National Health Accounts Subanalysis for HIV/AIDS

Transcription

1 National Health Accounts Subanalysis for HIV/AIDS St Vincent & the Grenadines June 2006 Final Report UNAIDS/Abt Associates National Health Accounts

2 Contents Contents... i Acknowledgements Introduction...1 Study rationale...1 Structure of the report Background...3 Socioeconomic and demographic context...3 The health system...4 Epidemiological profile of HIV/AIDS...5 National response to HIV/AIDS Methods...12 Overview of the approach...12 Definition of HIV/AIDS health care expenditure...13 Training and capacity building...13 Data collection...14 Data analysis Results...18 Overview of HIV/AIDS spending...18 Financing sources...19 Financing agents...20 Flow of funds from financing sources to financing agents...21 Health providers...21 Flow of funds from financing agents to health providers...22 Health functions...23 Flow of funds from financing agents to health functions...27 Target groups and beneficiaries Discussion...30 Main Findings...30 Limitations...30 Conclusion...31 Appendix 1 NHA Classifications...32 Appendix 2 NASA Classifications...36 Appendix 3 Survey Tools...39 i

3 Acknowledgements The exercise was coordinated by the Ministry of Health and the Environment, Government of St Vincent and the Grenadines. The completion of the report owes much to the efforts of the technical team which was formed at the initial National Health Accounts training. In particular, the following people made important contributions at various stages during the training, data collection, data analysis and report writing: Yvonne Bonadie, Anne DeRoche, Del Hamilton, Severlina Layne-Cupid, Margarita Tash, Odway Thomas, Mrs Bonadie, Genevieve John, Louise Tash, Irwin Martin, Cosmore Dennis, Harold Lewis, Maxine Glasgow, Kiyjuana Cambridge, Fitz Jones, John Hall, David Telesfor, Sharlene Antoine, and Cherrlyn Glyn. The exercise was given technical and financial support from UNAIDS through the Partners for Health Reform plus (PHRplus) Project (USAID funded). UNAIDS/Abt Associates National Health Accounts

4 1. Introduction Study rationale The Caribbean is the second most infected region with HIV in the world. An estimated 440,000 people are estimated to be HIV positive and with more than 29,000 deaths in 2004, it is the leading cause of death amongst adults aged in the region. HIV/AIDS is more than a serious public health problem; it can have a huge socioeconomic impact and turn back the clock on many years of development as has become apparent in many African countries struggling to get to grips with the epidemic. In response to the epidemic, many countries including St Vincent and the Grenadines have developed comprehensive plans to curb the spread of the virus and provide care and treatment to those living with HIV/AIDS. As efforts to fight the disease are scaled up, it is critical to understand how resources are being used to allocate funds effectively. More specifically, we need to know how much is being channelled to HIV/AIDS, from which sources, and for what purposes. Only with this information is it possible to quantify resource gaps, identify if strategic priorities are being sufficiently funded and develop appropriate evidencebased financing policies. Here, we report the findings of a study analysing the flow of funds to HIV/AIDS activities in St Vincent and the Grenadines in The objectives of the study were as follows: To gain a comprehensive and detailed picture of HIV/AIDS spending in St. Vincent and the Grenadines. To estimate flows of both payments in the public and private sectors and donor funding with respect to HIV/AIDS. To better inform the allocation of resources in a more efficient manner to prevent, treat and mitigate the HIV/AIDS pandemic and to effectively support the St Vincent and the Grenadines public health care system. We used the system of National Health Accounts (NHA) methodology to track financial flows to HIV/AIDS from the financing sources, through the financing agents who control how the money is used, to the health providers and the end uses of the money. NHA is the predominant method used to track health resources at the country level, is internationally accepted and has been conducted in almost 70 middle and low income UNAIDS/Abt Associates National Health Accounts 1

5 countries. Since the approach is systematic and standardised, results are internationally comparable. It provides sufficiently disaggregated information to review performance assessment by service area, such as voluntary counselling and testing; antiretroviral therapy; and prevention of mother to child transmission. Structure of the report The report is structured as follows. Chapter 2 gives an overview of the socioeconomic situation, the health system, the epidemiological profile of HIV and recent efforts to combat the disease in St Vincent and the Grenadines. Chapter 3 describes the methods used in the HIV/AIDS subanalysis, the data collection process and analysis of data. Chapter 4 presents the main results, which are further discussed in chapter 5. UNAIDS/Abt Associates National Health Accounts 2

6 2. Background Socioeconomic and demographic context St. Vincent and the Grenadines is one of the island chains of the Windward Islands in the Eastern Caribbean. It is located 21 miles south of St. Lucia and 100 miles west of Barbados. In size, St. Vincent and the Grenadines is 18 miles long and 11 miles wide with an area of 150 square miles, inclusive of Bequia, Mustique, Mayreau, Canouan, Union Island and Palm Island. St Vincent and the Grenadines enjoys an all-year-round average temperature of degrees Fahrenheit. It is susceptible to occasional hurricanes, tropical storms, volcanic eruptions and earthquakes. The Gross Domestic Product (GDP) of St Vincent and the Grenadines in 2004 was EC$ 1.1 billion (EC$ 9,483 per capita) representing a 2.8% real increase over The service sector is the main contributor to the economy, after the decline of agriculture during the 1990s. Other important sectors include banking, insurance, electricity and water, and manufacturing. The proportion of the population in poverty was estimated at 42% according to the Poverty Assessment Study Report of Poverty is greater among female heads of households, while the rural population is slightly worse off than those living in urban areas. It is estimated that 10% of the population have no formal education and are thus deemed functionally illiterate. In the 2001 population census, the total population for the country was recorded at 106,253. Males (50.5%) account for slightly more than females (49.5%) in the total population. Of the total population, 30.7 % were under 15 years of age; the age group years represented 27.8% while the age group years represented 21.1 %. The age group years accounted for 13.2 % while the 65 years and over category represented 7.3 %. The population of St Vincent and the Grenadines is young (Figure 1). UNAIDS/Abt Associates National Health Accounts 3

