LESOTHO NATIONAL AIDS SPENDING ASSESSMENT (NASA) FOR THE PERIOD 2005/ /08

Transcription

1 LESOTHO NATIONAL AIDS SPENDING ASSESSMENT (NASA) FOR THE PERIOD 2005/ /08 National AIDS Spending Assessment (NASA) 1

2 NASA Team: Khobotle Mokete Section Head M&E NAC Relebohile Tshehlo Research Officer NAC Lineo Mahula Data Officer M&E NAC Lineo Seitlheko Research Officer NAC Thenjiwe Jankie Research Officer NAC Mohau Mokoatsi Research Officer UNAIDS Pheello Pompong Research Officer UNAIDS Dlamini Mosele Research Officer UNAIDS Abhimanyu Chitoshia Consultant UNAIDS National AIDS Spending Assessment (NASA) 2

3 Table of Contents Abbreviation...5 Acknowledgements...6 Executive Summary...8 Introduction...9 Global and Regional Epidemic...9 National Status of the Epidemic...9 Lesotho National Strategic Plan for HIV and AIDS Resource Mobilization for the Fight against HIV and AIDS Lesotho s NASA Study Objectives Definition of Concepts Methodology Overall Approach Preparatory Phase Data Collection Qualitative Data Collection and Analysis Data Processing Assumptions Estimation of Expenditure on STI and AIDS through Health System Drug Procurement & Supply Costs Limitations Findings of the NASA Total Expenditure on HIV and AIDS in Lesotho Total Expenditure on HIV and AIDS by Sources of Funding Expenditure Breakdown by AIDS Spending Category Expenditure Breakdown by NSP Categories Spending Priorities by Sources of Funding for 2005/ Spending Priorities by Sources of Funding for 2006/ Spending Priorities by Sources of Funding for 2007/ Expenditure on Prevention Activities Expenditure on Beneficiary Populations Expenditure through Providers of Services Qualitative Data Findings Process of Funding Reporting Requirements Funding Envelopes and Disbursals Communication Gaps Human Resource Capacity Recommendations Recommendations Relating to Reporting and Information Systems Recommendations Relating to Spending Priorities and Achievement of NSP Goals 38 Recommendations to NAC Recommendations to Ministry of Health and Social Welfare Recommendations to Development Partners and UN Agencies Recommendation relating to subsequent NASA Appendix I: Status of Data Collected with Comments Appendix II: ASC Priorities vs NSP Priorities National AIDS Spending Assessment (NASA) 3

4 Appendix III: Total Spending by Expanded Categories for 2005/06 and 2006/0746 Appendix IV: NASA Matrices for 2005/06 and 2006/ Appendix V Estimation of Expenditure on STI and AIDS through Health System 51 Appendix VI: NASA Data Collection Forms and Processing Tools Figures Figure 1: Total Expenditure in Maloti on HIV and AIDS in Lesotho for the financial years 2005/06, 2006/07 and 2007/ Figure 2: Total Expenditure in Maloti by Sources of Funding for 2005/06, 2006/07 and 2007/08 20 Figure 3: Expenditure Breakdown in Maloti by ASC for 2005/06, 2006/07 and 2007/ Figure 4: Actual Spending Priorities based on NSP categories for 2005/06, 2006/07 and 2007/08 22 Figure 5: Planned NSP Spending Priorities for 2006/07 and 2007/ Figure 6: ASC based Expenditure Breakdown in Maloti by Sources of Funding for 2005/06.24 Figure 7: ASC Based Expenditure Breakdown in Maloti by Sources of Funding for 2006/07 24 Figure 8 ASC Based Expenditure Breakdown in Maloti by Sources of Funding for 2007/08.25 Figure 9 Prevention Expenditure Percentage Breakdown for 2005/06 from all Sources Figure 10 Prevention Expenditure Percentage Breakdown for 2006/07 from all Sources Figure 11 Prevention Expenditure Percentage Breakdown for 2007/08 from all Sources Figure 12 Prevention Expenditure Breakdown in Maloti for all Sources for 2005/06, 2006/07 and 2007/ Figure 13 Treatment & Care Expenditure Percentage Breakdown for 2005/06 from all Sources 29 Figure 14 Treatment & Care Expenditure Percentage Breakdown for 2006/07 from all Sources 29 Figure 15 Treatment & Care Expenditure Percentage Breakdown for 2007/08 from all Sources 30 Figure 16 Treatment & Care Expenditure Breakdown in Maloti for all Sources in 2005/06, 2006/07 and 2007/ Figure 17 Beneficiary Population Based Programmatic Expenditure Breakdown in Maloti for 2005/06 32 Figure 18 Beneficiary Population Based Programmatic Expenditure Breakdown in Maloti for 2006/07 33 Figure 19 Beneficiary Population Based Programmatic Expenditure Breakdown in Maloti for 2007/08 33 Figure 20 Programmatic Expenditure Breakdown in Maloti Based on class of Providers for 2005/06, 2006/07 and 2007/ Tables Table 1: General targets from the National Strategic Plan Table 2: National Strategic Plan and AIDS Spending Category Mapping Table 3 Estimated Costs of the NSP Table 4: Service types with unit cost and quantity availability Table 5: Matrix with Unit Cost Availability and Gaps Table 6: HIV +ve Patient Proportion for Hospitals Abbreviation AIDS ALAFA ART ARVs BHA CHAL Acquired Immunodeficiency Syndrome Apparel Lesotho Alliance to Fight AIDS Antiretroviral Therapy Antiretrovirals Boston Health Alliance Christian Health Association of Lesotho CRS Catholic Relief Services DFID UK Department for International Development FBO Faith Based Organization FIDA Federation of Women Lawyers in Lesotho GFATM Global Fund to Fight TB, AIDS and Malaria GoL Government of Lesotho National AIDS Spending Assessment (NASA) 4

