Achieving Value for Money in HIV, Health and Development

27 May 2015
Annie Holmes

Experts attend UNDP social protection and HIV course in South Africa

April 2015 saw a significant advance for STRIVE’s innovative co-financing model, with a UNDP course for policymakers to introduce the idea of multi-sector funding for programmes that achieve multiple benefits.

Held in Cape Town on 27–30 April 2015, the course linked social protection with HIV prevention as an entry point. UNDP, with funding from the Government of Japan, commissioned the Economic Policy Research Institute (EPRI) to develop the course materials and deliver the training in partnership with STRIVE.

Government participants attended from Tanzania, Malawi, South Africa and Ethiopia. They represented different sectors, including finance, development planning, health, education, social welfare and national AIDS bodies.

UNDP delegates came from their regional office in Addis Ababa, country offices in Kenya, Malawi and Tanzania and a PEPFAR representative attended too. The STRIVE team comprised Michelle Remme (London School of Hygiene & Tropical Medicine) and Maria Cabrera (Wits Reproductive Health and HIV Institute) while Professor Charlotte Watts (LSHTM) participated and presented by video link up.

The course

The first day set the scene, showing the link between social protection and HIV in the context of an “upstream” and structural approach.

  • A UNDP presentation drew on Brian Lutz and Roy Small’s discussion paper on cash transfers and HIV prevention.
  • Professor Watts presented on STRIVE’s work on structural drivers and HIV risk.
  • Different mechanisms to achieve social protection were discussed.
  • Co-financing was introduced as a cross-sectoral pooling of funds to achieve the objectives.

At the end of Day One, country teams began discussing sectoral objectives in relation to overall national development goals. Here, the social protection angle proved an effective way to stimulate discussion. After the co-financing paper was presented on Day Two, interesting discussions addressed the way decisions are made about resource allocation.

If you are in the Ministry of Finance and you have extra money, how do you decide where to allocate it: a malaria programme or an education programme? I had people discuss that and realise that their decisions are based on what they prefer and things they think will actually work. 

Michelle Remme, health economist, LSHTM/ STRIVE

UNDP course participants

EPRI designed an extremely effective co-financing game, played online. Teams played together without realising this at the beginning. Each representing a different ministry, they had to allocate a percentage of their funds to different investments. At first, they made fairly ad hoc decisions. Next, the organisers applied a so-called integrated evaluation framework. The first round of grades were poor – Cs and Ds. After a while and with some hints, people realised that their grades changed when someone else made a change – in other words, their investments impacted each other. For instance, HIV suddenly achieved a B grade because Education had increased their investment in early childhood. The game was really enjoyable and made the point that an evaluation framework is necessary, and that it needs to assess complementary programme impact across the different sectors.

The activity showed that if they invested together, they would reap synergies and do better overall. 

Country teams went on to identify interventions where this approach could be applied:

  • The Tanzanian team focused on the Tanzania Social Action Fund (TASAF). This is the national cash transfer programme, currently run as a project with a World Bank loan. A 2014 WB evaluation found a range of impacts on health, education, agricultural assets and household savings.
  • For South Africa, the team focused on a programme to create youth groups for adolescent girls, offering a range of services conditional on attendance.
  • The Malawi team chose an integrated social protection package including an input subsidy programme for agriculture and school feeding.
  • The Ethiopian example involved building separate sanitary facilities in schools, a programme currently funded by a single donor with the potential to be scaled up nationally with benefits for education, water and sanitation, health, gender equality and, therefore, long-term economic growth.

The exercise brought potential benefits to the surface, along with challenges to be addressed. Would one sector invest in an intervention to be delivered by another sector? The issue of accountability becomes more important, as does measuring outcomes. On the other hand, as one participant noted, “it makes sense to pay someone else to do it if they achieve better results.”

UNDP course participants

Lessons and shifts

A stumbling block is the term ‘co-financing’. For many people, this has the connotation of joint government–donor funding. Typically, the Global Fund and others use “co-financing” to mean counterpart financing, so it may be necessary to coin another term. EPRI director Michael Samson proposed ‘public super goods’ as a term for interventions with multiple benefits that need to be co-financed – a suggestion addressed in Michelle Remme’s blog about the course for the Rush Foundation.

The model developed by STRIVE used an illustration with funding from multiple government sectors. However, donor funds may play more of a role in practice. At the outset, there might be a key role for donors to play in facilitating the introduction and uptake of the approach. Cost-effectiveness is often not factored into decisions at national level, but it does to a certain extent get factored into global donor decisions. For example, the evidence of impact from the Zomba trial has persuaded PEPFAR to include cash transfers in their DREAMS initiative (helping girls develop into Determined, Resilient, AIDS-free, Mentored, and Safe women).

Other challenges arise when trying to calculate actual figures, based on savings and benefits. “How much does my sector get and how much am I willing to pay for it? How much is it worth to society or to me?” Within the health sector, these calculations can be made in terms of Disability Adjusted Life Years (DALYs), but few comparable equivalents exist in other sectors. Timeframes present another issue for the highly political process of resource allocation. Sectors may be reluctant to pay upfront now to achieve benefits later. Willingness to pay depends on a great many factors in practice.

UNDP course participants

Next steps

Participants left with plans to feed back to their ministries, ideally to the Permanent Secretary level, and to introduce the concept to sectors that did not attend. The ideal audience is likely to be the central Ministry of Finance, who disburses funds to sectors and to decentralised government structures.

For UNDP, the course was a first phase and will be refined based on this experience and finalised as a package to be rolled out, probably as a one-day course for senior decision-makers. STRIVE is working on two co-financing cases studies, in Tanzania and South Africa, and will follow up on this entry point.