7 Figure 1. Population pyramid for St Vincent and the Grenadines Female Male ,000 4,000 2, ,000 4,000 6,000 Thousands The crude birth rate of the country has continued to decline and stood at 18.7 per 1000 population in Total fertility recorded 2.4 births per woman and total life expectancy at birth has increased to 73 years. Taking into account natural population change and net migration, the population is estimated not to have changed significantly since The health system The Ministry of Health and the Environment (MoHE) is the main government body responsible for health and its mission is to mobilise resources at local, regional and international levels for the purpose of planning, controlling and evaluating health delivery systems tailored appropriately to the needs of the population. It values health care as a basic right, client participation at all levels of health care and intersectoral collaboration. Health services in St Vincent and the Grenadines are provided predominantly by the government. There is no system of user fees in place hence government provided health services are free of charge to the patient. The health system is organised according to a district structure. The nine health districts in St Vincent and the Grenadines contain a network of thirty-nine health centres, which provide primary health care services to the population. Each health centre caters to an average population of 2,900 and no one is required to travel more than three miles to their nearest facility. At least one district nurse midwife, a nursing UNAIDS/Abt Associates National Health Accounts 4

8 assistant and a community health aide staff a health centre. Other members of the district health team include a district medical officer, a health nursing supervisor, a pharmacist and an environmental health officer. Family nurse practitioners are responsible for providing health services in schools. Available primary health care services include: maternal (ante-, intra-, and post-natal care); child health care services including immunisation and school health; family planning services; emergency health care; special chronic diseases; screening services; community nutrition; health promotion and education; and pharmaceutical services. Primary level care is supplemented by five rural hospitals, a nursing home and the Milton Cato Memorial Hospital (MCMH), which is a 211 bed secondary level care facility located in Kingstown. It provides specialist services in most major areas of medicine. A private hospital also provides complementary services. The HIV/AIDS unit within the MoHE manages the HIV/AIDS programme. Treatment and care is provided in a centralised manner for the entire country by the MCMH. These services are almost all entirely free of charge to the patient. There are few private providers of HIV/AIDS services. HIV screening is also centralised at a laboratory housed within the MCMH, although there is also private laboratories offering testing services. Chronic non-communicable diseases account for the greatest mortality and morbidity in the country. Over the period , the five leading cause of death were: cancer (all forms); ischaemic heart disease; endocrine and metabolic diseases; immunity disorders (includes diabetes and HIV/AIDS); and cerebrovascular and hypertensive disease. Whilst the threat of HIV/AIDS looms large, it is currently not the major public health problem in St Vincent and the Grenadines. Epidemiological profile of HIV/AIDS St Vincent and the Grenadines recorded the first case of HIV infection in 1984 and at the end of 2004 had reported a cumulative total of 796 cases. Over the same period 431 persons have progressed to full blown AIDS and 405 have died. A trend analysis over the last two decades shows a rising annual HIV incidence, with the highest recorded number of new cases in 2004 (Figure 2). In the past seven years, the number of new AIDS cases and deaths has remained relatively constant with no obvious rising trend. If anything the number of reported AIDS deaths has shown a slight decrease in recent years. AIDS related deaths account for about 5% of total deaths and rank as the fifth leading cause of death in St Vincent and the Grenadines. UNAIDS/Abt Associates National Health Accounts 5

9 The most common direct causes of death include pneumonia, wasting syndrome, toxoplasmosis, renal failure and meningitis. Figure 2. Trends in the epidemiology of HIV and AIDS New cases of HIV New cases of AIDS AIDS deaths In 2004, 108 new cases of HIV were recorded, representing a 25% increase over the incidence during the previous year (Table 1). A total of 40 clients progressed to AIDS indicating a 30% reduction compared the previous year. During the last 4 years ( ) AIDS related deaths have plateaued. Of the total new cases of HIV in 2004, 40% were employed, 51% were unemployed and for 9% their employment status was unknown. HIV affects a broad spectrum of workers including security guards, labourers, chauffeurs, domestic, cart vendors, masons, sailors, mechanics and clerks. The number of persons living with HIV/AIDS at the end of 2004 was 391, which based on the total population from the 2001 census, implies a HIV prevalence rate of 0.4%. These epidemiological country statistics are based on health facility visits and the actual prevalence rate is likely to be slightly higher given that some cases go unreported, partic ularly in the initial stages of the disease. The current surveillance system bases estimates on cases reported during clinical presentation at the main hospital and thus captures patients in the late stages of the disease. It is therefore commonplace for patients identified as UNAIDS/Abt Associates National Health Accounts 6