5 GTZ German Technical Cooperation HBC Home Based Care HIV Human Immunodeficiency Virus HPSU Health Planning Statistics Unit, MoHSW IPD Inpatient Department LIRAC Lesotho Inter Religious AIDS Consortium LPPA Lesotho Planned Parenthood Association LSC Lesotho Save the Children LRC Lesotho Red Cross M Maloti (Lesotho Currency) MoAFS Ministry of Agriculture and Food Security MoET Ministry of Education and Training MoGYSR Ministry of Gender Youth Sports and Recreation MoHSW Ministry of Health and Social Welfare MSF Medecins Sans Frontieres NAC National AIDS Commission NASA National AIDS Spending Assessment NDSO National Drug Supply Organization NGO s Non-Governmental Organizations NSP National Strategic Plan OI Opportunistic Infections OOPE Our-Of-Pocket Expenditure OPD Out Patient Department PEP Post-Exposure Prophylaxis PEPFAR Presidential Emergency Plan for AIDS Relief PLWHA People living with HIV/AIDS PMTCT Prevention of Mother-to- Child Transmission PSI Population Services International PU Pharmaceutical Unit, MoHSW SIPAA Support to International Partnership against AIDS in Africa STI Sexually Transmitted Infections TB Tuberculosis TSF Technical Support Facility TTL Touching Tiny Lives UN United Nations UNAIDS Joint United Nations Program on HIV/AIDS UNDP United Nations Development Programme UNGASS United Nations General Assembly Special Session on HIV and AIDS UNICEF United Nations Children s Fund USAID United States Agency for International Development URC University Research Co., LLC VCT Voluntary Counseling and Testing WFP World Food Programme WHO World Health Organization National AIDS Spending Assessment (NASA) 5

6 Acknowledgements The National AIDS Commission would like to thank all civil society organizations, development partners, UN Family Agencies and donors that provided data and therefore contributed to the success of this assessment. It would not have been possible to compile the National AIDS Spending Assessment if it were not for the support provided through your organizations. Gratitude is due to the team that worked on this exercise comprising NAC and UNAIDS staff members. The entire team including those who left before the exercise was over did a good job under trying circumstances since it was the first time the country undertook the exercise and organizations which had to provide financial data were suspicious and thought they were being audited. UNAIDS is a strong partner and ally in the fight against the pandemic and their unwavering support in this endeavour is testimony to National AIDS Spending Assessment (NASA) 6

7 this fact. We would further like to thank the German Technical Cooperation (GTZ) for providing funding to support and assist UNAIDS in providing technical support to the NASA process. NAC is further indebted to the Government Ministries that took part, in particular the Ministry of Health and Social Welfare (MOHSW) through its various departments. The Ministry of Finance and Development Planning through the Global Fund Coordinating Unit and other units provided critical information. Without these Ministries support this assessment would not have seen light of day. The Technical Support Facility (TSF) provided technical support to the team working on the NASA.. We are thankful to them for their assistance and look forward to a continued collaboration in similar future endeavours. National AIDS Spending Assessment (NASA) 7

8 Executive Summary Lesotho has an estimated population of 1.8 million people. Out of this population approximately 270,000 are HIV positive as per estimates carried out towards the end of Also there are an estimated 62 new HIV infections and 50 deaths due to AIDS per day. The National AIDS Commission decided to carry out the National AIDS Spending Assessment (NASA) in The results of this assessment were to be used for in-country policy and UNGASS reporting requirements. The data on expenditure shows a percentage of the real expenditure on the ground. In some cases, such as prevention and OVC support, it is estimated to show approximately 80% of the overall expenditure on HIV and AIDS. This round of the NASA looked at expenditure from public and international sources. Private expenses were not included in this report. The NASA estimations show that overall; Lesotho spent a total of M on HIV and AIDS between 2005/06 and 2007/08. Although the total reported HIV and AIDS expenditure decreased only by 5% from 2005/06 to 2006/07, total reported expenditure increased by 23% between 2006/07 and 2007/08. HIV and AIDS spending in 2007/08 nearly doubled the spending in 2006/07. External financing sources account for 60% of all HIV expenditure during 2005/ /08. Public funds constituted 38% of the total HIV and AIDS expenditure, while private sources of funding accounted for only 2%. A further disaggregation of data by the NASA AIDS Spending Categories show that the key spending priorities between 2005/06 and 2007/08 have been on treatment & care (37%); programme management (17%); OVCs (14%) and prevention (11%). Treatment & care expenditure decreased from M73.9 million in 2005/06 to M62.5 million in 2006/07 and increased to M190.6 million in 2007/08; while expenditure on prevention decreased from M38.5 million in 2005/06 to M23.3 million in 2006/07 and increased to M36 million in 2007/08. Total spending on OVCs also decreased from M59.3 million in 2005/06 to M25.9 million in 2006/07 but increased to M40.9 million in 2007/08. The reduction in expenditure on OVC shows the reliance on one development partner in this crucial mitigation area, reduced movement of tonnage by WFP in 2006/06 lead to a gap being created in the expenditure. The largest expenditure on prevention in 2005/06 were on the areas of STI management (26%), BCC (17%) and VCT (13%); in 2006/07, the areas were, VCT (28%), PMTCT (24%) and STI management (10%); while in 2007/08, the areas were VCT (38%), PMTCT (29%) and Condom Social marketing (10%). Treatment and care expenditure was mostly directed to ARVs, OI treatment and Nutritional Support in all the financial years. PLWHA saw the largest expenditure directed towards them as a beneficiary and OVCs saw the second largest expenditure during the period of the assessment. This shows the GoL,s commitment to providing free treatment to HIV positive persons. The largest expenditure on prevention was directed to the general population. The public providers provide majority of the HIV and AIDS services (52%) over the period of the assessment, 2005/ /08; followed by the international providers with (39%). The funding flows through the National NGOs and FBOs is the lowest at 8% of the total spending in 2005/ /08 combined together. National AIDS Spending Assessment (NASA) 8

