South Africa's Investment Case- What are the country's
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South Africa’s Investment Case –
What are the country’s
“best buys” for HIV and TB?
Gesine Meyer-Rath1,2, Calvin Chiu1, Leigh Johnson3, Kathryn Schnippel4, Teresa
Guthrie5, Sarah Magni6, Yogan Pillay7, Fareed Abdullah8, Eva Kiwango9
on behalf of the Investment Case Task Team and Steering Committee
1 Health Economics and Epidemiology Research Office (HE2RO), University of the Witwatersrand/ Boston University
2 Center for Global Health and Development, Department of International Health, Boston University
3 Centre for Infectious Disease Epidemiology and Research (CIDER), University of Cape Town
4 Right to Care
5 Guthrie Consult
6 Anansi Health Consulting
7 National Department of Health
8 South African National AIDS Council
9 UNAIDS South Africa
Health Economics and Epidemiology Research Office
HE RO
2
Wits Health Consortium
University of the Witwatersrand
The purpose and uses of the South African HIV Investment Case
Introduction to Investment Approach: Why, and why here
Evidence review: How we knew what to include
Modelling: How we projected impact and cost
Contents Results: The best buys for HIV
Results: The best buys for TB
Expenditure analysis: Can we afford it?
Knowledge gaps and way forward
Discussion
In 2015, the NDoH and SANAC are pondering a number
of questions…
With new ART eligibility guidelines on the horizon and prevention programmes
needing scale-up,
with the flat-lining of donor support and limp economic growth,
can we afford to continue our commitment to HIV therapy and prevention?
Can we do better?
For less money?
In summary,
• Are there things we are not doing that we need to be doing?
• Are there things we are doing but we are using the wrong approach?
• Are there things that we are doing right but not at the right scale?
• Are there things we are doing that will not make a difference that we need
to stop doing (or continue doing for political reasons)?
3
Key questions to the Investment Case • How much does it cost to fund the current HIV and TB programmes in the medium/long term? • How much does it take to get to 90/90/90 for both HIV and TB by 2020 and what is the most cost-effective way of doing so? • What is the impact of maximising the efficiency of the HIV and TB programmes? • What is the impact of the critical enablers and how much will it cost to fund them?
The IC’s objective is to calculate the cost, impact and
cost-effectiveness of HIV and TB interventions
Impact and cost is being considered over 20 years (2015 to 2034), under 8 scenarios:
HIV TB
1 Baseline scenario 1 Baseline scenario
Keeps coverage of all interventions Keeps coverage of all interventions
constant at 2014 levels constant at 2014 levels
2 Government targets scenario 2 TB 90/90/90
Projects the epidemic under the Announced by Minister Motsoaledi at
current government targets the World Lung Conference in Barcelona,
November 2014
3 Optimisation
Optimisation routine scales up • Screen 90% of vulnerable populations
interventions in order of their cost • Diagnose and treat 90% of TB cases
effectiveness (cost per life year saved) • Treat 90% of cases successfully
A) until current budget envelope is reached
B) until HIV 90/90/90 targets are reached
4 Budget scenario
Maximises efficiency and feasibility 5The South African Investment Case aims at informing
and, if needed, changing national policy
Informing:
National-level MTEF envelope (Phase 1)
Relevant domestic
budgets for HIV and TB HIV Conditional Grant (Phase 2 onwards)
Concept note for GFATM Prov’l Equitable Share (Phase 2 onwards)
proposal(s)
Donor budgets (incl.
PEPFAR)
Audience: cabinet, national departments incl. Treasury, SANAC, premiers,
provincial, district and local AIDS councils, civil society, private sector,
development organisations
6The purpose and uses of the South African HIV Investment Case
Introduction to Investment Approach: Why, and why here
Evidence review: How we knew what to include
Modelling: How we projected impact and cost
Contents Results: The best buys for HIV
Results: The best buys for TB
Expenditure analysis: Can we afford it?