10 HIV positive to soon develop AIDS. A survey in 2002 based on a sample of 1,700 pregnant women suggested a prevalence rate of 0.6%. Table 1. Recent HIV/AIDS epidemiological situation Year New HIV cases New AIDS cases Deaths PLWHAs a (0.3%) (0.4%) a Values in brackets indicate estimated prevalence rate The cumulative number of new HIV cases over the period shows that the disease has largely affected males. Males represent 61% of all cases, while females account for 37% (Figure 3 inset). Data suggests that recently that has been a growing feminisation of the epidemic. In the initial years of the disease the male to female ratio of seropositive persons was 5:2. The gap has now narrowed to an average ratio of 3:2 for the past four years. An age group population pyramid of new cases of HIV shows that the majority of cases (70%) fall within the age group. Teenagers account for 6% of all new cases, and paediatric cases make up 4%. The distribution by age indicates that HIV targets the economically most active as confirmed by experiences in other countries and regions of the world (Figure 3). Over the period , the main route of transmission has been heterosexual intercourse, representing 68% of all cases of HIV. Only 12% of cases have been reported as being spread through homosexual / bisexual contact. Vertical transmission, commonly referred to as mother-to-child transmission, is the cofactor accounting for 16% of cases (Figure 4). The first case of mother-to-child transmission was reported in 1988 and since then 30 cases have been identified. Since 1997, the number of cases has steadily declined through this mode of transmission. UNAIDS/Abt Associates National Health Accounts 7

11 Figure 3. Population pyramid of HIV incidence in 2004 not stated 2% female 37% male 61% Female Male <5 yrs <5 yrs Number of HIV Positive Figure 4. Modes of HIV transmission Bisexual 4% Unknown 4% Vertical 16% Homosexual 8% Heterosexual 68% UNAIDS/Abt Associates National Health Accounts 8

12 National response to HIV/AIDS The Government of St Vincent and the Grenadines established a National AIDS programme on the technical advice of PAHO / WHO / CAREC soon after the first case of HIV was diagnosed in The Ministry of Health and the Environment was quick to educate all staff within the ministry and have heads of programmes develop plans to support HIV persons who present themselves at health facilities. Educational programmes were rolled out across government and the efforts were made to inform the general public. A Cabinet appointed advisory committee was set up to coordinate efforts directed at reducing the incidence and to provide overarching guidance to the MoHE. Whilst the programme was successful in increasing awareness in the population, it did little in the way of care and treatment for people living with HIV/AIDS (PLWHAs) and it was not clear that there was any positive impact on sexual behaviour. After broad consultation with key stakeholders, the government developed a National HIV/AIDS and STI Strategic Plan , which were then revised for the period The plan is built upon five strategic pillars: (i) strengthen intersectoral management, organisational structures and institutional capacity; (ii) develop, strengthen and implement HIV/AIDS/STI prevention and control programmes with priority given to youth and high risk or vulnerable groups; (iii) strengthen care, support and treatment programmes for PLWHAs and their families; (iv) conduct HIV/AIDS related research; and (v) upgrade surveillance systems. Recent government efforts to combat the disease in various strategic areas are summarised below. Treatment and care A formalized system of care and treatment offering antiretroviral drugs (ARVs) to HIV/AIDS clients commenced nationally in August ARVs are heavily subsidised by government and provided through the Milton Cato Memorial Hospital. The government participates in a regional initiative to pool funds for the procurement of ARVs and in this way is able to benefit from the lower prices associated with bulk purchasing. In support of this programme the clinical laboratory of the Milton Cato Mem orial Hospital increased its capacity to perform and analyse CD4 counts through immunomagnetic separation technology. A Becton-Dickins FACS count flow cytometer became operational in March In addition, a Clinical Care Coordinator, Clinical Care Manager and Counselors were assigned to the programme to provide support. By mid May 2005, a total of 144 clients (35% of PLWAs) were registered on the Care and Treatment Programme. Of these 136 were adults and 8 children. UNAIDS/Abt Associates National Health Accounts 9

13 Voluntary counselling and testing Voluntary counselling and testing (VCT) is an important element of the government s HIV/AIDS prevention strategy and is seen as an intervention feasible for scaling up across the country. It allows individuals to make appropriate HIV prevention decisions if they are aware of their HIV status. In preparation for service delivery, VCT providers and trainers have been receiving overseas training since Several national VCT workshops have been organized and approximately 55 health care workers and other appropriate personnel have been locally trained to deliver VCT services. A total of 6 trainers and 1 advance trainer have already been trained overseas. The target is to establish a total of 18 VCT sites at various locations throughout St Vincent and the Grenadines. Prevention of mother-to-child transmission In 1998, a mother to child transmission prevention (PMTCT) project was launched by the Kingstown Medical College in collaboration with the Ministry of Health and the Environment. The project piloted an antiretroviral drugs and continued for 13 months. A total of 2,589 pregnant mothers took part in the study. At the beginning of 2000, the Ministry of Health and the Environment assumed complete responsibility PMTCT programme and offered VCT to all pregnant mothers and Nevirapine combined with replacement feeding for all mothers and babies as required. There is close monitoring of all HIV positive children by the consultant paediatrician of the MCMH and the counsellors of the HIV/AIDS unit. A mother to child transmission (MTCT) policy manual aimed at addressing policy issues in the ante, intra and postnatal periods was formulated in year This manual is currently under revision and should be completed by the end of year Information, education, communication The government has used IEC as a central strategy in the prevention of HIV. The role of the media was recognised as important for effective implementation of this strategy and so efforts to brief the media and identify how they could provide support were undertaken. The general public was targeted with educational programmes using films, drama, poetry, calypso, talk shows, and interviews. Educational items were complemented by pamphlets, billboards, posters and public service announcements. Community outreach workers provided follow-up to these messages and were able to gather feedback as to the level of understanding in the population. The private sector, NGOs and the church all worked together with the government to implement the IEC action plan. Blood safety During the early years of the HIV/AIDS epidemic in St. Vincent and the Grenadines high priority was given to transfusion of safe blood. Intervention measures such as HIV antibody screening, blood donor selection, UNAIDS/Abt Associates National Health Accounts 10