9 Introduction Global and Regional Epidemic HIV and AIDS epidemic continues to pose a greatest challenge to human health and development, and has destroyed both the social and economic fabric of societies. The epidemic has already claimed 2.1 million lives each year and another 33.2 million people are currently living with HIV and AIDS world wide. Most of HIV and AIDS cases are reported in the developing world with the Sub-Saharan nations being the worst affected. The epidemic has caused a shift in the resource allocation globally and nationally, with more resources at national and household level being re-directed to health expenditure. The world has to cope with this devastating situation and immediate efforts are needed to curb the spread of the epidemic and improve the livelihood of the people. The epidemic has called for a global action to fight against HIV and AIDS epidemic, and these lead individual countries to align their national policy frameworks with the international agenda. The action plans to fight the epidemic were set at all levels, international, regional and national arenas as a way of governments to show their political commitment In 2001 during the United Nation General Assembly Special Session, a Declaration of Commitment on HIV/AIDS was endorsed by the leaders of 189 countries. The Declaration is the first global "battle plan" against AIDS and was also a global call for the resources that were (and are) so urgently needed. The declaration established the necessity of a monitoring process which requires the submission of periodic reports to UNAIDS on national progress focusing on domestic HIV programs. A set of indicators were established to allow the General Secretariat and member states to follow-up on the accomplishment of the different goals of the declaration. The declaration rests on three principles and they are as follows; one coordinating authority one multi-sectoral strategic framework one monitoring and evaluation framework National Status of the Epidemic The population of Lesotho is estimated at 1,880,661 of which males constitute 916,282 and females 964, Lesotho is ranked third with adult HIV prevalence rate of 23.2% in the world. The estimations reveal that there are 62 new HIV infections and about 50 deaths due to AIDS each day. So there is an estimated 270,000 people living with HIV in Lesotho in the latter part of Of these, there are 11,809 infected children and 258,472 adults. Females continue to be more infected with HIV with an estimated 153,581 infected as compared to their male counter parts with an estimated 116,692 infected. There has been no significant change in the national adult HIV prevalence since 2005 and this shows that the prevalence is stabilizing. The sentinel surveillance conducted in 2007 showed that there is no major difference in HIV prevalence among women attending ANC clinics 2. 1 Bureau of Statistics, Census 2006 Preliminary Report 2 UNGASS Report 2007 National AIDS Spending Assessment (NASA) 9

10 HIV and AIDS National Strategic Plan for Given the intensity of the epidemic and both the national and international commitments made by the country there was a need to develop one strategic framework backed up by a comprehensive national HIV and AIDS monitoring and evaluation system. The purpose of the National Strategic Plan (NSP) is firstly to articulate, disseminate, and educate the public at large on agreed national priorities and strategies within a five year period ( ). Another purpose is to provide a clear guidance for Ministries, districts, NGOs, the private sector and other stakeholders to enable them to work in collaboration towards achieving the intended goal of the National Response to HIV and AIDS, which is to: scale up universal access to information, knowledge and services to enable individuals to protect themselves from HIV infection and access treatment, care, support and impact mitigation services, and emphasize with those affected by HIV and AIDS 3 Key Strategic targets and focus areas: Management and coordination; Prevention Treatment, care and support; and Impact mitigation Table 1: General targets from the National Strategic Plan Impact Indicator New infections reduced from 2.9% per year in 2005 to less than 2.0% per year Prevalence of mother to child transmission of HIV reduced Percentage of AIDS orphans identified and accessing OVC services increased Persons needing ART and able to access free ART services increased PLWHAs have disclosed their status and are involved in reinforcement of positive living for those living with HIV/AIDS Baseline Year Target Year 2005/ % 2.0% 25% 10% Not available 90% Not available 80% Not available 30% Resource Mobilization for the Fight against HIV and AIDS The declaration of commitment serves as a platform for global resource mobilization for the fight against HIV and AIDS, and also enables countries to increase financial resources available for HIV and AIDS. Since the adoption of the declaration of commitment in 2001, the global financial resources increased from 1623 million USD to an estimated 10 billion USD by the end of It is evident that the resources allocated for HIV and AIDS have increased globally. As a response, it was necessary for the country to mobilize resources for the fight against HIV and AIDS and comply with its commitments. With the aim to reduce HIV prevalence in Lesotho, it is 3 National Strategic Plan National AIDS Spending Assessment (NASA) 10