Knowledge gaps and way forward
DiscussionThe South African Investment Case is an extension of
the investment framework
The 2011 Political Declaration on HIV/AIDS includes a pledge to reduce new HIV
infections, deaths due to HIV and HIV-related stigma by 50% by 2015
Key to this is the introduction of an investment approach to achieve substantial
and sustainable impacts on the global HIV response
In South Africa, during 2013 the NDOH and SANAC initiated the application of the
investment framework to the twin epidemics of HIV and TB
The categories included in the South African Investment Case include:
• Biomedical interventions The South African Case puts the optimisation of
• Behavioural interventions allocative efficiency at the heart of the exercise,
• Technical efficiency factors by using a novel optimisation methodology that
• Strategic enablers and allows the consideration of the combined
impact of a large number of interventions
development synergies
8Lancet Article: 2011
• Investment Approach by Investment framework study group, an international
group of experts, including from UNAIDS, the GFATM, the Bill & Melinda Gates
Foundation, civil society organisations, national AIDS programmes, the World
Bank, the WHO, UNICEF, CHAI, CGD and PEPFAR
• We have done a lot- we are doing quite well with a number of biomedical
interventions
• But we can do better- we are not doing as well at preventing transmission…
• The flat-lining of resourcesObjectives of the Investment Approach
• Introduces a long term view on return on HIV and TB investments – look further than
5-year cycle of the NSP
• Quantifies returns on investments in the response
– Reducing new infections, keeping people alive
• Uses evidence to identify priorities and gaps in HIV and TB response
• Corrects the mismatches between the epidemic and response
– Focusing efforts on key locations and populations with the greatest needs
• Supplies a realistic appraisal of existing resourcesWhat is an Investment Case?
1. A document that pulls together the HIV and TB investment logic:
– a description of smarter investments over the long-term (typically 10+ years)
2. Can be articulated in a variety of forms, based on a country’s specific contexts and
needs
– Is sometimes different from a NSP, which often includes an extensive and
aspirational articulation of needs
3. Unites diverse stakeholders including Treasury, departments of Health, Education,
Social development; Civil Society; PLHIV; and international partners
4. Articulates a common effort to identify implementation efficiencies
11UNAIDS Investment Framework
2. CRITICAL 1. BASIC PROGRAMME ACTIVITIES
OBJECTIVES
ENABLERS Key
populations
PMTCT
Social enablers
• Political commitment &
advocacy Behaviour Stopping new
• Laws, policies & change infections
practices Condoms
communication
• Community mobilization
• Stigma reduction
• Mass media
• Local responses, to
change risk
Other
environment
TE
prevention fa Male
Care &
Programme enablers circumcision
treatment Keeping
• Community-centered
design & delivery people alive
• Programme
communication
HCT 4. EFFICIENCY FACTORS
• Management & incentives
• Production & distribution
• Research & innovation
TB
Efficiency
Efficiency Efficiency
Efficiency
factor factor factor factor
3. SYNERGIES WITH DEVELOPMENT SECTORS Efficiency
EfficiencyEfficiency
Efficiency Efficiency
factor
factor factorfactor
factor
Social protection; Education; Legal Reform; Gender equality; Poverty reduction;
Gender-based violence; Health systems (incl. treatment of STIs, blood safety); Community systems; Employer practices.Relationship between Investment Case and other analyses
National ART Cost National TB Cost
NDP Model (HE2RO) Model (HE2RO)
HSS
(HRH plan) (since 2009) (since 2011)
NSP
PSPs (2012 -2016) Aids2031 APT (CHAI)
MDG (2012 -2016) (2009) (2013)
Countdown, NSP and PSP Mid
HLM Targets Term Reviews FIN-CAP (HE2RO)
NHI, PHC re- NASA (CEGAA)
(2015) (since 2013)
engineering (2007/8 –
NDoH APP 2009/10)
NSP MTEF
Guidelines, Policies, (2017 -2021)
Campaigns
Treasury & fiscal trends
PEPFAR
Conditional grant
transition
Spectrum INVESTMENT
estimates (2014) CASE Global Fund
Investment
Thembisa
HIV KYE/KYR
(since 2013) New Programme
(2011) HIMS
technologies evaluations
DHIS, EMIS
TB KYE/KYR Surveys NDOH Joint HIV, TB &
(2014) HSRC, NCS, Special studies PMTCT review,
STATS SA
YRBS Confidential enquiries, HST MNCH
GHSThe purpose and uses of the South African HIV Investment Case
Introduction to Investment Approach: Why, and why here
Evidence review: How we knew what to include
Modelling: How we projected impact and cost
Contents Results: The best buys for HIV
Results: The best buys for TB
Expenditure analysis: Can we afford it?