14 prevention of avoidable transfusion, and blood banking were implemented. HIV screening of blood donors began in the early 1990 s and continues to this day. The incidence of HIV among blood donors in St Vincent and the Grenadines remains very low at around 0.2%. Monitoring and surveillance In 1999, the clinical laboratory in the MCMH was upgraded so that confirmatory HIV tests could be conducted locally on the island, a task previously done through the Caribbean Epidemiology Centre. Seropositive studies were conducted on antenatal patients to establish the prevalence of HIV in the population and these have been ongoing. In addition, a coding system was put in place to ensure patient confidentiality and laboratory forms were used to gather data on essential epidem iological data. UNAIDS/Abt Associates National Health Accounts 11

15 3. Methods Overview of the approach This chapter describe the methods of data collection and analysis used to derive the results presented in this report. The methods are internationally recognised and have been refined and standardised through application in a wide number of developing countries. The approach permits international comparisons, while at the same time is sufficiently flexible to be orientated towards country specific policy questions and health system design. The approach is based on the NHA framework and International Classification of Health Accounts, adapted for the purposes of tracking both health and non-health HIV/AIDS expenditures. Within this framework, HIV/AIDS expenditures are linked in a series of two-dimensional matrices, which track the flow of all funds for HIV/AIDS from the sources of finance (financing sources) through the institutions that manage the monies (financing agents) to the end users (health providers), as illustrated in figure 5. At the provider level, we identify the services and medical goods (health functions) that are purchased with these funds. Figure 5. Flow of resources between different entities (illustrative) The study is referred to as a HIV/AIDS subanalysis as it is typically conducted as a secondary analysis within a general NHA, using consistent methods and classifications. There are practical and methodology UNAIDS/Abt Associates National Health Accounts 12

16 reasons for encouraging such an approach. First, there are tremendous efficiency gains to be had from the training and data collection when the HIV/AIDS component is carried out as part of a general NHA. It ensures the HIV/AIDS analysis is not conducted in a vertical, parallel manner. Second, country level capacity is built more effectively. Third, HIV/AIDS subanalyses require estimates of total health expenditure in order to capture non-targeted HIV/AIDS expenditures. In other words, we include not only those expenditures that are clearly identified in budgets as HIV/AIDS targeted expenditures but also a proportion of the shared health costs, such as salaries of health workers, which contribute in some measure to the provision of HIV/AIDS services. In order to apportion these general health care expenditures to HIV/AIDS, we must have an appreciation of the overall health resource envelope. In most middle and low-income countries, systems that track expenditures according to diagnosis related groups are not in place; therefore we use a combination of unit cost and utilisation data to calculate non-targeted HIV/AIDS expenditures. The approach also improves the consistency and validity of indicators one might want to derive, such as the proportion of total health expenditure spent on HIV/AIDS. In the case of St Vincent and the Grenadines, the principal analysis was HIV/AIDS and while general health care expenditures from public and external sources were analysed for the purposes of apportioning funds, these are not reported. However, it is hoped that the training in the NHA methodology and the collection of health care expenditure data can be capitalised on in the future to generate NHA estimates. Definition of HIV/AIDS health care expenditure When tracking resource flows for HIV/AIDS, we must be entirely clear on what we define as expenditure on HIV/AIDS activities. In line with the Guide to Producing National Health Accounts, a functional approach is used to define HIV/AIDS health care spending. Thus, HIV/AIDS health care expenditures must be on those activities that are (i) primarily intended to have an impact on the health status of people living with HIV/AIDS in a given time period; and (ii) intended to prevent the spread of HIV/AIDS, which may target the population at large. Due to the multisectoral nature of HIV/AIDS interventions, the classification system also captures non-health expenditures on HIV/AIDS. Training and capacity building At the beginning of the process, a two-day training workshop was held with staff from the MoHE, Ministry of Finance, other ministries, health managers, health providers, PAHO and civil society organisations. Some staff within the MoHE had previously received regional training in the NHA approach, and there was a desire to build upon this initial capacity building so that a sectorwide NHA could be conducted in future. With this in mind, the objectives of the workshop were as follows: UNAIDS/Abt Associates National Health Accounts 13

