Funding For HIV and Non-Communicable Diseases: Implications For Priority-Setting in The Pacific Region

HEALTH POLICY AND HEALTH FINANCE KNOWLEDGE HUB
WORKING PAPER SERIES NUMBER 1 | MARCH 2010
Funding for HIV and Non-Communicable Diseases: Implications for Priority Setting in the Pacific Region
Joel Negin
Sydney School of Public Health and Menzies Centre for Health Policy, University of Sydney, Australia.
Helen M. Robinson
Consultant, Nossal Institute for Global Health, University of Melbourne, Australia.
The Nossal Institute for Global Health
www.ni.unimelb.edu.au
KNOWLEDGE HUBS FOR HEALTH

Strengthening health systems through evidence in Asia and the Pacific
WORKING PAPER SERIES
ABOUT THIS SERIES

This Working Paper is produced by the Nossal Institute for Global Health at the University of Melbourne, Australia. The Australian Agency for International Development (AusAID) has established four Knowledge Hubs for health, each addressing different dimensions of the health system: Health Policy and Health Finance; Health Information Systems; Human Resources for Health; and Womens and Childrens Health. Based at the Nossal Institute, the Health Policy and Health Finance Knowledge Hub aims to support regional, national and international partners to develop effective evidence-informed policy making, particularly in the field of health finance and health systems. The Working Paper series is not a peer-reviewed journal; papers in this series are works-in-progress. The aim is to stimulate discussion and comment among policy makers and researchers. The Nossal Institute invites and encourages feedback. We would like to hear both where corrections are needed to published papers and where additional work would be useful. We also would like to hear suggestions for new papers or the investigation of any topics that health planners or policy makers would find helpful. To provide comment or get further information about the Working Paper series please contact; ni-info@unimelb.edu.au with Working Papers as the subject. For updated Working Papers, the title page includes the date of the latest revision. Funding for HIV and Non-Communicable Diseases: Implications for Priority Setting in the Pacific Region First draft March 2010 Lead author: Joel Negin Sydney School of Public Health and Menzies Centre for Health Policy, University of Sydney, joel.negin@sydney.edu.au Other contributors: Helen M. Robinson, Consultant, The Nossal Institute for Global Health, University of Melbourne This Working Paper represents the views of its author/s and does not represent any official position of The University of Melbourne, AusAID or the Australian Government.
ACKNOWLEDGEMENTS
The HIV funding information was collected in collaboration with the George Institute for International Health (http://www.thegeorgeinstitute.org/) and with Associate Professor Heather Worth of the University of New South Wales, as part of work commissioned by the Commission on AIDS in the Pacific.
Funding for HIV and Non-Communicable Diseases
NUMBER 1 | MARCH 2010
ABSTRACT
Objectives: There has been increasing global interest in documenting funding flows for health, but none of that work has focused on the Pacific region. This paper outlines external funding for two specific areas of overseas development assistance (ODA) for health in the regionHIV/AIDS and non-communicable diseases (NCDs) during 2002-09. These are compared to the comparative disease burdens, and some initial thoughts are presented on the dynamics of setting donor health priorities in the Pacific. Methods: Empirical data on development partner aid funding were accessed through a review of web sites, annual reports, published data, funding proposals and other publicly available documentation of donor country aid agencies, multilateral agencies and programs and that of recipient governments. The document review was supplemented by 27 key informant interviews to verify and clarify the available data. Interviewees were drawn mainly from bilateral and multilateral agencies active in the Pacific and researchers working in the field. The HIV component was commissioned work for the Commission on AIDS in the Pacific. Results: Despite much higher mortality rates from NCDs, external funding for HIV is higher than for NCDs. From 2002 to 2009, funding totalled US$68,481,730 for HIV and US$32,910,778 for NCDs. External assistance for HIV activities in the Pacific in 2009 was more than US$18 million, while funding for NCDs in the same year was almost US$12 million. Conclusions: Despite cooperation from many agencies, the funding data were difficult to gather, highlighting the need for greater transparency of funding information and more thorough record keeping. The external funding does not align with the disease and mortality figures, and further interviews suggested that donor funding decisions in the region are driven not by local priorities but by factors including a strong global HIV community, the commitment to the Millennium Development Goals (MDGs) and the lack of coherence in the way NCDs are presented to policy makers.
