Viet Nam National AIDS Spending Assessment Draft Report November Table of Contents. List of Figures 4

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1 Viet Nam National AIDS Spending Assessment Draft Report November 2011 Table of Contents List of Figures 4 1

2 List of Tables 5 Acronyms and Abbreviations 6 Acknowledgements 7 Forward 8 Overview of Viet Nam AIDS Expenditures, Executive Summary 11 I. Introduction HIV Situation in Viet Nam National Response to HIV in Viet Nam Institutional Framework of National HIV Response National Policy on HIV Objectives of the National AIDS Expenditures Assessment (NASA) 19 II. Methodology The NASA Approach Preparatory Phase Data Collection Data Validation Secondary Data Sources Data Processing and Analysis Limitations and Challenges 25 III. HIV Funding Sources and Mechanisms Public Funds International Funds Private Funds (including Household Expenditures) 30 IV. Total AIDS Expenditures Overview of AIDS Expenditures AIDS Expenditures by Financing Source AIDS Expenditures by Financing Agent AIDS Expenditures by Service Provider Flow of Funds Flow of Funds from Financing Source to Financing Agent Flow of Funds from Financing Agent to Service Provider AIDS Expenditures by Program Area Prevention Care and Treatment Orphans and Vulnerable Children Programme Management and Administration Human Resources Social Protection and Social Services 59 2

3 6.1.7 Enabling Environment Research AIDS Expenditures by Beneficiary Population AIDS Expenditures by Production Factor 63 V. Recommendations 65 VI. Appendices 66 Appendix 1: References 66 Appendix 2: Data Collection Form 67 Appendix 3: List of Organizations Providing Data for NASA 72 Appendix 4: NASA/NHA Collaboration in Viet Nam 75 Appendix 5: Key Assumptions IN DATA processing for different sources 3

4 List of Figures Figure 1. Distribution of reported HIV cases by age group and by year, Figure 2. Distribution of reported HIV cases by gender and by year, Figure 3. HIV prevalence among IDUs in Viet Nam, Figure 4. HIV prevalence among FSWs in Viet Nam, Figure 5. Organisational system of AIDS response in Viet Nam Figure 6. Main funding sources for HIV in Viet Nam, Figure 7. National expenditures on HIV by categories, Figure 8. Financial flow scheme Figure 9. Funding flow of the National Target Programme on HIV Figure 10. Flow of provincial annual budget allocation for AIDS Figure 11. PEPFAR s flow of funds Figure 12. GFATM s Flow of Funds Figure 13. Total national expenditure on AIDS, Figure 14. Share of major sources in total national AIDS expenditure, Figure 15. Disaggregation of international AIDS financing sources, Figure 16. Households expenditures versus public expenditures on AIDS, Figure 17. Share of AIDS expenditures by financing agents, Figure 18. Percentage share of service providers in AIDS expenditures, Figure 19. Disaggregation of bilateral expenditures by financing agents, Figure 20. Disaggregation of multilateral expenditures by financing agents, Figure 21. Percentage share of service providers in total MOH s AIDS transfer, Figure 22. Percentage share of service providers in other public financing agents transfer, Figure 23. Percentage share of service providers in total international NGOs transfer, Figure 24. Percentage share of service providers in total expenditures of bilateral financing agents, Figure 25. Percentage share of service providers in total transfer of multilateral financing agents, Figure 26. Percentage share of key programmatic areas in AIDS expenditure, Figure 27. Expenditure disaggregation of each financing source by key intervention area, Figure 28. Share of public, private and international sources in preventive expenditure, Figure 29. Percentage share of care and treatment expenditure, Figure 30. Share of public, private and international sources in care and treatment expenditure, Figure 31. Disaggregation of OVC expenditures, Figure 32. Expenditure on programme management and administration, Figure 33. Percentage share of public and international sources in programme management expenditure, Figure 34. Percentage disaggregation of AIDS expenditure by six beneficiary groups, Figure 35. Disaggregation of AIDS expenditure by types of expenditures, Figure 36. Disaggregation of AIDS current expenditure by production factors, List of Tables Table 1. Type and number of organisations providing AIDS expenditure data Table 2. General statistics on national AIDS expenditure, Table 3. Summary of AIDS expenditures in Viet Nam by financing source, , in US$

5 Table 4. Public, Private and International AIDS expenditures in Viet Nam, Table 5. Public AIDS expenditure by source of funding, Table 6. Summary of AIDS expenditures by international source, Table 7. AIDS expenditures by international financing source, Table 8. Private financing sources for AIDS, Table 9. AIDS expenditures by major financing agent, Table 10. AIDS expenditures by service provider, Table 11 Summary of AIDS expenditures by major service provider, Table 12. Disaggregation of public source AIDS expenditures by financing agent, Table 13. Disaggregation of bilateral AIDS expenditures by financing agent, Table 14. Disaggregation of multilateral AIDS expenditure by financing agent, Table 15. Disaggregation of MOH AIDS expenditure by service provider, Table 16. Disaggregation of DOH AIDS expenditures by service provider, Table 17. Disaggregation of other public financing agents AIDS expenditure by service provider, Table 18. Disaggregation of international NGO AIDS expenditures by service provider, Table 19. Disaggregation of bilateral financing agents AIDS expenditures by service provider, Table 20. Disaggregation of multilateral financing agents AIDS expenditures by service provider, Table 21. AIDS expenditures by key programmatic area, Table 22. AIDS expenditures by key intervention area and financing source Table 23. Expenditures on HIV prevention, Table 24. Expenditures on major prevention categories, Table 25. Public, private and international expenditures on HIV prevention activities, Table 26. Expenditures on care and treatment, Table 27. Expenditures of public, private and international sources on care and treatment, Table 28. Expenditures on OVC, Table 29. Expenditures on programme management and administration strengthening, Table 30. Public and international expenditures on programme management and administration strengthening, Table 31. Expenditures on human resources, Table 32. Expenditures on social protection and social services, Table 33. Expenditures on an enabling environment, Table 34. Expenditures on HIV-related research, Table 35. AIDS expenditures by six beneficiary population groups, Table 36. AIDS expenditures by beneficiary populations, Table 37. Disaggregation of AIDS expenditures by production factor,

6 Acronyms and abbreviations ADB Asian Development Bank AHF AIDS Healthcare Foundation AIDS Acquired Immune Deficiency Syndrome ART Anti Retroviral Therapy ARV Anti Retroviral ASC AIDS spending categories AusAid Australian Agency for International Development BP Beneficiary Population CHAI Clinton Health Access Initiative DFID UK Department of International Development DKT Dhammendra Kumar Tyagi DOH provincial Department of Health FA Finanacing Agent FS Financing Source GFATM Global Fund to Fight AIDS, Tuberculosis and Malaria HCMC Ho Chi Minh City HIV Human Immunodeficiency Virus IDU Injecting drug user IOM International Organisation of Migration M&E Monitoring and evaluation MdM Médecins du Monde (France) MOH Ministry of Health MOLISA Ministry of Labour, Invalid and Social Affairs DOLISA provincial Department of Labour, Invalid and Social Affairs MSM Man having sex with man NGO Non-governmental organization NHA National health accounts NORAD Norwegian Agency for Development Cooperation OI Opportunistic infection OVC Orphans and vulnerable children PAC Provincial AIDS Centre PEPFAR President's Emergency Plan for AIDS Relief PF Production Factor PLHIV People Living with HIV PS Provider of Services RNE Royal Netherlands Embassy STI Sexually transmitted infections FSW Female sex workers UNAIDS Joint United Nations Programme on HIV/AIDS UNAIDS Joint UN Programme on HIV/AIDS UNDP United Nations Development Programme UNESCO United Nations Educational, Scientific and Cultural Organization UNFPA United Nations Population Fund UNGASS United Nations General Assembly Special Session UNGASS United Nations General Assembly Special Session on HIV/AIDS UNICEF United Nations Children s Fund UNIFEM United Nations Development Fund for Women UNODC United Nations Office on Drugs and Crimes UNV United Nations Volunteer Programme VAAC Viet Nam Administration for AIDS Control WB World Bank WHO World Health Organization 6

7 Acknowledgements This report is a joint product of the Vietnam Authority of HIV/AIDS Control (VAAC) and the Joint United Nations Programme on HIV/AIDS (UNAIDS). Special appreciation goes to Dr. Nguyen Thanh Long, Director of VAAC for his exceptional support throughout the report compilation process. Thank you to Ms. Duong Thuy Anh for providing steady guidance and coordination of the overall study, and to the NASA study team consisting of Vu Ngoc Uyen, Tran Xuan Bach, Duong Viet Tuan, Nguyen Ngoc Linh, Nguyen Thu Ha, Nguyen Phuoc Ha, Anastasiya Nitsoy and Mahesh Sharma for its determined work in helping to compile this report. PEPFAR Viet Nam Coordinator Viviane Chao, the PEPFAR Management Team and PEPFAR implementing partners deserve particular recognition for their efforts to provide critical data and significant support to the entire NASA process. Officials from Provincial AIDS Centres in those provinces included in the assessment offered their assistance in ensuring that the NASA accurately captures AIDS expenditures at the sub-national level. In addition, special appreciation must go to Dr. Vladanka Andreeva and Dr. Nguyen Cam Anh from UNAIDS in Viet Nam for their unwavering assistance with coordination of communication with stakeholders, and collaboration across the project including the approach, interpretation of data and presentation of this report, as well as to UNAIDS headquarters and the UNAIDS Regional Support Team for Asia and the Pacific for providing their invaluable technical and financial support to the NASA process. 7

8 Forward 8

9 Overview of Viet Nam AIDS expenditures, AIDS expenditures by Funding Source: Total expenditures: US$ 222,428,564 Public: US$ 28,429,437 International: US$ 161,948,287 Private: US$ 32,050,840 AIDS expenditures by Financing Agent: Public: US$ 107,092,204 International: US$ 83,638,391 Private: US$ 31,697,968 AIDS expenditures by Service Provider: Public Providers: US$ 143,159,614 (64%) Private Non-Profit: US$ 44,940,176 (20%) Bilateral and Multilaterals: US$ 29,195,874 (13%) Private for-profit: US$ 4,543,595 (2%) Non-classified: US$ 589,305 (0.3%) AIDS expenditures by Programmatic Area: Prevention (approximately 32% of total expenditure) Total expenditure: US$ 71,510,071 Main expenditures categories: Communication and BCC US$ 14,285,265 Harm reduction for IDU US$ 10,476,950 FSW and clients US$ 6,938,729 PMTCT US$ 4,075,664 Voluntary counselling and testing US$ 3,792,702 Vulnerable and accessible populations US$ 2,285,634 Community mobilisation US$ 2,136,730 MSM US$ 1,842,982 Care and Treatment (approximately 26% of total expenditure) Total expenditure: US$ 57,187,275 Main expenditures categories: Outpatient Care US$ 41,475,915 Inpatient care US$ 6,195,605 Other care and treatment services US$ 9,515,705 OVC (approximately 1% of total expenditure) Total expenditure: US$ 2,297,286 Programme Management (approximately 30% of total expenditure) Total expenditure: US$ 67,725,314 Main expenditures categories: Planning, coordination and programme mgmt US$ 42,497,238 Upgrading facilities and construction US$ 7,895,627 M&E US$ 6,202,473 Surveillance US$ 1,887,100 Human resources (7% of total expenditure) Total expenditure: US$15,125,609 Social Protection and Social Services( less than 0.3% of total expenditures) Total expenditure: US$ 647,289 Enabling Environment (approximately 3% of total expenditure) Total expenditure: US$ 6,019,750 HIV related Research (approximately 1% of total expenditure) Total expenditure: US$ 1,919,934 AIDS expenditures by Beneficiary: 9

10 PLHIV: US$ 61,356,481 MARP: US$ 34,090,485 General Population: US$ 20,483,936 Other key and accessible groups: US$ 19,630,409 AIDS expenditures per capita: Annual per capita AIDS expenditure: US$ 1.3 Annual AIDS expenditure per person living with HIV: US$

11 EXECUTIVE SUMMARY This National AIDS Spending Assessment (NASA) was conducted by Viet Nam Authority of HIV/AIDS Control (VAAC) in It captures AIDS expenditures by nearly all national and international funding sources in Viet Nam over a two year period: NASA tracks resources of health services, social mitigation, education, labour, justice and other sectors to embody the multi-sectoral response in Vietnam Through its findings, NASA aims to inform and support the development of Viet Nam s new National Strategy on HIV Prevention and Control with a Vision Towards The assessment utilizes the NASA methodology to systematically captures the flow of HIV-related financial resources from their origin to their ultimate beneficiary across various sources and service providers, and as delivered through a range of transactional mechanisms. NASA defines a transaction as consisting of the flow of financial resources from their origin with a financing sources until their final administrative or programmatic expenditure in support of a beneficiary population, and it reconstructs each transaction along this continuum to ensure accounting accuracy and avoid double-counting. The assessment produces double entry tables to illustrate clearly the origin and destination of resources. NASA uses both top-down and bottom-up resource tracking techniques to obtain and consolidate this information. The top-down approach tracks sources of HIV funding from donor reports, commitment reports and government budgets; conversely, bottom-up tracking captures HIV expenditures from service providers expenditure records, facility level records and governmental department expenditure accounts. As part of the assessment, interviews were conducted with key national and international financing agents based in Hanoi and Ho Chi Minh City. In addition, expenditure data from provincial government budgets were obtained from 53 provincial AIDS centres (PAC). In total, 95 organisations contributed data and information to the assessment. Secondary financial data were used only where primary data were unavailable. The principal sources of secondary data used in the NASA include the results of the UNGASS survey of AIDS expenditure conducted by VAAC and UNAIDS, which tracks results through the end of 2009, as well as estimates of some public and household expenditures, for which data were unavailable. The key findings of the Viet Nam National AIDS Spending Assessment are as follows: 1. The volume of financial resources channelled to the national HIV response is substantial. In , more than US$ 222 million was spent on HIV-related activities. During this period, the per capita annual AIDS expenditure was US$1.3 and US$ 469 was spent per each Person Living with HIV (PLHIV) in Viet Nam. Overall, between 2008 and 2009, total actual AIDS expenditure increased by 31%. 2. Viet Nam s HIV response is funded by public, private and international sources. Public source, including the central and provincial budgets, provided 13% of national AIDS expenditures. Overall, 90% of public funds for AIDS came from the health sector. 3. International partners are the cornerstone of Viet Nam s HIV response, not only in providing financial resources but also as programme decision makers and service providers. International partners provided US$ 162 million (73% of national expenditures) for HIV-related activities in and directly administered US$ 84 million (38% of national expenditures) during this same period. 4. In , 82% of HIV prevention, and 51% of HIV care and treatment, expenditures were covered by external funds. 5. Private expenditures exceeded public expenditure on AIDS in The majority of private expenditures were out-of-pocket payments by PLHIV. 6. As the largest national AIDS financing agent, the Viet Nam Ministry of Health (MOH) plays the prominent role in determine how AIDS programmes are funded in the country. The MOH oversaw US$ 83 million AIDS funds (38% of national AIDS expenditures) in International NGOs are critical players in Viet Nam HIV response. From , they were responsible for directing 20% of total national AIDS expenditures. 8. The public sector provided the majority (64%) of HIV-related services; international and national NGOs provided 20%; and 17% of AIDS expenditures were made by external bilateral and multilateral agencies. 9. The majority of AIDS expenditures in were concentrated in three core areas: prevention (32% of total); treatment and care (26%); and programme management (30%) 11