17 To train participants on the basic principles and methodology of the National Health Accounts, and its application to tracking to HIV/AIDS expenditures. To sensitise participants to the policy benefits of conducting a NHA HIV/AIDS subanalysis. To train participants on the steps required to carry out a NHA HIV/AIDS subanalysis and the information requirements to conduct the exercise. To review basic data analysis techniques to produce reliable results. Participants were trained in both the theory and practicalities of conducting a NHA, and provided with a training manual for future reference. The workshop also afforded an opportunity to identify a technical team and prepare the data collection plan. In summary, the participants successfully: (i) developed country specific classifications for the NHA subanalysis for HIV/AIDS; (ii) drew up a comprehensive list of existing data sources; (iii) developed a data collection plan with assigned responsibilities; (iv) defined the technical team and leader; and (v) agreed upon a set of survey questionnaires to use to collect primary data. The consensus was to analyse the flow of HIV/AIDS funds for 2004, the most recent year for which data was available. Following the workshop, a wider group of relevant organisations were invited to attend a launch meeting to incorporate feedback into the planning process and improve awareness that would later facilitate data collection. Data collection The data collection plan listed all possible sources of information and who would be responsible for the collection of the data. Both primary and secondary data sources were identified, and questionnaires were developed to guide the data collection process. The collection of primary data was carried out using a combination of survey questionnaires and semi-structured interviews. Questionnaires were administered to private health care providers, private laboratories, private insurance companies, non-governmental organisations, and the Milton Cato Memorial Hospital (see Annex 3) by the NHA technical team. Although a survey tool was designed for district hospitals and health centres, this was not carried out as the secondary data found within the health information system was deemed adequate. Follow-up interviews were organised with some institutions to clarify responses and gather additional information. The sources of primary and secondary data, a description of the data and the number of entities surveyed (in brackets) are summarised in table 2. UNAIDS/Abt Associates National Health Accounts 14

18 There were no study design and sample selection issues. We sought to survey all possible institutions, identified during the training workshop. Much of the public sector expenditure data was available off the shelf within the financial expenditure management systems of government. As the main provider of HIV/AIDS services in the country, the Milton Cato Memorial Hospital was surveyed to gather additional data on service utilisation and unit costs since the expenditures on HIV/AIDS could not be disentangled from other health expenditures within the budget execution report of the hospital. Table 2. Data, sources, and descriptions Primary Data Collection Description Private clinics (4) Private insurance companies (2) Survey tool Survey tool Out-of-pocket expenditures made at private clinics providing HIV/AIDS related services Expenditures reimbursed by private insurance companies for HIV/AIDS related services Milton Cato Memorial Hospital (1) Survey tool Financial and health information Private laboratories (2) Non-governmental organisations (8) Central medical store, MoHE (1) Survey tool Survey tool Interview Utilisation of testing services and patient charges Expenditures made on HIV/AIDS related activities Import of ARV drugs, condoms and drugs for opportunistic infections Units cost data of lab tests at MCMH Interview Cost of each type of lab test Private retailers of condoms (1) Interview Out-of-pocket expenditure on condoms Secondary Data Source Description Census 2001 MoF Population data for per capita indicators Macroeconomic data MoF & IMF GDP and exchange rate information HIV/AIDS epidemiology profile MoHE HIV and AIDS statistics including Govt response Utilisation of services HIS Outpatient visits by type of service Communicable disease report 2004 HIS Import of medical commodities MoF Import of condoms Incidence of STIs and other communicable diseases Ministry of Health executed budget MoF Actual expenditure details of the MoHE Ministry of Social Welfare executed budget Vote accounts records of MoHE programmes Cost of health services in SVG 1997 MoF MoHE MoHE Actual expenditure details of the MoSW Detailed expenditure records by line item Total and unit cost estimates of health services by type of provider Donor agencies were not surveyed directly. None of these organisations were resident in the country, working rather on a regional level based at one of the other Caribbean islands. While standard NHA practice UNAIDS/Abt Associates National Health Accounts 15

19 is to cross-check data collected from multiple sources, in the case of donor expenditures we had to rely on single sourced information obtained from the MoHE, other ministries and NGOs. However, given the small size of the country, the technical team was confident the Government ministries and NGOs had a comprehensive picture of external financing for HIV/AIDS. Private expenditure data was the most difficult to obtain, requiring different survey tools tailored to each type of private institution. Fortunately, the private sector in St Vincent and the Grenadines is limited largely to the capital, where it is itself small. We interviewed private health care providers (4), the private laboratory (2), the central private provider of condoms (1), private insurance companies (2), and non-governmental organisations (8). Of the four private health clinics, only two provided HIV/AIDS related health services. One private laboratory provided tests relating to HIV/AIDS and the two insurance companies only made payments for HIV tests, as their insurance policies did not cover persons living with HIV/AIDS. Condoms sold in private outlets are purchased by a central private importer hence their expenditure data included all condom sales in the private sector. The response rate for the questionnaires was high. As the private sector is so small and there were almost no external donors providing HIV/AIDS funds in 2004, the data collection was made considerably easier. Furthermore, the centralised system operated by the Government ensured easy access to information and precluded any problem of discrepancies arising between expenditure estimates of the MoHE and decentralised levels of the health system. There was some reluctance on the part of private entities to disclose financial information. Efforts were made to follow-up with these respondents in person to verify the validity of the answers. Experience in others countries has shown that this is often the case during the first NHA exercise in a country and the situation tends to improve once people have become accustomed and better understand the rationale behind the exercise. There was no formal data entry process, as the volume of data was small. Responses were entered into excel spreadsheets and used in conjunction with secondary data sources to populate the NHA tables. Both the raw and analysed data are currently housed at the MoHE, within the Planning Unit and HIV/AIDS Unit, available for further analysis. UNAIDS/Abt Associates National Health Accounts 16