11 estimated that a minimum of USD million will be required for the period There are many partners committing resources to fight the epidemic, which include Irish Aid, United States Government-PEPFAR, European Union, GTZ, DFID, and the Global Fund for AIDS, TB and Malaria, World Bank as well as UN family. For the decision making process and formulation of policies aimed to reduce the spread of HIV and AIDS epidemic there is a need for tracking the use of funds. It is important to reflect on which areas need more funding and which have been overlooked during allocation of funds. In a nutshell, the assessment indicates how resources can be effectively and efficiently allocated to all areas targeted to combat and reduce HIV infections. Thus, to perform this task, it was found worthwhile to collect financial information from donors, development partners, government departments, multilateral agencies, foundations and NGOs, CHAL and other stakeholders involved in the fight against HIV and AIDS. Lesotho NASA The National AIDS Spending Assessment (NASA) is a tool designed to track the HIV and AIDS financial flows and actual expenditure at a country level. In essence, this systematic methodology captures all HIV expenditures, namely, health and non-health expenditures such as social mitigation, education, labour, justice and sectors related to HIV and AIDS. In addition, it follows the flow of funds from their origin down to the final destination being the beneficiaries receiving goods and services. NASA is one of the data sources for UNGASS indicators that are used to collect accurate and consistent data on how funds are spent at the national level and where those funds are sourced. This is tracked by financing source whether it is public, private or foreign and among the different providers and beneficiaries (target groups). It is of utmost importance on the grounds that it furnishes the results that would be used to analyze the efficiency and the effectiveness of resource allocations for all HIV and AIDS programmatic areas. The Lesotho NASA will includes tracking of expenditure for public sources, external sources, flow of funds from their origin all the way to the beneficiaries and will cover the financial years 20005/06, 2006/07 and 2007/08. The HIV and AIDS spending will be captured at the national and district levels and the beneficiaries of spending will be identified in as far as the data allow. The production factors have not been included, except for easily available ARV program. Study Objectives The overall goal of NASA is to contribute to the strengthening of comprehensive tracking of actual spending (from international/external and public sources) that comprises the national response to HIV and AIDS in Lesotho, to leverage both technical and financial support for the development, implementation, management, monitoring and evaluation of the national response. Specific objectives of the assessment are: To identify and measure all domestic/public and international/external expenditure on HIV and AIDS in Lesotho for the years of assessment, and to present these according to the thematic AIDS Spending Categories. To build the capacity of NAC NASA research team to undertake the NASA. To develop tools and systems for tracking of resources for all implementers on an ongoing basis within NAC. 4 The resource need does not include the new WHO guidelines for ART that have increased the ART needs in the country to approx. 81,000 National AIDS Spending Assessment (NASA) 11

12 To catalyze and facilitate actions which strengthen and institutionalize country level tracking of expenditure, and co-ordination by NAC. To synthesize this data into strategic information products to inform decision-making. National AIDS Spending Assessment (NASA) 12

13 Definition of Concepts Most of the terms used in the study would be clearly understood by the reader. There are however some terms that form definitions inside the NASA classifications. To make sure all the readers have a similar understanding and understand the scope of terms such as Human Capital, their definitions are listed below: AIDS Spending Category (ASC) it is the broad categories to which the assessment assigns expenditure on HIV and AIDS. Any expenditure captured has to be for a function an ASC (used interchangeably). The basic 8 ASCs or functions are defined below. Prevention set of activities or programmes designed to reduce risky behaviour. Results include a decrease in HIV infections among the population and improvements in the quality and safety in health facilities in regard of therapies administered to HIV and AIDS patients. Care and Treatment all expenditures, purchases, transfers and investment incurred to provide access to clinic and home/community-based activities for the treatment and care of HIV-infected adults and children. Programme Management and Administration Strengthening expenses that are incurred at administrative levels outside the point of health care delivery e.g. M&E, management of AIDS programmes, facility upgrading through purchases of laboratory equipment and of telecommunications, etc. Human Capital expenditure on health care workers and managers who work in the HIV and AIDS field through their recruitment, retention, deployment and rewarding of quality performance. Social Protection and Social Services functions of government relating to the provision of cash-benefits and benefits-in-kind to categories of individuals defined by needs such as sickness, old age disability, unemployment, social exclusion, and so on. HIV and AIDS- related research generation of knowledge that can be used to prevent disease, promote, restore, maintain, protect, and improve the population s development and the people s well being. Out of Pocket Expenses it is expenditure carried out by households and individuals to get services related to HIV and AIDS. For example, household income spent on treatment and care services and pooled funds of support groups to provide support. National AIDS Spending Assessment (NASA) 13