Funding for HIV and Non-Communicable Diseases: Implications for Priority Setting in the Pacific Region i
ii Funding for HIV and Non-Communicable Diseases: Implications for Priority Setting in the Pacific Region
INTRODUCTION
The three or four decades following the Second World War brought dramatic improvements in the quality of health of most people living in Pacific island countries (PICs). Data on estimated life expectancy of both men and women indicate that these countries have relatively low rates of adult mortality. Declining adult mortality from 1970 until 2000 also reflects a generally positive situation, particularly for women (WHO 2003). Today, the health situation in the region does not look quite as rosy. Most PICs seem unlikely to achieve the targets for 2015 established by regional MDGs (AusAID 2009). Despite the historic successes and the availability of health aid, it seems there is a risk that the health gains of last century will be eroded, with the possibility of reversals for future generations in some communities. Given this background, we feel it is important to examine the relationships between national policy makers and their development partners to gain insights into how better to align development efforts and so improve aid effectiveness through more sustainable processes and partnerships. The Paris Declaration on Aid Effectiveness and the Accra Agenda for Action (OECD 2008) agreed that countries should take charge of setting priorities for themselves and drive their own policy agendas. But is this happening? Are flows of overseas development assistance making it too difficult for small countries to set their own health priorities? ODA for health makes up a relatively large component of health funding in PICs. Much of this aid is directed towards disease-specific initiatives, and it is not clear whether the health priorities implied by ODA priorities match the health priorities of the countries. Recently, there has been greater global recognition of funding imbalances. Gostin and Mok (2009) argue that the problem of skewed priorities in international assistance mean a significant amount of funding is directed towards specific diseases or narrowly perceived national security interests that have been placed high on the global health agenda by a small number of wealthy donors (such as OECD countries, the Gates Foundation and the Global Fund). Gostin (2007) argues that rich countries and philanthropists have often set priorities that do not reflect local needs and preferences. The Paris Declaration and Accra Agenda both highlighted the need for disease control programs to be better integrated into efforts to strengthen health systems; Cometto, Ooms et al (2009) believe the emphasis on vertical disease control programs can exacerbate problems for developing country health systems. This paper takes a first step towards understanding this situation by examining external funding for two specific areas of health ODA in PICsHIV/AIDS and non-communicable diseases (NCDs)1during 200209. The funding situation is assessed in conjunction with comparative disease burdens in order to develop a better understanding of the dynamics of donor health priorities in the region. Internationally, there has been considerable recent work in this area (McCoy, Chand et al 2009; Shiffman 2009), but little work has been done specifically on the Pacific region. The paper is an initial review of available sources on levels of funding in the region and what they suggest about priorities for health. By focusing the review on external funding, we can more easily see the extent to which highlevel promises and pledgesby PICs and by development partnersare translated into action by providing resources. This empirical analysis aims to assess funding for HIV/AIDS and NCDs, comment on what these relative funding levels suggest about whose policies more strongly influence priorities and set a baseline for future comparisons of development partner priorities for HIV and NCDs in the Pacific. HIV and NCDs were selected for this study because: both are relatively recent phenomena in burden of disease for PICs; oth require long-term and sustainable treatments that have profound impacts on health policy making and b resourcing (Bischoff, Ekoe et al 2009); oth have considerable impact on the economies and community life of PICs due to the premature loss of b productive adults; both are largely preventable.
1 Non-communicable diseases are principally cardiovascular diseases, cancers, chronic respiratory diseases and diabetes, as classified by the International Statistical Classification of Diseases and Related Health Problems rules used by WHO to produce internationally comparable health metrics (WHO 2008).
Funding for HIV and Non-Communicable Diseases: Implications for Priority Setting in the Pacific Region 1
In the paper, we first describe how we collected and analysed the data. We describe the disease burden associated with each condition. We then briefly describe the characteristics of development assistance in PICs and measure funding available for the HIV and NCD response in the region. We then discuss the findings and their implications for health policy making in PICs and, finally, the implications of these findings for future work.
