MINISTRY OF HEALTH AND SOCIAL SERVICES

REVISED COSTING OF NAMIBIAS 3RD HIV/AIDS MEDIUM TERM PLAN (MTP III) TECHNICAL REPORT
_________________________________________________________________________

October 2007 

Published by: The Ministry of Health and Social Services, Directorate for Special Programmes A Technical Report on the Revised Costing of Namibias Third Medium Term Plan Commissioned by: The Ministry of Health and Social Services Funded by: European Commission (HIV/AIDS Response Capacity Development Programme) and Presidents Emergency Plan for AIDS Relief First published 2007 Copyright 2007 Directorate for Special Programmes Ministry of Health and Social Services PO Box 13198, Windhoek All rights reserved. The report was written to assist Namibia with the management of the National HIV/AIDS response. It may be quoted provided the source is acknowledged. The document may not be used for commercial purposes or for profit. For additional copies contact the Directorate for Special Programmes, MoHSS Layout and Printing: John Meinert Printing

ACKNOWLEDGEMENTS We gratefully acknowledge the support of the Ministry of Gender and Child Welfare, Ministry of Regional and Local Government, Ministry of Labour and Social Welfare, Ministry of Education, Ministry of Information and Broadcasting, the Office of the Prime Minister, the National Planning Commission, NIP, NABCOA, NANASO, Lironga Eparu, Nawalife Trust, Social Marketing Association and many other stakeholders who contributed to this exercise (see also Appendix III). We also want to thank the Primary Health Care, Policy Planning & Human Resources Development, Human Resource Management, Pharmaceutical Services and the Finance Directorates within the Ministry of Health and Social Services for collaborating and supporting the Resource Needs Estimation. Finally, we want to thank those who participated in the consensus consultation meeting on 14 & 15 February 2007 and/or in one of the many other consultations, and we wish to express our sincere gratitude for the valuable contributions and guidance provided. Thanks are also to the staff in the EC funded Namibia HIV/AIDS Response Capacity Development Programme (HRCDP) and PEPFAR for their technical input and funding support.

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FOREWORD HIV/AIDS remains a major developmental challenge all over the world and is a leading cause of death in Namibia. The HIV/AIDS pandemic has been with us for many years and following the statistics we hope we have reached the peak of the epidemic. Unfortunately, the prevalence rate is still unacceptably high and Namibia has made strong commitment to Universal Access in the UNGASS 2006 political declaration and the African Union Ministers of Health meeting in 2007. This revised MTP III Resource Needs Estimation has been a very useful exercise for the national response planning. The investment needed to combat the disease and to ensure universal access coverage is high. In 2007, we seem to reach 70% coverage of the people living with HIV/AIDS who are eligible for antiretroviral treatment (ART). The number of Orphans and Vulnerable Children is expected to stabilize if we manage to reach 80% coverage of the ART programme in 2009. However, we still face challenges in bringing services closer to the communities and related to male involvement. It is common knowledge that providing treatment for life and mitigating the impact of HIV/AIDS is very costly and difficult to sustain. Therefore we need to redouble our efforts in prevention and Namibia is faced with a huge challenge in changing behaviour to reduce HIV transmission. The national HIV campaign on Be There to Care, that focuses on healthy relations, and linked campaigns on Consistent Condom Use, Proud to be tested, and Stop TB, carry highly relevant messages to the people of Namibia and we all need to internalize those messages. This costing report also clearly indicates that for the coming years increased resources are needed to reduce the HIV prevalence and that it is pertinent that the GRN scales up resources to the overall multi-sectoral response for sustainability. However, external support remains needed. The National AIDS Executive Committee advised to update this Resource Needs Estimation (RNE) every two years and I would highly recommend this, as this will be a necessary tool in support of the overall health and development planning. I wish to express my sincere gratitude to the costing working group that did an excellent job in compiling the information and came up with this report. I want to thank Dr. Norbert Forster, Deputy Permanent Secretary (MoHSS) and Abner Xoagub, Head ENARS, Directorate for Special Programmes (MoHSS) for their strategic leadership in this exercise. I thank Ella Shihepo, Director Special Programmes for facilitating and Ambrosius Uakurama RM&DC, Directorate for Special Programmes (MoHSS) for leading the coordination of the overall process, the consultants Gayle Martin and Filip Meheus for developing the RNE model and scenarios, Claire Dillavou (Strategic Information Officer, CDC) for her valuable comments, and Jeanette de Putter (Senior Technical Advisor, DSP, MoHSS) for her technical input and pulling the whole exercise together.

