HIV expenditure by origin of resources

Export Indicator

Domestic and international HIV expenditure by programme category and financing source
What it measures

In-country expenditures of HIV programmes and services by source in a standardized and comparable manner according to mutually exclusive categories. The HIV expenditures by programme or service reported here would need to be consistent with the number of people who have received the services (as reported elsewhere in Global AIDS Monitoring).

Rationale

The indicator to be reported is total and subtotal HIV expenditures by services or programme categories and by financing sources. There are eight core sub-indicators that map to Commitment 8. These are outlined under Annex 3. 

By the end of 2018, the international and domestic resource availability for the HIV response reached an estimated US$ 19 billion (in 2016 dollars) in low- and middle-income countries. Achieving country and global targets requires increased focus, resources, programme effectiveness and efficiency to provide the HIV care, treatment and prevention to reduce HIV incidence and extend life. 

It is critical to identify long-term, sustainable financing sources, including domestic resource mobilization, to maintain and build upon the success achieved. However, filling the financing gap and pursuing efficient resource allocation can only be achieved by assessing and managing the resources available and their use. 

The quantification of financing flows and expenditures helps to examine the questions of who benefits from HIV programmes and to determine the current state of allocations for HIV programmes and services that focus on key or other specific populations. 

The vast majority of the AIDS Spending Categories (or ASCs, per National AIDS Spending Assessment [NASA] classifications) or the sub-indicators are drawn from existing frameworks and are now structured around the 10 commitments derived from the 2016 Political Declaration on Ending AIDS. The resource needs for low- and middle-income countries resulted in a target to mobilize at least US$ 26.2 billion (in 2016 US dollars) by 2020.

 

Numerator

Not applicable

Denominator

Not applicable

Calculation

Social accounting and costing principles need to be applied for producing expenditure data. Rules, frameworks and principles are described in the specific manuals and guidelines (links provided below). 

The calculation of each service/programme or sub-indicator may have individual characteristics to ensure proper accounting of all components (e.g., direct and shared costs of service provision) and to avoid double-counting; these calculations may be different by each financing source and service delivery modality (or even by service provider). Further guidance is available in the respective guidelines and manuals listed at the end of this section. 

The quantification is limited to in-country expenditures, using international development assistance funds and the expenditures incurred using public or private funds. 

There are certain requirements for data collection and quality to ensure the reliability and validity of the indicators to assure credibility. 

The conciliation of top-down estimates (from the financing sources) and bottom-up (from the costing of service delivery) provides the best assessment of the total HIV in-country spending. 

Financial and programme records from providers or service delivery organizations are the basis for data collection. 

There are significant documented discrepancies between budgetary allocations and actual expenditures. Budget analysis is not recommended as the sole basis for reporting total in-country HIV expenditure. 

It is good practice to validate expenditures funded by international sources, national financing sources and financing agents, as well as with all relevant stakeholders.

Data type:

Currency and monetary values

Method of measurement

Data collection tools

Countries develop their reports on HIV expenditures by core programme/service categories and financing sources using the national funding matrix template. A full range of HIV programme categories is provided in Annex 2. If countries have developed a full and proper NASA, the filling of the funding matrix constitutes only an output template from the exercise. If countries have developed a health account using the SHA-2011 framework, the cells of the funding matrix can be filled, particularly for the international sources, and in some cases, for the domestic private and public sources of financing.

Primary:

  • NASA.

Alternative:

  • Budget analysis.
  • System of Health Accounts 2011 (SHA-2011) with HIV module. 

Note

  • When a NASA is not available, countries may use centrally produced results from the PEPFAR expenditure reporting system. 

  • Health accounts using the SHA-2011 framework with full disease distribution attempt to capture top-level elements of the NASA ASCs. However, depending on the objectives of a given resource-tracking exercise, SHA-2011 may or may not inform on the totality of HIV granular expenditure (disaggregated by programme) as required. The SHA-2011 accounting framework may have to be supplemented by robust costing principles to disaggregate the HIV portion of the joint costs incurred by the system.

Measurement frequency

Annually for calendar or fiscal year. Since the results of any accounting exercise may take time longer than the deadline for annual reporting, countries may submit preliminary results, which will be substituted when final results are available. In this reporting cycle, we suggest that countries submit any number of annual final reports available from the last five years, indicating their status as preliminary or final and whether they substitute for previous reports. It is not required to resubmit the data that have previously been reported and that remained unchanged. The UNAIDS team can be contacted for assistance if countries would like to submit recently amended or final reports on expenditures prior to 2015.

Disaggregation
  • Financing source
  • HIV and AIDS programme categories
  • For selected sub-indicators, countries are encouraged to report expenditures on the most salient commodities under each of the relevant programmes representing sub-indicators, as data allow. Reporting of total expenditures by programme is acceptable if the dissagregation is not known but there is certainty that both commodities and service delivery costs are included.

Strengths and weaknesses

Countries that have appropriately implemented a full NASA are able to fill the template with an output table from the NASA exercise. Final country estimates need to be validated with all stakeholders and triangulated to increase reliability and validity. 

Countries that have implemented an SHA-2011 annual exercise may need to ensure that the allocation keys used to estimate HIV expenditures from the utilization of the health system are updated and allow the granular data for domestic sources. This process may not use certified data as some accounting principles might require. Countries that have just started the process of full distributional health accounts need to validate the results with other existing sources and all stakeholders to increase reliability and validity of the estimates, particularly the overall level, potential duplication and significant unaccounted expenditures. Countries using health accounts should add non-health-related expenditures and ensure that consistent HIV expenditure is reported, particularly for shared costs in the health system. The implementation of health accounts needs medium- to long-term planning, and it is resource-intensive and depends on coordination between health accountants and programme managers. 