Knowledge gaps and way forward
DiscussionProcess
PHASE 1 (Oct 2013-June 2015) PHASE 2 (June-Aug 2015)
National level results Provincial level results
1. Evidence review Provincial HIV Business Plans
– Selection of interventions in sub-working • Full TB cost model
groups
– 2-day stakeholder consultation • TB efficiency factors
– Grading of evidence by consultants
– Grading of evidence by modellers
2. Analysis
– Cost and cost-effectiveness of HIV and TB PHASE 3 (Sept 2015 onwards)
programmes Sub-provincial level results
– Optimisation of HIV programme
• Geospatial modelling
– Expenditure analysis
3. Review of results by stakeholders District HIV and TB Implementation
Plans
15In the evidence review we used a number of criteria,
including…
1. Availability of data on effectiveness
2. Data shows that intervention/ efficiency factor/ enabler is in fact
effective; includes
• Comparison with baseline/ “before intervention”
• Impact on HIV endpoints (mortality, incidence, coverage with any other
HIV intervention, sexual behaviour)
3. Strong preference for data from South Africa (unless none available)
4. Setting and target population are relevant to intervention under study
5. If no impact shown (equivalence studies), evidence of impact on cost
required
16Suggested interventions were filtered through an
evidence review process
Interventions, efficiency factors,
260
77
enablers and synergies suggested
by stakeholder consultation
337
Available evidence
(working groups)
138
Good quality of evidence
(working groups/ consultants)
Good quality of evidence
51
(modellers); ability to be modelled
• 24 HIV interventions, 3 TB intervention groups
• 9 efficiency factors
• 13 enablers and development synergies
17Through the filtering process a total of 24 HIV
interventions were included…
Care and treatment Comprehensive condom programming:
• Cotrimoxazole • Condom availability
• ART at current guidelines • Male and female condom education
• Universal test and treat
Medical male circumcision (MMC) PMTCT
• General population MMC • Initiation of triple ART during pregnancy
• Early infant male circumcision
• Age targeting (10-14, 15-19, 20-24, 25-49) Social behaviour change communication
• Campaign 1 (message: adolescent testing,
HIV counselling and testing (HCT)
multiple partners)
• General population HCT • Campaign 2 (condom usage)
• Testing of pregnant women • Campaign 3 (testing, condom usage)
• Testing of adolescents
• Infant testing at birth Other biomedical prevention
• Infant testing at 6 weeks
• PrEP for discordant couples
Key populations (Main analysis) • PrEP for adolescents
• PrEP for sex workers • Microbicides
Key populations (Sub-analysis)
• Packages of care for young women, sex workers, MSM and IDU 18… as well as 13 enablers and development synergies…
(Budget scenario only)
Critical enablers Synergies
• Community-based GBV intervention • Pharmacovigilance
(SASA!) • Supply chain reforms
• HIV prevention for alcohol and drug users • Supporting orphan girls to stay in school
• Alcohol counselling in STI clinics • School based HIV/STI risk reduction
• Parental monitoring • State-provided child-focused cash transfers
• School feeding • Vocational training for adolescent girls
• Positive parenting
• Teacher support
Enablers that are part of baseline
• NIMART (80% coverage by 2016/17)
• Defaulter tracers, SMS systems
• Community mobilisation/ demand creation for almost all interventions (MMC, HCT, PrEP,
microbicides)
• Included SBCC as interventions
19…and 9 efficiency factors.
(Budget scenario only)
ART efficiency factors HCT efficiency factors
• Adherence clubs • Mobile HCT
• Home-based ART • Home-based HCT
• Point-of-care CD4 • Workplace HCT
• GP down referral • PICT
• Community-based adherence • HCT invitations to pregnancy partners
supporters
20QUESTIONS?
21The purpose and uses of the South African HIV Investment Case
Introduction to Investment Approach: Why, and why here
Evidence review: How we knew what to include
Modelling: How we projected impact and cost
Contents Results: The best buys for HIV
Results: The best buys for TB
Expenditure analysis: Can we afford it?
Knowledge gaps and way forward
DiscussionModel suite:
Data flow between models
HIV COST MODEL
THEMBISA
(Main analysis) - ART: National ART
TIME Cost Model
(TB Impact TIME TB COST
(NACM)
Model
(TB MODEL
and Model and Estimates)
Impact
Estimates) - All other HIV
GOALS interventions
(Key populations analysis only)
Life years saved over 20 years Cost over 20 yearsSome epidemiological assumptions
(Thembisa)
• 80% reduction in infectiousness after ART Calibrated to historic HIV prevalence,
initiation mortality and coverage data
• 60% reduction in HIV susceptibility in
men who are circumcised 14 000 000 Total HIV tests performed in SA
14 000 000
•
12 000 000
Condom usage 12 000 000
10 000 000
10 000 000
– 31% reduction in unprotected sex 8 000 000 8 000 000
Model Model
after HIV diagnosis 6 000 000
6 000 000
Reported
Reported
4 000 000
– A further 32% reduction in 4 000 000
2 000 000
2 000 000 0
unprotected sex after ART initiation
1995
2000
1996
1997
1998
1999
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
0
– An average of 3.4 condoms are
1995
2000
1996
1997
1998
1999
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
%60%
of South African men circumcised, 2012-13
distributed for each condom used to 60%
50%
protect a sex act 50%
40%
• Sexual behaviour 40%
Data
30% Data
Adjusted
– An average 20-year old woman in the
30%
Adjusted
20% Model
20% Model
high risk group has 3.3 new sexual
10% 10%
partners each year
0% 0%
15-19 25-29
15-19 20-24 20-24 25-29
30-3430-34
35-3935-39 40-44
40-44 45-49
45-49 50-5455-59
50-54 55-59Unit costs: Three methods
Total cost of an intervention = target population x intervention unit cost
Unit cost = sum of (cost per ingredient x quantity of ingredient)
• Based on data from literature (54% of all included interventions):
– Used South African data where possible, some of it unpublished
– Updated input costs (drug cost, salaries etc) to 2014
– Corrected all else for inflation
• Based on ingredients (35%):
– Only if no literature was available
– Used same input costs as above; based quantities on literature or past
budgets or assumption
• Based on expenditure data (10%):
– Only if no literature and no information on quantities was available
– Based on expenditure records of implementing agenciesKey questions • How much does it cost to fund the current programme in the medium/long term? • How much does it take to get to the 90/90/90 targets by 2020 and what is the most cost-effective way of doing so? • What is the impact of maximising the efficiency of the programme? • What is the impact of the critical enablers and how much will it cost to fund them?