12 10. In , PLHIV benefitted from 28% of AIDS expenditures; 15% were directed towards most-at-risk populations (MARPs); 9% towards the general population; and 39% were expended on non-targeted interventions. 11. The majority (81%) of AIDS expenditures in were current expenditures. Capital expenditures account for a minimal share of total expenditures. 12. The proportion of AIDS expenditures that are not disaggregated by type of expenditure remains quite large, primarily due to insufficient detail available in the collected data. The limited capacity of current AIDS accounting systems impedes the ability to conduct a production factor analysis. 13. Gender-disaggregated data on beneficiaries was often not available. Recommendations for future action 1. NASA should be embedded as a routine exercise at the national level in Viet Nam to support strategic planning and analysis, and to help guide implementation of the national HIV response. 2. NASA also should be conducted at the provincial level, which would allow for a more in-depth analysis of AIDS expenditures at the sub-national level and support strategic policy and programme planning. 3. Key experiences and lessons learned from the inaugural Viet Nam NASA should be documented, analysed and incorporated, as appropriate, within future national AIDS spending assessments. 4. NASA findings should be broadly disseminated among key national and international stakeholders to ensure their utilisation. 5. NASA could be used as a good secondary source for costing and estimation of unit cost for package of interventions 12

13 I. INTRODUCTION 1.1 HIV SITUATION IN VIET NAM The HIV epidemic in Viet Nam remains in a concentrated stage, with the highest HIV prevalence found in specific populations namely injecting drug users (IDU), female sex workers (FSW) and men who have sex with men (MSM). The HIV epidemic may have begun to stabilize, as reflected by stable trends in HIV prevalence among IDUs and FSWs in many places, while in other places these trends are increasing, such as in the northwest (Dien Bien and Son La). 1,2 HIV prevalence among other sentinel groups, such as male military recruits and pregnant women, is low and also shows signs of stabilizing. According to the Viet Nam HIV/AIDS Estimates and Projections , adult HIV prevalence (aged 15-49) remains low at 0.43% in It is estimated there will be 254,000 people living with HIV (PLHIV) by 2010 and up to 280,000 by HIV cases have been reported nationide in all 63 provinces/cities, 97.5 % of districts, and 70.5% of wards/communes. As of 31 December 2010, there were reported HIV cases and 49,477 deaths due to AIDS-related illnesses. In 2010, there were 13,815 newly-reported HIV cases and 2,589 AIDS-related deaths. According to the available data, the majority of PLHIV are under 40. People aged years account for more than 82% of all reported cases. According to the available data, men accounted for 71% of all reported cases in NATIONAL RESPONSE TO HIV IN VIET NAM The achievements that reflect Viet Nam s efforts and illustrate its commitments during the reporting period include: (1) increased political commitment and leadership, which have resulted in positive changes in the response; (2) improved collaboration between ministries to ensure a stronger multisectoral response and improved service delivery, as shown by the rapid increase in the number of people accessing HIV prevention, care and support services; (3) an increased focus on prevention, which resulted in the expansion of harm reduction programs, especially the Needle and Syringe Program (NSP) and National Pilot Methadone Maintenance Therapy (MMT) Program for Drug Users; (4) rapid expansion of the Antiretroviral Therapy (ART) Program; and (5) greater and more meaningful participation of civil society in the national response Institutional Framework of the National HIV Response The HIV response in Viet Nam is coordinated by the National Committee for HIV, Drugs and Prostitution, Prevention and Control. The Chairman of the Committee is the Vice-Prime Minister and members of the Committee are the leaderships of all sectoral administrations. The Ministry of Health (MOH) plays the role of focal point for the National Committee and the Viet Nam Administration for HIV Control (VAAC), under the MOH, reports to the National Committee on national HIV issues and progress on behalf of the MOH. Other departments inside the MOH, research institutions and central hospitals under direct MOH management lead in their respective areas of technical expertise. Donor-funded projects with their management units under direct management of the MOH are a unique feature of Viet Nam. There are five projects with Central Project Management Units (CPMU) that operate under direct management of the MOH: ADB, GFATM, WB, DFID and CDC Life-Gap. Other ministries and sectoral managements are involved in AIDS prevention and control through operation of their multi-tasked units and personnel in charge of AIDS, and typically have their own AIDS-related policies and programmes in their area of specific responsibilities. At provincial level, the Provincial Committee for HIV, Drugs and Prostitution, Prevention and Control coordinates the multisectoral HIV response in each province. The Department of Health and health facilities network play the key roles in this system. The Provincial AIDS Centre (PAC), reporting to the Department of Health, is the specialised unit on AIDS. A myriad of service providers and institutions are engaged in the HIV response in Viet Nam, and their activities range broadly from HIV prevention, care and treatment provision, to advocacy and involvement in policy-making, monitoring and evaluation and strategic information. 1 Report on HIV/AIDS Prevention and Control Programmes in 2008.VAAC, Report on 2009 HIV/AIDS Epidemic report. VAAC, Viet Nam HIV/AIDS Estimates and Projections MOH, Report on 2010 HIV/AIDS Epidemic report. VAAC, More detail on the achievement please see UNGASS Country Progress report, VAAC

14 In addition, the HIV coordination system varies in some provinces. While the majority of provinces have established a Provincial AIDS Centre (PAC) as the primary specialised health facility, in others, such as Ho Chi Minh City, the Provincial AIDS Committee directly coordinates and manages the multisectoral AIDS response. Figure 5 Viet Nam organisational system of AIDS response National Committee for fighting AIDS, drug abuse and sex trade Party and Mass organisations Ministry of Health Other Ministries and sectoral organisations Provincial Committees on AIDS Party and mass organisation network at local level Viet Nam Administration for AIDS Control MOH s departments, research institutions, central hospitals Donor-funded AIDS Project Management Units at MOH Multi-tasked units and personnel responsible for AIDS Multi-sectoral system of AIDS response at local level Provincial AIDS Centre Local health care system AIDS Project Management Units at local level Donor-funded projects and NGOs also play important roles in Viet Nam national HIV response. There are ongoing efforts to coordinate the activities as well as harmonise cost norms of donor-funded projects, NGOs and public sector actors. However, considerable work remains to be done in this area National Policy on HIV Viet Nam passed the Law on HIV Prevention and Control in 2006, and it serves as the principal legislative document affirming the fundamental legal rights of PLHIV. According to the Law, along with other civil rights, PLHIV have the right to live in their community; to receive health care and treatment; to receive education and training and work; to have confidentiality in terms of their HIV status; and to refuse diagnostic and treatment measures at the last stage of AIDS. The national legal and policy framework on HIV has been steady improved in recent years. An Amendment of the Criminal Code in 2009 reclassifies drug users as patients rather than criminals, thereby lowering the barriers they face in accessing HIV prevention, treatment, care and support services. Moreover, the Law on Health Insurance passed in 2008 recognizes HIV as an health issue covered by health insurance. The National Strategy on HIV prevention and control in Viet Nam till 2010 with a vision to 2020, which was approved in March 2004, serves as a framework to guide all 18 Government Ministries and their Departments, 63 provincial authorities, civil society and international partners in their HIV-related activities. The strategy mandates that specific line ministries and their departments must be engaged in the HIV response and emphases the importance of a multisectoral and coordinated response to address the HIV epidemic, including with specific attention to populations at higher risk for HIV infection. The National Strategy has two goals and three main objectives: (1) To reduce HIV prevalence among the general population to below 0.3% by 2010 with no further increase after 2010; and (2) To reduce the adverse impacts of HIV on socio-economic development. The main objectives under these goals are: (a) To control HIV transmission among most-at-risk populations and the general population through implementing comprehensive harm reduction intervention measures; (b) To ensure the provision of care and appropriate treatment for PLHIV; and (c) To improve the management, monitoring, surveillance 14

15 and evaluation systems for the HIV prevention and control programme. There are also nine action programmes that underpin implementation of the strategy, which are: 1. Behavioural Change Information, Education and Communication; 2. HIV Harm Reduction Intervention and Transmission Prevention; 3. Care and Support for HIV-infected People; 4. HIV Surveillance and Monitoring and Evaluation; 5. Access to HIV Treatment; 6. Prevention of Mother-to-Child HIV Transmission; 7. Sexually Transmitted Infections Management and Treatment; 8. Blood Transfusion Safety; and 9. Enhancing Capacity development and International Cooperation. National monitoring reports demonstrate that significant progress has been made towards fulfilment of the main objectives set forth in the Strategy. Particularly notable achievements during the period are: (1) Increased political commitment and leadership resulting in positive changes in the response; (2) Improved collaboration between ministries has ensured a stronger multisectoral response and a subsequent improvement in service delivery, most notably in the rapid increase in the number of people who have access to HIV prevention, treatment, care and support services; (3) A focus on prevention has resulted in the expansion of harm reduction programmes, especially the needle and syringe programme and the national pilot methadone maintenance therapy programme for drug users; (4) Rapid expansion of the antiretroviral therapy programme; and (5) Greater and more meaningful participation of civil society in the national response. In 2009 the National Programme of Action on Children affected by HIV until 2010 with the vision to 2020 was approved. It set out specific objectives and directions for the national HIV response as it relates to children. By this way, the government prioritized support to OVC as an important objective in the years to come. 1.3 OBJECTIVES OF THE NATIONAL AIDS EXPENDITURE ASSESSMENT (NASA) NASA will help to strengthen the national HIV response in Viet Nam by generating valuable information on the overall flow of national and international financial resources, their specific administrative and programmatic uses and the benefits they bring, particularly to populations at higher risk for HIV infection. This assessment focuses on tracking national HIV expenditures in Viet Nam for the period The data compiled through NASA will also support Viet Nam to have the best available financial data on which to make strategic policy and programmatic decisions related to its HIV epidemic. The overall goals of NASA are to: 1. Systematically monitor HIV financial flows at the national and regional/provincial level 2. Develop a strategy involving multisectoral and multi-level key partners to track AIDS expenditures in Viet Nam; and 3. Build national capacity for systematic monitoring of HIV financing flows using NASA methodology. The specific objectives are to: Develop a data collection plan for the national level as well as all regions and departments, including identifying key stakeholders/entities among financing sources (FS), financing agents (FA), and users/providers in the public and private sectors; Collect, validate and analyze financial data gathered at national and regional/provincial; and 15

16 Present and disseminate findings, including through the development of a complete set of NASA matrices. 6 6 NASA Viet Nam Terms of Reference,

17 II. METHODOLOGY 2.1 THE NASA APPROACH The National AIDS Spending Assessment (NASA) approach to resource tracking is a comprehensive and systematic methodology used to determine the flow of resources intended to support national HIV response. The tool tracks actual expenditures (public, private and international) both in health and non-health sectors (social mitigation, education, labour and justice), which comprise the national response to HIV. 7 The primary purpose of tracking HIV expenditures is to inform the most appropriate allocation of HIV-related financial resources and programmatic activities across the country. In this vein, NASA provides information that will contribute to a better understanding of a country s financial absorptive capacity, as well as of the equity, efficiency and effectiveness of the current HIV resource allocation process. In addition to establishing a continuous information system for HIV-related financing, NASA facilitates a standardized reporting of indicators monitoring progress towards achieving agreed targets under the Declaration of Commitment adopted by the 2001 United Nations General Assembly Special Session on HIV/AIDS (UNGASS). 8 The NASA systematically captures the flow of financial resources from their origin to their ultimate beneficiary across various sources and service providers, and as delivered through a range of transactional mechanisms. NASA defines a transaction as comprising the flow of financial resources from their initial transfer to an HIV service provider to their final administrative or programmatic expenditure in support of a beneficiary population (see Figure 1). NASA uses both top-down and bottom-up resource tracking techniques to obtain and consolidate this information. The top-down approach tracks sources of HIV funding from donor reports, commitment reports and government budgets; conversely, bottom-up tracking captures HIV expenditures from service providers expenditure records, facility level records and governmental department expenditure accounts. Figure 8 Financial flow scheme Financing Source Financing Agent Provider ASC 1 ASC 2 Production Factors 1 Beneficiary Populations 1 Production Factors 2 Beneficiary Populations 2 In cases where data are missing, internationally accepted costing techniques and standards are used to estimate past actual expenditures. Ingredient and step-down costing is used for direct and shared expenditure for HIV, while shared costs are allocated to the most appropriate utilization factor. As part of its methodology, NASA employs double-entry tables or matrices to illustrate clearly the origin and destination of financial resources. This helps to avoid double-counting of HIV expenditures, as every transaction is reconstructed all the way from its original funding source to the recipient service provider or beneficiary population; as such, this more rigorous method is superior to a simple addition of all expenditures by each partner that commits resources to HIV-related activities. In order to be accurate and effective, NASA requires that the study team have sufficient background information, a well defined set of financial actors as information sources, a clear understanding of users and informants interests, and the support of an inter-institutional group to facilitate their access to information, participate in data analysis and contribute to data dissemination. NASA classification follows internationally-accepted standard accounting methods and procedures, including following the framework of the system of National Health Accounts (NHA). Tracked financial flows and AIDS expenditures are organized across three dimensions: financing, provision of HIV services and their use. These 7 UNAIDS, 2006: National AIDS Spending Assessment: a notebook on methods, definitions and procured for the measurement of HIV financing flows and expenditures at country level. (Draft work in progress). 8 Declaration of Commitment adopted by the United National General Assembly Special Session on AIDS (UNGASS) 17

18 classifications and categories comprise the framework of the NASA system (UNAIDS 2009). These dimensions incorporate six categories: 9 Financing 1. Financing Agents (FA) are entities that pool financial resources to finance service provision (purchaser-agent) as well as make programmatic decisions regarding the type of activities and the specific service provider involved in the actual service delivery. 2. Financing Sources (FS) are entities that allocate funding to HIV in general and provide money to financing agents. Provision of HIV services 3. Providers (PS) are entities that engage in the production, provision and delivery of HIV services. 4. Production factors/resource costs (PF) are inputs (labour, capital, natural resources, know how and entrepreneurial resources). Use 5. AIDS spending categories (ASC) are HIV-related interventions and activities. 6. Beneficiary populations (BP) are groups targeted with services e.g., PLHIV, injecting drug users. 2.2 PREPARATORY PHASE- Extensive preparations for the NASA were undertaken well before its roll out. To initiate the preparatory process, UNAIDS Viet Nam organised a one-week training course on the NASA methodology and its implementation approach for VACC and UNAIDS personnel as well as national consultants who would be involved in conducting the assessment. Additional advance work included preparation of a concept note and a detailed road map to guide the NASA process. Following this, a series of mapping exercises were conducted to identify the key stakeholders in the national HIV response, particularly those that expend substantial HIV funds in Viet Nam. Wherever possible, the team sought to establish the principal resources flows that exist from each financing source to its respective financing agents and service providers. Resulting from the stakeholder mapping exercise were a series of Maps of Actors, which helped to determine for which financial actors the NASA team would track AIDS expenditures. For an example of NASA Map, see Appendix XX. The NASA data collection form was prepared based on the guidelines of the NASA Manual, and also incorporated technical input received from NASA advisers and UNAIDS. (The data collection form is included in Appendix 1.) The NASA team worked closely with the NHA team to ensure that NASA results are consistent with and can be readily used for the HIV subaccount of the NHA and HAPSAT. Given the similarities in data needs and output between the NASA and the NHA, and the fact that these first-ever conducted assessments each provide HIV-related resource tracking in support of Viet Nam development of its National HIV Strategic Plan ( ), UNAIDS Viet Nam and USAID (through the Health Systems 20/20 project) coordinated NASA and NHA data collection to avoid duplication of effort and reduce the burden placed on respondents. (See Appendix 4 for a more detailed description of collaboration between the NASA and NHA.) A NASA orientation workshop was jointly organized by VAAC and UNAIDS Viet Nam on 6 August 2010 for all key national and international partners in the HIV response, including government officials, civil society organizations, UN representatives and bilateral agencies. Following the workshop, VAAC formally sent information and a request letter to all relevant ministries, institutions, donor agencies, NGOs and other stakeholders asking for their support for the NASA process, including by providing requested information to the NASA team. Under the leadership of VAAC, and with technical support from UNAIDS, a NASA task force was also formed. The task force was comprised of VAAC and UNAIDS staff leading the assessment, as well as two international and five national consultants. The PEPFAR country office provided a staff member to support the task force in data collection from PEPFAR implementing partners. A detailed list of the NASA taskforce is provided in Appendix XX. A clear division of labour was then established among all NASA team members, and a senior team member was assigned to lead each group responsible for core components of data collection and processing DATA COLLECTION 9 For more detail please refer to UNAIDS (2009), National AIDS Spending Assessment (NASA) Classification and Definition. 18