14 Methodology This section contains a description of the approach, methods and limitations of the National AIDS Spending Assessment (NASA) conducted in Lesotho. Overall Approach NASA s methodology supports the compilation of consistent estimates, reasonably comparable over time and across countries. Robustness to inter-temporal comparison is critical. A key concern of the international community and national decision makers is to track the degree of effectiveness of the efforts to increase overall resource availability. Consistency of the measurement concepts captured at different points in time is essential to ensure that valid comparisons are possible. The equitable and efficient distribution of resources between countries constitutes a key concern of the international community 5. The multi-sectoral approach without efficient and effective central coordination leads to an uncoordinated and fractured response. Unless there are very few financiers of the response, it is extremely difficult to get a single view of the final outcome of the cumulative financing in a country. Thus the NASA looks to provide a view of the combined effect of the individual responses of the different sectors. This is important for directing the national response and enables the coordinating body to carry out its function. NASA is aimed at capturing most of the financial transactions occurring in relation to HIV and AIDS. NASA identifies the financing sources, financing agents and service providers. It follows the financial transaction from its source down to the final destination (i.e. the beneficiaries receiving goods and services). Financing sources are entities that provide money to financing agents, financing agents are entities that pool financial resources to finance programmes of provision of services, and providers are entities that engage in the production, provision and delivery of HIV and AIDS services. In addition, it is not limited to health-related spending, but identifies and captures all the other spending related to HIV and AIDS, such as social mitigation, legal services, educational and life-skills activities, psychological support, care for Orphans and Vulnerable Children (OVCs), and those efforts aimed at creating a conducive and enabling environment. NASA methodology combines both the bottom-up and the top-down procedures. Bottom-up procedure involves building up expenditures from service providers expenditure records, facility level records and governmental department expenditure accounts, whereas top-down procedure involves breaking down expenditures from sources of funds e.g. donor reports, commitment reports and governmental budgets. This matrix reflects the ability of many low-per-capita income countries to deliver for their own goals as well as for those of the community of nations appropriate information about the resource flows, the costs and the price of services and goods delivered for hundreds of activities contributing to the fight against the HIV and AIDS epidemic. \ NASA serves several purposes within different time-frames. In the short term, NASA might be used to provide information on the UNGASS indicator for public, international and private expenditure: in the longer-term, the full information provided by NASA may be used to: 5 UNAIDS National AIDS Spending Assessment: a notebook on methods, definitions and procured for the measurement of HIV/AIDS financing flows and expenditures at country level. Joint United nations Programme on HIV/AIDS (UNAIDS). UNICEF, WFP, UNDP, UNFPA, UNODC, ILO, UNESCO, WHO, World Bank, 2007 National AIDS Spending Assessment (NASA) 14

15 Monitor the implementation of National Strategic Plan Monitor advances towards completion of internationally or nationally adopted goals such as universal access to treatment and care Provide evidence of compliance with the principle of additionality required by some international donors or agencies; and Lead to evidence based programming Preparatory Phase Team Formation & Training On 1 st October 2007 the Section Head for Monitoring and Evaluation (M&E) attended a five day training workshop on NASA in Johannesburg. On 19 th November 2007 a consultant joined the local team to carryout the assessment. The recruitment process at UNAIDS for research assistants was carried out in early December after which on 12 th December the research assistants joined to form the Lesotho NASA team. Training for them was conducted in the second week of December 2007 for one day. The NAC also recruited another two research assistants who attended trainings, but were only able to join the team in early January. Thus, the NASA team comprised of members from NAC and UNAIDS. Database of all Stakeholders A database of all the stakeholders involved in HIV and AIDS was developed using the information obtained from NAC (e.g. NAC grantees) and UNAIDS database. This database was further built upon during the course of the fieldwork. Based on the team s interactions with NGOs and development partners about their implementing partners, the research assistants kept going-on until they reached the agencies that actually implemented the program on the ground. Obtaining Permissions Letters asking for the permission to collect the data were sent to selected government ministries, external and internal agencies working on HIV and AIDS by NAC. The letters were delivered during the month of November. The office of the Principal Secretary of the Ministry of Health and Social Welfare prepared a memo to all the health centers in an effort to facilitate data collection. Since it was the first NASA, there were some problems related to data collection in some areas. Finance Personnel Workshop on NASA The NASA requires detailed information that functionally fits between the finance and programme staff of an organization. Since the larger agencies would need a long lead time to report on the data, the finance personnel from these agencies were trained on the NASA process. Some government ministries and NGOs were invited and trained on the NASA. It involved giving them a rundown of the NASA followed by practical filling of the questionnaire by using test cases. A number of agencies showed interest in getting a copy of the NASA classification document. They were given a copy and provided with the link where they could access the latest versions in the future. Data Collection Adoption and Administration of Questionnaires The NASA questionnaires were sent to the key respondents and appointments then made during which data was requested and the forms completed. Generally the questionnaires were too complicated to be self administered, therefore researchers undertook extensive searches for the National AIDS Spending Assessment (NASA) 15

