Total HIV expenditure

Export Indicator

Domestic and international HIV expenditure by programme categories and financing sources
What it measures

Financing flows and expenditures of in-country HIV programmes/services by source in a standardized and comparable manner according to mutually exclusive categories. The HIV expenditures by programme or service here reported would need to be consistent with the number of people who have received the services reported elsewhere.

Rationale
The international and domestic resource availability for the HIV response reached an estimated US$ 19.1 billion in low- and middle-income countries by the end of 2016. Achieving country -and global- targets requires increased focus, resources, programme effectiveness and efficiency to provide the HIV care, treatment and prevention to reduce HIV incidence and extend life.

It is critical to identify long-term, sustainable financing sources including domestic resource mobilization, to maintain and build upon the successes achieved. Yet, filling the financing gap and pursuing efficient resource allocation can only be achieved by assessing and managing the resources available and their use.

The quantification of financing flows and expenditures helps to examine the questions of who benefits from HIV programmes and to determine the current state of allocations for HIV programmes/services in the targeting of key or other specific populations.

The National AIDS Spending Assessment classifications and definitions developed by UNAIDS are recommended as the framework to track and report HIV expenditure.

NASAs have been applied in more than 70 countries worldwide. NASA’s classifications were defined by aligning the AIDS Spending Categories (ASC) to the programmes or services costed as part of the resource needs estimation process, which are the interventions/services with known impact on the HIV relevant outcomes, i.e. HIV incidence and AIDS-related mortality. In addition, NASAs provide a comprehensive set of mutually exclusive AIDS Spending Categories (ASC) to classify additional expenditures that may exist in any given country, even if they do not correspond to the resource needs estimation. The alignment between resources available and resource needs by specific services or programmes was designed to measure the financing gap and indicate insufficiency of resources or potential efficiency gains to be achieved by each programme for the combination of sources and providers.

There are other resource tracking approaches which have also been applied to assess HIV expenditures from domestic and international sources, including Health Accounts, Budget reviews, and ad-hoc surveys. We recommend the use of social accounting frameworks (NASA and SHA) to best report on this indicator.

The indicator and sub-indicators here described can be extracted directly from a NASA exercise. Other approaches may or may not directly provide the whole set of sub-indicators here listed. In such instances, it is recommended to provide the information in the AIDS funding matrix at the level of granularity available from the resource tracking methodology employed by the country and explicitly indicate the non-availability of disaggregated information as applicable.

As in previous years, the basis for this report is the National Funding Matrix, a reporting template which sets out HIV programme areas disaggregated by individual interventions or services and by financing source. This matrix was designed to include the totality of resources invested in HIV in a given year by all sources, thus there is a longer list of services/programmes which can be used to describe the use of the resources, while only a subset will be used to inform the sub-indicators.

The vast majority of the AIDS Spending Categories (ASCs) or the sub-indicators are not new, but are drawn from existing frameworks and are now structured around the 10 commitments derived from the 2016 Political Declaration on HIV and AIDS: On the Fast-Track to accelerate the fight against HIV and to end the AIDS epidemic by 2030.

The cover page of the funding matrix has been expanded to capture information on budgets and the resource tracking exercises conducted in the country.

The indicator to be reported is “Total HIV Expenditure” by services or programme categories and by financing sources. There are eight core subindicators as outlined hereafter:

COMMITMENT 8: Ensure that HIV investments increase to US$ 26 billion by 2020, including a quarter for HIV prevention and 6% for social enablers

8.1. Total HIV Expenditure (by service/programme category and financing source)

A. Expenditure on HIV testing and counselling (non-targeted)

B. Expenditure on antiretroviral therapy (adults and paediatric)

C. Expenditure on HIV-specific laboratory monitoring (CD4 cell counts, VL quantification)

D. Expenditure on TB/HIV

E. Expenditure on the five pillars of combination prevention:

  • Prevention for young women and adolescent girls (10-24 years, exclusively in high prevalence countries)
  • Voluntary medical male circumcision (exclusively in high prevalence countries)
  • Pre-exposure prophylaxis (PrEP) stratified by key population (gay men and other men who have sex with men (MSM); sex workers; persons who inject drugs (PWIDs); transgender persons; prisoners; young women and adolescent girls (10-24 years); serodiscordant couples)
  • Condoms (non-targeted)
  • Prevention among key populations (gay men and other MSM; sex workers and their clients; PWIDs; transgender people; prisoners and other incarcerated people).

F. Expenditure on prevention of vertical transmission of HIV

G. Expenditure on social enablers

H. Expenditure on cash transfer for young women and girls (10-24 years, high prevalence countries; HIV-earmarked budgets)

The definition of the core sub-indicators and associated criteria such as scope, disaggregation, target populations, methods of measurement are summarily provided below. More detailed information on the full range of HIV programme areas and interventions is provided in Annex 2. In addition, to assist with data collection and reporting Annex 2 provides a crosswalk between HIV programme categories of the national funding matrix and the AIDS Spending Categories of the National AIDS Spending Assessment. The definition, scope and boundaries for the services included in the National Funding Matrix to be reported in the online reporting tool will be described in more detail in the indicator registry.