METHODOLOGY
The methodology is in two parts. First, the empirical data on development partner aid funding were accessed through a review of web sites, annual reports, published data, funding proposals and other publicly available documentation of donor country aid agencies, multilateral agencies and programs and that of recipient governments. As a result, the funding data come largely from publicly available primary sources, including the Global Fund to Fight AIDS, Tuberculosis and Malaria, the Secretariat of the Pacific Community (SPC), US Centres for Disease Control and Prevention (CDC), UNAIDS, World Health Organization (WHO) and AusAID. The academic literature was reviewed through reference lists of relevant articles identified. Searches focused on the period from 2000 to 2009. Wherever possible, all data have been cross-referenced against other sources, including published data from other researchers working in this area. All financial data are presented in current US dollars unless otherwise noted. Secondly, the results of this review were supplemented by field interviews to verify and clarify the meaning of the publicly available data. Interviewees were mainly from bilateral and multilateral agencies active in the Pacific and researchers working in the field. They were involved in funding decisions regarding HIV and NCDs. The interviews were conducted either in person or by telephone. Interview topics included how the funding priorities were set and what process was used to determine allocations. Email was used for follow-up questions, clarifications and requests for confirmation of specific points. Ethical approval for the interview process was given by the University of NSW and the University of Sydney Human Research Ethics Committees. Confidentiality for interviewees was guaranteed to encourage more open discussion. Where direct quotes are provided, names are not attributed. As is often the case with interviews of key policy makers, not all those approached were able to complete an interview. Data for the HIV component of this study were collected as part of work for the report of the Commission on AIDS in the Pacific (2009) and used with the permission of the Commission. There have been many calls in recent health research literature for more transparency by aid donors in reporting aid flows (McCoy, Chand et al 2009; IHME 2009). With the entrance of new players, such as the Gates Foundation and the Global Fund, to an already crowded stage, it is difficult to piece together a full and clear picture of the purposes of various funding projects and programs, and the resources they involve. The work undertaken here has proven no less difficult. Generally, it is easier to distinguish aid programs for HIV because they are generally delivered through stand-alone projects, while those directed to NCDs are more difficult to identify or separate from overall health budgets. Domestic funding was not systematically collected due to difficulties in gathering such data broken down by disease areas.
CURRENT BURDEN OF DISEASE IN PACIFIC ISLAND COUNTRIES

Before investigating funding levels for the two priority areas selected for this study, we outline here the Pacific burden of disease. The Pacific region accounts for just 0.2% of the global burden of HIV and AIDS, the majority of these cases occurring in Papua New Guinea (PNG), Australia and New Zealand (UNAIDS 2008). According to data provided by the SPC, as of the end of 2008 there were 1337 cumulative reported cases of HIV and AIDS across the PICs and territories (excluding PNG) (SPC 2009). Fourteen of 21 Pacific countries and territories have fewer than 25 reported cases of HIV and AIDS, making it clear that HIV is not currently a large public health burden in many of these countries. Table 1 shows the numbers of cumulative HIV and AIDS cases in each of the countries of the region.
2 Funding for HIV and Non-Communicable Diseases: Implications for Priority Setting in the Pacific Region
Table 1. Pacific population and reported cases of HIV and AIDS, 2008
Country MELANESIA (excluding PNG) Fiji New Caledonia Solomon Islands Vanuatu MICRONESIA Federated States of Micronesia Guam Kiribati Republic of Marshall Islands Nauru Northern Mariana Islands Palau POLYNESIA American Samoa Cook Islands French Polynesia Niue Pitcairn Islands Samoa Tokelau Islands Tonga Tuvalu Wallis and Futuna ALL PICs (excluding PNG) Population (mid-2008) 1,804,350 831,600 241,700 503,900 227,150 525,309 110,600 172,300 95,500 52,700 9,900 64,109 20,200 649,650 65,000 13,500 261,400 1,600 50 179,500 1,200 102,300 9,700 15,400 2,979,309 HIV reported cases: cumulative 590 259 316 10 5 331 35 187 54 13 2 32 8 334 3 2 286 0 0 16 0 15 10 2 1,255 Cumulative incidence per 100,000 32.7 31.1 130.7 2.0 2.2 63.0 31.6 108.5 56.5 24.7 20.2 49.9 39.6 51.4 4.6 14.8 109.4 0.0 0.0 8.9 0.0 14.7 103.1 13.0 42.1
Note: Kiribati reporting period Dec 2004; Tuvalu reporting period Dec 2005. Source: SPC 2009.
