes for orphans: $1.5 million • Drugs for OIs: $1.0 million • Rural condom distribution: $1.0 million • Resource mobilisation: $1.0 million • Electronic and print media programmes featuring opinion leaders: $0.8 million
Criteria 1: Will the intervention affect the course of the epidemic and/or significantly affect the lives of those already infected?
How have successful countries changed the course of the epidemic? • Uganda • Abstinence, Be Faithful, Condoms • Voluntary Counselling and Testing • Strong political leadership • Thailand • Condoms (100% Condom Use Policy) • STI treatment • Targeted interventions (i.e., CSWs) • Senegal • Strong religious & political leadership • Brazil • Leadership and emphasis on treatment for all
Which Interventions Can Have the Greatest Impact on the Course of the Epidemic? Based on simulation modeling of typical high prevalence urban areas.
Treatment Interventions and Their Likely Impact High Impact Interventions • HAART for PLHAs (Hammer et al., 1996) • Cotrimoxazole for PLHAs (Anglaret et al., 1999) • DOTS for TB and HIV/AIDS (Floyd et al., 1997) Low/No Impact Interventions • Pneumococcal vaccine (French et al., 2000) • Isoniazid preventive therapy (Hawken et al, 1997)
Criteria 2: Is the intervention affordable?
Criteria 3: Does the Intervention Have Adequate Political Support?
Policy Questions • Is there the political support to work with marginalised groups (i.e., gay men, sex workers, people living with HIV/AIDS)? • Can a large-scale investment in treatment be politically sustained?
Criteria 4: Is the Intervention Cost-Effective?
Cost-Effectiveness of AIDS Interventions in Africa Cost per HIV Infection Averted Source: Various economic analyses in Sub-Saharan Africa
Are ARVs Cost-Effective for Limiting MTCT in S. Africa? • “Although antiretrovirals may be relatively cost-effective in this setting, the budget required is currently unaffordable.” (Wilkinson, 1998) • “Antiretroviral interventions are probably cost effective across a wide range of settings...” (Söderlund, 1999) • “A national programme to reduce mother-to-child transmission of HIV infection in South Africa would be an affordable, cost-effective, and potentially cost-saving public health intervention (Wilkinson, 1999) • “…limited use of ARVs could have an immediate and substantial impact on South Africa’s AIDS epidemic.” (Wood, 2000)
Criteria 5: Does the Intervention Warrant Public Subsidy?
Questions to Ask • Does people put a high value on the intervention? • Do the benefits of the intervention extend beyond the consumers (public good)? • Can the consumers (or others) pay for the intervention?
What Interventions have the Highest Priorities (Kenyan data) Source: Forsythe et al, 2000.
Public Goods • Tb treatment • STD treatment • Voluntary counseling and testing • Condom distribution
Willingness to Pay for Care and Prevention (Kenya Data) Source: Forsythe et al, 2000.
Criteria 6: Is the Intervention Equitable?
Equity Questions • How does the intervention affect the poor? • The introduction of HAART would disproportionately hurt the poor of Cote d’Ivoire (Brunet-Jailly, 1998) • The lack of HAART disproportionately hinders the poor in developing countries (Thomas, 1998)
Lesotho: Available Resources Millions $US/yr $10 Million
Resource Requirements Millions $US/yr $333 Million $10 Million
Revising Budgetary Requirements Millions $US/yr $333 Million $99 Million $10 Million
Finalizing Budgetary Requirements Millions $US/yr $333 $99 $41 $10
Conclusions • Policymakers need to establish and use criteria for setting priorities when allocating resources for HIV/AIDS programmes. • Resources should be allocated in a manner that is consistent with a country’s HIV/AIDS priorities.