19 The Vietnam NASA collected AIDS expenditure data for 2008 and Fiscal years 2008 (Oct 2007 Sept 2008) and 2009 (Oct 2008 Sept 2009) were used for the analysis of PEPFAR funds. For the remainder of the funds, calendar years were used to process the data. To ensure the most comprehensive possible scope, NASA sought to collect AIDS expenditure data from all organisations that are involved in supporting the HIV response in Viet Nam, including from the public sector, bilateral donors, multilateral institutions, international NGOs and the private sector (see Table 1 for a breakdown of organisations that contributed data to the NASA). For each financing agent, interviews were conducted with their representatives in Hanoi and Ho Chi Minh City. In addition, data on HIV expenditures from provincial budgets were collected from 53 provincial AIDS centres. AIDS expenditures by other public health institutions (e.g., national, regional, provincial and district hospitals; commune health centres; the pharmaceutical system) as well AIDS expenditures by the national health insurance system were not collected in the NASA. Table 1 Type and number of organisations providing AIDS expenditure data Type of respondent organisations Number of respondent organisations Public organisation 70 Bilateral organisation 7 Multilateral organisation 9 International NGO 7 International for-profit firm 2 Total 95 The data collection process often required several visits to each relevant organisation, including follow up visits in order to clarify any areas of confusion relating to the classification and recording of AIDS expenditures by category, or if inconsistencies were found in the received data. To the greatest extent possible, individual materials were collected from each funding source to aid a better understanding of the different types of intervention, implementation modalities and beneficiaries, project documents, annual reports, progress reports, annual work plans and budgets associated with various funding entities. Information obtained through narrative reports, articles and websites also aided this process as well as that of assigning appropriate FS, FA and PS codes. The NASA process of data collection lasted for approximately three months Data Validation The validation of the processed data was a critical step in the overall NASA exercise. Validation was conducted throughout the entire assessment, beginning with direct communication between the NASA team and each organization, and followed up by validation meetings first with the PEPFAR implementing partners, and later with all major HIV stakeholders in Viet Nam. Two validation workshops were organised with PEPFAR The initial validation workshop was held on 24 September 2010, and focused on validation of the NASA assumptions made regarding PEPFAR expenditures and assignment of FA, PS, ASC, BP. The second such workshop took place on 26 April 2011, and focused on validating the subanalysis conducted of PEPFAR AIDS expenditures with PEPFAR implementing partners. Following these validation efforts, the preliminary NASA results were presented to VAAC as well as key national and international partners during a workshop on sustainability of HIV response, which was held in HCMC on 12 May Secondary Data Sources As referenced in Section 2.1, secondary data were used only in cases where primary data were unavailable. Overall, the NASA used two types of secondary sources: (1) The UNGASS survey of AIDS expenditures (reporting on UNGASS Indicator 1), which was conducted by VAAC in collaboration with UNAIDS and captured expenditures through the end of This source was consulted to fill in data gaps from several bilateral sources (e.g., Australia, Denmark, Ireland and the Netherlands) as well as public (provincial) budget expenditures; (2) Estimated out-of-pocket expenditures of PLHIV and their families provided by the USAID-supported Health Policy Initiative (HPI), which conducted a survey of such expenditures in Estimations Besides secondary data source, there are several estimates were made and used in this NASA based on the availability of raw data which can help to estimate the following expenditures 19

20 Estimation of recurrent expenditures of PACs (for 11 out of 64 PAC who did not provided information on this expenditure) Ho Chi minh City s provincial budget on supporting Provincial Government personnel working on HIV; Expenditures of the labour sector on AIDS-related services, including supporting PLHIV in public orphanages and social houses, payment of incentives to staff who cared AIDS patients and payment of medicine support to trainees in rehabilitation centres Expenditures of household spending on anti-hiv testing for blood screening in different setting DATA PROCESSING AND ANALYSIS Data processing consisted of five stages. Stage 1: Upon receipt, all data were immediately checked for consistency, clarity and depth of detail. If any data inconsistency was discovered, the submitting organisation was contacted for clarification. Stage 2: Once the data was deemed complete and consistent, NASA financial transactions were constructed using a pre-designed excel sheet. This necessitated assigning a particular NASA classification to each expenditure item. This stage also entailed cleaning the data as well as triangulating the three dimensions (source, provision and use) and six vectors (source, agent, providers, AIDS expenditure category, production factor and beneficiary population) to ensure consistency. TRANSACTIONS PROCESSING FILE NASA / MEGAS Switchboard Name of institution: User: OBSERVATIONS - NOTES: Amounts in: Local Currency $ Total amount: Name Classification Function control cell: 0 Financing Source: FS-FA Transfers Status: 1 Financing Agent: FA-PS Transfers RTS Transaction #: Provider: PS Spent - Received Services Delivered Total transaction amount: 0 Region Aids Spending Category: Beneficiary Population: Production Factors: Beneficiary Beneficiary Beneficiary Aids Spending Category: Comments Expenditure Expenditure Expenditure Population: Population: Population: Stage 3: Once the transaction was constructed and all the data triangulated, the data were entered into a Resource Tracking Software specifically designed for NASA data analysis. Each transaction was separately entered with its identified financing source, financing agent, service provider(s), AIDS spending category, production factor and beneficiary population. The software performed various checks and automatically indicated if any data problems were present. Stage 4: Given the large volume of data involved, the NASA team then used Stata software to check and correct all data classifications and analysis. Stata not only allowed the team to check for overall consistency of the dataset, but also to identify errors for later correction in RTS. Stage 5: Stata was used to generate the NASA tables. General rules guiding data processing and analysis In conducting data processing and analysis, the NASA team followed a range of general rules to aid classification of HIV-related activities being undertaken by various organisations within specific AIDS expenditure and beneficiary population categories, specifically in instances were data limitations or inconsistencies arose. These general rules included: 1. Most training activities were coded under ASC (with assigned BP.06 Non-targeted interventions) unless it was clear from the activity description that it was an in-service training. In this case it was classified as a part of the respective activity. Exceptions to this were made for trainings for a) peer educators (coded under ASC Community mobilisation either for PLHIV or MARP-targeting interventions), b) family members of PLHIV on home-based care (coded under ASC Non-medical home-based care) and c) teachers (coded under ASC Youth in school). 20

21 2. Activities related to policy development, legislative revision, strategic information and coordination meetings as well as conferences and experience sharing were coded under ASC Planning, coordination and programme management. 3. Due to an insufficient level of detail in collected data, in many case it was not possible to disaggregate activities such as BCC, VCT, STI and other services into separate ASCs according to the specific beneficiary population. In these cases, the codes ASC Communication for Social and behavioural change not disaggregated by type, ASC Voluntary counselling and testing and ASC Prevention, diagnosis and treatment of STIs were are typically used for service delivery to the general population were assigned for the relevant activities. In these instances, beneficiary population is coded as BP Most-at-risk populations not broken down by type, BP Other key populations not disaggregated by type or BP Specific accessible populations not disaggregated by type, depending on the type of the activity. 4. In instances where coding problems arose, either due to miscoding in the self-administered data collection forms, or as a result of technical errors made during data input, the NASA team sought clarification from the organisation with which the data originated. 5. In some cases, activities were not sufficiently defined or disaggregated in the available data to allow for assigning of a specific ASC, which necessitated classifying them in a more general manner (e.g., ASC Prevention not elsewhere classified). This approach sought to preserve the exhaustiveness of the overall expenditure tracking, but left a significant amount of resources difficult to analyze. In absence of more detailed information, various informed assumptions were also used to disaggregate such activities into multiple categories and thereby assign them NASA codes. 6. There were cases when expenditure totals appearing in the data collection forms did not match detailed, disaggregated data per provider or per activity implemented. In these instances, these data were rechecked with the organisation of their origin. 7. Some challenges emerged due to the complexity of the NASA methodology and its classification system namely that the Financing Sources and Providers of Service identified in the data collection form by the submitting organisation did not correspond with NASA classifications and definitions. In these cases, the NASA team sought clarification from the data source and attempted to make an appropriate classification. For example, Code PS Ambulatory care were assigned for a wide range of organisations including Provincial Preventive Medicine Center, Provincial AIDS Center, Communication Center, Population Center, VCT sites... Code PS Mental health and substance abuse facilities were assigned for Detention Centers (05-06 Center) and Methadone Clinics. Code PS Foster Home Center were assigned for Public Social Houses 8. Processing of expenditure data by Production Factors was a time- and labour-intensive undertaking. In many instances, data collected was insufficiently detailed to allow for a clear identification of Production Factors. In such cases, the NASA team used code PF Current expenditures not disaggregated by type, or PF Capital expenditure not disaggregated by type. At times, it was not possible to identify whether expenditures were current or capital expenditures, and here the code PF.98 Production factors not disaggregated by type was employed. 2.5 LIMITATIONS AND CHALLENGES There were a number of limitations and challenges associated with conducting the NASA in Viet Nam. First, as multiple financial flows each involve numerous intermediary partners prior to the actual expenditure of funds, it was often a challenge to reconstruct transactions correctly, and to avoid double-counting or data loss. Second, the wide variety of HIV service providers and their multifunctional scope of work added to the difficulty of identify the primary role of each institution and assigning of a PS code. Third, significant variations in accounting systems, fiscal years and classification of spending categories among national institutions, and various donors supported projects, created challenges for data synthesis and comparability. Fourth, it was often difficult to obtain financial expenditure information from private sources and direct health care providers. 21

22 III. HIV FUNDING SOURCES AND MECHANISMS 3.1 PUBLIC FUNDS Public expenditures consist of two principal sources: central government revenues and provincial government revenues. Overall, there are three main public funding channels for HIV in the period : (1) The National Target Programme on HIV; (2) Annual budget allocation for HIV-related public organisations; and (3) Public investment programme. National Target Programme on HIV The National Target Programme on HIV (NTP) is a multi-sectoral framework coordinated by the Ministry of Health to address the HIV epidemic. The overall budget of the NTP through 2010 was approved by the Prime Minister s Decision No. 108 in The annual NTP budget allocation is provided by the Ministry of Finance based on the MOH s annual plan. Central government revenues constitute the main source of funds for the NTP. Budget allocation for the NTP at the central level is made through the MOH s account. The MOH transfers the NTP s funds to each relevant department, research institution and hospital under its management as well as to the other public entities outside the health sector, such as mass organisations and some NGOs, involved in the NTP s implementation. The central government also transfers designated NTP funds to 63 Provincial People s Committees, which then allocate funds to designated implementers in their respective province. Provincial authorities can contribute additional funds to NTP implementation at their discretion. As it was not possible to separate directly resourced provincial funds from those that originated from the central budget, the NASA team classified all NTP expenditures as central budget expenditures. Figure 9 Funding flow of the National Target Programme on HIV Central Government Budget Ministry of Finance NTP on HIV Ministry of Health Public health units at Central level: Departments inside MOH VAAC Research and education institutions under MOH s management Central Hospitals Other Ministries: Agriculture & Rural Development; Education & Training; Construction; Justice; Communication; Culture; Labour; Transport; Supreme s Procurator; Military Management; Planning and Investment. Mass organisations (Women s Union, Youth Union, Farmer Union, Fatherland Front, Trade Union) Provincial Government budget Department of Health Public entities at local level: Hospitals AIDS, Preventive Medicine, Reproductive Health Centres and other ambulatory care facilities; Commune Health Centres Social Education and Work Centres for IDUs and SW Public Orphanages and Social Houses Annual budget allocation for HIV-related public organisations 22

23 In accordance with the Budget Law (2002), the central budget is determined to cover recurrent expenditures of the public organisations of the central level, and the provincial budget to support routine operation of the public organisations of the provincial, district and commune levels. At the central level, the MOH is responsible for the majority of HIV expenditures, which primarily relate to the HIVrelated policy making, coordination and monitoring functions of the departments and institutions under its management. All other ministries and mass organisations have some HIV-related expenditures; however, these are normally covered by non-hiv budget lines (e.g., multi-tasked personnel or workshops). Annual provincial HIV budgets typically are distributed across several line departments namely, health, labour, and others. HIV funds are an integral part of the annual budget allocation. Recipients of HIV funds in the health sector include facilities that provide specialised HIV services (e.g., AIDS departments in hospitals or provincial AIDS centres), and all health care workers who enjoy AIDS-specific allowances in accordance with health personnel policy. There are no HIV-specialised facilities in other sectors; however, significant funds are allocated for HIV in accordance with various HIV-related government policies and the respective personnel policies of each sector. The primary channels of annual HIV budget allocation are illustrated in Figure 4. Figure 10 Flow of provincial annual budget allocation for AIDS Provincial Government Budget Department of Health Department of Labour, Invalid & Social Affairs Other line departments AIDS-specialised organisations: Provincial AIDS Centres Hospitals with AIDS departments Health personnel directly providing care to PLHIV (AIDS allowance) PLHIV in social education and work centers, social houses, orphanages (AIDS allowance); PLHIV in community (support) Personnel directly providing services to PLHIV (AIDS allowance) Health personnel directly providing care to PLHIV (AIDS allowance) Public Investment Programme Some provinces have made significant capital investments in construction and infrastructure of the Provincial AIDS Centres (PAC) through PIP. For the purposes of the NASA, all such investments are classified as expenditures o the provincial budget. 3.2 INTERNATIONAL FUNDS International grants account for the majority of HIV funds in Viet Nam over the period of There are 28 international donors financing HIV efforts in the country, including bilateral (12), multilateral (12), and foundations (4). PEPFAR As a PEPFAR focus country, Viet Nam receives significant US Government financial and in-kind resources to support its national HIV response. PEPFAR funds designated for Viet Nam are channelled from various US government agencies to different type of recipients. PEPFAR funds are administered at two levels: the US-based headquarters office and the Viet Nam field office. The NASA is only able to track funds flowing from the PEPFAR Viet Nam office to PEPFAR partners in Viet Nam, and does not include the proportion of funds expended by the headquarters of USbased government agencies or PEPFAR implementing partners that does not reach Viet Nam. 23

24 As illustrated in Figure 5, NASA captures funding flows from the four US government agencies comprising PEPFAR: the US Agency for International Development (USAID), the US Centers for Disease Control and Prevention (CDC), the US Department of Defence (DOD) and the US Department of State (DOS). USAID and CDC are the principal US agencies support HIV-related activities in Viet Nam, and each channel funds to various types of recipients, including public entities, international and local NGOs, for-profit companies, UN agencies and other US government agencies in Viet Nam. The US DOS and DOD direct their far smaller budgets though other NGOs and international universities. Figure 11 PEPFAR flow of funds OGAC (PEPFAR) USAID HQ CDC HQ Other USG Agency HQ USAID Viet Nam Office CDC Viet Nam Office Other USG Agency Field Office (SAMHSA, DOD) Recipient Organizations: NGOs, Universities, For Profit Firms, Government Agencies, USG Sub Recipient Organizations: NGOs, Universities, For Profit Firms, Government Agencies Implementation Other Bilateral Donors Other bilateral HIV donors in Viet Nam include the United Kingdom, Australia, Sweden, France, the Netherlands, Denmark, Germany, Ireland, Canada and Japan. Most of their funds are transferred directly to Vietnamese government agencies. Some small grants are also given to NGOs and international universities. The Asian Development Bank During , ADB funded two projects on HIV: the Project on HIV Prevention among Youth and the Mekong Sub- Region Project on HIV. The first project was managed by the MOH s Department of Population, and funding recipients included population facilities, other public entities and NGOs that work with youth. The second project was a regional initiative supporting six provinces to undertake prevention activities. The World Bank The World Bank (WB) project on HIV is managed by the MOH and covers 20 provinces. The WB Central Project Management Unit (WB CPMU), which is based at the MOH, receives funds from the WB and allocates them to 20 Provincial Project Management Units (PPMUs) for implementation. The WB CPMU also directly finances some HIV activities undertaken by the MOH s research institutions, several provincial preventive medicine centres as well as social education and work centres for IDU and SW. Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) 24