The optimisation process for HIV selected the most cost
effective interventions over a moving baseline
Calculated Added most cost
Baseline incremental cost effective intervention
effectiveness to baseline
Condom
Analyse all 50 options: 1 Condoms (90%)
availability (60%)
• 24 interventions Baseline Option
MMC (30%) 2 MMC (90%)
• up to 3 coverage levels
ART (60%)
(30%, 60%, 90%) 3 ART (90%)
50 Condoms (30%)
Each option includes the cost
and impact of scaling one
intervention up (or down) PLUS
spin-off effects on the entire Ran optimisation twice:
HIV programme A) until current budget envelope was reached
B) until 90/90/90 targets were reached
27The purpose and uses of the South African HIV Investment Case
Introduction to Investment Approach: Why, and why here
Evidence review: How we knew what to include
Modelling: How we projected impact and cost
Contents Results: The best buys for HIV
Results: The best buys for TB
Expenditure analysis: Can we afford it?
Knowledge gaps and way forward
DiscussionOptimisation results
Intervention
Condom availability (90%)
MMC (90%)
SBCC campaign 1 (90%)
MMC age group targeting
Testing at 6 weeks (90%)
(90%)
ART at current guidelines (85%)
PMTCT B+ (60%)
HCT (90%)
SBCC campaign 3 (90%)
Universal test and treat (90%)
Testing of adolescents (90%)
Birth testing (90%)
PrEP for sex workers (90%)
Microbicides (90%)
PrEP for adolescents (90%)
PrEP for discordant couples (90%)
Condom education (90%)
Early infant male circumcision (90%)Optimisation results
Intervention
Condom availability (90%)
MMC (90%)
AFFORDABLE UNDER
SBCC campaign 1 (90%) CURRENT BUDGET
MMC age group targeting
Testing at 6 weeks (90%) Budget in 2016/17
(90%)
ART at current guidelines (85%) ZAR 21.7 billion
PMTCT B+ (60%)
HCT (90%)
SBCC campaign 3 (90%) 90/90/90 TARGETS
Universal test and treat (90%)
Testing of adolescents (90%)
Birth testing (90%)
PrEP for sex workers (90%)
Microbicides (90%)
PrEP for adolescents (90%)
PrEP for discordant couples (90%)
Condom education (90%)
Early infant male circumcision (90%)South Africa has passed peak incidence- the choice is
how rapidly to further reduce it going forward
The introduction of ART
has already done much to
reduce incidence
Regardless of what
is spent, HIV will
not (quite) be
eliminated by 2030
NSP: 50% reduction in
2012 incidence by 2016
UNAIDS: Elimination (=IncidenceLikewise, AIDS deaths have already
declined massively
The curves of HIV
mortality and
incidence have both
already been bent
32The cost of HIV in South Africa will continue to rise…
The government
targets scenario is
affordable under
the current budget
Even under baseline, the
cost of HIV will increase
every year over the next
20 years, by 140%
33… but could start decreasing over the next 10-15 years
90/90/90 will cost
more until 2031,
then decrease
below baseline
Even the constrained
optimisation requires
additional investment in the
long run, but will cost less
than baseline from 2024 on
34Summary of cost and cost effectiveness by scenario
Baseline Government Optimisation 90/90/90
targets with
constraint
Life years saved [millions] (% change on baseline)
- 2015-2019 - 3.48 (16%) 2.14 (10%) 8.07 (37%)
- 2015-2034 - - 10.8 (18%) 26.8 (45%)
Total cost [billion 2014 ZAR]
- 2015-2019 122 131 129 157
- 2015-2034 688 - 675 743
Incremental cost [billion 2014 ZAR] (% change on baseline)
- 2015-2019 10 (8%) 7 (6%) 35 (29%)
- 2015-2034 - -14 (-2%) 55 (8%)
Incremental cost per life year saved
- 2015-2019 R 2,742 R 3,250 R 4,181
- 2015-2034 - Cost saving R 2,055
35Can we improve the efficiency of services?