20 Data analysis After data collection was completed, we populated four NHA tables, cross-checking data from multiple sources to ensure amounts were consistent and reliable. The results were validated with members of the technical team in the MoHE and the HIV/AIDS unit to guarantee there were no data gaps and that the estimates were credible. Aggregate results were presented in local currency and converted into US dollars based on purchasing power parity to permit international comparisons of findings across countries. We also derived public health spending on HIV/AIDS as a proportion of total public health spending to provide an indicator of the Government s commitment to fighting HIV/AIDS. We conducted a beneficiary analysis to determine who benefits from funds targeted for HIV/AIDS activities. It compliments findings on how much is spent to fight HIV/AIDS to show whether those in need are benefiting from these investments. We define the beneficiary groups according to severity of the disease, populations at risk, other populations of interest, and non-targeted funds. A robust beneficiary analysis typically utilises data from a household or PLWHA survey. In the absence of any client survey, we performed a simple analysis, assigning expenditures to beneficiary groups on the basis of their functional classifications. For this reason, the findings should be seen as indicative only as they reflect the distribution of funds to intended beneficiaries rather than actual beneficiaries. UNAIDS/Abt Associates National Health Accounts 17

21 4. Results This chapter describes the financing of HIV/AIDS related services and commodities in St. Vincent and the Grenadines for the year NHA summarise results in four core tables that show the flow of funds from: (i) financing sources to financing agents; (ii) financing agents to health providers; (iii) financing agents to health functions; and (iv) health providers to health functions. The main results and findings from the NHA HIV/AIDS subanalysis are presented below in a structured way according to the flow of funds between these different actors within the health system. The NHA tables are shown in full in the annex I. Overview of HIV/AIDS spending In 2004, total health expenditure on HIV/AIDS in St. Vincent and the Grenadines was estimated at EC$ 1.52 million (US$ 0.66 million). The total accounts for 0.14 % of GDP and represents an expenditure of EC$ 14.3 per capita. For the purposes of international comparisons, the per capita HIV/AIDS expenditure was US$ 9.6 based on purchasing-power-parity (PPP). Expenditure on ARV treatment, including the cost of outpatient visits and drugs, was EC$ 383 per PLWHA (Table 3). There were 35 PLWHAs in 2004 receiving ARV treatment. Out-of-pocket payments make up 15% of total HIV/AIDS expenditure, suggesting the financial barrier to accessing HIV/AIDS services is relatively low. Table 3. HIV/AIDS financial indicators for St Vincent and the Grenadines in 2004 Indicators Unit Amount Total health expenditure on HIV/AIDS EC$ 1,517,457 US$ 559,947 Per capita health expenditure on HIV/AIDS EC$ 14.3 US$ PPP 9.6 Expenditure on ARV treatment per PLWHA EC$ 383 US$ PPP 258 OOP spending as % of total HIV/AIDS expenditure % 15% Source: NHA HIV/AIDS Subanalysis 2004 If we look at the breakdown of HIV/AIDS expenditure between the broad multisectoral categories, we see the focus of efforts to combat HIV/AIDS is on prevention, although treatment and care consumes a significant proportion (Figure 6). Of total HIV/AIDS funds including non-health activities such as mitigation and care of orphans, 54% were spent on preventive activities, while 40 % went on care and treatment for UNAIDS/Abt Associates National Health Accounts 18

22 PLWHAs and those affected. There was minimal expenditure on administration through the national HIV/AIDS programme (6%). Figure 6. Breakdown of HIV/AIDS expenditure in 2004 Administration 6% HIV Prevention Activities 54% Care and Treatmen 40% Financing sources The public sector was the major financing source of HIV/AIDS interventions in 2004, contributing EC$ 1.23 million (81%) to the national response effort (Table 4). Private sources accounted for EC$ 270,500 (18%) of HIV/AIDS spending. Private companies did not provide any HIV/AIDS funds in The involvement of international donors was minimal, contributing just EC$ 15,600 (1%). While two large donor financing agreements had been approved in 2004 a World Bank loan / grant and a Global Fund grant the former did not disburse and the latter disbursed just EC$ 7,790 during that year. Other donors included CAREC and the Bahamas National Drug Agency. UNAIDS/Abt Associates National Health Accounts 19

23 Table 4. HIV/AIDS expenditures by financing sources in St Vincent and the Grenadines in 2004 Code Financing Source Amount % HIV/AIDS health expenditure 1,515, FS.1 Central Govt Revenue 1,231, FS.2.1 Private Employers 0 0 FS.2.2 Private Households 270, FS.3 International Donors 15,560 1 Private 18% International Donors 1% Source: NHA HIV/AIDS Subanalysis 2004 Public 81% Government expenditure on HIV/AIDS represented approximately 3.3% of its expenditure on health and 0.3% of total government expenditure. This provides an indication of the level of government commitment in fighting HIV/AIDS and should be considered in conjunction with the current epidemiological profile of the disease for the country. Financing agents Financing agents refer to those entities within St Vincent and the Grenadines that manage the funds for HIV/AIDS. The flow of funds from financing sources to financing agents suggests that the large majority (82%) of resources for HIV/AIDS are under the control of the Ministry of Health and the Environment (Table 5). Other ministries manage 0.3% of HIV/AIDS funds and private insurance companies 3% whilst private household out-of-pocket payments represent 15%. Table 5. HIV/AIDS expenditures by financing agents in St Vincent and the Grenadines in 2004 UNAIDS/Abt Associates National Health Accounts 20