25 The Global Fund HIV project in Viet Nam is coordinated by the Umbrella Project Management (UPM), which is based at the MOH and consists of three sub-projects managed by three government line agencies: MOH, MOLISA and the Women s Union. The UPM receives disbursement from the GFATM and channels these funds to the Sub-Project Management of the MOLISA and Women s Union. The Umbrella Project Management also manages the sub-project of the MOH. In this capacity, it transfers funds to Global Fund s Provincial Project Management Units (GF PPMU) in 20 provinces covered by the project for implementation. At the central level, the MOH s sub-project finances the HIV activities of the central hospitals and research institutions that fall under the MOH s management. Both GF sub-projects of MOLISA and Women s Union are centrally managed. The recipients of funds from the MOLISA Sub-project Management are social education and work centres for IDUs and SW, which are under management of the General Department for Social Evil Prevention. The Women s Union sub-project implementers are community-based and home-based care groups managed by local women s unions. Figure 12 GFATM s Flow of Funds GFATM Sub-project Management of MOLISA Umbrella Project Management based at MOH Sub-project Management of Women s Union Social education and work centres for IDUs and SW Central Hospitals and Research Institutions under MOH 20 GF Provincial Project Management Units WU s communitybased and homebased care groups UN Agencies Key United Nations agencies involved in supporting Viet Nam s national HIV response include: WHO, UNICEF, UNDODC, UNAIDS, UNDP, UNESCO, UN Women, and UNFPA. UN agencies do not use financial intermediaries for their funding. All UN funds are transferred directly to implementers of HIV activities. Recipients of UN funds include public entities, Vietnamese NGOs and CBOs. 3.3 PRIVATE FUNDS (INCLUDING HOUSEHOLD EXPENDITURES) The majority of private funds expended for HIV-related activities are comprised of household out-of-pocket payments. Such expenditures primarily consist of: (1) payment for the care and treatment of PLHIV made by themselves and their families; (2) direct outlays by individuals to screen their blood donations for HIV; and (3) and private purchases of key commodities (e.g., condoms, clean needles). There are also some expenditures by private businesses for HIV prevention (e.g., purchase of condoms by hotels and guesthouses for free distribution on their premises). 25

26 IV. TOTAL AIDS EXPENDITURES OVERVIEW OF AIDS EXPENDITURES IN Overall, Viet Nam spent US$ 222,428,564 in response to its HIV epidemic from Between 2008 and 2009, total AIDS expenditures in Viet Nam increased by 31%. Figure 13 Total national AIDS expenditures, Per capita AIDS expenditures increased from US$0.79 in 2007, to US$1.13 in 2008 to US$1.47 in Using the MOH medium estimate of the number of PLHIV in Viet Nam (MOH, 2009), the NASA determined that AIDS expenditure per PLHIV in the country increased from US$ 301 in 2007, to US$ 416 in 2008 and to US$ 520 in AIDS expenditure per PLHIV was nearly six times that for health. Table 2 General statistics on national AIDS expenditures, Indicators Total AIDS expenditures, in US$ 66,280,815 96,208, ,219,787 Estimated number of PLHIV, medium scenario 220, , ,557 AIDS expenditures as a percentage of GDP 0.09% 0.11% 0.13% AIDS expenditures as a percentage of overall health expenditures 1.5% 1.7% No data AIDS public expenditures as a percentage of government budget expenditures on health 0.8% 1.3% 1.1% Per capita expenditure, in US$ Per capita overall health expenditure No data Per capita AIDS expenditure AIDS expenditure per PLHIV Source: NASA Viet Nam, 2010; Viet Nam HIV Estimates and Projections , MOH, 4/2009; National Health Account, MOH, 2010; Statistical Year Book, General Statistical Office, 2011; Government Budget Balance sheet 2007 and Government Budget Plan 2008 and 2009, Ministry of Finance, UNGASS survey, UNAIDS Viet Nam, AIDS Expenditures by Financing Source The NASA defines financing sources as entities that provide money to financing agents. HIV-related activities in Viet Nam were supported by three major sources: public, private and international funds. Total expenditures by and the proportional share of each major financing source in are illustrated in Table 3 and Figure 9. Table 3: Summary of AIDS expenditures in Viet Nam by financing source, (US$) Source 2008 % 2009 % % Public 13,459,880 14% 14,969,558 12% 28,429,437 13% Private 16,014,322 17% 16,036,518 13% 32,050,840 14% International 66,734,575 69% 95,213,712 75% 161,948,287 73% 26

27 Total 96,208, ,219, ,428,564 Figure 14 Share of major sources in total national AIDS expenditure, Public 13% Private 14% International 73% Table 4 presents a more detailed disaggregation of each financing source. As it demonstrates, external expenditures grew substantial from 2008 to 2009, while domestic sources (except for provincial government budgets, which increased proportionally) remained relatively stable. Table 4 Public, Private and International AIDS Expenditures in Viet Nam, (US$) Source Total Public 13,459,880 14,969,558 28,429,437 Central government budget 6,832,580 6,737,254 13,569,834 Provincial government budget 6,627,300 8,232,304 14,859,604 Private 16,014,322 16,036,518 32,050,840 For-profit entities 82, , ,393 Household funds 15,931,741 15,891,706 31,823,446 International 66,734,575 95,213, ,948,287 Direct bilateral contributions 48,552,930 71,836, ,389,738 Multilateral agencies managing external resources 17,849,999 22,975,234 40,825,232 International not-for-profit organisations and foundations 331, , ,317 Total 96,208,777 26,219, ,428,564 Public financing sources Public sources accounted for 13% of total AIDS expenditures in Following the Budget Law (2002), public sources consist of two horizontal levels: the central government budget and the provincial government budget. The overall share of the central government budget in national AIDS expenditures fell from 7% in 2008 to 5% in 2009; the share of the provincial government budget remained stable at 7%. Ninety percent of public AIDS expenditures came from the health sector. The Provincial Department of Labour, Invalid and Social Affairs contributed 10% of public expenditures. The role of other sectors in financing the national HIV response is negligible. Table 5 illustrates this situation. Table 5 Public AIDS expenditure by source of funding, (US$) Organisation 2008 % 2009 % % Health sector: Ministry of Health 6,832,580 51% 6,711,254 45% 13,543,834 48% Provincial Department of Health 5,221,097 39% 6,755,838 45% 11,976,935 42% Other sectors: Women s Union 0% 26,000 0% 0% Provincial Department of Labour, Invalid and Social Affairs 1,406,203 10% 1,476,466 10% 2,882,668 10% Total 13,459,880 14,969,558 28,429,437 27

28 International financing sources International assistance constitutes the major source of AIDS expenditures in Viet Nam, accounting for 73% of total AIDS expenditures from About three-quarters of all international AIDS expenditures were in the form of bilateral grants. Multilateral donors were responsible for the remaining external resource expenditures during this period. International non-profit organisations and foundations provided only 0.5% of total AIDS expenditures from Table 6 Summary of AIDS expenditures by international source, (US$) Source 2008 % 2009 % Total % Direct bilateral contributions 48,552, ,836, ,389, Multilateral agencies managing external resources 17,849, ,975, ,825, International non-profit organisations and foundations 331, , , Total 66,734, ,213, ,948, Figure 15 Disaggregation of international AIDS financing sources, International not-for-profit organisation, 0.5% Multilateral, 25.2% Bilateral, 74.3% 28

29 Table 7 AIDS expenditures by international financing source, (US$) Organisation Total Bilateral organisations Government of Australia 1,205,251 2,471,859 3,677,110 Government of Denmark 954, ,800 Government of France 593, ,866 1,192,012 Government of Germany 596, , ,503 Government of Netherlands 581, , ,255 Government of Sweden 953, ,912 1,402,074 Government of UK 4,470,027 2,256,690 6,726,717 Government of United States 38,894,158 64,978, ,872,318 Others 304, , ,950 Multilateral organisations Asian Development Bank (ADB) 6,251,409 6,320,161 12,571,570 Global Fund for AIDS, Tuberculosis and Malaria (GFATM) 2,871,788 5,829,561 8,701,349 UN Agencies 1,877,157 1,670,997 3,548,154 World Bank (WB) 5,548,183 8,443,612 13,991,796 Others 1,301, ,902 2,012, International non-profit organisations (Ford, 331, , ,317 Gates, AHF) Total 66,734,575 95,213, ,948,287 Private financing sources Private sources contributed 14% of total AIDS expenditures in Viet Nam from Most private expenditures were household out-of-pocket payments. The contribution of for-profit institutions to overall AIDS expenditures captured in this period of time was insignificant. Table 8 Private financing sources for AIDS, (US$) Source Total Household funds 15,931,741 15,891,706 31,823,446 For-profit institutions 82, , ,393 Total 16,014,322 16,036,518 32,050,840 Figure 11 compares private and public AIDS expenditures in 2008 and During this period, private expenditures exceeded public ones; however, the gap between the two sources narrowed, with the ratio of private to public expenditure declining from 1.2:1 in 2008 to 1.1:1 in Figure 16 Households expenditures versus public expenditures on AIDS, Millions US$ Private expenditure Public expenditure 29

30 4.1.2 AIDS Expenditures by Financing Agent (FA) As defined by the NASA, FA or purchaser-agents are intermediary entities that transfer resources from financing sources to service providers. FA also determine the type of HIV services to be provided and the specific service provider involved in their delivery. Therefore, the FA plays a crucial role in determining overall effectiveness of the national HIV response. The main FAs engaged in the national HIV response in Viet Nam include the MOH and its sectoral departments at provincial level (Department of Health); other ministries and their sectoral departments; bilateral and multilateral agencies; international and national non-profit organisations and households. While international for-profit entities are involved, their role is fairly negligible. Table 9 AIDS expenditures by major financing agent, (US$) Financing agent 2008 % 2009 % Total % Public, total 46,878, ,213, ,092, MOH 36,819,554 46,291,075 83,110,629 Department of health 5,221,097 6,755,838 11,976,935 Other public 4,838,028 7,166,611 12,004,639 Private, total 15,879, ,818, ,697, International, total 33,450, % 50,187, ,638, Bilateral 11,661,023 16,522,377 28,183,401 Multilateral 4,531,107 4,851,099 9,382,207 International non-profit 17,236,312 27,363,310 44,599,622 organisations International for-profit 22,000 1,451,161 1,473,161 organisations Total 96,208, % 126,219, % 222,428, % Figure 12 illustrates the proportional share of each major financing agent in terms of national AIDS expenditures. The MOH clearly plays the principal role in decision making on HIV programme funding. Overall, the health sector comprised of the MOH and the provincial Departments of Health managed 43% of all HIV resources from Figure 17 Share of AIDS expenditures by financing agent, AIDS Expenditures by Service Provider (PS) The NASA defines service provider as any entity that engages in the production, provision and delivery of HIV services. In Viet Nam the main providers of HIV services are public health facilities and institutions, including public hospitals and ambulatory care facilities (ambulatory care facilities include Provincial AIDS centers, VCT sites and OPC located outside hospital environment, Preventive health center, Health Education center, Population Centers; 30

31 and the departments under the MOH, including health research institutions and health project management units. Other major HIV service providers are: the AIDS Committee of Ho Chi Minh City s municipal authority; facilities under management of the Ministry of Labour, Invalid and Social Affairs (e.g., social houses for homeless PLHIV, orphanages, social work centres for IDUs and FSW); international and national civil society organisations; informal community-based organisations; bilateral and multilateral agencies; and for-profit institutions. NASA data on AIDS expenditures by service providers for are presented in Table 10. The results show that AIDS expenditures of major service providers, including by MOH departments, public ambulatory care facilities and hospitals, civil society organisations and NGOs and bilateral agencies all increased substantial between 2008 and Table 10 AIDS expenditures by service provider, (US$) Organisation Total Public PS Hospitals 16,036,019 20,747,537 36,783,556 PS Ambulatory care 28,173,354 32,812,124 60,985,478 PS Mental health and substance abuse 1,604,221 2,278,144 3,882,365 facilities PS Secondary education 1,454 2,276 3, PS Higher education 315, , ,027 PS Foster homes/shelters 124, , ,312 PS Research institutions 837,010 2,194,080 3,031,090 PS Departments inside the Ministry of Health 10,023,544 12,691,256 22,714,800 PS Departments inside the Ministry of 139,264 67, ,295 Education PS Departments inside the Ministry of 3,075 1,728,778 Defence PS Departments inside the Ministry of Labour 112,082 1,725, ,622 PS Departments inside the Ministry of Justice 3,690 3,540 6,245,717 PS Ho Chi Minh City s AIDS Committee 4,495,479 6,242,026 4,915,479 PS Governmental organizations n.e.c. 420,000 All PS Parastatal entities 412,439 1,030,928 1,443,366 Non-profit PS Self-help and community-based 5,464,261 5,454,932 10,919,192 organizations 3.1 PS Civil society organisations 13,827,711 17,451,973 31,279,684 PS All PS Other non-profit organisations 635,717 2,105,583 2,741,300 For-profit PS Health care facilities 1,126,410 1,126,410 2,252,820 PS All PS Other for-profit organisations 408,238 1,882,537 2,290,775 Bilateral and Multilateral Bilateral 9,957,925 13,395,776 23,353,701 Multilateral 2,212,678 3,629,495 5,842,172 Other providers n.e.c 294, , ,305 Total 96,208, ,219, ,428,564 Table 11 summarises the relative share of major service providers in terms of total AIDS expenditures. It shows that the public sector plays the primary role in the provision of HIV services. From , 64% of HIV expenditures were implemented by public entities. Table 11 Summary of AIDS expenditures by major service provider, (US$) Service providers 2008 % 2009 % Total % Public entities 62,281, ,878, ,159, Non-profit entities 19,927, ,012, ,940, For-profit entities 1,534, ,008, ,543, Bilateral and multilateral agencies 12,170, ,025, ,195, Providers n.e.c 294, , , Total 96,208, ,219, ,428,

32 Figure 18 Percentage share of service providers in AIDS expenditures, FLOW OF FUNDS The NASA allows for tracking of funding flows from financing sources to financing agents and onward to service providers. This flow of funds is summarised in this section Flow of Funds from Financing Sources to Financing Agents Public sources Public funds consist of central budget revenues and provincial budget revenues. The majority of central budget AIDS expenditures (including the NTP on HIV and other budgeted expenditures) were channelled to the MOH. The Women s Union (coded as parastatal organisation) reported a minimal level of central AIDS expenditures. The provincial AIDS budget was comprised of the provincial departments of health (81% of all provincial expenditures) and other provincial sectoral departments (19%). Table 12 Disaggregation of public source AIDS expenditures by financing agent, (US$) Total Financing Financing Agent Agent Code Central Provincial Central Provincial Central Provincial budget budget budget budget budget budget FA Ministry of Health 6,832,580 6,711,253 13,543,834 Provincial Departments FA ,221,097 6,755,838 11,976,935 of Health Other provincial FA ,476,465 2,882,668 sectoral departments 1,406,203 Parastatal FA ,000 26,000 organizations Total public source expenditures 6,832,580 6,627,300 6,737,254 8,232,304 3,569,834 14,859,604 International sources International funding sources include bilateral and multilateral donors, as along with international non-profit organisations and foundations. As NASA captures AIDS expenditures only for international NGOs and foundations that are physically located in Viet Nam, for these entities the financing source and financing agent are one and the same. Therefore, in this section, we omit international NGOs and foundations as FS, and focus solely on the flow of funds from bilateral and multilateral sources to their financing agents. Bilateral AIDS expenditures support HIV programmes managed by public sector entities, bilateral and multilateral agencies, international NGOs and international for-profit organisations. In total, 29% of bilateral resources were channelled to the MOH s AIDS programmes during Other public organisations shared 8% of total AIDS expenditures. 32