• “Budget” scenario:
Based on 90/90/90 optimisation scenario, but more feasible and
more efficient
• Shifted out scale-up of UTT until 2017/18 (and slower)
– everything else to 2015/16
• Added efficiency factors and enablers that were
– suggested during stakeholder process and
– documented government policy
even if no evidence to their effectiveness
367 efficiency factors
ART efficiency factors HCT efficiency factors
• Adherence clubs (13% reduction in • Mobile HCT
ART cost)
• Home-based HCT
• Home-based ART (2% reduction in
ART cost) • PICT
• Point-of-care CD4 • HCT invitations to pregnancy partners
3713 enablers and development synergies
Critical enablers Synergies
• Community-based GBV intervention • Pharmacovigilance
(SASA!) • Supply chain reforms
• HIV prevention for alcohol and drug users • Supporting orphan girls to stay in school
• Alcohol counselling in STI clinics • School based HIV/STI risk reduction
• Parental monitoring • State-provided child-focused cash transfers
• School feeding • Vocational training for adolescent girls
• Positive parenting
• Teacher support
38The inclusion of enablers decides whether the Budget
scenario can be funded by the current budget
The Budget scenario
will increase the
2016/17 HIV budget by
21% with enablers…
It will require
additional funding for
… and reduce it by 7%
without enablers. foreseeable future
(15-20 years)Coverage under Budget scenario: Interventions
2015/16 2016/17 2017/18 2018/19
ART
Total number of patients on ART 3,829,518 4,599,413 5,153,374 5,703,950
Number of people starting ART 472,482 904,872 672,702 670,995
MMC
Total number of circumcisions 370,046 1,432,949 1,065,636 738,813
Condoms
Number of condoms distributed 345,304,237 437,292,843 446,283,183 455,646,125
HCT
Total HIV tests performed at ages 10+ 10,683,700 34,311,200 35,325,100 35,975,400
PMTCT for mothers not on ART
Mothers not on lifelong ART (PMTCT B) 11,485 9,750 7,479 5,331
Mothers not on any ART (PMTCT) 41,270 33,742 24,970 17,738
Key populations
CSW reached with combination prevention
package and outreach 105,533 109,062 112,927 116,864
Social behaviour change communication
Number of people reached by SBCC campaign 1 8,840,907 8,755,506 8,628,471 8,519,220
Number of people reached by SBCC campaign 2 41,637,519 42,196,231 42,743,316 43,280,853
Number of people reached by SBCC campaign 3 48,667,230 49,320,270 49,959,720 50,588,010
40Coverage under Budget scenario: Enablers
(Target population covered by HIV budget)
% covered by HIV budget
SASA! GBV intervention 20% 1,834,540 1,859,484 1,884,011 1,908,077
Supporting adolescent orphan girls
to stay in school 50% 383,646 377,677 371,999 370,928
School based HIV/STI risk reduction
intervention 100% 4,664,390 4,591,820 4,522,780 4,509,760
Empowerment based HIV
intervention for alcohol and
substance abuse users 10% 189,763 192,535 195,098 197,592
Risk reduction counselling for
alcohol in STI clinics 10% 43,701 44,305 44,866 45,453
Life skills and vocational training for
adolescent girls out of school 100% 2,609,857 2,589,715 2,552,726 2,512,710
School feeding 20% 192,453 189,458 186,610 186,073
Parental monitoring 20% 292,843 288,287 283,953 283,135
Teacher support 10% 146,421 144,143 141,976 141,567
Positive parenting 20% 292,843 288,287 283,952 283,135
41Results of key populations sub-analysis
Young women package:
PrEP, cash transfers, condom promotion and provision, HIV testing and counselling, school-based HIV and
violence prevention, community mobilisation
IDU package:
harm reduction programmes (needle and syringe programmes), opioid substitution and peer outreach
MSM package:
risk-reduction activities, outreach (including by peers), condom use, prevention and treatment of STIs),
HCT, and initiatives to ensure that these groups are able to access these services
CSW package:
STI treatment, peer outreach and counselling, condom promotion, removing stigma and discrimination,
elimination of gender-based violence, HIV testing and treatment, and programmes addressing clients
Young women IDU MSM CSW
HIV infections averted (% change on baseline)
2015-2019 14.95% 1.72% 0.06% 0.81%
2015-2034 21.92% 3.29% 0.16% 1.65%
Incremental cost of HIV programme (% change on baseline)
2015-2019 16.32% 0.15% 0.44% 0.16%
2015-2034 20.64% 0.18% 0.55% 0.20%
Cost per life-year saved
2015-2019 51,711 2,743 250,667 7,052
42
2015-2034 3,936 231 14,780 542Conclusions of the HIV Investment Case:
Impact (1)
• The South African Investment Case will not result in a programme
which “bends the curve” of HIV incidence or deaths.