At the same time, WHO data (WHOSIS 2009) indicate that NCDs are the leading cause of death in most PICs, contributing approximately 75% of deaths in 2007; for example, 82% of deaths in Fiji during 2007 are attributed to NCDs (WHOSIS 2009). NCDs also contribute a very large proportion of morbidity for people living in the Pacific region, and indications are that NCD-related mortality and morbidity are rising (WHO 2007, 2009). Rates of diabetes in the Pacific are among the highest in the world, with a prevalence of more than 40% among adults aged 25 to 64 years in American Samoa, Tokelau and the Marshall Islands and rates of 13% or higher in Tonga, Tuvalu, Samoa and French Polynesia (Colagiuri, Palu et al 2008; Buckley and Colagiuri 2007). Levels of overweight and obesity in the region are extremely troubling and range from 47% to 93% in countries that have completed STEPS surveys, being over 80% in Samoa and Tonga (WHO 2009).2 Data on body mass index, obesity and risk factors from a number of sources highlight the threat of chronic NCD in the Pacific (Schultz, Vatucawaqa et al 2007; Rasanathan and Tukuitonga 2007; Carlot-Tary, Hughes et al 1998; Colagiuri, Muimuiheata et al 2002; Keke, Phongsavan et al 2007). The impact of these high rates of NCDs on health budgets is immense, as much as 60% of health budgets in some Pacific island countries being allocated to expensive overseas care for those affected (WHO 2007). A World Bank document estimated that in Samoa in 2000, NCDs accounted for over 43% of total health care expenditure (World Bank 2008). Overall, while NCDs are a major contributor to mortality in the region, WHO data show that AIDS-related mortality is extremely low or does not exist in the countries of the region (Figure 1).
2 World Health Organizations STEPwise approach to surveillance (STEPS), http://www.who.int/chp/steps/en/.
Figure 1. Deaths due to NCDs and AIDS per 100,000 population, by country, 2002 and 2005
Source: WHOSIS 2009.
Funding for Disease Control in the Pacific
For the size of their economies and populations, Pacific countries receive some of the largest ODA amounts in the world (AusAID 2009; Hughes 2003). The three million people in the Pacific (excluding PNG) received US$706.5 million in ODA in 2007 or US$235.51 per capita (AusAID 2009). Australia, New Zealand, Japan and the USA are the major bilateral development partners, along with the multilateral World Bank and Asian Development Bank (ADB). Although detail is difficult to confirm, Hanson (2009) reports that Chinas aid to the region is estimated at between US$100 million and US$150 million per year, including both loans and direct grants. Development assistance for health in the Pacific has been increasing over the past decade (Figure 2). Most PICs received increasing amounts of aid, particularly after 2000. Micronesia and the Marshall Islands receive levels of funding that place them among the largest recipients of per capita health assistance in the world (IHME 2009). The Solomon Islands, Palau, Tonga and the Cook Islands (as well as the aforementioned Micronesia and Marshall Islands) all received more than US$20 per capita per year (annualised over the past three years) in health assistance.3 IHME (2009) estimates that Australian health aid increased from US$28 million in 1990 to US$220 million in 2007 (in constant 2007 dollars). While not all of this aid went to the Pacific, a considerable proportion did. At the same time as there have been increases in ODA for health, many PIC governments made modest increases to their health expenditures. In most of the larger Pacific countries, per capita government spending on health increased less than the global average (AusAID 2009). Government health spending in Fiji, the Solomon Islands, Vanuatu, Marshall Islands, Palau and Tonga all increased by less than 25% between 2000 and 2006 in purchasing power parity terms, against a lower middle income country average of 86% and a low income country average of 62% (AusAID 2009).
In comparison, in 2007 per capita health aid was US$4.38 for Ethiopia and US$7.68 for Cambodia. However, two of the three African islands that have comparable challenges of remoteness and lack of economy of scale are also recipients of high levels of per capita development assistance for health: Sao Tome and Principe (US$23.26) and Cape Verde (US$21.22). The Comoros, on the other hand, receive only US$2.51less than any Pacific Island for which data are available.
Figures 2A, 2B and 2C. ODA per capita for health, by recipient, 1990-2007, in constant 2007 US$
Note that the vertical scale is different in each figure. Source: IHME 2009
Funding for HIV Response
In determining the extent of funding going to HIV activities in PICs, we included funding for all activities related to prevention, care and treatment. Activities directed towards HIV together with other related goals, including for example tuberculosis or maternal care, were included only if the response to HIV was clearly identifiable and could be isolated or, in the case where the aims were clearly integrated with HIV, they were included as a whole. In cases where HIV and reproductive health were part of the same initiative, as is the case with many UNFPAfunded projects and programs, these were included in their entirety. The amount of external funding available for HIV activities in the Pacific has been increasing for the last decade and reached US$18 million in 2009 (Figure 3). Notable issues include the large amount of US government fundingexclusively to the six US-affiliated countries and territoriesand large amounts provided by AusAID and the Global Fund. This is in the context of total global funding for HIV and AIDS increasing dramatically over the past decade, from less than US$300 million in 1996 to US$10 billion in 2007 (UNAIDS 2008). Domestic expenditure was not included, but, based on interviews and document review, this was determined to be either very small or even non-existent in many countries. Data on HIV-related household expenditure were not available, nor does the
NUMBER 1 | MARCH 2010 Funding for HIV and Non-Communicable Diseases: Implications for Priority Setting in the Pacific Region 5
Figure 3. External funding for HIV activities by source, 2001-2009, in constant 2007 US$ million
Notes: Funding for New Caledonia, French Polynesia and Wallis and Futuna was not included due to lack of availability and to ensure comparability with NCD data. Double counting is possible in the figure although we have tried to avoid it as much as possible. Although we obtained some data on NGO funding, in many cases that funding was provided by donor agencies, so NGO funds were not included to avoid possible double counting. We also acknowledge that some donors will include only programmatic costs and others might include travel, salaries and administrative costs. UNICEF funding figures were not provided despite multiple requests. Funding data for 2001-04 are particularly unreliable; many agencies did not have records of past expenditure and had no institutional memory from which to gather such information. No funding was found from the Bill and Melinda Gates Foundation or the Clinton Foundation.