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TABLE OF CONTENTS Executive Summary. .................................................................................................................... vii Introduction.....................................................................................................................................................................1 A. Purpose of the Report........................................................................................................................................2 B. HIV/AIDS Situation and Economic Context.................................................................................................2 C. Process...................................................................................................................................................................4 D. Methodology.........................................................................................................................................................5 E. Data Collection and Verification......................................................................................................................7 F. Limitations, General Information and Specific Assumptions. .....................................................................8 G. Key results of Resource Needs Estimation and Scenario Modelling......................................................20 H. Resource Gap Analysis......................................................................................................................................24 I. Conclusion and Implications.............................................................................................................................26 Appendix I. Summary RNE sheets.............................................................................................................................30 Appendix II. MTP-III Components, programme areas..........................................................................................44 Appendix III. Consultative Meeting Attendance List.............................................................................................46 Appendix IV. Circumcision: What do we know to date?. ....................................................................................56 Appendix V. Data Sources and other.......................................................................................................................59 Table of Figures Figure 1: Basic Approach to the Resource Estimation Model. .........................................................................5 Figure 2: Flow Chart of Data Inputs and Approach of Resource Needs Model.........................................6 Figure 3: Basic costing principles. ............................................................................................................................9 Figure 4: Total Resource Needs by Cost Area for all scenarios. ..................................................................10 Figure 5: Resources Required for High, Medium and Low Scenarios...........................................................21 Figure 6: Breakdown of Resource Requirement for the High, Medium, and Low scenarios..................21 Figure 7: Share of Resources Required for Prevention, Care and Treatment............................................22 Figure 8: Preliminary Resource Gap Analysis (20072012).. ...........................................................................25 Figure 9: MTP III National Programme Goals.....................................................................................................44 Figure 10: Relationship between HIV prevalence and reduction in HIV incidence......................................56 Figure 11: Relationship between male circumcision prevalence and reduction in HIV incidence............................................................................................................................................56 List of Tables Table 1. Summary programme areas included in the Resource Estimation.................................................8 Table 2. Share of MTP III Component for High, Medium and Low Scenarios.......................................... 22 Table 3. Comparison of Resource Needs Estimates with Selected Economic Indicators (in millions). ....................................................................................... 23 Table 4. Comparison of per capita Resource Needs Estimates with Health Expenditure (in millions).......................................................................................................... 24 Table 5. Committed Resources for HIV/AIDS (2005). ................................................................................... 24 Table 6. Summary High Scenario......................................................................................................................... 30 Table 7. Summary Medium Scenario. .................................................................................................................. 33 Table 8. Summary Low Scenario. ......................................................................................................................... 36 Table 9. Summary Scenario Comparison. .......................................................................................................... 39 Table 10. Main Sectors in the Multi-Sectoral Response................................................................................... 45

