CHINA: AIDS Expenditure Tracking in Public Disclosure Authorized Guangxi Zhuang Autonomous Region A Case Study China Health Economics Institute And The World Bank Public Disclosure Authorized Human Development Unit East Asia and Pacific Region Public Disclosure Authorized The World Bank January, 2007 Document of the World Bank Public Disclosure Authorized Acknowledgements This report has been prepared by a team comprising Shiyong Wang (World Bank); Q Zhu (Guangxi Center for Disease Control); Y Zhao, Y Zhang, J Liu, and Q Wan (China National Institution for Health Economics); M Tan and H Li (Guangxi Regional Health Bureau); and H Huang (Municipal Bureau of Health, Liuzhou, Guangxi). The work was done under the supervision of Ana Revenga, Task Team Leader for the China AIDS AAA Program, and benefited from inputs from David Wilson (World Bank), Emiko Masaki (ADB) and Dr. Viroj Tangcharoensathien (IHPP, Thailand). 2 Table of Contents List of Acronyms ............................................................................................................................................... 5 Executive Summary .......................................................................................................................................... 6 Introduction ..................................................................................................................................................... 10 Chapter 1: Background ................................................................................................................................... 12 1.1 Social-economic Information on Guangxi Zhuang Autonomous Region and the County of Luzhai 12 1.2 HIV/AIDS Epidemics in Guangxi and Luzhai ........................................................................ 13 1.3 Delivery of HIV/AIDS Prevention and Care ........................................................................... 15 1.4 HIV/AIDS Financing ................................................................................................................ 17 Chapter 2: Purposes and Methodology ......................................................................................................... 18 2.1 Purposes ..................................................................................................................................... 18 2.2 Definition and Boundaries of HIV/AIDS related Expenditures ............................................ 18 2.2.1 HIV/AIDS Expenditures .................................................................................................. 18 2.2.2 Boundaries ........................................................................................................................ 19 2.3 Methodology ............................................................................................................................... 19 2.4 Study Tools ................................................................................................................................. 19 Chapter 3 Results ............................................................................................................................................ 21 3.1 The Total Expenditure on HIV/AIDS in Luzhai County ....................................................... 21 3.1.1 OOP Payment ................................................................................................................... 24 3.1.2 Financial Input from Government .................................................................................... 25 3.1.3 Contribution from International Organizations ................................................................ 27 3.2 HIV/AIDS Expenditure by Service Provider in Luzhai ......................................................... 28 3.3 HIV/AIDS Fund Flow ............................................................................................................... 31 3.3.1 Key Government and International Financial Inputs for HIV/AIDS Prevention and Control in Guangxi .................................................................................................................... 31 3.3.2 Budget Preparation ........................................................................................................... 32 3.3.3 Funds Flow ....................................................................................................................... 34 3.3.4 Financial Management ..................................................................................................... 36 Chapter 4: Discussion .................................................................................................................................... 39 4.1 Sustainability of HIV/AIDS Financing .................................................................................... 39 4.1.1 Low Share of Public Spending on HIV/AIDS ................................................................. 39 4.1.2 Disproportional Allocation to the Local level .................................................................. 40 4.2 Equity of HIV/AIDS Financing ................................................................................................ 41 4.2.1 Allocation of Government Earmarked Transfers for HIV/AIDS ...................................... 41 4.2.2 OOP Payments for HIV /AIDS Prevention and Control .................................................. 44 4.3 Efficiency of Funds’ Utilization ................................................................................................ 45 4.4 Integration of Resources for HIV/AIDS Prevention and Control ......................................... 47 4.5 Limitations of the Methodology ............................................................................................... 47 4.5.1 Different scenarios for the calculation of total HIV/AIDS Expenditure .......................... 47 4.5.2 Need for better estimation of OOP Payments .................................................................. 48 4.5.3 HIV/AIDS Expenditures at Private Service Providers ..................................................... 49 4.5.4 Underestimation of Co-payment by Insurance Schemes .................................................. 49 4.5.5 Limited data availability ................................................................................................... 50 Chapter 5 Conclusions and Recommendations ..................................................................................... 51 3 5.1 Achieving a Better Understanding of the Overall Financial Needs and Inputs for HIV/AIDS Prevention and Control ............................................................................................... 51 5.2 Increasing the Input from the Central/provincial Government and Alleviating the Financial Burden to PHAs .............................................................................................................. 52 5.3 Using current Input for HIV/AIDS Prevention and Control effectively .............................. 53 5.4 Improving the Equity and Rationality of the Government’s Input for HIV/AIDS Prevention and Control .................................................................................................................. 53 5.5 Integrating Resources for HIV/AIDS Prevention and Control ............................................. 54 ANNEXES ......................................................................................................................................................... 55 4 List of Acronyms AA HIV/AIDS Account ART Antiretroviral Therapy BMI Basic Medical Insurance CDC Center for Disease Control CSWs Commercial Sex Workers EPS Epidemic Prevention Station FDG Focus Group Discussion GFATM Global Fund for HIV/AIDS, Tuberculosis and Malaria HRGs High Risk Groups IDUs Injecting Drug Users IEC Information, Education, and Communication MMT Methadone Maintenance Therapy MA Medical Assistance MSM Men Having Sex with Men NCMS New Cooperative Medical Scheme NEP Needle Exchange Program NHA National Health Account OI Opportunistic Infections OOP Out-of Pocket PET Public Expenditure Tracking PHA People Living with HIV/AIDS PMTCT Prevention of Mother to Child Transmission PQ Price and Quantity STIs Sexually Transmitted Infections TEA Total Expenditure on HIV/AIDS TEH Total Expenditure on Health TEPH Total Expenditure on Public Health THCs Township Health Centers TGEA Total Government Expenditure on HIV/AIDS VCT Voluntary Counseling and Testing WB World Bank WHO World Health Organization 5 Executive Summary The Chinese government‘s spending on HIV/AIDS has increased dramatically in recent years. It only accounts, however, for a part of the total resources dedicated to HIV/AIDS. The fragmented nature of HIV/AIDS financing makes it difficult to register the flows of funds in a holistic and useful manner. More importantly, there are questions over the extent to which increased resources for HIV/AIDS have been allocated and utilized in an equitable and effective manner in order to achieve the intended outcomes specified in the Second Five Year Action Plan for HIV/AIDS Prevention and Control (2005-2010). This study was designed to gain a better understanding of possible impediments to an effective local HIV/AIDS response. It mainly focused on: (a) assessing different aspects of HIV/AIDS financing such as sources of financing, HIV/AIDS related services and their providers being financed, and beneficiaries; (b) estimating households‘ out of pocket spending on