figure include any domestic private sector spendingfor example, spending by employers or corporations on HIV prevention or treatment. Where possible, actual expenditure has been included rather than budgeted or forecast figures, but this was not available from all agencies. Analysis of funding by country reveals that five of the eight largest recipients of HIV funds in the Pacific for which country data are available are the US-affiliated countries and territories (Figure 4). These countries and territories receive levels of US government funding that dwarf that disbursed by the Global Fund and the AusAID-funded Pacific Regional HIV/AIDS Program (PRHP). Only two countries, Palau and the Federated States of Micronesia, receive funding from all three sources. US government spending on HIV represents very high per capita funding in some of the countries and territories, particularly in Palau (see Figure 5). Other small Pacific island countries, such as Tuvalu, Niue, the Cook Islands and Tokelau, also receive large amounts per capita. Some of the countries with larger populations, such as Fiji, Vanuatu, Samoa and the Solomon Islands, receive smaller amounts per capita. Fiji, with a relatively larger number of cases, receives only US$0.40 per person per year from these three major funding sources. However, per capita spending is not a completely accurate measure. A large fixed-cost component in HIV responsesparticularly for treatment elementsmakes per capita figures disproportionately large for small island states. The various funding sources for HIV activities in the region function differently. While the ADB and Global Fund contributions are channelled through the SPC and managed regionally, US funding is provided directly to country governments and is earmarked for HIV activities. The UN programs and WHO work largely through their regional technical networks, and, as of 2009, AusAID and NZAID have developed a pooled funding mechanism called the Pacific HIV Response Fund. More discussion of the manner in which these funding sources operate is available in Commission on AIDS in the Pacific (2009).
Figure 4. HIV funding from PRHP, USA and the Global Fund, by country, 2004-07, in constant 2007 US$
Notes: HIV funding by country was available for only a few of the sources. The Pacific Regional HIV/AIDS Program (which includes substantial amounts of Australian, New Zealand and French funding), Global Fund and US government data were available by country. ADB funding data are not currently available by country, nor is the funding provided by UN agencies. Some of these funds are provided at the regional level and therefore cannot be broken down by individual country. The data available are from 2004 to 2007 for the three sources outlined and cover only the countries that receive funding from those sources. The amount noted is cumulative over the four years 2004 to 2007. Figures represent funding disbursed.
Figure 5. Annual HIV funding per capita from PRHP, US and the Global Fund, 2004-07, in constant 2007 US$
Notes: Australia-US exchange rate is based on an average from 1 January 2004 to 31 December 2007 (0.7731); population figures for 2005.
Funding for NCD Activities
Despite the high NCD disease burden in the Pacific, the NCD response has received less funding from donor partners than HIV. Analysis of funding information from the major development partnersincluding CDC, NZAID, AusAID, Japan and Francereveals that limited funding was allocated to NCD prevention and treatment up to 2008 (Figure 6). Prior to 2008, the US was the major bilateral funder of NCD activities, with some contribution from Australia in the form of the Pacific Action for Health Project from 2002 to 2005. Financial support from New Zealand was focused on tobacco control and promotion of physical activity as well as funding medical treatment provided in New Zealand. As of 2007, external funding for NCD activities in the Pacific amounted to less than US$1 per capita. By 2009, this had increased to US$3.85. These figures do not include funding that some individual countries receive directly from the World Diabetes Foundation, World Heart Foundation and similar organisations. These data were not readily available, and amounts are likely to be very small since, when interviewed, the major regional actors in NCD control were not aware of specific projects or funding. Other prominent global health funders, such as the Gates Foundation, did not provide funding for NCD activities in the region. Funding for NCD control has increased since 2008 (mostly from CDC and the governments of Australia and New Zealand). As would be expected, US funding is directed to US-affiliated countries and territories and is managed through the same grant program that supports domestic state health agencies. Specific funding streams include diabetes prevention and control, health promotion for the chronically ill, cancer prevention and control and tobacco-related projects. Cancer-related projects receive more than US$3 million annually. From 2008, Australia and New Zealand funded the joint WHO and SPC Pacific NCD Framework, a new initiative that finally brought the NCD response in the region to the fore, including a grants program to fund various NCD activities. One interviewee stated that the French government had initially committed to providing funds to the NCD framework but pulled out due to the financial crisis. Considerably more donor funding has been provided for HIV responses than for NCD control. From 2002 to 2009, funding for HIV in the Pacific totalled US$68,481,730 and for NCDs US$32,910,778. Figure 7 illustrates the different levels of funding.