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ABBREVIATIONS & ACRONYMS AIDS ANC ART ARV BCC BCI BSS CAA CACOC CBO CPT C&T DACOC DHS GDP GF GRN HAART HBC HIS HIV HR IEC IGAs IPT MAWF MFMR MoE MIB MoHSS MTEF MTP II MGECW MRLGHRD MYFC NABCOA NACOP NAEC NGO NANASO OPM OMAs OVC PCR PEP PEMP PHC Acquired Immuno-Deficiency Syndrome Ante-Natal Care Anti-Retroviral Therapy Anti-Retroviral Behaviour Change Communication Behaviour Change Intervention Behavioural Surveillance Survey Catholic Aids Action Constituency AIDS Co-ordinating Committee Community Based Organisation Co- trimoxazole Preventive Therapy Counselling and Testing District AIDS Coordinating Committee Demographic Health Survey Gross Domestic Product Global Fund Government of the Republic of Namibia Highly Active Anti-Retroviral Treatment Home Based Care Health Information System Human Immuno-deficiency Virus Human Resources Information, Education, Communication Income Generating Activities Isoniazid Preventive Therapy Ministry of Agriculture, Water and Fisheries Ministry of Fisheries and Marine Resources Ministry of Education Ministry of Information and Broadcasting Ministry of Health and Social Services Medium Term Expenditure Framework Second Medium Term Plan [1999-2004] Ministry of Gender Equality and Child Welfare Ministry of Regional and Local Government, Housing and Rural Development My Future My Choice National Business Coalition on HIV/AIDS National Aids Co-ordination Programme National Aids Executive Committee Non-Governmental Organization Namibian Network for AIDS Service Organisations Office of the Prime Minister Organisations, Ministries and Agencies Orphans and Vulnerable Children Polymerase Chain Reaction Post-Exposure Prophylaxis Performance and Efficiency Management Programme Primary Health Care

PLWHA PMTCT+ RACOC RNE RNM SSC STI UN UNAIDS UNGASS USAID VCT WFP

People living with HIV/AIDS Prevention of Mother to Child Transmission (plus on-going treatment) Regional AIDS Co-ordinating Committee Resource Needs Estimation Resource Needs Methodology Sector Steering Committee Sexually transmitted Infection United Nations United Nations Joint Programme on HIV/AIDS United Nations General Assembly Special Session on HIV/AIDS United States Agency for International Development Voluntary Counselling and Testing World Food Programme

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EXECUTIVE SUMMARY The Namibian National Strategic Plan on HIV/AIDS (2004 - 2009): Third Medium -Term Plan, (MTP III) provides an all-inclusive strategy for effective management and control of the HIV/AIDS epidemic. The MTP III has been implemented for almost four years now and a mid-term review took place in June/July 2007. The need for a revised resource estimation exercise was identified based on current achievements, roll-out process and addressing constraints in HIV/AIDS programmes. The main objective of the Resource Needs Estimation (RNE) was to develop a detailed costing of the national HIV/AIDS response and bring in various scenarios to assist decision makers in policy making and strategic planning. Namibias HIV prevalence in pregnant women peaked in 2002 at 22.3%, and subsequently showed a decline to 19.7% in 2004 and then rose again to 19.9% in 2006. These figures suggest that: (1) The prevention efforts have to be consolidated and intensified; and (2) Care and treatment as well as impact mitigation still need to be further expanded to adequately cover their target populations. Namibia, being a high prevalence country, still needs substantial resources to finance the national HIV/ AIDS response. However, the mobilisation of external resources is often complicated as a result of Namibias classification as a low-middle income country. The country is expected to be able to finance a substantial part of the HIV/AIDS response. But the country has one of the highest income disparities of the world and 56% of the population lives below US$ 2 per day and therefore more challenges ahead in terms of resource allocation. The overall RNE process took six months. Extensive consultations with all relevant stakeholders took place to collect and verify data, to develop the RNE model, and to reach consensus on costing sheets and scenario modeling. Data collection, verification and consensus building was the most challenging part of the exercise. However, the longer programmes are being implemented, the better the data. The scenarios were set to help in the roll-out and/or setting up of national HIV/AIDS programmes, and also help to facilitate strategic decision making. The RNE estimates the financial resources required to implement the national HIV/AIDS response through to 2012. The Resource Needs Estimation (RNE) methodology, endorsed globally by UNAIDS was customized for Namibia reflecting the specific features of the Namibian epidemic and the HIV response. The basic approach of the RNE is to use four basic criteria; the size of the population being targeted by the intervention or service, the coverage of that target population being reached by the intervention (2005/06), the target setting up to 2012/13, and the unit cost to provide that intervention or service. Using this approach, high, medium, and low scenarios were estimated for each service provided to the Namibian people around HIV/AIDS. In the majority of cases, the high scenario aims towards the standards of Universal Access, while the low scenario reflects the current capacity and resource constraints, and the medium scenario is an alternative option in between. The RNE 2007, however, has some limitations. It covers 19 extensive programmes areas but the following programme areas are either not included or could not be adequately costed due to time constraints and/ or data constraints: a) - Information, Education and Communication; Social Mobilization and Behavior Change Communication; b) - Opportunistic Infections; c) - HIV related in-patient costs; d) - Palliative Care; e) - Male circumcision; and f) - the MTP III component on Enabling Environment (although some elements are integrated into the various programme areas). vii