24 Code Financing Agent Amount % HIV/AIDS health expenditure 1,515, HF Ministry of Health 1,243, HF Other Ministries 3, Private Insurers 3% Other Ministries 0.3% Private Outof-Pocket 15% HF.2.2 Private Insurers 39,732 3 HF.2.3 Private OOP Payments 230, Source: NHA HIV/AIDS Subanalysis 2004 MoHE 82% Flow of funds from financing sources to financing agents The financing sources to financing agents matrix (FS x HF) shows the flow of the funds between these two types of health care entities (annex I). All funds from donor sources, and almost all public money for HIV/AIDS were channelled through the MoHE. There was an allocation of EC$ 120,000 made to the Ministry of Social Welfare by the government to provide economic support to PLWHAs. Although a small proportion of these funds were spent on drugs for opportunistic infections, the majority went on non-health activities. These expenditures fall outside the boundary of the health accounts and are instead included as a non-health activity under mitigation. The majority of resources coming form household sources are channelled as out-of-pocket payments (85%), whilst 15% flow to private insurance companies. The role of insurance companies in managing funds for HIV/AIDS is minimal in St Vincent and the Grenadines because they do not provide insurance cover for PLWHAs as they represent too great a risk. It is common practice that to enrol on a health insurance scheme, an individual must take a HIV test to prove that he/she is seronegative. Health providers The largest provider of HIV/AIDS services is the Milton Cato Memorial Hospital, which consumes 59% of total HIV/AIDS resources. Provision and administration of the HIV/AIDS public health programme, consisting of largely expenditures within the HIV/AIDS unit, accounts for 25% of total funds. There were only three private providers of HIV/AIDS services and expenditures made at these clinics were minimal. It is likely that there were expenditures at private clinics abroad; however it was not possible to capture these flows. UNAIDS/Abt Associates National Health Accounts 21

25 Table 6. HIV/AIDS expenditures by health providers in St Vincent and the Grenadines in 2004 Code Health Provider Amount % HIV/AIDS health expenditure 1,515, HP MCMH 896, HP.3.1 Private Clinics 5, HP Public Health Centres 8,249 1 HP Private Laboratories 148, HP.4.1 Pharmacies 75,750 5 MCMH 59% Private Clinics 0.4%Public Health Centres 1% Private Labatories 10% Pharmacies 5% HP.5 Provision & Admin of Public Health Program Source: NHA HIV/AIDS Subanalysis , Provision and Admin of Public Health Programme 25% Flow of funds from financing agents to health providers The flow of funds from financing agents to health providers shows how funds were allocated to the providers of HIV/AIDS services by those who manage the resources (Appendix). In 2004, the MoHE managed EC$ 1,243,028 of HIV/AIDS funds and of this total 65% was allocated to the Milton Cato Memorial Hospital, 34% to the provision and administration of public health programmes and 0.6% to public health centres (Figure 7). There were some resources, such as the purchase of a CD4 count machine that flowed through the HIV/AIDS unit to the MCMH. These funds were classified under MCHM, the institution in which the resources were ultimately used. Private household out-of-pocket expenditures were made at private laboratories (48%), private pharmacies (31%), the MCMH (19%), and private clinics (2%). Although HIV/AIDS services are typically provided free of charge at the MCMH, some have to pay out-of-pocket for STI tests, and it is these expenditures which accounts for the hospital s share of resource flows from private household OOP to providers (Figure 8). Figure 7. Flow of HIV/AIDS funds between the MoHE and health providers UNAIDS/Abt Associates National Health Accounts 22

26 Provision and admin of public health programs 34% Public health centers 0.6% MCMH 65% Figure 8. Flow of HIV/AIDS funds between private households OOP and providers MCMH 19% Pharmacies 31% Private clinics 2% Private laboratories 48% Health functions Health functions describe how resources were used to purchase HIV/AIDS services from the providers of health care. HIV/AIDS health functions can be categorised into the following broad set of services: personal health services; prevention and public health services; administration; and non-health services. The strategy to fight HIV/AIDS in St Vincent and the Grenadines has a mulitsectoral component to it, and therefore it is important to consider the non-health interventions such as mitigation for PLWHAs and care of orphans. However, these activities fall outside our NHA expenditure boundary and are only included when we refer to multisectoral functions. When we consider these multisectoral functions, we see that HIV/AIDS efforts in St Vincent and the Grenadines are currently orientated towards personal health services, UNAIDS/Abt Associates National Health Accounts 23

27 accounting for 64% of HIV/AIDS expenditure (Figure 9). Personal health services include the curative care provided to patients, ancillary services and medical goods given to outpatients. Prevention and public health services represent 19% of the total, health administration and health insurance 9% and non-health activities 8%. There was no HIV/AIDS related capital formation in The following sections analyse more closely expenditures within these broad categories of health functions. Figure 9. HIV/AIDS expenditure by health function in 2004 Prevention & Public Health Services 19% Health Admin 9% Non-Health Activities 8% Personal Health Services 64% For personal health services, EC$ 598,500 (54%) was spent on clinical laboratory tests and diagnostic imaging (Table 7). These included all HIV screening tests, STI tests and all test and x-rays for PLWHAs in both the MCMH and private laboratory in St Vincent and the Grenadines. In terms of curative care services, the majority is spent on inpatient care dealing with both opportunistic infections and routine illnesses of PLWHAs. The EC$ 26,000 spent on outpatient care consists of mainly the visits of PLWHAs for ART. The cost of ARV drugs is included under medical goods to outpatients and this accounts for 13% of the total. The purchase of condoms in private outlets was estimated at EC$ 72,000 or 7% of the total. UNAIDS/Abt Associates National Health Accounts 24