33 International NGOs were the largest financing agents of the bilateral donors, accounting for 36% of this financing source through their implementation of HIV interventions. Bilateral agencies directly expended 23% of total funds for their own programmes. Table 13 Disaggregation of bilateral AIDS expenditures by financing agent, (US$) Financing Agent Total % Public Ministry of Health 15,541,346 19,003,720 34,545, % Other public organisations 3,431,826 5,664,145 9,095, % Private 114, , , % International Bilateral 11,661,023 16,522,377 28,183, % Multilateral 1,158,500 2,420,602 3,579, % International non-profit organisations 16,623,511 26,556,863 43,180, % International for-profit organisations 22,000 1,451,161 1,473, % 3.1 Total 48,552,930 71,836, ,389, Figure 19 Disaggregation of bilateral AIDS expenditures by financing agent, (US$) There are only two types of financing agent for multilateral funding sources: the MOH and multilateral financing agents. The MOH expended 86% of the resources and the remainder were used by the multilateral agencies to finance their own HIV activities. A negligible percentage of funds were also transferred from the multilateral donors to international NGOs,. 33

34 Table 14 Disaggregation of multilateral AIDS expenditures by financing agent, (US$) Financing Agent Total % Public Ministry of Health 14,445,628 20,576,101 35,021, % International Multilateral 3,372,608 2,383,800 5,756,408 14% International non-profit organisations 31,763 15,333 47, % Total 17,849,999 22,975,234 40,825,232 Figure 20 Disaggregation of multilateral AIDS expenditures by financing agent, Multilateral 14% MOH 86% Flow of funds from financing agents to service providers The Ministry of Health (MOH) as a financing agent As a financing agent, the MOH pooled resources from the public sector and international donors to finance its HIV activities. The resources managed by the MOH increased by 26%, from US$ 36.8 million in 2008 to US$ 46.2 million in Overall, 92% of all AIDS funds managed by the MOH were channelled to three service providers: ambulatory care facilities (48% of all expenditures), hospitals (22%) and departments inside the MOH (22%). Table 15 Disaggregation of MOH AIDS expenditures by service provider, (US$) Service provider Total % Public PS Hospitals 7,525,836 10,848,764 18,374,600 22% PS Ambulatory care 19,334,735 20,631,614 39,966,350 48% PS Mental health and substance abuse 171, , ,682 facilities 1% PS Higher education 308, , ,762 1% PS Foster homes/shelters 17,202 17,202 0% PS Research institutions 699,043 1,351,245 2,050,288 2% PS Departments inside the Ministry of Health 7,904,724 10,425,526 18,330,250 22% PS Departments inside the Ministry of 18,451 Education 18,451 0% PS Departments inside the Ministry of 3,075 Defence 3,075 0% PS Departments inside the Ministry of Labour 54, , ,020 0% PS Departments inside the Ministry of Justice 3,690 3,540 7,230 0% PS Ho Chi Minh City s AIDS Committee 560, ,072 1,363,914 2% All PS Parastatal entities 167, , ,729 0% Non-profit PS Civil society organizations 50, , ,077 1% Total 36,819,554 46,291,075 83,110,629 34

35 Figure 21 Percentage share of service providers in total MOH AIDS transfer, Ho Chi Minh City s AIDS Committee, 2% MOH's departments, 22% Civil society organizations, 1% Hospitals, 22% Research institutions, 2% Higher education, 1% Mental health and substance abuse facilities, 1% Ambulatory care, 48% The Provincial Departments of Health (DOH) as financing agents The HIV funds managed by the provincial departments of health were mainly used to maintain operation of the Provincial AIDS Centres (PAC). Table 16 Disaggregation of DOH AIDS expenditures by service provider, (US$) Service provider Total % Public PS Ambulatory care 5,175,368 6,706,318 11,881,686 99% PS Ho Chi Minh City s AIDS Committee 45,729 49,520 95,249 1% Total 5,221,097 6,755,838 11,976,935 Other public institutions as financing agents The Other public financing agents category includes all public financing agents beyond the MOH and provincial Departments of Health. The resources managed by this group of financing agents increased by 49%, from US$ 4.7 million in 2008 to US$7.0 million in Providers receiving a significant portion of HIV funds from other public financing agents include health facilities (20% of total transfer of other public financing agents); social education and work centres for IDUs and FSW, classified as NASA category PS (24%), and the Ho Chi Minh City AIDS Committee (51%). Table 17 Disaggregation of other public financing agents AIDS expenditures by service provider, (US$) Service provider Total % 35

36 Public PS Hospitals 409, , , % PS Ambulatory care 647, ,209 1,611, % PS Mental health and substance abuse 1,404,669 1,443,007 2,847, % facilities PS Secondary education 1,454 2,276 3,730 0% PS Higher education 7,000 7, % PS Foster home/shelters 97, , , % PS Research institutions 45,998 90, , % PS Departments inside the Ministry of Labour ,759 15, % PS Ho Chi Minh City s AIDS Committee 2,002,245 3,991,198 5,993, % All PS Parastatal entities 74,895 45, , % Non-profit PS Foster homes/shelters (Non-profit) 15,769 18,382 34, % For-profit PS For-profit private sector providers n.e.c. 31,887 31, % Total 4,710,740 7,014,384 11,725,125 Figure 22 Percentage share of service providers in other public financing agents transfer, Parastatal entities 1% Hospitals 6% Ambulatory care 14% HCMC AIDS Committee, 52% Mental health and substance abuse facilities, 24% Research institutions, 1% Foster homes/shelters, 2% International non-profit organisations and foundations as financing agents International non-profit organisations channelled 66% of HIV funds under their control to the international and national NGO service providers. Other service providers receiving a significant portion of funds from international non-profit financing agents were ambulatory care facilities (9% of all AIDS funds managed by international NGOs), MOH departments (6%) and hospitals (5%). Table 18 Disaggregation of international NGO AIDS expenditures by service provider, (US$) Service provider Total % Public PS Hospitals 287,147 1,948,748 2,235,895 5% PS Ambulatory care 1,201,955 2,657,202 3,859,157 9% PS Mental health and substance abuse 22,067 15,036 37,103 0% facilities PS Foster homes/shelters 9,561 9,561 0% PS Research institutions 475, ,253 1% 36

37 PS Departments inside the Ministry of Health 1,082,648 1,594,867 2,677,515 6% PS Departments inside the Ministry of Labour 4,329 1,080,579 1,084,908 3% PS Ho Chi Minh City s AIDS Committee 226,274 1,359,762 1,586,035 4% All PS Parastatal entities 96, , ,946 1% Non-profit PS Civil society organizations 12,781,636 15,897,382 28,679,018 66% Other non-profit organisations 439, ,025 1,180,588 3% For-profit Other for-profit organisations 408, ,025 1,095,263 3% Total 16,559,506 26,813,737 43,373,243 Figure 23 Percentage share of service providers in total international NGOs transfer, Other non-profit organisations, 3% For-profit organisations, 3% Hospitals, 5% Ambulatory care, 9% Research institutions, 1% MOH's Departments, 6% Labour Ministry's Departments, 3% Civil society organizations, 66% Ho Chi Minh City s AIDS Committee, 4% Parastatal entities, 1% Bilateral agencies as financing agents Bilateral financing agents used 83% of all funds to finance their HIV-related activities (primarily for programme management and administration). This fund flow pattern is illustrated in Table 19. Table 19 Disaggregation of bilateral financing agents AIDS expenditures by service providers, (US$) Service provider Total % Public PS Hospitals 566, ,294 1,103, % PS Mental health and substance abuse 5,904 5,904 0% facilities PS Research institutions 91, , , % PS Departments inside the Ministry of 43,446 31,870 75, % Health PS Ho Chi Minh City s AIDS Committee 730, , % PS Governmental organisations n.e.c 420, , % All PS Parastatal entities 50, , , % Non-profit PS Higher education (non-profit) 180, , , % PS Research institutions (non-profit) 740, , % PS Self-help and informal community-based 34,329 organizations 34, % 37

38 For-profit PS Research institutions (for profit) 300, , % Bilateral and multilateral PS Bilateral agencies 9,957,925 13,395,776 23,353, % Total 11,661,023 16,522,377 28,183,401 Figure 24 Percentage share of service providers in total AIDS expenditures of bilateral financing agents, Hospitals Research institutions (governmental) HCMC AIDS Committee Governmental organizations n.e.c. Parastatal entities Bilateral agencies 83% Higher education Research institutions (Non-profit) Research institutions (For profit) Bilateral agencies Multilateral agencies as financing agents From , multilateral financing agents channelled the majority of their funds (62%) to support their own HIV programme management and administration. Other service providers receiving significant transfers from the multilateral agencies were the various MOH departments (sharing 17% of all multilateral financing agents transfer) and the Ho Chi Minh City s AIDS Committee (10%). Table 20 Disaggregation of multilateral financing agents AIDS expenditures by service providers, (US$) Service provider Total % Public PS Hospitals 35,942 35, % PS Mental health and substance abuse 146, , , % facilities PS Higher education 24,265 24, % PS Research institutions 71,566 71, % PS Departments inside the Ministry of 992, ,993 1,631, % Health PS Departments inside the Ministry of 120,813 67, , % Education PS Departments inside the Ministry of 49,508 79, , % Labour PS Ho Chi Minh City s AIDS Committee 929,897 38, , % 3.1 All Parastatal entities 24,200 24,200 48, % PS Non-profit PS Higher education (non-profit) 3,291 3,291 0% PS Self-help and informal community-based 25,000 25,000 organizations 0.3% PS Civil society organizations 54,729 52, , % Bilateral and multilateral PS Multilateral agencies 2,212,678 3,603,495 5,816,172 62% 38

39 Total 4,531,107 4,851,099 9,382, Figure 25 Percentage share of service providers in total transfer of multilateral financing agents, Ambulatory care 4% Research institutions 1% MOH's departments 18% Education Ministry's departments 2% Multilateral agencies 62% HCMC AIDS Committee 10% Labour Ministry's departments 1% Parastatal Civil society organizations organizations 1% 1% 39

40 6.1 AIDS EXPENDITURES BY PROGRAMMATIC AREA The NASA also allows for tracking of AIDS expenditures by programmatic area. NASA categorises such expenditures across eight core areas of HIV intervention. As is summarised in Table 22, expenditures in all programmatic areas increased significantly between 2008 and Prevention accounted for the highest proportion (32%) of total AIDS expenditures from , followed by programme management (30%) and care and treatment (26%). Expenditures on orphaned and vulnerable children (OVC) increased by the greatest percentage (63%) over this period. Table 21 AIDS expenditures by key programmatic area, (US$) AIDS expenditure area 2008 % 2009 % Total % Prevention 31,913,528 33% 39,596,542 31% 71,510,071 32% Care and Treatment 24,274,597 25% 32,912,678 26% 57,187,275 26% Orphaned and vulnerable children 872,092 1% 1,425,733 1% 2,297,826 1% Programme management 28,980,144 30% 38,745,169 31% 67,725,314 30% Human resources 6,600,136 7% 8,525,473 7% 15,125,609 7% Social support and social services 286,045 0% 361,244 0% 647,289 0% Enabling environment 2,574,830 3% 3,444,920 3% 6,019,750 3% HIV related Research 706,912 1% 1,208,027 1% 1,914,939 1% Total 96,208, ,219, ,428,073 Figure 26 Percentage share of key programmatic areas in AIDS expenditures, Human resources 7% Enabling environment 3% Research 1% Program management 30% OVC 1% Care and treatment 26% Prevention 32% Table 23 disaggregates AIDS expenditures by key intervention area and major sources of funding. Public financing concentrated on programme management and administration (55% of expenditures) and prevention (20% of expenditures); private financing was mostly spent on care and treatment (77%); and the international financing was channelled principally to prevention (37%), programme management (32%) and care and treatment (18%). Figure 21 illustrates the percentage share of each key intervention area in terms of total expenditure of public, private and international financing sources. 40

41 Table 22 AIDS expenditures by key intervention area and financing source (US$) AIDS expenditure area Public Private International Total Prevention 2,868,970 2,935,193 3,665,585 3,687,724 25,378,974 32,973,625 31,913,528 39,596,542 Care and Treatment 1,793,931 1,813,447 12,347,089 12,347,089 10,133,578 18,752,141 24,274,597 32,912,678 OVC 50,618 42,359 1,648 1, ,827 1,381, ,092 1,425,733 Programme management 7,016,284 8,400,076 21,964,352 30,345,093 28,980,635 38,745,169 Human resources 1,722,478 1,778,481 4,877,658 6,746,992 6,600,136 8,525,473 Social support 3, , , , ,244 Enabling environment 2,574,830 3,444,920 2,574,830 3,444,920 Research 3, ,187 1,208, ,912 1,208,027 Total 13,459,880 14,969,558 16,014,322 16,036,518 66,734,575 95,213,712 96,208, ,219,787 Figure 27 AIDS Expenditure disaggregation of each financing source by key intervention area, % 20% 23% 0% 4% 1% 7% 37% Prevention Care and treatment OVC 13% 32% Program management Human resources 55% Public source Prevention 0% 77% Private source 1% 18% International source Social support Enabling environment Research Expenditures on HIV prevention increased by 25% over the NASA period, from US$ 31.9 million in 2008 to US$ 39.6 million in While HIV prevention expenditures were distributed across 47 three-digit ASC (see Table 23), 80% of HIV prevention expenditures were concentrated in ten categories (see Table 24). These categories included: prevention activities not disaggregated by intervention (20% of preventive expenditures); communication for social and behavioural change not disaggregated by type (16%); blood safety (12%); behaviour change communication (BCC) as part of programmes for IDUs (6%); PMTCT not disaggregated by intervention (6%); VCT (5%); BCC as part of programmes for sex workers and their clients (5%) and interventions for IDUs not disaggregated by type (5%). Table 23 Expenditures on HIV prevention, (US$) ASC Code AIDS Expenditure by Category of Prevention ASC Health-related communication for social and behavioural change 1,228,732 1,605,414 ASC Non-health-related communication for social and behavioural change 226,145 78,898 Communication for Social and behavioural change not disaggregated by ASC type 5,406,407 5,739,670 ASC Community mobilization 1,325, ,898 ASC Voluntary counselling and testing (VCT) 1,308,824 2,483,879 ASC VCT as part of programmes for vulnerable and accessible populations 255, ,593 Condom provision as part of programmes for vulnerable and accessible ASC populations 25,931 43,858 41

42 ASC STI as part of programmes for vulnerable and accessible populations 602, ,950 ASC BCC as part of programmes for vulnerable and accessible populations 177, ,318 Interventions for vulnerable and accessible population not disaggregated ASC by type 22, ,747 ASC Prevention youth in school 316, ,497 ASC Prevention youth out-of-school 440, ,000 ASC BCC as part of prevention of HIV transmission aimed at PLHIV ,679 ASC Prevention of HIV transmission aimed at PLHIV not disaggregated by type 234, ,299 ASC VCT as part of programmes for sex workers and their clients 12,564 19,584 ASC Condom provision as part of programmes for sex workers and their clients 844,002 1,304,762 ASC STI as part of programmes for sex workers and their clients 11,372 38,715 ASC BCC as part of programmes for sex workers and their clients 1,710,246 1,796,509 ASC Interventions for sex workers and their clients not disaggregated by type 422, ,322 ASC Other interventions for sex workers and their clients, n.e.c. 21,167 25,464 ASC VCT as part of programmes for MSM 210 7,972 ASC Condom provision as part of programmes for MSM 156, ,413 ASC STI prevention and treatment as part of programmes for MSM 179 2,472 ASC Behaviour change communication (BCC) as part of programmes for MSM 389, ,581 ASC Programmatic interventions for MSM not disaggregated by type 288, ,931 ASC VCT as part of programmes for IDUs 60,307 50,522 ASC Condom provision as part of programmes for IDUs 107, ,387 ASC BCC as part of programmes for IDUs 2,671,045 1,716,098 ASC Sterile syringe and needle exchange as part of programmes for IDUs 213, ,411 ASC Drug substitution treatment as part of programmes for IDUs 455,323 1,111,217 ASC Programmatic interventions for IDUs not disaggregated by type 1,185,861 2,064,478 ASC Other programmatic interventions for IDUs, n.e.c. 8,750 12,456 ASC BCC as part of programmes in the workplace 16,722 86,716 ASC Programmatic interventions in the workplace not disaggregated by type 247, ,519 ASC Condom social marketing 2,153 ASC Public and commercial sector male condom provision 46, ,681 ASC Microbicides 18,328 23,599 ASC Prevention, diagnosis and treatment of sexually transmitted infections (STI) 235, ,899 ASC Pregnant women counselling and testing in PMTCT programmes 2,766 2,766 ASC Safe infant feeding practices (including substitution of breast milk) 17,296 14,151 ASC PMTCT not disaggregated by intervention 1,650,721 2,385,565 ASC PMTCT activities n.e.c. 2,399 ASC Blood safety 4,316,317 3,965,650 ASC Safe medical injections 35,848 61,727 ASC Universal precautions 1,086 5,225 ASC Post-exposure prophylaxis not disaggregated by intervention 308 ASC Prevention activities not disaggregated by intervention 5,189,465 8,866,050 Total expenditures on prevention 31,913,528 39,596,542 42