 

 

Numerator

Not applicable

Denominator

Not applicable

Calculation

Social accounting and costing principles are applied. Rules, frameworks and principles are described in the specific manuals and guidelines (links provided below).

The calculation of each service/programme or sub-indicator may have individual characteristics to ensure proper accounting of all components (e.g. direct and shared costs of service provision) and to avoid double counting; these calculations may be different by each financing source and service delivery modality (or even by provider of services). Further guidance is available in the respective guidelines and manuals listed at the end of this section.

The quantification is limited to in-country expenditures, volumes of antiretroviral drugs procured and distributed and disaggregates by the expenditures using international development assistance funds and the expenditures incurred using public or private funds.

There are certain requirements for data collection and quality to ensure reliability and validity of the indicators to assure credibility.

The conciliation of top-down estimates (from the financing sources) and bottom-up (from the costing of service delivery) provides the best assessment of the total HIV in-country spending.

Financial and programme records from providers or service delivery organizations are the basis for data collection.

There are documented significant discrepancies between budgetary allocations and actual expenditures. Thus budget analysis is not recommended as the sole basis to report total in-country HIV expenditure.

It might be good practice to validate expenditures funded by international sources, national financing sources and financing agents, as well as all relevant stakeholders.

Method of measurement

Data Type

Currency and monetary values; monetary values and volumes of ARVs and commodities in general procured and distributed.

Data collection tools

Countries develop their reports on HIV expenditure by programme/service categories and financing sources using the national funding matrix template. A full range of HIV programme categories is provided in the Annex 2. If countries have developed a full and proper NASA, the filling of the funding matrix constitutes only an output template from the exercise. If countries have developed a health account using the SHA-2011 framework, the cells of the funding matrix can be filled, particularly for the international sources, and in some cases for the domestic financing.

Method of Measurement

Primary: 

  • National AIDS Spending Assessments (NASA)
  • Logistics Management Information systems (LMIS) and Procurement Supply Chain Management systems for information on commodities.

Alternative: 

  • System of Health Accounts 2011 (SHA-2011)

Note: 

  • Countries may use centrally produced results for PEPFAR Expenditure Analysis to report on in-country expenditure financed by PEPFAR and the different agencies involved. 
  • Health Accounts using the System of Health Accounts-2011 framework with full disease distribution attempt to capture top-level elements of National AIDS spending categories. However, depending on the objectives of a given resource-tracking exercise, the System of Health Accounts 2011 may or may not inform on the totality of HIV granular expenditure (disaggregated by programme) as required. The SHA-2011 accounting framework may have to be supplemented by costing principles to disaggregate HIV part of the joint costs incurred by the system.
Measurement frequency

Annually for calendar or fiscal year. Since the final results of any accounting exercise may take time longer than the deadline for annual reporting, countries may submit preliminary results which will be substituted when final results are available. In this reporting cycle, we suggest that countries submit up any number of annual final reports available from the last 5 years, indicating their status as preliminary or final and whether these substitute previous reports. It is not required to re-submit the data that have previously been reported and remained unchanged. UNAIDS team can be contacted for assistance if countries would like to submit more recent reports on expenditures prior to 2010.

Disaggregation
  • Financing source
  • HIV and AIDS programme categories
  • For selected sub-indicators, countries are encouraged to report expenditures on the most salient commodities under such programme (e.g. Antiretrovirals in the antiretroviral treatment sub-indicator) separately from the rest of other direct and indirect expenditures like service delivery, etc.
  • Commodities, unit prices and volumes are to be reported by funding source in the respective table.
     
Strengths and weaknesses

 

Countries which have implemented a full National AIDS Spending Assessment (NASA) appropriately are able to fill the template with an output table from the NASA exercise. However, NASAs are labour intensive (and potentially relatively costly) and take time to be properly developed, use a combination of accounting and costing techniques, thus the costing estimates are not certified data as some accounting principles might require. Final country estimates need to be validated with all stakeholders and triangulated to increase reliability and validity.

The countries which have implemented a SHA-2011 annual exercise may need to ensure that the allocation keys used to estimate HIV expenditures from the utilization of the health system are updated and allow the granular data for domestic sources. This process may not use certified data as some accounting principles might require. Countries which have just started the process of full-distributional health accounts need to validate the results with other existing sources and all stakeholders to increase reliability and validity of the estimates, in particular the overall level, potential duplication and significant unaccounted expenditures. The non-health expenditures need to be added. The implementation of health accounts need medium- to long-term planning, are resource intensive and depend on coordination between health accountants and programme managers.

 

Countries using budget analysis need to ensure that allocated budgets were actually spent as planned -or otherwise, and supplement the estimates for the expenditures which do not occur based on an earmarked budget.