• Government policy is already relatively efficient, but can be
improved:
– Increase condom availability to 570 million per year (below current targets)
– Increase access to male medical circumcision, but lower current targets
– Implement social and behavioural change communication programmes
that focuses on
• increasing HIV testing uptake in adolescents
• discouraging multiple sexual partners
– Use the money saved to scale up ART as much as possible.
43Conclusions of the HIV Investment Case:
Impact (2)
• If we want to reach the 90/90/90 targets by 2020, we need to
– increase testing to >35 million tests per year for the foreseeable future,
using all testing modalities (home-based testing, mobile testing, PICT, etc)
– initiate between 670,000 and 900,000 people on ART per year until 2019
– have 5.7 million people on ART by 2018/19
– increase availability of adherence clubs and home-based ART (the only
cost saving interventions we found).
• We did not find critical enablers to be able to compete with other
interventions on the base of HIV endpoints, but there are other
reasons why they need to be scaled up further.
44Conclusions of the HIV Investment Case:
Cost
• In South Africa, we can’t save money by front loading the HIV budget over
a short period of time
• The total cost of the HIV programme will increase no matter the mix of
interventions chosen because of South Africa’s generalised epidemic and
government’s pre-existing commitment to fund lifelong ART to existing
patients.
• It is in the hands of the government to decide when total costs will start
to decrease- spending more later will lead to a increase in total spend.
Over the next 20 years, the HIV budget will increase
– by 140% under the Baseline scenario
– by 120% under the Constrained optimisation
– by 130% under the 90/90/90 scenario.
• Increasing the efficiency of services first, before expanding eligibility and
coverage, is more cost effective than the other way around.
45The purpose and uses of the South African HIV Investment Case
Introduction to Investment Approach: Why, and why here
Evidence review: How we knew what to include
Modelling: How we projected impact and cost
Contents Results: The best buys for HIV
Results: The best buys for TB
Expenditure analysis: Can we afford it?
Knowledge gaps and way forward
DiscussionTB 90-90-90 2016 - 2020
WHO post-2015 strategy to end the TB epidemic
TB 90-90-90 plan for 2016-2020 WHO strategy for 2035
1 90% of high risk and vulnerable 95% reduction in TB deaths by 2035
groups screened for TB
If no active TB, initiate preventative therapy
2 90% of prevalent TB diagnosed and 90% reduction in TB incidence by
treated 2035
If HIV co-infected, initiate ART
3 90% of TB treated successfully No family is burdened with
If drug-resistant, 75% success
catastrophic expenses due to TB
47TB Incidence
500,000
Ambitious scale up of HIV
450,000
programme alone does
400,000
not meet TB targets
350,000
300,000
250,000
200,000
150,000
100,000
Ambitious scale up of
50,000 currently available TB tools
not enough to end TB
0
2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 2035
TB Base, HIV Base TB Base, HIV ICunconstr TB Base, HIV ICconstr
TB Base, HIV 90-90-90 TB 90-90-90, HIV Base TB 90-90-90, HIV ICunconstr
TB 90-90-90, HIV ICconstr TB 90-90-90, HIV 90-90-90 WHO-Target
48TB Deaths
140,000
Even ambitious HIV
scale up does not
120,000 achieve significant
reductions in TB deaths
100,000
80,000
60,000
690,000 TB deaths could be averted
40,000
over the next 20 years
20,000
0
2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 2035
TB Base, HIV Base TB Base, HIV ICunconstr TB Base, HIV ICconstr
TB Base, HIV 90-90-90 TB 90-90-90, HIV Base TB 90-90-90, HIV ICunconstr
TB 90-90-90, HIV ICconstr TB 90-90-90, HIV 90-90-90 WHO targets
49TB Case Registration
400,000
Future reductions in TB
350,000
burden require increased
case finding now
300,000
250,000
200,000
150,000
100,000
50,000
0
2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 2035
TB Base, HIV Base TB Base, HIV ICunconstr TB Base, HIV ICconstr TB Base, HIV 90-90-90
TB 90-90-90, HIV Base TB 90-90-90, HIV ICunconstr TB 90-90-90, HIV ICconstr TB 90-90-90, HIV 90-90-90
50Total Cost of TB Program (ZAR millions)
10,000
9,000 The TB 90-90-90 campaign
requires a budget increase
8,000 of 46% over the next 5 years
7,000
6,000
5,000
4,000
3,000
2,000 TB investment can be
cost saving once burden
1,000 of treatment and
hospitalization reduced
0
2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 2035
TB Base, HIV Base TB Base, HIV ICunconstr TB Base, HIV ICconstr TB Base, HIV 90-90-90
TB 90-90-90, HIV Base TB 90-90-90, HIV ICunconstr TB 90-90-90, HIV ICconstr TB 90-90-90, HIV 90-90-90
51Allocation of budget shifts as TB incidence falls
Allocation of NTP expenditure Most expensive
100%
component of TB budget
90%
80%
currently: TB treatment
70% and hospitalization of
60% drug-resistant TB
50%
40%
30%
Future allocation:
20%
diagnosis and prevention
10%
0%
2015 2016 2017 2018 2019 2020
Diagnostics Treatment Patient Support
Patient HS Usage HIV-TB Program SupportConclusions Conclusions
of the TB Investment Case
1• National and global incidence & mortality targets in 2025 are obtainable
with current interventions available.