43 Table 24 Expenditures on major preventive categories, (US$) ASC Code AIDS Expenditure Categories Total ASC Prevention activities not disaggregated by intervention 5,189,465 8,866,050 14,055,516 ASC BCC not disaggregated by type 5,406,407 5,739,670 11,146,077 ASC Blood safety 4,316,317 3,965,650 8,281,967 ASC BCC as part of programmes for IDUs 2,671,045 1,716,098 4,387,143 ASC PMTCT not disaggregated by intervention 1,650,721 2,385,565 4,036,286 ASC Voluntary counselling and testing (VCT) 1,308,824 2,483,879 3,792,702 BCC as part of programmes for sex workers and their ASC clients 1,710,246 1,796,509 3,506,755 Programmatic interventions for IDUs not ASC disaggregated by type 1,185,861 2,064,478 3,250,339 ASC Health-related BCC 1,228,732 1,605,414 2,834,146 Condom provision as part of programmes for sex ASC workers 844,002 1,304,762 2,148,764 Total expenditures on ten major preventive categories 25,511,619 31,928,075 57,439,693 Overall, international sources accounted for 82% of prevention expenditures, private sources for 10% and public source for 8%. Table 26 details expenditures of public, private and international sources on HIV prevention activities. 43

44 Table 25 Public, private and international expenditures on HIV prevention activities, (US$) ASC Code AIDS Expenditure Categories of Prevention Public Private Internation al Public Private Internatio nal ASC Health-related BCC 291, , ,251 1,229,163 ASC Non-health-related BCC 30, ,489 29,571 49,327 ASC BCC not disaggregated by type 1,262,547 4,143,859 1,256,849 4,482,821 ASC Community mobilization 32,761 1,293,071 2, ,342 ASC VCT 63,124 1,245,700 71,809 2,412,070 ASC VCT as part of programmes for vulnerable 255, ,593 and accessible populations ASC Condom provision as part of programmes for 25,931 43,858 vulnerable and accessible populations ASC STI as part of programmes for vulnerable and 602, ,950 accessible populations ASC BCC as part of programmes for vulnerable 177, ,318 and accessible populations ASC Interventions for vulnerable and accessible 18,880 3, ,186 population not disaggregated by type ASC Prevention youth in school , ,497 ASC Prevention youth out-of-school 1, , ,000 ASC BCC as part of prevention of HIV ,679 - transmission aimed at PLHIV ASC Prevention of HIV transmission aimed at 34, ,449 14, ,668 PLHIV not disaggregated by type ASC VCT as part of programmes for sex workers and their clients 12,564 19,584 ASC Condom provision as part of programmes for 185, , , ,935 sex workers and their clients ASC STI as part of programmes for sex workers 11,372 38,715 and their clients ASC BCC as part of programmes for sex workers and their clients 1,710,246 1,796,509 ASC Interventions for sex workers and their clients 1, , ,322 not disaggregated by type ASC Other interventions for sex workers and their 21,167 25,464 clients, n.e.c. ASC VCT as part of programmes for MSM 210 7,972 ASC Condom provision as part of programmes for - 37, ,708-65, ,248 MSM ASC STI prevention and treatment as part of ,472 programmes for MSM ASC BCC as part of programmes for MSM , ,581 ASC Programmatic interventions for MSM not , ,931 disaggregated by type ASC VCT as part of programmes for IDUs ,307 2,549-47,973 ASC Condom provision as part of programmes for 2,621 24,774 79,806-43, ,944 IDUs ASC BCC as part of programmes for IDUs - - 2,671, ,716,098 ASC Sterile syringe and needle exchange as part ,894 24, ,789 of programmes for IDUs ASC Drug substitution treatment as part of 1, ,446 1,777-1,109,440 programmes for IDUs ASC Programmatic interventions for IDUs not 12,067-1,173, ,064,478 disaggregated by type ASC Other programmatic interventions for IDUs, - - 8, ,456 n.e.c. ASC BCC as part of programmes in the workplace , ,716 ASC Programmatic interventions in the workplace 7, ,000 5, ,678 not disaggregated by type ASC Condom social marketing 2, ASC Public and commercial sector male condom , ,681 44

45 provision ASC Microbicides 18, , ASC Prevention, diagnosis and treatment of STI 123, , , ,395 ASC Pregnant women counselling and testing in 2, , PMTCT programmes ASC Safe infant feeding practices (including , ,151 substitution of breast milk) ASC PMTCT not disaggregated by intervention 131,929-1,518, ,791-2,280,774 ASC PMTCT activities n.e.c. 2, ASC Blood safety 446,747 3,069, , ,633 2,905, ,000 ASC Safe medical injections 35, ,317-41,410 ASC Universal precautions 1, ,007 ASC ASC Post-exposure prophylaxis not disaggregated by intervention Prevention activities not disaggregated by 342, ,271 4,499, , ,271 7,976,110 intervention Total expenditures on prevention 2,868,970 3,665,585 25,378,974 2,935,193 3,687,724 32,973,625 Figure 28 Share of public, private and international sources in HIV prevention expenditures, Public, 8% Private, 10% International 82% Care and Treatment Expenditures on care and treatment increased by 36% over the NASA period, from US$ 24.3 million in 2008 to US$ 32.9 million in In particular, expenditures on ART services, including nutritional support and laboratory monitoring, rose 32% over this period, from nearly US$ 7 million in 2008 to US$ 9.2 million in 2009, an increase of 32%. Care and treatment activities that received the most financial support were: home-based medical care (accounting for 19% of total care and treatment expenditures); care and treatment services not disaggregated by intervention (17%); OI outpatient prophylaxis and treatment not disaggregated by type (15%); Inpatient care services not disaggregated by intervention (10%); and First-line ART adults (10%). These five top-funded ASC attracted 70% of care and treatment expenditures. Table 26 Expenditures on care and treatment, (US$) ASC Code AIDS Expenditure Categories of Care and Treatment Total

46 09 ASC Provider-initiated testing and counselling (PITC) 96, , ,362 ASC OI outpatient prophylaxis 29, , ,985 ASC OI outpatient treatment 333, , ,091 ASC OI outpatient prophylaxis and treatment not 4,192,690 4,258,295 8,450,985 disaggregated by type ASC First-line ART adults 1,540,752 4,001,053 5,541,805 ASC Second-line ART adults 847, ,392 ASC Adult antiretroviral therapy not disaggregated by line of 990,359 1,709,363 2,699,723 treatment ASC First-line ART paediatric 143, ,000 ASC Second-line ART paediatric 197, ,000 ASC Paediatric antiretroviral therapy not disaggregated by 119, , ,472 line of treatment ASC ART not disaggregated neither by age nor by line of 3,521, ,782 4,485,298 treatment ASC Nutritional support associated to ARV therapy 3,321 21,361 24,682 ASC Specific HIV-related laboratory monitoring 807,329 1,063,967 1,871,297 ASC Psychological treatment and support services 5,751 9,333 15,085 ASC Outpatient palliative care 329, , ,647 ASC Home-based medical care 5,439,943 5,457,932 10,897,874 ASC Home-based non medical/non-health care 1, ,153 ASC Home-based care not disaggregated by type 572,934 1,575,061 2,147,996 ASC Outpatient care services not disaggregated by 278,204 1,770,864 2,049,068 intervention ASC Inpatient treatment of opportunistic infections 62, , ,352 ASC Inpatient palliative care , ,968 ASC Inpatient care services not disaggregated by 2,829,133 2,825,660 5,654,793 intervention ASC Inpatient care services n.e.c ASC Patient transport and emergency rescue ASC Care and treatment services not disaggregated by 3,119,551 6,395,796 9,515,346 intervention ASC Care and treatment services n.e.c Total expenditures on care and treatment 24,274,597 32,912,67 57,187,275 8 Figure 23 illustrates the distribution of care and treatment expenditures by group of activities. ART services, including nutritional support and laboratory monitoring associated with ART accounted for 28% of all care and treatment expenditures; home-based care (23%); outpatient care (16%); and inpatient prophylaxis and treatment of opportunistic infections (11%). 46

47 Figure 29 Percentage share of care and treatment expenditures, Other services, not disagregated 22% Outpatient OI prophylaxis and treatment 16% Inpatient care 11% Home-based care 23% ART s ervices, including nutritional support and lab monitoring 28% Disaggregating care and treatment expenditures by their sources of funding revealed that 51% of care and treatment services in were covered by international sources; private sources which mainly come from out of pocket payment (43%) and public sources (6%) covered the remainder. Figure 30 Share of public, private and international sources in care and treatment expenditures, Public 6% International 51% Private 43% International sources focused the majority of their care and treatment-related AIDS expenditures in several areas: care and treatment services not disaggregated by intervention received 28% of total international care and treatment expenditures; antiretroviral therapy not disaggregated neither by age nor by line of treatment (15%); first-line ART adults (14%); and adult antiretroviral therapy not disaggregated by line of treatment (9%). Combined, these four ASC comprised 67% of international expenditures on care and treatment. In total, 80% of public care and treatment expenditures were spent on two ASC: adult first-line ART (42% of all public care and treatment expenditures), and care and treatment services not disaggregated by intervention (38%). The entirety of private funds for care and treatment were expended within three ASC: home-based medical care (44% of all private care and treatment expenditures), OI outpatient prophylaxis and treatment not disaggregated by type (33%) and inpatient care services not disaggregated by intervention (23%) Table 27 Expenditures of public, private and international sources on care and treatment, (US$) ASC Code Care and treatment ASC

48 ASC ASC ASC ASC ASC ASC ASC ASC ASC ASC ASC ASC ASC ASC ASC ASC ASC ASC ASC ASC ASC ASC ASC ASC ASC ASC Public Private Internatio nal Public Private Internation al Provider- initiated testing and - 255,291 counselling (PITC) 21,641-74,430 - OI outpatient prophylaxis 94,659 13,123-16,304 17,898 - OI outpatient treatment 352,909 96, ,111 93,843 - OI outpatient prophylaxis and 153,019 treatment not disaggregated by 49,063 4,101,7 41,860 3,510 4,101,7 type First-line ART adults 728, , ,958-3,205,094 Second-line ART adults - 847,392 - Adult antiretroviral therapy not disaggregated by line of 2, ,961 2,159-1,707,204 treatment First-line ART paediatric - 143,000 - Second-line ART paediatric - 197,000 - Paediatric antiretroviral therapy - 257,058 not disaggregated by line of ,414 - treatment ART not disaggregated neither 957,419 by age nor by line of treatment 35,694-3,485,822 6,363 - Nutritional support associated to ,361 ARV therapy 3, Specific HIV-related laboratory - monitoring ,714-1,063,967 Psychological treatment and - 9,333 support services 729-5,023 - Outpatient palliative care 8,410 93, , ,274 - Home-based medical care 5,429,9-5,429,9 28, , Home-based non medical/nonhealth - care Home-based care not disaggregated by type 25, ,902 17,925-1,557,136 Outpatient care services not disaggregated by intervention 13, ,839 23,528-1,747,336 Inpatient treatment of 218,141 opportunistic infections 28,999-33,188 26,024 - Inpatient palliative care - 233, Inpatient care services not 2,815,3 -,815,39 10,268 disaggregated by intervention 2, ,850 2 Inpatient care services n.e.c. 492 Patient transport and emergency 40 rescue 246 Care and treatment services not disaggregated by intervention 676,982 2,442, ,902-5,684,894 Care and treatment services - n.e.c. 123 Total expenditures on care 12,347, 12,347, and treatment 1,793, ,133,57 1,813, ,752, Orphans and Vulnerable Children 48

49 OVC expenditures increased by 63% over the NASA period, from US$ million in 2008 to over US$ 1.4 million in As OVC services were often provided as a package of services, it was not possible for the NASA team to disaggregate a large portion of expenditures into two-digit sub-categories.. In these two years, such expenditures increased by 16%; however, as a percentage of total OVC expenditures, institutional care fell from 32% to 23% due to significant programmatic expansion in other categories. Overall, 96% of OVC expenditures in were financed by international sources. Table 28 Expenditures on OVC, (US$) ASC Code AIDS Expenditures Categories Total ASC OVC Education 14,798 7,054 21,853 ASC OVC Basic health care 23, , ,297 ASC OVC Family/home support 1, ,574 ASC OVC Community support 54,441 15,239 69,681 ASC OVC Social services and Administrative costs 10,637 10,637 ASC OVC Institutional care 282, , ,462 ASC OVC Services not disaggregated by intervention 436, ,925 1,396,410 ASC OVC Services n.e.c. 58,912 58,912 Total expenditures on OVC 872,092 1,425,733 2,297,826 Figure 31 Disaggregation of OVC expenditures, Thousands US$ 1,600 1,400 1,200 1, % 68% Services n.e.c. Services not disaggregated by intervention Institutional care OVC Social Services and Administrative costs Community support % 23% Family/home support Basic health care Education Programme Management and Administration Expenditures on programme management and administration strengthening increased by 34% over the NASA period, from nearly US$ 29 million in 2008 to US$ 38.7 million in Planning, coordination and programme management was the major expenditure category during this period, accounting for 63% of total expenditures in this intervention area. Other significant categories included: monitoring and evaluation (accounting for 9% of total programme management expenditures); programme management and administration not disaggregated by type (8%); upgrading laboratory infrastructure and new equipment (6%); and upgrading and construction of infrastructure not disaggregated by intervention (5%). The five top ASC codes together accounted for 91% of total expenditures on programme management and administration strengthening. Table 29 Expenditures on HIV programme management and administration, (US$) ASC Code AIDS Expenditure Categories Total ASC Planning, coordination and programme management 23,282,571 42,497,238 19,214,666 ASC Administration and transaction costs associated with 612, ,079 1,382,536 managing and disbursing funds ASC Monitoring and evaluation 3,028,040 3,162,314 6,190,354 ASC Operations research 118, , ,301 49

50 ASC Serological-surveillance (serosurveillance) 350,847 1,534,961 1,885,808 ASC HIV drug-resistance surveillance 1,292 1,292 ASC Drug supply systems 669, ,286 1,260,311 ASC Information technology 185,107 52, ,184 ASC Patient tracking 13,117 13,117 ASC Upgrading and construction of infrastructure 67,167 67,167 ASC Upgrading laboratory infrastructure and new equipment 1,222,446 3,121,932 4,344,378 ASC Construction of new health centres 2,783 2,783 ASC Upgrading and construction of infrastructure not 1,618,024 1,775,770 3,393,794 disaggregated by intervention ASC Upgrading and construction of infrastructure n.e.c ,921 87,505 ASC Mandatory HIV testing (not VCT) 24,503 3,068 27,571 ASC Programme management and administration not 1,747,546 3,700,278 5,447,824 disaggregated by type ASC Programme management and administration n.e.c 104,140 53, ,151 Total 38,745,169 67,725,314 28,980,144 Figure 32 Expenditures on programme management and administration, % 5% 9% Planning, coordination and programme management Monitoring and evaluation 8% 9% 63% Programme management and administration not disaggregated by type Upgrading laboratory infrastructure and new equipment Upgrading and construction of infrastructure not disaggregated by intervention Other program management services Programme management expenditures were covered by two financing sources: public and international funds. International sources financed 77% of programme management expenditures, and the remainder (23%) were supported from public sources. 50