Figure 6. External funding for NCD programs in the Pacific, by source, 2002-09, in constant 2007 US$ million
Note: Funding for New Caledonia, French Polynesia and Wallis and Futuna not included.
Figure 7. External Funding for HIV and NCD Responses in the Pacific, by Source, 2002-09, in constant 2007 US$
KEY FINDINGS
While the data are somewhat limited, a number of key messages emerge from this study of funding for HIV and NCD responses: vidence-based policy analysis and policy making require reliable data. Despite cooperation from many E agencies, the various funding data were difficult to gather, confirming what others who have attempted to gather similar data have noted. There is therefore a need for more thorough record keeping and greater transparency in access to funding information. onetheless, the results clearly show that donor funding does not align with burden of disease and mortality N figures. Despite the low burden of disease for HIV, external actors provide significantly more funding for HIV response than for NCD activities. While there may be good reasons why funding does not align with the burden of disease, the disparities seen in the Pacific are significant. here does not appear to be a clear rationale supporting the patterns of donor funding. Some highly T affected countries receive little compared to those with lower disease burdens; and some countries with small populations receive more than those with much larger populations. To some extent, funding appears to follow historic and geopolitical interests.
DISCUSSION
The purpose of this paper was not to discuss appropriate levels of funding for HIV or for NCD control in the PICS at the current time or in the future. Rather, we set out to look more closely at the overall process of policy making and priority setting in health. The analysis here has several limitations, mostly related to the availability
Table 2. Framework for political priority setting for global initiatives

Determinant of political priority Actor power Description Factors shaping political priority
The strength of the Policy community cohesion: the degree of coalescence among the individuals and organisations network of individuals and organisations that are centrally involved concerned with the issue with the issue at the global level Leadership: the presence of individuals capable of uniting the policy community and acknowledged as particularly strong champions of the cause Guiding institutions: the effectiveness of organisations or coordinating mechanisms with a mandate to lead the initiative Civil society mobilisation: the extent to which grassroots organisations have mobilised to press international and national political authorities to address the issue at the global level
Ideas
The ways in which those involved with the issue understand and portray it
Internal frame: the degree to which the policy community agrees on the definition of, causes of and solutions to the problem External frame: public portrayals of the issue in ways that resonate with external audiences, especially the political leaders who control resources Policy windows: political moments when global conditions align favourably for an issue, presenting opportunities for advocates to influence decision makers Global governance structure: the degree to which norms and institutions operating in a sector provide a platform for effective collective action
Political contexts
The environments in which actors operate
Issue characteristics
Features of the problem
Credible indicators: clear measures that show the severity of the problem and that can be used to monitor progress Severity: the size of the burden relative to other problems, as indicated by objective measures such as mortality levels Effective interventions: the extent to which proposed means of addressing the problem are clearly explained, cost effective, backed by scientific evidence, simple to implement and inexpensive
Source: From Shiffman and Smith (2007)
of data and the limited time available for the study, but also related to an understanding of the broader issues of priority setting. It is presented as a preliminary review of the situation with the aim of stimulating further research and analysis. Understanding the current burden of disease is important, but it is not necessarily the best or only guide to meeting future needs. In a broader sense, interpreting the allocation of ODA for health as a matter of choosing between NCDs and HIV control and treatment is practically and conceptually unwarranted. Health systems need the capacity to manage both of these disease categories, along with a range of other equally complex challenges. And there remains a clear need to maintain vigilance against communicable diseases, including HIV, given the vulnerability of small island populations. In practice, common interests and multiple policy objectives need to be addressed simultaneously. The common nature of treatment regimes for AIDS and many NCDs as chronic diseases in fact allows for strong synergies in the development of responses (Bischoff, Ekoe et al 2009). At the core of both the Paris Declaration and the Accra Agenda is the need to reform the way aid is managed and delivered with a focus on achieving better alignment and harmonization through building more effective and inclusive partnerships. Both documents highlight the need for greater ownership by developing countries of their own development agenda and for donors to support this aim. The Pacific Island Forum Secretariat, the governments of Fiji and the Cook Islands and the major donors active in the region are all signatories to the Paris Declaration. However, the results of our preliminary investigation indicate that there has so far been little progress in achieving alignment and harmonization in ODA for health in