2• Finding and successfully treating TB now can reduce incidence and impact
of TB over the next 20 years.
3• TB targets will not be reached by HIV prevention and treatment alone. A
comprehensive, combination package of TB and HIV prevention,
intensified case finding, diagnosis and high quality treatment is required.
4• However, TB costs will come down after 5 years of high investments.QUESTIONS?
54The purpose and uses of the South African HIV Investment Case
Introduction to Investment Approach: Why, and why here
Evidence review: How we knew what to include
Modelling: How we projected impact and cost
Contents Results: The best buys for HIV
Results: The best buys for TB
Expenditure analysis: Can we afford it?
Knowledge gaps and way forward
DiscussionThe SAG contributes the majority of funding, which
mainly goes to HIV – past spending trends
ZAR Total HIV and TB ZAR
Total HIV and TB
Billions
spending by source Billions spending by focus
25 25
22.1 22.1 HIV/TB
19.2 0.7 0.4 TB
19.2
20 17.4 3.7 GF 20 3.7 HIV
0.4 PEPFAR
17.4 0.2
0.2 3.9 SAG 0.2 3.3
15 3.9 15 3.4
10 10
17.8 18.0
14.9 15.7
13.3 13.8
5 5
0 0
2011 2012 2013 2011 2012 2013
US$ 2.3 billion in 2013/14
SAG = 80% (16% inc ann.av)
PEFPAR = 17% (5% dec)
GF = 3% (77% increase)
NB. GF TB expenditure could not be separated within the SDAs. Excludes USAID additional contributions to
TB (not reported in the EA data): USG FY11: $13,972,000, USG FY12: $12,000,000, USG FY13: $12,008,901.
56 |Proportional contribution shows programme reliance
(vulnerability?) on specific sources (2013/14)
Social behaviour change communica on
Other biomedical preven on
Programme Enablers
Medical male circumcision
PMTCT
Key popula ons
HCT
Social Enablers
Care and treatment
Comprehensive condom programming
TB
Non SA IC
HIV not disaggregated
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
GLOBAL FUND PEPFAR SAG
57 | gTotal future funding is projected to increase modestly, but
will fall short of what is needed for meeting the 90-90-90
targets (Budget scenario): will SA graduate?
ZAR
ZAR Estimated future funding Billions Potential HIV funding gap
Billions commitments 34.2
35 32.4
29.8 31.0
25 24.2
0.8 30 26.1
22.2
20.6 21.0 1.9 23.3 24.4
19.2 25 22.2
20 2.0 20.6 21.0
2.8 20
3.3
15 3.7 15
10
10 21.5
19.4 5
15.6 17.4
14.0 0.0 0.0 0.0 0.0 0.0
0
5
-5 -2.8
0 -10 -8.8 -8.8 -8.0 -8.1
2014/15 2015/16 2016/17 2017/18 2018/2019
2015 2016 2017 2018 2019
GF PEPFAR SAG Total Resource Needs Funding Gap
Available Fund Projections
…but will not be enough to meet the requirements
Total future funding will increase due to
of the 90-90-90 targets
greater contributions from the SAG…
(on average, 36% more between 2016-’19)
58 |TB: Resource Needs (90-90-90) and the Potential
Funding Gap (ZAR billions, 2015-2019)
10
ZAR Billions
8
6
4
2
-
2015 2016 2017 2018 2019
( 2)
( 4)
( 6)
Total resources needed for TB TB Funding projec ons Funding gap for TB only
59 |SA Health and HIV Budgets (ZAR bill, 2009/10-2019/190
200 14,00% Total na onal health HIV and
AIDS alloca ons (incl. CG to
180 provinces; NDOH alloca ons,
12,00% and provinces' own ES
alloca ons)
160
Consolidated na onal &
140
10,00% provincial health budget
120
R' billion
8,00%
Health as share of
100
consolidated na onal
6,00% spending (%)
80
60 4,00% Health HIV as share of
consolidated health spending
40 (%)
2,00%
20
Health HIV as share of
consolidated government
- 0,00%
2009/10 2010/11 2011/12 2012/13 2013/14 2014/15 2015/16 MTEF 2016/17 MTEF 2017/18 MTEF spending (%)
Outcome Outcome Outcome Adjusted
Appro
60 | R4D.orgCan we afford it….?