51 Table 29 Public and international expenditures on HIV programme management and administration, ASC Code ASC ASC ASC ASC ASC ASC ASC ASC ASC ASC ASC ASC ASC ASC ASC ASC ASC AIDS Expenditure Categories Public International Public International Planning, coordination and programme management 3,826,386 15,388,280 5,521,260 17,761,312 Administration and transaction costs associated with managing 21, ,025 14, ,976 and disbursing funds Monitoring and evaluation 560, ,095 2,437,436 2,602,222 Operations research 50,872 74,795 43, ,030 Serological-surveillance 167,132 (serosurveillance) 349,018 1,829 1,367,829 HIV drug-resistance surveillance 1,292 Drug supply systems 40, , ,286 Information technology 5, ,207 52,077 Patient tracking 12, Upgrading and construction of infrastructure 67,167 Upgrading laboratory 123,804 infrastructure and new equipment 296, ,660 2,998,127 Construction of new health centres 2,783 Upgrading and construction of infrastructure not disaggregated 1,403, ,224 1,691,165 84,605 by intervention Upgrading and construction of infrastructure n.e.c ,921 Mandatory HIV testing (not VCT) 3,068 24,503 Programme management and administration not disaggregated 264,551 1,482, ,149 3,478,129 by type Programme management and 46,431 6,581 administration n.e.c 103, Total expenditures on 7,016,284 21,964,352 8,400,076 30,345,093 programme management and administration 51

52 Figure 33 Percentage share of public and international sources in HIV programme management expenditures, Public 23% International 77% Human resources Expenditures on human resources increased by 29% over the NASA period, from US$ 6.6 million in 2008 to US$ 8.5 million in Of these expenditures, 82% went to support training of staff; the vast majority of other expenditures were monetary incentive payment for staff. Table 31 Expenditures on human resources, (US$) ASC Code AIDS Expenditures Categories Total ASC Monetary incentives for other staff not disaggregated by type 1,236,687 1,282,863 2,519,550 ASC Monetary incentives for physicians not disaggregated 72,790 95, ,986 by type ASC Formative education to build-up an HIV workforce 9,841 9,841 ASC Training 5,261,850 7,091,858 12,353,707 ASC Human resources not disaggregated by type 18,968 55,558 74,525 Total expenditures on human resources 6,600,136 8,525,473 15,125, Social Protection and Social Services Expenditures on social protection and social services increased by 26% over the NASA period, from US$ 0.28 million in 2008 to US$ 0.36 million in Such expenditures were comprised of: income-generation for PLHIV and social protection services and social services not disaggregated by type. Table 30 Expenditures on social protection and social services, (US$) ASC Code AIDS Expenditure Categories Total ASC HIV-specific income generation projects 282, , ,467 ASC Social protection services and social services not 3, , ,821 disaggregated by type Total expenditures on social protection and social services 286, , , Enabling environment Expenditures on interventions to support an enabling environment increased by 34% over the NASA period, from nearly US$ 2.6 million in 2008 to US$3.4 million in The majority of expenditures to support an enabling environment were directed towards advocacy and AIDS-specific institutional development, which respectively accounted for 51% and 37% of total expenditures from This categories were also those solely financed by international sources. 52

53 Table 31 Expenditures to support an enabling environment, (US$) ASC Code AIDS Expenditure Categories Total ASC Advocacy 1,160,594 1,884,347 3,044,941 ASC Provision of legal and social services to promote 25, , ,579 access to prevention, care and treatment ASC Capacity building in human rights 16,078 21,507 37,585 ASC Human rights programmes not disaggregated by type 5,000 5,000 ASC AIDS-specific institutional development 1,021,171 1,181,837 2,203,009 ASC AIDS-specific programmes focused on women 122, , ,942 ASC Enabling environment not disaggregated by type 177,211 89, ,069 ASC Enabling environment n.e.c. 51,836 19,791 71,627 Total expenditures on Enabling environment 2,574,830 3,444,920 6,019, HIV- related Research Expenditures on HIV-related research increased by 71% over the NASA period, from US$ 0.71 million in 2008 to US$ 1.2 million in Research categories receiving the most funding in this area were clinical research (39% of total HIV-related research expenditures) and social science research not disaggregated by type (33%). HIV-related research was financed by exclusively by international sources. Table 32 Expenditures on HIV-related research, (US$) ASC Code AIDS Expenditure Categories Total ASC Biomedical research 81,427 81,427 ASC Clinical research 378, , ,652 ASC Epidemiological research 3,075 3,075 ASC Behavioural research 10,000 10,000 ASC Social science research not disaggregated by type 109, , ,448 ASC HIV-related research activities not disaggregated by 205, , ,338 type ASC HIV-related research activities n.e.c. 30,000 30,000 Total expenditures on research 706,912 1,208,027 1,914, AIDS EXPENDITURES BY BENEFICIARY POPULATION NASA also allows for classification of AIDS expenditures by beneficiary population supported. NASA methodology classifies beneficiary populations into six categories. Table 35 itemizes annual AIDS expenditures by three-digit category of beneficiary population. Overall, from , 28% of AIDS expenditures benefitted PLHIV. Expenditures on activities targeting most-atrisk populations, (including IDUs, FSW and MSM) increased from 13% of total AIDS expenditures in 2008 to 17% of total AIDS expenditures in Key population groups, including OVC, children born or to be born to women living with HIV and recipients of blood or blood products, benefitted from 5% of total AIDS expenditures from Specific accessible populations, including people attending STI clinics, factory employees, the military and students, received 4% of total AIDS expenditures over this same period. The general population benefitted from 9% of total AIDS expenditures from , and 39% of total expenditures supported non-targeted activities, including training, programme management and administration, M&E and investment in infrastructure. 53

54 Table 33 AIDS expenditures by six beneficiary population groups, (US$) BP code Beneficiary population group 2008 % 2009 % Total % BP.01 PLHIV 26,628,661 BP.02 "Most-at-risk" 2,926,226 populations BP.03 Key populations 5,365,754 BP.04 Specific accessible populations 4,450,927 BP.05 General population 9,460,272 BP.06 Non-targeted interventions 37,376,446 Total 96,208, % 13.4% 5.6% 4.6% 9.9% 38.8% ,727,820 21,164,259 6,471,014 3,342,714 11,023,664 49,490, ,219, % 16.8% 5.1% 2.6% 8.7% 39.2% ,356, % 34,090, % 11,836, % 7,793, % 20,483, % 86,866, % 222,428, Figure 34 Disaggregation of AIDS expenditures by six beneficiary population groups, Non-targeted interventions 39% PLHIV 28% General population 9% Specific accessible populations 4% "Most-at-risk" population 15% Key populations 5% Table 34 AIDS expenditures by beneficiary populations, (US$) Beneficiary population codes BP BP BP BP BP BP Beneficiary populations Total Adult and young people (aged 15 over) living with HIV 3,350,018 7,796,613 11,146,631 Children (aged under 15) living with HIV 1,509,119 2,679,265 4,188,384 People living with HIV not disaggregated by age or gender 21,769,524 24,251,941 46,021,465 IDU and their sexual partners Female sex workers and their clients Male non-transvestite sex workers (and their clients) 4,684,359 6,255,120 10,939,479 3,310,031 3,547,359 6,857,390 32,680 32,680 54

55 BP BP BP Sex workers, not disaggregated by gender, and their clients 266, , ,137 MSM 798, ,818 1,770,692 Most-at-risk populations not disaggregated by type 3,834,061 9,837,045 13,671,106 BP BP BP BP BP BP BP BP BP BP BP BP BP BP BP BP BP BP BP BP BP BP BP BP BP OVC 576,837 1,199,393 1,776,230 Children born or to be born of women living with HIV 1,639,808 2,215,826 3,855,634 Migrants/mobile populations Indigenous groups 33,535 48,437 81,972 16,501 35,285 51,786 Prisoners and other institutionalized persons 20,198 33,442 53,640 Truck drivers/transport workers and commercial drivers 112, ,730 Children and youth out of school Institutionalized children and youth Recipients of blood or blood products Other key populations not disaggregated by type People attending STI clinics Junior high/high school students University students Health care workers Sailors 1,415 1,415 1,454 2,363 3,817 2,717,633 2,495,410 5,213, , , , , , ,660 42,253 25,000 67, , , ,901 36,155 61,727 97,883 19,510 19,510 Military 253, , ,075 Police and other uniformed services (other than the military) 5,007 5,007 Factory employees (e.g. for workplace interventions) 601, , ,400 Specific accessible populations not disaggregated by type 3,187,555 2,113,720 5,301,275 Specific accessible populations n.e.c. 7, , ,677 Female adult population 330, , ,061 General adult population (aged older than 24) not disaggregated by gender 17, , ,469 Children (aged under 15) not disaggregated by gender 84,274 7,031 91,305 Youth (aged 15 to 24) not disaggregated by gender 2,256,265 2,991,428 5,247,693 General population not disaggregated by age or gender. 6,772,176 7,182,230 13,954,407 BP.06 Non-targeted interventions 37,376,446 Total 49,490,316 86,866,763 96,208, ,219, ,428,073 55

56 8.1 AIDS EXPENDITURES BY PRODUCTION FACTORS NASA also allows for classification of AIDS expenditures by production factors. NASA defines production factors (or resource costs) as inputs used to provide AIDS-related services. By types of expenditures, 81% of AIDS expenditures from were current expenditures. Capital expenditures account for only 5% of all expenditures, and 13% of expenditures are unclassified due to a lack of information. Detailed disaggregation of production factors is summarised in Table 37. Figure 35 Disaggregation of AIDS expenditures by types of expenditures, Production factors not broken down by type 13% Capital expenditures 5% Current expenditures 82% Table 35 Disaggregation of AIDS expenditures by production factors, (US$) Production Production factor Total % factor code PF Wages 12,501,550 14,642,981 27,144,530 12% PF Social contributions 139, , ,964 0% PF Non-wage labour income 208, , ,616 0% PF Labour income not disaggregated by 6,614 94, ,172 0% type PF Antiretrovirals 1,451,351 1,719,885 3,171,236 1% PF Other drugs and pharmaceuticals 6,797,325 6,820,714 13,618,039 6% (excluding antiretrovirals) PF Medical and surgical supplies 977,305 1,491,694 2,468,999 1% PF Condoms 760,385 1,270,566 2,030,952 1% PF Reagents and materials 3,250,074 3,730,726 6,980,800 3% PF Food and nutrients 116, , ,111 0% PF Uniforms and school materials 41,957 68, ,306 PF Material supplies not disaggregated by 4,398,779 5,621,157 10,019,936 5% type PF Other material supplies n.e.c. 38,530 8,387 46,916 0% PF Administrative services 1,516,199 2,422,075 3,938,274 2% PF Maintenance and repair services 169, , ,414 0% PF Publisher, motion picture, broadcasting 4,641,155 5,005,526 9,646,681 4% and programming services PF Consulting services 2,525,605 1,769,631 4,295,236 2% PF Transportation and travel services 1,544,528 1,865,923 3,410,451 2% PF Housing services 105,646 95, ,529 0% PF Logistics of events, including catering 4,055,840 2,667,910 6,723,750 3% services PF Financial intermediation services 7,334 2,960 10,294 0% PF Services not disaggregated by type 1,419,376 2,606,464 4,025,840 2% PF Services n.e.c. 6,780 6,780 0% PF Current expenditures not disaggregated 33,594,782 47,346,435 80,941,217 36% by type PF Current expenditures n.e.c. 686,509 25, ,363 0% 56

57 PF Laboratory and other infrastructure 6,729 91,278 98,007 0% upgrading PF Buildings not disaggregated by type 1,135,481 1,264,847 2,400,328 1% PF Vehicles 27,505 27,505 0% PF Information technology (hardware and 131, , ,885 0% software) PF Laboratory and other medical equipment 665, ,625 1,227,591 1% PF Equipment not disaggregated by type 1,096,042 1,165,913 2,261,955 1% PF Capital expenditure not disaggregated by 1,446,926 3,875,323 5,322,249 2% type PF Capital expenditure n.e.c. 77,826 77,826 0% PF.98 Production factors not disaggregated by 10,686,509 19,137,304 29,823,813 13% type Total production factors 96,208, ,219, ,428,563 Overall, current expenditures on HIV-related activities totalled to $180.9 million in Of these expenditures, 15% were on labour costs (e.g., wages, social contributions). Material supplies (e.g., antiretrovirals and other drugs, condoms and reagents) comprised 21%, and services accounted for 18%. Due to a lack of information, 45% of current expenditures could not be disaggregated by type. Figure 36 Disaggregation of current AIDS expenditures by production factors, Labour, $27,895,282 Current expenditures not broken down by type, $81,653,579 Material supplies, $38,753,296 Services, $32,601,249 57

58 V. RECOMMENDATIONS The NASA marks the first-ever study to capture comprehensive AIDS expenditure data related to the multi-sectoral national HIV response in Viet Nam, as well as to track the specific HIV services being provided using these resources and their ultimate beneficiaries. The NASA results highlight the critical roles of various stakeholders in addressing the HIV epidemic in Viet Nam, the scope of their activities, the character of their linkages as well as and the broader impact of their interventions. Gaining a greater understanding of these factors is an essential step towards informing and enabling effective coordination and strategic planning of the national HIV response. Based on the key findings from the NASA, this section highlights a series of recommendations for future action for consideration by national and international decision makers and HIV programme planners. Recommendations for future action 1. NASA should be embedded as a routine exercise at the national level in Viet Nam to support strategic planning and analysis, and to help guide implementation of the national HIV response. 2. NASA also should be conducted at the provincial level, which would allow for a more in-depth analysis of AIDS expenditures at the sub-national level and support strategic policy and programme planning. 3. Key experiences and lessons learned from the inaugural Viet Nam NASA should be documented, analysed and incorporated, as appropriate, within future national AIDS spending assessments. 4. NASA findings should be broadly disseminated among key national and international stakeholders to ensure their utilisation. 5. Cooperation with key international donors, including PEPFAR, to crosswalk their AIDS expenditures categories with those of NASA should be continued and strengthened to enhance the accuracy and utility of future assessments. 58

59 VI. APPENDICIES APPENDIX 1: REFERENCES MOH (2010). Circular No.1991/BYT-AIDS dated 6/4/2010 to the Vice-Prime Minister Truong Vinh Trong to report on HIV/AIDS epidemic in MOH (2009). Vietnam HIV/AIDS Estimates and Projections , MOH-VAAC, 4/2009. USAID and the Futures Group. Economic and Public Health Survey of Institutional and Community Responses to Injecting Drug Use and HIV/AIDS in Viet Nam, Decision of the MOH No.36/2008/QD-BYT dated 28/10/2008 on Approval of the National Action Program on Blood Safety for Prevention of HIV Transmission period Decision of the Prime Minister No.108/2007/QD-TTg dated 17/7/2007 on Approval of the National Target Program on Prevention and Combating Some Social and Dangerous Diseases and HIV/AIDS in the period Government of Vietnam, Vietnam Country Progress Report 3/2010. ABT- USAID/HPI- PLHIV- Out of expenditure survey, unpublished report 59

