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Challenges in Donor Funding in Zambia: the Example of HIV/AIDS Funding Preliminary observations 3/18/2018 Challenges in Donor Funding in Zambia: the Example of HIV/AIDS Funding Preliminary observations 3/18/2018 27 May 2008 1

Outline of the Presentation l A) Health Care Financing: ¡ 1. Main Sources of Outline of the Presentation l A) Health Care Financing: ¡ 1. Main Sources of Health Financing. ¡ 2. Health Financing Modalities. ¡ 3. Recent changes to the Funding Modalities. ¡ 4. Donor funding to health. l B) Challenges of HIV/AIDS funding for the health sector: ¡ 5. Overall ¡ 6. Procurement ¡ 7. Management information systems l HR: talked about elsewhere…? ? [Sylvia, you may have to include a few slides on this during the workshop; you decide] 3/18/2018 2

1. Main Sources of Health Financing l MOFNP – taxes (and small? medical levy) 1. Main Sources of Health Financing l MOFNP – taxes (and small? medical levy) l Households – OOP, inc. user fees*; and (community) pre-payments. l External/donor funds – foreign taxes and other external funds (through GIs). l Other sources: ¡Medical saving scheme (mining companies); ¡private health insurance, ¡other e. g. , fuel contribution by Total ¡potentially SHI, etc 3/18/2018 3

2. Health Financing Modalities l SWAp = GBS through MOFNP. l SWAp = direct 2. Health Financing Modalities l SWAp = GBS through MOFNP. l SWAp = direct funding of expanded basket. ¡ SWAp is strongly preferred by MOH. l Vertical funding GAVI, GF, etc. earmarked to specific interventions in health and is on-budget. l Parallel funding: e. g. , PEPFAR, which is earmarked to specific interventions in health and is off-budget. l Facility and community level financing: ¡ User fees (now in urban areas only). ¡ Pre-payment schemes? ? ? ¡ Other income generating activities Sylvia, maybe provide a few examples verbally during presentation (look in PETS report if you need ideas) 3/18/2018 4

3. Changes to the Funding Modalities l Zambia Aids Policy (2005) & Joint Assistance 3. Changes to the Funding Modalities l Zambia Aids Policy (2005) & Joint Assistance Strategy for Zambia (JASZ) defining Wider Harmonization in Practice (WHIP). l WHIP has involved: ¡ Movements from project to GBS. ¡ Interim movements were observed: l Movement to GBS e. g. , EU, Df. ID, etc. l Movement away from health to other sectors e. g. , DANIDA initially moved to education. l Some stayed in Health e. g. , Sida, Df. ID (replacement fund in 2005/06) but are intending to move. 3/18/2018 5

4. Donor Funding: Average Shares of Total Health Expenditure in 2004 (Source: NHA) update 4. Donor Funding: Average Shares of Total Health Expenditure in 2004 (Source: NHA) update with NHA 2007/08, if that is available… 3/18/2018 6

B) Challenges of HIV/AIDS funding for the health sector: l Recall: ¡ 5. Overall B) Challenges of HIV/AIDS funding for the health sector: l Recall: ¡ 5. Overall l. Size of the funds l. Planning difficulties l. Emerging difficulties in implementation ¡ 6. Procurement l. New systems and implication ¡ 7. Management information systems l. New systems and implication Add “ 8. Human resource” if you included some slides on HR 3/18/2018 7

5. Overall Challenges of HIV/AIDS Funding (Size of the funds) 3/18/2018 8 5. Overall Challenges of HIV/AIDS Funding (Size of the funds) 3/18/2018 8

5. Overall Size of HIV/AIDS Funding – cont’d 3/18/2018 9 5. Overall Size of HIV/AIDS Funding – cont’d 3/18/2018 9

5. Overall Size of HIV/AIDS Funding – cont’d 3/18/2018 10 5. Overall Size of HIV/AIDS Funding – cont’d 3/18/2018 10

5. Overall Challenges of HIV/AIDS Funding – Cont’d l Implication of the size…: ¡National 5. Overall Challenges of HIV/AIDS Funding – Cont’d l Implication of the size…: ¡National stewardship is potentially weakened. ¡Preferred SWAp (all the systems, processes, structures, tools, etc) is potentially undermined. ¡Reporting allegiances are potentially formed with funders. ¡Mutual accountability is potentially weakened. ¡Potential health systems distortions / destabilization… 3/18/2018 11

5. Overall Challenges of HIV/AIDS Funding – Cont’d l Potential health systems distortions / 5. Overall Challenges of HIV/AIDS Funding – Cont’d l Potential health systems distortions / destabilization: ¡ Planning cycle mismatches make coordination difficult. ¡ Unplanned HIV/AIDS spending that shows up in health facilities at district level make it hard for MOH to request for supplementary budgets from MOFNP. ¡ HR and other resource deflections (time, attention, etc) goes to well funded programme HIV/AIDS l Specific health system effects ¡ Procurement in health ¡ Management information systems 3/18/2018 12

6. Procurement in Health l New systems: HIV Procurement. xls, and l How involving 6. Procurement in Health l New systems: HIV Procurement. xls, and l How involving is HIV procurement? 3/18/2018 13

6. Procurement in Health – cont’d l Implication of new procurement systems and demands: 6. Procurement in Health – cont’d l Implication of new procurement systems and demands: ¡(+) More efficient HIV procurement systems, e. g. , less stock-outs. ¡(-) Coordinator difficulties, e. g. , with transportation/distribution schedules. ¡(-) Limited externalities LMU has limited spillover to general health procurement (PSU). ¡(-) Further limitation of MOH stewardship (not adequately involved in HIV procurement planning). 3/18/2018 14

7. Management Information Systems l HIS: HIV & Health Info Systems. xls, and l 7. Management Information Systems l HIS: HIV & Health Info Systems. xls, and l How is health information generated and collected? 3/18/2018 15

7. Health information systems – cont’d l Implication of new HISs and demands: ¡(+) 7. Health information systems – cont’d l Implication of new HISs and demands: ¡(+) Much more information generated. Note: HMIS has had its own weaknesses, but with HIV… ¡(-) Disproportionately more information for HIV/AIDS is generated – resource deflection: l. ARTIS is information heavy (combination of multiple systems that previous existed) extra burden for HWs; & it has been unable to integrate with HMIS. l. SMARTCare was originally for overall patient records/HMIS, but to date ART, ANC-PMTCT & VCT are the only automated services. ¡(-) Limited feedback to lower levels, does not improve with HIV/AIDS focus info. systems. 3/18/2018 16

Recommendation for Global Partners MOH point of view: l Increased commitment/support to national health Recommendation for Global Partners MOH point of view: l Increased commitment/support to national health systems and programmes; buy into SWAp (joint planning, joint procurements, integrated financing / accounting / information / reporting / etc. systems, etc. ). l Improve information sharing about funding amounts and timings, towards improving predictability and fostering national planning/priority setting. l Full subscription by all partners to principle of mutual accountability. 3/18/2018 17

Conclusion Point of view of the series of studies: l A lot has not Conclusion Point of view of the series of studies: l A lot has not been covered here (further research is required…) l From preliminary observations: ¡ Government systems require attention. ¡ Government is not sufficiently honouring Aduja declaration & may be sending negative signal. ¡ Partners are not unified: in their willingness to lose some amount of identity; & in buying into government systems. l Long road ahead in building HS, which will require dialogue and like mindedness. 3/18/2018 18

Thank you for your attention, enjoy Livingstone 3/18/2018 19 Thank you for your attention, enjoy Livingstone 3/18/2018 19