Countries using budget analysis need to ensure that allocated budgets were spent as planned; the estimates for the expenditures that are not incurred using an earmarked budget should be added to each subtotal, as appropriate. 

Countries have the choice of reporting on: (a) separate costs (commodities and service delivery) if they have the data; (b) on only one cost (if that is what is available); or (c) a dissagregated total that includes both commodities and service delivery.

Further information

Process flow for reporting on this indicator:

List of core sub-indicators and associated statistical metadata

Sub-indicators

Disaggregation

Target population

What it measures

8.1. Total HIV expenditure

Funding source, service/ programme category

Not Applicable

Total expenditure from all sources spent on HIV and AIDS at the national level, including health and non-health.

A. Expenditure on HIV testing and counselling (non-targeted; specific commodities separately)

 

Funding source

General population under specific indications

HIV testing and counselling is used to refer to all services involving HIV testing provided with counselling, including: client-initiated HIV testing and counselling; provider-initiated testing and counselling; HTC as part of a campaign, or through outreach services or through home-based testing.

Direct expenditures in the purchase of reagents for laboratory and rapid tests to be reported separately from other costs as available.

B. Expenditure on antiretroviral (ARV) therapy (adults and paediatric; specific commodities separately)

Funding source, adults and children (younger than 15 years old)

Persons living with HIV

Antiretroviral therapy.

Direct expenditures in the purchase of antiretrovirals separately from other from other costs as available).

Unit prices and volumes of commodities procured/distributed.

C. Expenditure on HIV-specific laboratory monitoring (specific commodities separately)

Funding source

Persons living with HIV on Antiretroviral Therapy

Diagnostic services related to HIV clinical monitoring.

Direct expenditures in the purchase of reagents for laboratory for CD4+ cell counts and viral load quantification separately from other commodities and service delivery from other costs as available).

D. Expenditure on TB/HIV

(specific commodities separately)

 

Funding source

Persons living with HIV and people living with tuberculosis

 

Examinations, clinical monitoring, related laboratory services, treatment and prevention of TB (including isoniazid and drugs for treating active TB) as well as screening and referring clients of TB clinics for HIV testing and clinical care.

Direct expenditures in the purchase of drugs for the treatment and prevention of tuberculosis (including isoniazid and drugs for treating active Tb) separately from other commodities and service delivery costs as available.

E. Expenditure on the five pillars of combination prevention

(specific commodities separately)

Funding source, five pillars of combination prevention:

● Prevention for young women and adolescent girls (10-24 years, exclusively high prevalence countries)

● Voluntary medical male circumcision (exclusively high prevalence countries)

● Pre-exposure prophylaxis (PrEP) stratified by key population (gay men and other MSM; sex workers; PWIDs; transgender people; prisoners; young women and adolescent girls; serodiscordant couples).

● Condoms (non-targeted))

● Prevention among key populations (gay men and other MSM; sex workers and their clients; PWIDs; transgender people; prisoners).

General population, key populations

This subset of prevention services is labelled and defined as combination prevention. The rest of the HIV prevention services are to be specified within the categories of the national funding matrix as part of broader prevention services.

This subset includes prevention services specifically designed and delivered for each of the key populations, including prevention services for young women and adolescent girls (10-24 years) in high prevalence countries, men who have sex with men, sex workers and their clients, people who inject drugs, voluntary male medical circumcision, pre-exposure prophylaxis stratified by key populations, as well as condom promotion and provision for general population.

Direct expenditures in the purchase of condoms, needles, syringes and drugs for substitution therapy separately from other costs as available).

 

F. Expenditure on prevention of vertical transmission of HIV

(specific commodities separately)

Funding source

Pregnant women and newborns

Activities aimed at elimination of new HIV infections in children, including: HIV testing for pregnant women, antiretroviral therapy for pregnant women living with HIV and antiretroviral medicine prophylaxis for newborns, safe childbirth practices; counselling and support for maternal nutrition and exclusive breastfeeding.

Note: When a woman living with HIV receives antiretroviral therapy as a part of her treatment before she knows she is pregnant the antiretroviral treatment should be included under ARV therapy for adults.

G. Expenditure on social enablers

Funding source

Not Applicable

Activities to support the implementation of basic programmes as defined in the UNAIDS Investment Framework, including political commitment and advocacy; mass media; laws, legal policies and practices; community mobilization; stigma reduction and human rights programmes.

H. Expenditure on cash transfers for young women and girls (10-24 years, high prevalence countries; HIV earmarked budgets)

Funding source

Young women and girls (10-24 years)

Total expenditure on cash transfers for young women and girls (10-24 years). This is defined as a development synergy with implications for HIV prevention.

 

 
Further information

To access guidelines, framework tools and classifications for NASAs, please contact AIDSspending@unaids.org 

Health Accounts reports are available at the World Health Organization (WHO) Global Health Expenditure Database: http://apps.who.int/nha/ database/DocumentationCentre/Index/en 

Eurostat. HEDIC – Health expenditures by diseases and conditions. 2016 edition [Internet]. Luxembourg: Publications Office of the European Union; 2016 (http://ec.europa.eu/eurostat/web/products-statistical-working-papers/-/K...).