60 APPENDIX 2: DATA COLLECTION FORM National AIDS Spending Assessment (NASA) and National Health Accounts (NHA) Survey Name of Organisation Acronym of Organisation Address of Organisation: Status of Organisation Cross check the appropriate cell Organisation Public NGO Bilateral Multilateral National Provincial International Contact person in the organization Full name: Position: Telephone (Office/ Mobile): Address: The reported information is used in an aggregate manner only. The use of the reported information is strictly confidential and the ethic and administrative responsibility is ensured by the NASA Taskforce Year of report: Total Funds received by your organisation Funds Transferred to other organisations Funds Spent by your organisation TOTAL - - Currency reported: The exchange rate used: (Select the currency on which figures are reported on each year. Please specify the name of the curre (Type the currency rate are used) Funding for HIV/AIDS programs (*This section is only for donor and government respondents ): Please indicate the total amount disbursed by year (past and anticipated) for HIV/AIDS programs, including the total as well as a breakdown by specific activities supported Total Funds Currency (s elect the currency on which figures are Funding by HIV/AIDS service category Antiretroviral Therapy (ART) HIV Counselling and Testing (VCT) Prevention of Mother-to-Child Transmission (PMTCT) Care and Support - TB-HIV Care and Support - PRE-ART Care & Support - Non-ART Prevention 60

61 Resources Used in 2008 In the survey below, we ask you to report on: sources of your 2008 HIV/AIDS funding as well as the title and description of each project or activity your organization implemented; n transferred project funding, if applicable; the actual amount spent on each project or activity; and the beneficiary population(s) reached, including the number reached, if possible. direct project costs that are spent in the country (e.g. clinic support, condom distribution, or in-country project office costs). Exclude indirect costs that support functions performed ou a home office abroad). Financial resources used for specific activities NOTE: (I) Use one line per Beneficiary Population for the same activity. (II) Use a different row to report on funds used and another row for funds transferred even if both Currency 0 Financing source (Origin of the funds) Name of Project Name of Activity Description of Activity (1-2 sentences) If funds are transffered to other organisation, please specify the name of the organization Total Activity Amount (Expenditures, not budgeted amounts) 61

62 PRODUCTION FACTORS in 2008 Production factors are inputs used to produce an intervention/project activity NOTE: Insert row to add production factor as needed Description of the activity (as reported in worksheet '2008 Resources Used') Currency Production factors/inputs (list each item in one line) Factors List' tab *See 'Production PF.01 Current expenditures PF Labour income (compensation of employees and remuneration of owners) PF Wages PF Social contributions PF Non-wage labour income PF Labour income not broken down by type PF Labour income n.e.c. PF Supplies and services PF Material supplies PF Antiretrovirals PF Other drugs and pharmaceuticals (excluding antiretrovirals) PF Medic al and surgical supplies PF Condoms PF Reagents and materials PF Food and nutrients PF Uniforms and school materials PF Material supplies not broken down by type PF Other material supplies n.e.c. PF Services PF Adminis trative services PF Maintenance and repair services PF Publisher, motion picture, broadcasting and programming services PF Consulting services PF Transportation and travel services PF Housing services PF Logistics of events, including catering services PF Financial intermediation services PF Services not broken down by type PF Services n.e.c. PF Current expenditures not broken down by type PF Current expenditures n.e.c. PF.02 Capital expenditures PF Buildings PF Laboratory and other infrastructure upgrading PF Construction of new health centres PF Buildings not broken down by type PF Buildings n.e.c. PF Equipment PF Vehicles PF Information technology (hardware and software) PF Laboratory and other medical equipment PF Equipment not broken down by type PF Equipment n.e.c. PF Capital expenditure not broken down by type PF Capital expenditure n.e.c. PF.98 Production factors not broken down by type Total Amount reported on the spreadsheet : "2008 Resources Used" Control / Pending expenditures to classify in PF

63 List of production factors CURRENT EXPENDITURES Labour income (compensation of employees and remuneration of owners) Wages Social contributions Non wage labour income Labour income not broken down by type Labour income not elsewhere classified Supplies and services Material supplies Antiretrovirals Other drugs and pharmaceuticals (excluding antiretrovirals) Medical and surgical supplies Condoms Reagents and materials Food and nutrients Uniforms and school materials Material supplies not broken down by type Other material supplies not elsewhere classified Services Administrative services Maintenance and repair services Publisher, motion picture, broadcasting and programming services Consulting services Transportation and travel services Housing services Logistics of events, including catering services Financial intermediation services Services not broken down by type Services not elsewhere classified Current expenditures not broken down by type Current expenditures not elsewhere classified CAPITAL EXPENDITURES Buildings Laboratory and other infrastructure upgrading Construction of new health centres Buildings not broken down by type Buildings not elsewhere classified Equipment Vehicles Information technology (hardware and software) Laboratory and other medical equipment Equipment not broken down by type Equipment not elsewhere classified Capital expenditure not broken down by type Capital expenditure not elsewhere classified PRODUCTION FACTORS NOT BROKEN DOWN BY TYPE 63

64 List of Beneficiary Populations People living with HIV (regardless of having a medical/clinical diagnosis of AIDS) Adult and young people (aged 15 and over) living with HIV Adult and young men (aged 15 and over) living with HIV Adult and young women (aged 15 over) living with HIV Adult and young people (aged 15 over) living with HIV not broken down by gender Children (aged under 15) living with HIV Boys (aged under 15) living with HIV Girls (aged under 15) living with HIV Children (aged under 15) living with HIV not broken down by gender People living with HIV not broken down by age or gender Most-at-risk populations Injecting drug users (IDU) and their sexual partners Sex workers (SW) and their clients Female sex workers and their clients Male transvestite sex workers (and their clients) Male non transvestite sex workers (and their clients) Sex workers, not broken down by gender, and their clients Men who have sex with men (MSM) Most-at-risk populations not broken down by type Other key populations Orphans and vulnerable children (OVC) Children born or to be born of women living with HIV Refugees (externally displaced) Internally displaced populations (because of an emergency) Migrants/mobile populations Indigenous groups Prisoners and other institutionalized persons Truck drivers/transport workers and commercial drivers Children and youth living in the street Children and youth gang members Children and youth out of school Institutionalized children and youth Partners of people living with HIV Recipients of blood or blood products Other key populations not broken down by type Other key populations not elsewhere classified Specific accessible populations People attending STI clinics Elementary school students Junior high/high school students University students Health care workers Sailors Military Police and other uniformed services (other than the military) Ex combatants and other armed non uniformed groups Factory employees (e.g. for workplace interventions) Specific accessible populations not broken down by type Specific accessible populations not elsewhere classified General population General adult population (aged older than 24) Male adult population Female adult population General adult population (aged older than 24) not broken down by gender Children (aged under 15) Boys Girls Children (aged under 15) not broken down by gender 64

65 NASA Dimension and categories NASA_ key AIDS spending categories: ASC.01 Prevention: Prevention is defined as a comprehensive set of activities or programmes designed to reduce risky behaviour. Prevention services involve the development, dissemination, and evaluation of linguistically, culturally, and appropriate materials supporting programme goals. ASC.02 Treatment and Care: refers to all expenditures, purchases, transfers and investment incurred to provide access to clinic- and home- or community-based activities for the treatment and care of HIV-infected adults and children. ASC.03 Orphans and Vulnerable Children (OVC): An orphan is defined as a child under the age of 18 years who has lost one or both parents regardless of financial support (AIDS programme-related or not). Vulnerable children refer to those who are close to being orphans and who are not receiving support as orphans because at least one of their parents is alive, and at the same time their parents are too ill to take care of them. ASC.04 Strengthening of Programme Management and Administration: Programme expenditures are defined as expenses that are incurred at administrative levels outside the point of health care delivery. Programme expenditures cover services such as management of AIDS programmes, monitoring and evaluation (M&E), advocacy, pre-service training, and facility upgrading through purchases of laboratory equipment and of telecommunications. ASC.05 Incentives for the Recruitment and Retention of Human Resources Human 65

66 Capital: This category refers to services of the workforce through approaches for recruitment, retention, deployment and rewarding of quality performance of health care workers and managers for work in the HIV and AIDS field. ASC.06 Social Protection and Social Services (excluding OVC): Social protection conventionally refers to 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. ASC.07 Enabling Environment and Community Development: It includes a full set of services that generate an increased and wider range of support key principles and essential actions as well as policy development. ASC.08 HIV and AIDS-Related Research (excluding operations research): It covers researchers and professionals engaged in the conception or creation of new knowledge, products, processes, methods, and systems for HIV and in the management of the programmes concerned with HIV and AIDS 66

67 APPENDIX 3: LIST OF ORGANISATIONS PROVIDING DATA FOR NASA ADB CPMU WB CPMU GFATM CPMU Life-Gap CPMU PEPFAR Country Office USAID US DOD CDC SCMS AusAID DFID Irish Aid CIDA DANIDA JICA UNAIDS UNODC WHO UNFPA UNICEF UNESCO UNDP UNV FHI- Family Health International PACT Inc. Esther/ French Embassy (?) Abt Associate/HPI Chemonics International PSI- Population Services International Pathfinder Viet Nam MdM Canada/France MCNV- Medical Committee of Netherlands and VN PATH US Care international Clinton Foundation AHF: AIDS healthcare foundation Tuberculosis Control Assistance Programme, KNCV Foundation VAAC NIITD NIHBT NIHE NIDV Hanoi School of Public Health Ho Chi Minh City Committee on AIDS Prevention HCMC Pasteur Institute 67

68 Gen Department for Child Care & Protection, MOLISA Gen Department for Social Sponsorship, MOLISA Gen Department for Social Evil Prevention, MOLISA Dept for Student Affairs, MOET Women AIDS and Reproductive Health Centre, WU Central Youth Union An Giang Provincial AIDS Centre (PAC) PAC Da Nang PAC Hai Duong PAC Hai Phong PAC BR-VT PAC Bacgiang PAC Baclieu PAC Bacninh PAC Binhduong PAC Binhphuoc PAC Binhthuan PAC Camau PAC Cantho PAC Caobang PAC Daklak PAC Daknong PAC Dienbien PAC Dongnai PAC Dongthap PAC Gialai PAC Hagiang PAC Haiphong PAC Hanam PAC Hanoi PAC Hatinh PAC Haugiang PAC Hungyen PAC Khanhhoa PAC Kiengiang PAC Kontum PAC Laichau PAC Lamdong PAC Lang Son PAC Lao Cai PAC Longan PAC Nghe An PAC Ninhbinh PAC Ninhthuan PAC Phutho PAC Phuyen PAC Quangbinh PAC Quangnam PAC Quangngai PAC Quangninh PAC Quangtri PAC Soc Trang PAC Sonla PAC Tayninh PAC Thainguyen 68

69 PAC Thuathienhue PAC Tiengiang PAC Travinh PAC Tuyenquang PAC Vinhlong PAC Vinhphuc PAC Yenbai 69

70 APPENDIX 4: NASA/NHA COLLABORATION IN VIET NAM 1) Introduction a. UNAIDS and USAID (through the Health Systems 20/20 project) planned to support VAAC s development of the National HIV Strategic Plan ( ) by conducting HIV sector resource tracking in Vietnam for FY 2010, through the National AIDS Spending Assessment (NASA) and National Health Accounts (NHA) HIV subaccount, respectively. b. Because of the similarities in data needs and output, UNAIDS/Vietnam and Health Systems 20/20 decided to coordinate data collection in order to avoid duplication of effort and reduce the burden on respondents to the institutional survey on HIV expenditures. c. This section outlines the similarities and differences between the NASA and NHA HIV subaccount analyses and provides an overview of the joint NASA/NHA HIV subaccount conducted in Vietnam in ) Brief overview of NASA and NHA overlaps and differences a. NASA collects all HIV expenditure data; NHA HIV subaccount focuses on health and health-related expenditures (include definition) i. We can cite content from the NASA/NHA Crosswalk paper Linking NASA and NHA: Concepts and Mechanics b. Graph/chart to illustrate boundaries of NASA/NHA analyses, using Vietnam data 70

71 3) Summary of impetus for conducting joint NASA/NHA data collection in Vietnam a. Coordination i. To align with the Paris Declaration for Aid Effectiveness and UNAIDS 'Three Ones' principle for the coordination of national AIDS responses b. Simplification i. To reduce duplication of effort, respondent burden (since donors, NGOs, and government institutions would respond to a single joint data collection effort rather than two independent surveys) c. Impact i. To bring together key government stakeholders (e.g. VAAC & MOH Finance & Planning) that have distinct but related policy challenges and information needs ii. To link strategic discussions about HIV sector planning with overall health sector policy iii. To increase acceptance and use of results for policy (coordinated analysis and reporting allow for a single, consistent message as opposed to the potential for conflicting results and reports if NASA and NHA are conducted independently) d. Institutionalization i. To integrate HIV sector resource tracking within existing government mechanisms for HIV health and non-health expenditure data collection and analysis, facilitating routine, government-led exercises 1. The Financing and Planning Department of the Vietnam Ministry of Health regularly produces the general NHA estimation and would like to incorporate the HIV subaccount into this process as well (the NHA HIV subaccount was conducted once in Vietnam in 2006). With the addition of data collection to capture non-health HIV expenditures, the MOH Finance and Planning Dept. could regularly produce the needed data to generate both the NASA and the HIV subaccount. ii. To generate practical guidance from the Vietnam experience to inform joint NASA/NHA exercises in other countries 1. Include list of joint NASA/NHA exercises conducted elsewhere to date 71

72 4) Process for linking the NASA and NHA in Vietnam a. Logistical Approach i. UNAIDS and Abt Associates hired the same consultant to participate in the data collection and analysis for NASA and NHA, respectively, so that a single person would understand and track the methodology and collected data for both activities ii. Consultant hired for both activities provided both sides with regular updates on timing, process, technical/logistical issues iii. Both teams sent stakeholder/technical meeting invitations to the other partner to increase opportunities for input, joint development of strategies, approaches and assumptions b. Technical Approach i. Developed joint data collection instrument, based on the NASA instrument, (which typically collects more detailed expenditure information than the NHA survey); back-andforth exchange between NASA and NHA technical teams to develop mutually agreeable instrument ii. Data collection conducted by UNAIDS NASA team, including joint NASA and NHA consultant; NHA team provides technical input, including in the development of shared assumptions and harmonizing the methodological approach (e.g. through assignment of provider classifications, identification of financing agents, etc.) iii. Presentations on NASA/NHA linkage during NASA data collector training iv. Crosswalk from NASA data set to generate NHA tables 72

73 v. Close involvement of MOH Finance and Planning Dept. to ensure that NHA HIV subaccount is consistent with the general NHA; plans to incorporate HIV subaccount into general NHA report by MOH c. Stakeholder Approach i. Clear and repeated presentation to key stakeholders on objectives for NASA/NHA coordination ii. Coordinated dissemination products (separate reports with a shared annex and coordinated methodology section); (possible) joint policy brief focused on a specific issue iii. Development of relationship between VAAC and MOH Finance and Planning Dept.; emphasis on institutionalization 5) Practical, replicable 'lessons learned' from the Vietnam NASA/NHA collaboration a. Importance of regular technical communication regarding methodology and approaches between NASA and NHA teams b. Importance of emphasis on institutionalization so that activity is not carried out or viewed as a oneoff exercise; rather, technical issues/challenges should be approached/addressed taking into account existing mechanisms for data collection and use as much as possible c. Advantages of using the same consultant(s) for NASA and for NHA if possible creates common incentives; built-in incentive for consultant to save time through streamlining the data collection process d. Note that international partners may have an easier time collecting donor and NGO expenditure data; government departments may have an easier time collecting government expenditure information e. Do not try to combine everything in the first round both sides have their own process, timeline, expected deliverables (often in a particular format); first time conducting the joint process may require more time and effort to understand how best to work together. f. Suggestion to create joint presentations ahead of time regarding NASA/NHA methodology to share with stakeholders, technical subcontracting institutions, consultants, etc. Technical recommendations/revisions for NASA/NHA crosswalk document ANNEX 5: KEY ASSUMPTIONS IN DATA PROCESSING FOR DIFFERENT SOURCES NASA classification of NTP AIDS expenditures 73