16 information and held interviews with the key persons, which were necessary to unearth the information required. In a number of cases, donors requested simplified forms of the questionnaires to be sent to them so that they could reply to key questions through mail. Thus sections of the questionnaires were adapted into excel sheets that some donors and NGOs duly filled and sent back. Sources of Data Detailed expenditure records were obtained from the majority of primary sources of data for all the three financial years 2005/06, 2006/07 and 2007/08. For the purposes of this study the government s financial year was used (from 1 st April to 31 st March). In some cases data was not available or was obtained from secondary sources (e.g. expenditure of some NAC grantees and GFATM Grantees was captured from NAC and GFATM reports respectively). A detailed list is available in appendix I. The objective of the assessment was to capture all expenditure on HIV and AIDS, thus all agencies that were known to work in the field were contacted. Only in the case of line ministries were five ministries targeted. The criterion was the size of their HIV and AIDS programs. The list of ministries is: Ministry of Health and Social Welfare, Ministry of Gender, Youth, Sports and Recreation, Ministry of Education Ministry of Local Government and Chieftain Affairs Ministry of Agriculture and Food Security Qualitative Data Collection and Analysis The qualitative questions were extracted from the questionnaires seen in appendix VI. There were separate questions for sources and providers/agents. These questions were circulated to the agencies as part of the assessment. The responses were analyzed based on qualitative data analysis principles. Data Processing The data was received in a form of both hard and soft copies from donor reports and providers expenditure reports. The data collected was first captured in the primary excel sheets. The data was verified at the primary excel sheet stage to ensure its validity from the records of the source, the agents and the providers and also to avoid double counting. After verification, the data was moved to the data processing file to ensure completeness of the data. The entered data was checked, discussed by the team to ensure correct classification and cleared for entry at this stage. The data was then transferred to the NASA Resource Tracking Software (RTS), which has been developed to facilitate the NASA data analysis. The RTS outputs were exported to Excel to produce summary tables and graphics describing HIV and AIDS financial flows in several combinations for analysis. Assumptions A few development partners had different financial year periods from that used by the government Effort was made to capture the actual expenditure according to the government s fiscal year (from 1 st April to 31 st March). However, for some partners (e.g. UNICEF, World Vision, and ActionAid) that proved very difficult. Given the shortage of time, it was decided to assume that the expenditures fell into the government s fiscal year, and that the slight inaccuracies would be corrected for in the following year. Where the funds are pooled, the specific contribution of donor to the activities was assumed to be proportional to their contribution to the total income. The same rationale was also applied to any other spending. National AIDS Spending Assessment (NASA) 16

17 Estimation of Expenditure on STI and AIDS through Health System The expenditure on STI and AIDS through the health system has been captured through estimations. The unit costs for each of these services were available for some hospitals. Based on the location, management and size of the hospitals, the unit costs for the others were estimated. These unit costs were then multiplied with the number of times these services were used. In the case of STI services, it was the number of out patient visits. While in the case of AIDS patients in IPD, the proportion of total patients that were AIDS patients were used. For a more detailed methodology, please refer to Appendix V. Drug Procurement & Supply Costs The procurement of drugs for the health system in Lesotho is through a nodal agency called the National Drug Supply Organization (NDSO). Its procurement activities are controlled through the Pharmaceutical Unit (PU) of the MoHSW. A committee at the MoHSW sits to assess the ARV needs of the country on a periodic basis. Its outcome is to maintain sufficient stock levels within the country. For the purpose of the NASA, expense was considered to be accrued at the NDSO. This meant that stocks procured by NDSO were recorded as expenditure in the given period because all the stocks were consumed within the year of assessment as the demand for the drugs from the districts is high, turnover is fast and therefore they seldom have stocks left in the stores for long periods. Limitations This report is the first attempt to show a national picture of all expenditure on HIV and AIDS. It has a number of limitations, and a majority of them stem from the financial record keeping and monitoring and evaluation systems in the country. Key limitations that have had impact on the quality of the report are as follows: The data collection process was carried out during the months of December, January and February which were not ideal. Thus the actual time available to capture data was not adequate for the timelines set. Only five Ministries were interviewed based on the size of their HIV and AIDS programs. The team attempted to focus its resources given the time constraints. Expenditures that could not be definitively classified were recorded under programme management. Estimations on expenditure on AIDS through the health system were not able to capture the resources spent on TB other than in-patients diagnosed with TB and AIDS. It is known that there are other expenditures on TB, such as drugs and DOTS, but these were not captured. Expenditure on STIs in 2006/07 is based on patient data for only one quarter. Thus there may be an almost three times increase in STI expenditure in the said year. There was no data for the year 2007/08 The only out of pocket expenditure on HIV and AIDS captured in this report was consultation fees paid by users for prevention, diagnosis and treatment of STIs. No other private source of funds spent on HIV and AIDS were captured in this report except for the amount spent by NDSO on the drug supply system through its earnings, the fees paid by HIV positive patients at facilities for OPD services and the private funds spent by Help Lesotho and Touching Tiny Lives. In order to capture data on salaries of both health and non-health personnel, it would take time to disaggregate what percentage of salaries goes to HIV and AIDS related activities and National AIDS Spending Assessment (NASA) 17

18 what proportion of staff time is spent on HIV and AIDS activities. Therefore, given the short timeframe of the study, such data was not included. The GoL through the MoHSW provides CHAL hospitals with funds for providing care and treatment services. These funds are provided as salaries for some staff in CHAL hospitals. However, since the actual amounts and positions funded are not known, these amounts are shown as CHAL funds. Due to the rules and regulations under the US agencies, the team did not receive data from most of the US agencies Finally, the team accepts that the actual levels of spending shown in the report will always be under-reported. The problem of under-reporting is even more severe for local NGOs since no directory of local NGOs exist. The more visible international NGOs are easily accessed and more robust in their reporting. National AIDS Spending Assessment (NASA) 18