Further information

 

 List of core sub-indicators and associated statistical metadata

 

Sub-indicators

Disaggregation

Target population

What it measures

8.1. Total HIV expenditure

Funding source, service/ programme category

Not Applicable

Total expenditure from all sources spent on HIV and AIDS at the national level, including health and non-health.

A. Expenditure on HIV testing and counselling (non-targeted; specific commodities separately)

 

Funding source

General population under specific indications

HIV testing and counselling is used to refer to all services involving HIV testing provided with counselling, including: client-initiated HIV testing and counselling; provider-initiated testing and counselling; HTC as part of a campaign, or through outreach services or through home-based testing.

Direct expenditures in the purchase of reagents for laboratory and rapid tests to be reported separately from other costs as available.

B. Expenditure on antiretroviral (ARV) therapy (adults and paediatric; specific commodities separately)

Funding source, adults and children (younger than 15 years old)

Persons living with HIV

Antiretroviral therapy.

Direct expenditures in the purchase of antiretrovirals separately from other from other costs as available).

Unit prices and volumes of commodities procured/distributed.

C. Expenditure on HIV-specific laboratory monitoring (specific commodities separately)

Funding source

Persons living with HIV on Antiretroviral Therapy

Diagnostic services related to HIV clinical monitoring.

Direct expenditures in the purchase of reagents for laboratory for CD4+ cell counts and viral load quantification separately from other commodities and service delivery from other costs as available).

D. Expenditure on TB/HIV

(specific commodities separately)

 

Funding source

Persons living with HIV and people living with tuberculosis

 

Examinations, clinical monitoring, related laboratory services, treatment and prevention of TB (including isoniazid and drugs for treating active TB) as well as screening and referring clients of TB clinics for HIV testing and clinical care.

Direct expenditures in the purchase of drugs for the treatment and prevention of tuberculosis (including isoniazid and drugs for treating active Tb) separately from other commodities and service delivery costs as available.

E. Expenditure on the five pillars of combination prevention

(specific commodities separately)

Funding source, five pillars of combination prevention:

●         Prevention for young women and adolescent girls (10-24 years, exclusively high prevalence countries)

●         Voluntary medical male circumcision (exclusively high prevalence countries)

●         Pre-exposure prophylaxis (PrEP) stratified by key population (gay men and other MSM; sex workers; PWIDs; transgender people; prisoners; young women and adolescent girls; serodiscordant couples).

●         Condoms (non-targeted))

●         Prevention among key populations (gay men and other MSM; sex workers and their clients; PWIDs; transgender people; prisoners).

General population, key populations

This subset of prevention services is labelled and defined as combination prevention. The rest of the HIV prevention services are to be specified within the categories of the national funding matrix as part of broader prevention services.

This subset includes prevention services specifically designed and delivered for each of the key populations, including prevention services for young women and adolescent girls (10-24 years) in high prevalence countries, men who have sex with men, sex workers and their clients, people who inject drugs, voluntary male medical circumcision, pre-exposure prophylaxis stratified by key populations, as well as condom promotion and provision for general population.

Direct expenditures in the purchase of condoms, needles, syringes and drugs for substitution therapy separately from other costs as available).

 

F. Expenditure on prevention of vertical transmission of HIV

(specific commodities separately)

Funding source,

Pregnant women and newborns

Activities aimed at elimination of new HIV infections in children, including: HIV testing for pregnant women, antiretroviral therapy for pregnant women living with HIV and antiretroviral medicine prophylaxis for newborns, safe childbirth practices; counselling and support for maternal nutrition and exclusive breastfeeding.

Note: When a woman living with HIV receives antiretroviral therapy as a part of her treatment before she knows she is pregnant the antiretroviral treatment should be included under ARV therapy for adults.

G. Expenditure on social enablers

Funding source

Not Applicable

Activities to support the implementation of basic programmes as defined in the UNAIDS Investment Framework, including political commitment and advocacy; mass media; laws, legal policies and practices; community mobilization; stigma reduction and human rights programmes.

H. Expenditure on cash transfers for young women and girls (10-24 years, high prevalence countries; HIV earmarked budgets)

Funding source

Young women and girls (10-24 years)

Total expenditure on cash transfers for young women and girls (10-24 years). This is defined as a development synergy with implications for HIV prevention.

 

National AIDS Spending Assessment guidelines are available at: http://www.unaids.org/en/dataanalysis/datatools/nasapublicationsandtools

National AIDS Spending Assessment country reports are available at: http://www.unaids.org/en/dataanalysis/knowyourresponse/nasacountryreports

System of Health Accounts 2011 guidelines are available at: http://www.who.int/health-accounts/methodology/en

Health Accounts reports are available at the WHO Global Health Expenditure Database: http://apps.who.int/nha/database/DocumentationCentre/Index/en

Health Expenditures by Diseases and Conditions (HEDIC). Statistical working papers. Eurostat. 2016. Available at: http://ec.europa.eu/eurostat/web/ products-statistical-working-papers/-/KS-TC-16-008