Especially, the inpatient cost is expected to be quite large. Therefore, the low scenario will not be realistic for Namibia as parts of the above-mentioned programme costs are not included. The HIV in-patient cost, for example, is a substantial amount in addition to the current calculated cost. The February 2007 Catholic AIDS Action inpatient census data indicated that 43% of the patients admitted in the Catholic Health Service hospitals were HIV related. Extrapolating this percentage nation-wide will bring Namibia to an additional annual cost of N$ 244 million, which can be translated into an additional 16% or 13% on top of the respectively medium and high scenario average annual cost. The report describes in detail the general assumptions made for the RNE. Further it also elaborates on the specific assumptions with regard to the nineteen programme areas covered. Across all programme areas, the total average annual cost of monitoring and evaluation is estimated to be between 3% (high) and 4% (medium) and the management cost varies from 9% (high) to 10% (medium). The human resources cost accounts for is between 8% (high) and 11% (medium). The total resources required for the high scenario are increased from N$1,445 million (US$203 million) in 2007 to N$2,418 million (US$340 million) in 2012 (Figure 5). The resources required for the medium and low scenarios in 2012 are N$1,878 million (US$ 264 million) and N$1,514 million (US$213 million) respectively (Figure 5). The programme areas that account for the largest share of the total resource needs are: Anti-retroviral Therapy (ART), OVC support, Workplace programmes, Food Assistance, Home Based Care, Palliative Care and Psycho-Social Support, as well as Human Resources Management as illustrated in Figure 6. More information about the amounts in N$ are illustrated in Appendix I. Figure 5. Resources Required for High, Medium and Low Scenarios
Total Resources Required by Scenario (2007-2012, current N$ and US$)
N$ 2,500 US$350

US$300 N$ 2,000 US$250

N$ 1,500 US$200 High scenario Medium scenario N$ (million) N$ 1,000 US$150 US$ (million) Low scenario US$100 N$ 500 US$50

N$ 0 2007 2008 2009 2010 2011 2012

US$0

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Figure 6.

Breakdown of Resource Requirement for the High, Medium and Low Scenarios (annual average)

Total Resource Needs by Programme Area for all Scenarios (average annnual, 2007-2012, current N$ and US$)
N$2,000 Management/Coord., M&E US$250 Regional support Infrastructure N$1,600 US$200 HR PLHA support N$1,400 Food assistance & Nutrition OVC N$1,200 US$150 N$1,000 N$ (millions) N$800 US$100 N$600 TB HBC, Palliative Care, Psychosocial support Workplace & Mainstreaming
US$ (millions)

N$1,800

IEC, BCC,SM & youth skills Safe medical injection PEP Blood safety

N$400

US$50

STI Condoms C&T

N$200

N$0 High Medium Low

US$0

ART (incl TB/HIV - IPT/CPT) PMTCT

In the high scenario the impact mitigation component of MTP III was the highest (33%), followed by treatment, care and support (32%) and prevention (24%) (Figure iii, Table i). In the medium and low scenario, treatment accounts for the largest shares 37% and 33% respectively. The share allocated for prevention under this scenario is just over a fourth (25%) (Figure 7, Table 2). Figure 7. Share of Resources Required for Prevention, Care and Treatment
Total Resource Needs by MTP III Component for all Scenarios (average annual, 2007-2012, current N$ and US$)
N$2,000