HIV has been taking increasing share of the health budget
But the health budget has been receiving reduced share of the total
public budget (although increasing in nominal terms)
Over MTEF, the HIV allocations continue to increase, but at slower rate
– have we reached the ceiling for public funds for HIV?
Economic performance has been slow, affects the revenue from
taxation and therefore public funds available
Need to maximise impact and minimise wastage
Alternative funding domestic sources:
Earmarked special taxes/ levies?
Increase ‘sin taxes’?
Airtime taxes
Currency conversion tax
Financial transaction tax
Social impact bonds for HIV
Can we afford not to take bold steps to eliminate HIV?The purpose and uses of the South African HIV Investment Case
Introduction to Investment Approach: Why, and why here
Evidence review: How we knew what to include
Modelling: How we projected impact and cost
Contents Results: The best buys for HIV
Results: The best buys for TB
Expenditure analysis: Can we afford it?
Knowledge gaps and way forward
DiscussionLimitations of the analysis
• HIV Investment Case:
– Key populations analysis is based on different model
– 20-year projection period disadvantages interventions with late impact, eg EIMC
– No evidence of effect ≠ evidence of no effect
• Much more research needed on effectiveness of efficiency factors and enablers
– Many unit costs based on ingredient costing
• Much more research needed on costs of MMC, HCT, efficiency factors and enablers
– No clear idea of departments’ and Treasury’s willingness to pay
• TB Investment Case:
– Models the what if, not how
– Costs of scale-up not included
– High-risk groups not explicitly modelled
– EPTB not explicitly modelled
63Knowledge gaps
Impact:
• For many programme areas, only limited data on effectiveness
– Pre-ART care
– SBCC
– PrEP, PEP
– TB efficiency factors
– Almost all enablers that are currently funded from the HIV budget
Cost:
• Many critical unit costs based on ingredients or expenditure rather than full cost
analysis:
– MMC
– SBCC
– PrEP
– Enablers
ABSENCE OF DATA ON EFFECTIVENESS ≠ ABSENCE OF EFFECTIVENESS
but without impact data we can’t ascertain the value of an intervention
We need more, rather than less, evaluation (including of cost)
Please work with us to make phase 2 and 3 more meaningful.
64Implementation: District Implementation Plans
and GFATM concept note
Results of the IC are used in
1. 90/90/90 HIV and TB District Implementation Plans
– District-level HIV Business Plans from 2016/17 on
– Used unit cost and interventions from IC
– Phase 3 will generate district-level target populations and potentially
new optimisation
2. 2015 GFATM Concept Note
– Mostly for key populations services
– Used IC results for gap analysis
THE VALUE OF THE INVESTMENT CASE LIES IN WHETHER OR NOT THE
RECOMMENDATIONS CAN BE IMPLEMENTED.
WE NEED ALL OF YOU FOR THIS.
65Thanks to…
• 18 members of the Investment Case Steering
Committee
• 23 members of the Investment Case Task Team
• ~100 members of 11 sub-working groups
• ~250 participants of stakeholder workshop
• ~15 consultants and resource persons
• HE2RO, Results for Development, Right to Care, Avenir
Health and Aurum Institute for providing staff time
• USAID, SANAC, UNAIDS, GFATM, and Unicef for funding
Health Economics and Epidemiology Research Office
HE RO
2
Wits Health Consortium
University of the WitwatersrandThe purpose and uses of the South African HIV Investment Case
Introduction to Investment Approach: Why, and why here
Evidence review: How we knew what to include
Modelling: How we projected impact and cost
Contents Results: The best buys for HIV
Results: The best buys for TB
Expenditure analysis: Can we afford it?
Knowledge gaps and way forward
DiscussionYou can also read