the Pacific region. While there has been some increase in external funding for NCDs since 2008, the continuing imbalance in funding for NCDs compared to HIV/AIDS seems difficult to explain without considering the likelihood that donor priorities have driven the allocation process. It could be argued that the recent interest of the governments of the USA, Australia and New Zealand in providing increased funding for NCD control in some PICs may be the result of concern for establishing new development partnerships. Indeed, the NZAID Health Strategy 2008-13 (NZAID 2007) includes NCDs as one of its key themes perhaps in response to the repeated calls from PIC health ministers. But this does not explain, or justify, the situation prior to 2008. The disparities between external funding of NCDs and HIV and the burden of disease in PICs raises questions about how funding priorities are set. In their investigation of how issues find a place on the global health agenda, Shiffman and Smith (2007) developed a framework for analysing what they call the determinants of political priority for global initiatives. Table 2 illustrates their framework. The focus of this paper is to investigate issues related to funding priorities set by donors who themselves are active players on the global health stage. Considering the disparities in funding for NCDs and HIV and the lack of coherence provided by an examination of regional disease patterns in providing an explanation for this, it seems reasonable to consider the political determinants of priority setting using the Shiffman and Smith framework. The framework in fact has resonance with some of the ideas emerging from interviewees in our initial investigation, including within the funding agencies, ministries of health and regional bodies. Using the Shiffman Smith framework, Table 3 summarizes findings from our initial survey.
Table 3. Determinants of funding priorities for HIV and NCD responses in the Pacific
Determinant of political priority Actor power HIV Strong developed global policy community and institutions by around 2002 with UNAIDS, PEPFAR, Global Fund, including global champions Civil society mobilisation in the Pacific with Pacific Islands AIDS Foundation Long-standing interest of global actors in disease control means that major Pacific donors placed HIV high on their agenda Ideas Singularity of purpose around one disease makes for simplicity of message Well-developed global frame available that resonates with audiences Political contexts Inclusion in the MDGs and Global Fund put HIV on the agenda for donors and developing countries Being a single disease makes it easier to track and identify efforts and inputs Poor data on severity, but threat of HIV epidemic Infectious disease threatens donor neighbours Clearly developed HIV response with global evidence
Note: PEPFAR is the (US) Presidents Plan for AIDS Relief.
NCDs There are many NCDs, each having its own stakeholders, thus limiting cohesion of the policy community Greater diversity of actors and institutions makes co-ordination more difficult; hence mobilisation of key actors globally and in the Pacific is more difficult Limited voice of Pacific governments NCDs encompass many issues, which limits cohesion in the way issues are framed Myths of NCDs being diseases of rich, white males are difficult to counter NCD challenges overshadowed by MDGs
Issue characteristics
More complex interplay of multiple risk factors and interventions makes it more difficult to isolate inputs and efforts Poor NCD data limit clear indications of severity of problem Limited developing country evidence on effective interventions
These preliminary findings suggest a way forward for future in-depth research and are presented here to help galvanise discussion in the Pacific policy community. Using this analytical framework gives rise to a number of issues that require further investigation: Actor Power Shiffman (2009) has noted the effectiveness of the global HIV and AIDS lobby in raising support for HIV initiatives. The number of institutions, agencies and bodies, including UNAIDS, involved in fighting the epidemic is testament to the effectiveness of this lobby. Some interviewees noted that the NCD policy community is less cohesive because the different groups are engaged with disease-specific issues. In the Pacific region, civil society has mobilised in support of HIV prevention and control, for example in the form of the Pacific Islands AIDS Foundation. Equally strong lobby groups for NCDs are only now beginning to emerge globally and in the Pacific region (see IDF, IUAC et al 2009). Since the mid-1990s, PIC health ministers have expressed their commitment to NCD prevention and control on several occasions (WHO and SPC 2003; WHO and SPC 2005; WHO 2007). Despite this, development partners have been slow to recognise these efforts and provide appropriate funding, demonstrating both the limited voice of PIC health ministers and the dominance of global donor priorities. Ideas It appears that constructing a response to the HIV epidemic over more than 30 years has provided the opportunity to frame a response clearly around a single identifiable issue and to make it