19 Findings of the NASA The output of the assessment is a set of pivot tables that are crossed between the sources of funding, programming agents, implementing agencies and the category they fund or the beneficiary that gets the fund. The findings below would take these matrices and present some basic information on funding flows. The NASA is also meant to provide information for policy makers. As such the basic matrices are the best sources for them to mine for specific information. At the same time the NASA team during its consultations has had an opportunity to be a part of the current policy level discussions in the country. Therefore some of the findings would be presented to provide evidence for these discussions. It should be noted that the report only captures expenditures that were reported to the NASA team. Total Expenditure on HIV and AIDS in Lesotho The expenditure on HIV and AIDS was assessed for the financial years 2005/06, 2006/07 and 2007/08. Bearing in mind the limitations and assumptions specified earlier in the report, the National AIDS Spending Assessment (NASA), approximates that M was spent in Lesotho on HIV and AIDS between 2005/06 and 2007/08. Although the total reported HIV and AIDS expenditure decreased only by 5% from 2005/06 to 2006/07, total reported expenditure increased by 23% between 2006/07 and 2007/08. HIV and AIDS spending in 2007/08 nearly doubled the spending in 2006/07. There are a number of reasons that can be associated with a decline in expenditure in 2006/07: 1. There was an underestimation of the expenditure on STI (prevention), since OPD STI data was available for only one quarter in The expenditure by the GFATM reduced substantially due to 2006/07 being declared an interim period of the Round 2. Though expenditure continued, it dropped by M million. 3. WFP s distribution of supplies to OVC and PLWHA reduced by M 37.8 million in the financial year 2006/ Lack of bursary disbursal data from MoET for 2006/07. Figure 1: Total Expenditure in Maloti on HIV and AIDS in Lesotho for the financial years 2005/06, 2006/07 and 2007/08 Millions / / /08 National AIDS Spending Assessment (NASA) 19

20 Total Expenditure on HIV and AIDS by Sources of Funding Figure 2 below shows the expenditure by sources of funding for the three financial years. As can be seen from the figure, the overall spending on HIV and AIDS from public sources shows an increasing trend over the period of the assessment even though they constituted only 38% of the total reported HIV and AIDS expenditure. Estimates of the hospital costs which included OI treatment (T&C) and STI treatment (Prevention) are incorporated under public sources; these estimates did not have clear sources of funding but were assumed to be from the public for general health budget. It must be noted here that some expenditure from the international sources to some implementing partners goes through the Ministry of Finance and Development Planning and therefore was reported as expenditure from the public sources. External financing sources accounts for 60% of the national HIV and AIDS expenditure during the period of assessment. The Figure below shows that financing from international sources decreased in 2006/07, due to the reasons stated earlier, before more than doubling in 2007/08. As was mentioned in the study objectives, this assessment does not capture private expenditure on HIV and AIDS. However, while carrying out the assessment, some expenditure was recorded as private. This was the amount spent by NDSO on the drug supply system through its earnings, the fees paid by HIV positive patients at facilities for OPD services (recorded as out of pocket expenses) as well as the private funds spent by Help Lesotho and Touching Tiny Lives. Due to these expenses, the private sources accounted for only 2% during the reporting period. The amounts stated for 2006/07 include STI OPD data for only one quarter while in 2007/08 there was no STI OPD data at all. Figure 2: Total Expenditure in Maloti by Sources of Funding for 2005/06, 2006/07 and 2007/08 Millions / / /08 International 164,850, ,773, ,970,071 Private 7,711,865 3,887,837 5,744,424 Public 84,865, ,622, ,053,982 Public Private International Expenditure Breakdown by AIDS Spending Category Figure 3 gives a national perspective of the overall spending on the eight spending categories. The key spending priorities for the period 2005/ /08 have been on treatment & care (37%), programme management (17%), OVC (14%) and prevention (11%). National AIDS Spending Assessment (NASA) 20

21 The total reported expenditure on treatment and care decreased by 4% from 2005/06 to 2006/07 and increased by 39% between 2006/07 and 2007/08. Despite the increased caseload, there was a slight decrease in expenditure in 2006/07. This decrease is in spite of the increased outlay by GoL through the STI/HIV Directorate. The reasons are listed below: 1. The GFATM Round 2 interim period saw reduced expenditure on ARV and other treatment components 2. There was a drastic decrease in procurement of pediatric ARV by NDSO using GoL funds 3. Specific to the NASA methodology used in this assessment, the proportion of patients admitted who was HIV positive showed a decrease in 2006/07, signaling a decrease in estimated expenditure. The increase in expenditure between 2006/07 and 2007/08 can be attributed to the increased contribution by both the public and international sources in this area. This also indicates the government of Lesotho s commitment to providing free treatment to HIV positive persons. The reduction in expenditure on prevention from M38.5 million in 2005/06 to M23.3 million in 2006/07 can partly be attributed to incomplete STI figures. To a large extent the reduction was indeed due to fewer funds being actually spent on prevention. There was no data on prevention, diagnosis and treatment of STI in 2007/08. The reduction in the expenditure on OVC shows the reliance on one development partner in this crucial mitigation area, reduced movement of tonnage by WFP in 2006/07 lead to a gap being created in the expenditure. To some extent this situation has been mended through the EU s and GFATM Round 7 s long term focus on OVC. Research, Human Capital and Programme Management and Administration have seen an increase in expenditure during the period of assessment. Human Capital in this context is the expenditure on nurses, physicians and their training. It must be appreciated that the expenditure captured under Research is not very representative of the actual expenditure in the country. The expenditure reported in Figure 3 is an underestimation. However, the answer to the question of adequacy of expenditure is clear. A number of limitations of this study stem from the unavailability of studies and research on some key indicators. Total reported expenditure on Enabling Environment has seen a decrease of 13% from 2005/06 to 2006/07; on the other hand there was an increase of 21% between 2006/07 and 2007/08. It shows the reduction in the expenditure on issues such as advocacy, strategic communication, human rights and institutional development. The reduction in 2006/07 can be attributed to the phasing out of ActionAID s SIPAA project that was funded by DFID. Figure 3: Expenditure Breakdown in Maloti by ASC for 2005/06, 2006/07 and 2007/08 National AIDS Spending Assessment (NASA) 21