28 Table 7. HIV/AIDS expenditure on personal health services in St Vincent and the Grenadines in 2004 Code Health Provider Amount % Personal Health Services 1,090, Services of Curative Care 272, Diagnostic imaging 0.4% ARVs 13% OI drugs 1% Condoms 7% HC.1.1 Inpatient care 246, HC.1.3 Outpatient care 1 26,205 2 Inpatient care 23% Ancillary Services to Medical Care 598, HC.4.1 Clinical laboratory 593, HC.4.2 Diagnostic imaging 4, Medical Goods to Outpatients 219, HC ARV drugs 138, HC OI drugs 9,467 1 HC Condoms 71,968 7 Clinical laboratory 54% Outpatient care: ART 1% Outpatient care: STI management 0.8% Outpatient care: OI treatment 0.1% Source: NHA HIV/AIDS Subanalysis 2004 Voluntary testing and counselling accounts for almost half of prevention and public health services (Table 8). This includes the counsellors working within the HIV/AIDS units of the MoHE. The HIV/AIDS unit is active in carrying out IEC activities to prevent the spread of the disease, using radio, television, billboards and other forms of media. Expenditures on IEC activities were EC$ 39,000. All blood in St Vincent and the Grenadines is screened for HIV and this is carried out centrally at the MCMH. It accounts for 9% of prevention and public health services. The MoHE purchases and distributes condoms nationally. We assumed that 80% of condoms were for the purposes of HIV prevention, based on expert opinion of those working in the MoHE. These expenditures were EC$ 23,000, accounting for 7% of the total for services related to prevention and public health services. The prevention of mother-to-child transmission is offered free of charge to pregnant women and babies at the MCMH. These expenditures include the cost of outpatient visits, nevirapine and replacement feeding and amounted to US$ 13,400 for the ten mothers and fourteen babies provided with this service in Outpatient care includes management of sexual transmitted infections, as these expenditures were made during outpatient visits and were not part of any Government HIV or STI prevention programme. Although this classification of STI management is consistent with the International Classification of Health Accounts, note that some other classification systems may include these expenditures under prevention. UNAIDS/Abt Associates National Health Accounts 25

29 Table 8. HIV/AIDS expenditure on prevention & public health services in St Vincent and the Grenadines in 2004 Code Health Function Amount % Prevention & Public Health Services 319, HC PMTCT 13,394 4 Condom distribution 7% Other 18% PMTCT 4% HC VCT 156, HC Blood safety 29,090 9 HC IEC 39, IEC 12% HC Condom distribution 22,825 7 HC Other preventive services 58, Source: NHA HIV/AIDS Subanalysis 2004 Blood safety 9% VCT 50% Health administration and insurance totalled EC$ 107,400 in Since, there is no HIV/AIDS related health insurance, this amount represents administration of the HIV/AIDS programme (i.e. the HIV/AIDS unit). Lastly, EC$ 191,000 was spent on non-health HIV/AIDS related functions. In-kind benefits or economic support to PLWHAs was EC$ 143,000, consisting of mainly cash assistance and food. Psychosocial support to PLWHAs was provided through the HIV/AIDS unit by the resident psychologist (EC$ 38,000). An orphanage provided support to orphans of HIV/AIDS amounting to EC$ 10,000 (Table 9). UNAIDS/Abt Associates National Health Accounts 26

30 Table 9. HIV/AIDS expenditure on non-health functions in St Vincent and the Grenadines in 2004 Code Health Provider Amount % Non-Health Services 191, AD AD In-kind benefits to PLWHAs Psychosocial support to PLWHAs 143, , AD.1.2 Support to orphans 10,000 5 Psychosocial support 20% Support to orphans 5% Source: NHA HIV/AIDS Subanalysis 2004 In-kind benefits to PLWHAs 75% Flow of funds from financing agents to health functions The flow of funds from financing agents to health functions is shown in detail in the HF x HC matrix in the Appendix. The main financing agents are the MoHE and private household out-of-pocket expenditures so we focus on the flow of funds between these entities and health functions. The largest share of funds (32%) flowing from the MoHE are used for clinical laboratory tests (Figure 10), followed by inpatient care (20%). The MoHE manages all funds that are used to purchase ARV drugs and considering these were only provided to 35 patients in 2004, the share of 11% is significant. Almost all private household out-of-pocket expenditure is made on clinical laboratory testing and condoms (Figure 11). Since government services for HIV/AIDS are highly subsidised and in many cases free of charge, individuals do not have to contribute out-of-pocket to benefit from these services. Laboratory tests paid for out-of-pocket are mainly HIV screening and STI tests. Figure 10. Flow of HIV/AIDS funds between the MoHE and health functions UNAIDS/Abt Associates National Health Accounts 27