accessible to a wide range of policy makers (Shiffman 2009). Conversely, the fact that NCDs encompass many diverse issues, causes and solutions perhaps limits cohesion in the way the NCD challenge is framed. According to interviewees, HIVs status as an infectious disease played a role in its prominence. It appears that donors quickly realised the threat of rapid increases in prevalence and rightly acted to prevent such a spread; one donor interviewee asserted, for example, that the two main priorities of donors in the region over the past few years have been HIV and pandemic preparedness. Political Context One interviewee thought there was little action on NCDs in the region because they do not appear in the MDGs. While HIV and malaria are highlighted as priority diseases, NCDs were listed only under other major diseases in MDG 6. Despite this, some PICs have attempted to add NCDs to their country-specific MDGs. Once the response to a disease secures significant funding, it may be difficult to remove it from the policy agenda: Stuckler, King et al (2008) assert that imbalances in funding are self-sustaining because donors and international agencies develop expertise in an area and continue to provide funding unless unanticipated results emerge. Shiffman and Smith (2007) note the importance of norms and describe the shared beliefs about appropriate behaviour and the institutions that negotiate and enforce these norms. Stuckler, King et al (2008) assert that WHO plays an important normative role and influence global funding decisions. In the Pacific region, AusAID has also played a central role in its prioritisation of the response to HIV and the relative neglect of NCDs. Issue Characteristics Walt, Pavignani et al (1999) argue that strategic data collection, interpretation, analysis and dissemination are crucial to avoid discussions that can be erratic and ideologically based. Despite the significance of NCDs in the Pacific region, information on morbidity and (to a lesser extent) mortality has only recently become a focus of systematic data collection and reporting. WHO has supported countries in gathering information on NCD risk-factors, and, as of 2007, 15 countries had completed the WHO STEPS survey in their communities. The global HIV community has developed considerable evidence on effective interventions, but evidence on effective NCD interventions in low and middle-income countries has only recently been the focus of systematic research (Gaziano, Galea et al 2007; Lim, Gaziano et al 2007).
CONCLUSIONS
The analysis provided in this paper is preliminary and incomplete, and readers should be aware of the limitations of the data and the limited amount of time and resources available for this initial survey. As other authors have noted (Sridhar and Batniji 2008; IHME 2009), information about financial allocations for various health related activities is commonly fragmented and often inaccessible. The entrance of many new players, particularly those from the private or philanthropic sector, into the health assistance arena has made the tracking of funding flows more complex (IHME 2009), and weak monitoring and evaluation of project and program outcomes, particularly at the country level, makes the situation even more difficult. The lack of comprehensive data does not help to increase the quality of the debate. Data on government funding for national HIV and NCD responses were not collected for this study. It remains possible that, if large amounts of government funding for the HIV and/or NCD responses were identified, this would lead to different findings for some countries. But government funding for the HIV and NCD responses in the Pacific is unlikely to be large because overall government allocations for health care are limited. Annual per capita government expenditure on health in 2005 was, for example, only US$105 in Fiji, US$109 in Kiribati, US$91 in Samoa, US$79 in Tonga, US$44 in Vanuatu and US$26 in the Solomon Islands (WHOSIS 2009). Furthermore, discussions with policy makers indicated that government spending on NCDs and HIV was low, especially relative to need. While some stated that some funds were spent, for example, on treatment for NCDrelated conditions, domestic spending on NCD prevention was limited, and interviewees confirmed that most funding for these responses came from external sources. In the Pacific region, external funding for HIV is greater and more diverse than funding for NCDs, despite the significantly larger NCD disease burden. Using the available comparative data, this paper has begun an exploration of the dynamics of setting health policy priorities. This initial investigation of how the response to HIV emerged and persisted as a funding priority for Pacific countries and why NCDs have until recently been relatively neglected by donor partners brings to the fore issues of power, influence, use of evidence and agenda-setting processes. There may be, in reality, stronger synergies between NCD and HIV control than the shared chronicity suggested by Bischoff, Echo et al (2009). More significant lessons may be drawn perhaps from donor-funded programs that address HIV treatment and control which would be of value to expanding donor support in the so far relatively neglected area of NCDs. Analysis of these issues provides a fruitful area for further research.
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WORKING PAPER SERIES NUMBER 1 | MARCH 2010

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