South African ART policies between 2013/14 2014/15: An analysis of ARV Expenditure Gavin Surgey Teresa Guthrie 31 March 2015 DRAFT [Do not quote without prior permission]
Background Over 2.5m people on treatment in South Africa Globally 13m people on treatment at end 2013 (UNAIDS gap report, 2014) Recent policy change from CD4<350 to CD4<500 means more people eligible for treatment South Africa spent in excess of R15bn per year on HIV (public funds 2013/14) Greatest proportion goes towards Anti-Retroviral Treatment (ART) Approximately R7.6bn, 48% for ART (2013/14) Approximately R4bn, 24% for ARV (2013/14)
Purpose of Analysis A greater need to understand how planning and budgeting for ART take place Each year a consistent overspend of budget on ART has taken place In 2013/14, 110% of the conditional grant was expended, yet number of people on treatment was below target. The ARVs form the single largest cost component within the HIV expenditure (R4bn) In preparing for the new GF grant application, there is need to consider the resource requirements to reach 90-90-90 and, past spending adequacy so as to inform future planning
Research Questions How much money should be set aside for the provision of antiretrovirals i. 2014/15 at 350CD4, and ii. 2015/16 at 500CD4 criteria and at different scale rates? What were the amounts allocated provincially for ARVs (both CG and voted funds)? What is the contribution of the Global Fund to ARV financing? Are the provincial (or total national) allocated funds for ARVs adequate? What is provincial spending on ARVs in 2013/14 (both CG and voted)? What is the variation between provincial unit cost of ARVs per patient?
Methods & Sources National Resource Needs Estimations: National ART Costing Model (NACM) Budgeting Allocations and Process: HIV Conditional Grant Business Plans, DoH Quarterly Performance CG Reports Expenditure Analysis: BAS (for public funds) and EFRs and quarterly expenditure (for GF)
Synopsis of people on treatment (Actual vs targets) Number of patients remaining in care Number of new patients initiated on ART Prov 2013/14 2014/15 target 2013/14 2014/15 target EC 266 460 293 250 81 326 75 000 FS 145 307 166 450 40 285 37 000 GP 587 572 650 000 137 359 135 000 KZN 792 991 1 038 556 184 866 180 000 LP 189 002 239 100 61 649 52 600 MP 239 537 309 071 61 199 74 496 NC 39 158 44 959 9 469 8 772 NW 185 302 226 735 48 062 44 212 WC 156 703 166 111 35 298 35 000 ZA 2 602 032 3 134 232 659 513 642 080 Source: Provincial DORA Reports 2014/15
Estimated total cost of ARVs per year (ZAR mil, 2013/14-2015/16) Total drug cost for ARVs (adults and children, all lines) per year ZAR Millions 2013/14 (Dec 2012 tender) 3 742 2014/15 (Dec 2012 tender, Feb 2014 tender update, eligibility at 350) 4 278 2015/16 (Dec 2012 tender, Feb 2014 tender update, eligibility at 500 and PMTCT B+) 2015/16 (Dec 2012 tender, Feb 2014 tender update, universal test and treat) - basic scale-up 4 509 - rapid scale-up 4 887 - slow scale-up 4 122 - basic scale-up 4 705 - rapid scale-up 5 219 - slow scale-up 4 217 Source: Meyer-Rath, G (2015) National ART Cost Model, South Africa. Health Economics and Epidemiology Research Office, Boston University/ University of the Witwatersrand, Johannesburg.
ARV budget allocations through the CG (2013/14 &2014/15 per province) Business Plan allocation of expenditure for ARVs 2013/14 Allocation ZAR 2014/15 Allocation ZAR EC 302 708 000 462 000 000 FS 194 530 266 269 030 000 GP 970 529 000 871 000 000 KZN 900 000 000 1 061 713 000 LP 275 594 000 223 622 000 MP 237 030 000 251 433 000 NC 67 918 000 66 607 000 NW 244 198 600 276 503 000 WC 115 500 000 224 812 000 Total 3 308 007 866 3 706 720 000 Source: Conditional Grant Business Plans 2013/14 & 2014/15
Global Fund s contribution to ARVs (Expenditure Nat. 2012/13-2014/15) ARVs (ZAR) 2012/13 2013/14 2014/15 NDOH R91 638 240 R233 059 254 R 439 662 532,24 WCDOH R9 083 544 R6 076 469 R 19 050 188 Total R100 721 785 R239 135 723 R 458 712 720 Source: GF EFRs (2012/13 & 2013/14) & quarterly expenditure records NDOH and WCDoH (2014/15)
Public expenditure on ARVs (per province for 2013/14 - CG & ES) Based on Percentage DOH HIV CG DOH Voted Grand Total that is ARV only (avg 4% of total ARV spend) Eastern Cape 357 215 439 13 654 456 370 869 895 Gauteng 1 176 032 094 19 222 284 1 195 254 378 KwaZulu Natal 977 756 642 (493 155) 977 263 488 Mpumalanga 315 204 330 95 182 664 410 386 993 Northern Cape 77 005 676 157 523 77 163 199 Western Cape 154 318 320 16 156 760 170 475 081 North West 251 571 634-251 571 634 Free State 267 818 158-267 818 158 Limpopo 127 756 787-127 756 787 Grand Total 3 704 679 080 143 880 533 3 848 559 613 Source: BAS 2013/14 (spending on ART broken down by cost category)
Unit Costs of ARVs (ZAR, 2013/14) 2 500 2 000 1 500 Avg tender price 1 000 500 - Northern Cape Western Cape Free State Eastern Cape Gauteng Limpopo Mpumalanga KwaZulu Natal Average (excl.nw) Source: Authors own calculations (BAS 2013/14 and DHIS number of people on treatment) This shows the variation in unit cost per ARV across provinces. The red line indicates the average ARV drug costs based on tender prices.
2013/14 Comparison of figures Data Source Description Grand Total NACM Estimate of need 3 741 932 175 BAS Actual Govt Expenditure 3 848 922 509 GF Donor Funds 239 135 723 Total ARV Expenditure (BAS + GF) 4 088 058 232
Conclusion Total expenditure(govt and donor) was R4bn in 2013/14 National estimation of ARV need was R3.7bn for 2013/14 8.5% underestimation of national need Govt expenditure on ARV in line with national expenditure 2.8% over the NACM estimation Global Fund accounted for 5.9% of total ARV spend in 2013/14?