22 Millions / / /08 HIV/AIDS - Research 28, , ,946 Enabling Environment 9,633,850 6,075,870 12,059,381 Social Protection 31,490,057 20,902,252 26,536,321 Human Capital 6,213,599 17,800,137 42,839,344 Programme Management 38,316,316 53,402,224 59,383,629 OVC 59,266,049 25,875,234 40,868,517 Care & Treatment 73,948,177 62,532, ,562,835 Prevention 38,530,594 23,283,168 36,018,504 Expenditure Breakdown by NSP Categories Lesotho has a costed National Strategic Plan in which the resource requirements are modeled, therefore, to assist with the evaluation of whether the actual allocations spent between 2005/06 and 2007/08 meet or fall short of the estimated required resources for scaling up towards universal access targets, it is important to take the NASA expenditure data and map it to the NSP s programmatic categories. This was done as per Appendix II and the results are in Figure 4. Figure 4: Actual Spending Priorities based on NSP categories for 2005/06, 2006/07 and 2007/08 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 22% 16% 35% 38% 57% 31% 11% 15% 9% 28% 19% 18% 2005/ / /08 Impact Mitigation Treatment, Care & Support Prevention Mgt,Coordination & Support. On the other hand, when examining the expenditure required by the NSP in percentage terms Figure 5 was derived. Care must be taken when using the results from these two figures because percentage graph is more about funding priorities and allocative decisions (choices between interventions) and not about adequacy of amount. National AIDS Spending Assessment (NASA) 22

23 When comparing the proportional percentage spending in 2006/07 against the intended percentage proportions of the NSP goals, it appears that all the percentages fall short of the estimated required percentages except for programme management and administration strengthening which is much higher than the estimated percentage. In 2007/08, treatment & care, and programme management & administration strengthening percentages are higher than the estimated percentages, while prevention and impact mitigation fall short of the projected percentages. However, the total cost of the National Response was estimated to be M212 million in 2006/07 but the actual spending was M million. On the other hand in 2007/08 the estimated cost was M385 million and actual spending was a little bit higher at M million. This shows that the actual spending meet the estimated required resources for scaling up towards universal access targets but there is a need to shift resources to also meet the estimated required percentage allocations to different priority areas of the NSP. For further clarifications on the estimated costs of the NSP refer to Appendix II, Table 3. Figure 5: Planned NSP Spending Priorities for 2006/07 and 2007/08 100% 90% 24% 28% 80% 70% 60% 50% 40% 43% 41% Impact Mitigation Treatment, Care & Support Prevention Mgt,Coordination & Support 30% 20% 18% 17% 10% 0% 15% 15% 2006/ /08 Spending Priorities by Sources of Funding for 2005/06 As can be seen from figure 6 below, a larger part of the prevention expenditure (62.5% of the total spending on prevention) comes from international sources. Also, expenditure on treatment and care is supported by both international sources and public sources of funding. Majority of the expenditure on OVC is through international sources. These sources include UN agencies, GFATM and disparate multilateral sources. Expenditure by public sources also includes the bursaries given by the MoET to the OVCs. Spending on social protection is primarily through the WFP which provides complete household rations for PLWHA. The private sources also claimed a small contribution on both prevention and treatment & care. National AIDS Spending Assessment (NASA) 23

24 Figure 6: ASC based Expenditure Breakdown in Maloti by Sources of Funding for 2005/06 Millions Research Enabling Environment Social Protection Human Capital Program Mgt OVC Care & Treatment Prevention Public Private International Spending Priorities by Sources of Funding for 2006/07 Due to the sustained funding from GoL and reduced funding from international sources in the financial year 2006/07, the overall contribution from GoL has increased. Again in 2006/07, the spending on prevention came from international sources. More importantly, the overall expenditure decreased in both actual and percentage terms over 2005/06. The expenditure on treatment and care was sustained by the GoL despite decreases in expenditure from international sources (GFATM Round 2) over the fiscal year. Thus its percentage in the overall pie increased in light of overall decrease in expenditure. Information related to disbursal of bursaries by MoET in 2006/07 was unavailable which led to unreported expenditure on OVC by GoL. Figure 7: ASC Based Expenditure Breakdown in Maloti by Sources of Funding for 2006/ Millions Research Enabling Environment Social Protection Human Capital Program Mgt OVC Care & Treatment Prevention Public Private International National AIDS Spending Assessment (NASA) 24