N$1,800

US$250 Policy, Mgt, Coordination, M&E US$200 Infrastructure

N$1,600

N$1,400

N$1,200 US$150 N$1,000 N$ (millions) N$800 US$100 N$600

US$ (millions)

HR

Treatment

Mitigation

Prevention

N$400

US$50

N$200

N$0 High Medium Low

US$0

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Table 2. Share of MTP III Component for High, Medium and Low Scenarios.
High Scenario Prevention Impact Mitigation Treatment HR Infrastructure Policy, Management, Coordination, Monitoring and Evaluation TOTAL 24% 33% 32% 6% 2% 3% Medium Scenario 26% 24% 37% 8% 2% 4% Low Scenario 29% 22% 33% 9% 2% 4%

100%

100%

100%

The MTP III is consistent with broader development planning taking place in Namibia. The Third National Development Plan (NDP III) for 2007-2012 is currently being developed and the medium case scenario cost has been used for the NDP III resource estimates. The medium and high scenarios account for four percent and five percent respectively of the 2005 GDP and 12% and 15% respectively of the 2005 Government expenditure figures. The per capita average annual resource needs estimate for the health sector programme areas accounts for 47% (medium) and 49% (high) of the Total Health Expenditure (THE). However, as the latest national health accounts data are from 1999/00, the percentages are estimated slightly lower as the THE is expected to have increased. The share of the non-health sector programmes cost on the total cost is 44% (medium) and 52% (high). Given the existing information on resources based on pledges and commitments from donors, both external and domestic (for 2005 the estimate was N$692 million/US$97 million), the resource gap was assessed. As Namibia at the time that the costing was conducted did not have accurate data on funding disbursements, this report does not intend to draw evidence based conclusions on the N$ amounts for the resource gap. At the end of 2007, more accurate data will be available in the MoHSS/DSP funding database. It is also important to realize that funding commitments beyond two years are hardly available, and therefore one needs to be careful with funding projections over a period of five years. Further, it is assumed that the resources are currently available in-country could be allocated to other programme areas as well. This is however not always the case and currently some of the MTP III areas are grossly under-funded. Resources available are often tied to project and programme proposals and donor rules and regulations. Most flexible financing mechanisms, if implementation mechanisms and accountability structures allow, may be useful for Namibia in the longer run. In 2005, the external funding commitments accounted for 63% of the total national HIV/AIDS response resources. However, it is clear for both the medium as well as the high scenarios that resource mobilization from both national and external resources still needs to increase. The share of GRN funding needs to increase in order to allow health programmes to become less dependent on external funding and for the overall sustainability of the national HIV/AIDS response. The unit cost can become a useful tool to monitor costeffectiveness of programmes and therefore an additional tool for strategic planning. Above that beyond two years, the resource gap is worrisome.

Figure 8. Preliminary Resource gap analysis (20072012).

Resource Gap Analysis for all Scenarios (2007-2012, current N$ and US$)
N$2,500 N$2,000 N$1,500 N$1,000 N$500 N$0 2007 N$ (millions) N$500N$1,000N$1,500N$2,000N$2,500US$3512008 2009 2010 2011 2012 US$51US$ (millions) US$349

Resource requirement

US$249

US$149

US$49

US$151-

Resource gap

US$251-

High scenario

Medium scenario

Low scenario

Resources available

Conclusion The government of Namibia has committed itself to Universal Access targets in the AU meeting of health ministers (2007) and the UN High-level meeting on HIV/AIDS/UNGASS II (2006). These commitments are instrumental in developing and/or rolling out the national HIV/AIDS response. This also results in the fact that continuous efforts are needed for mobilizing and reallocating internal and external resources for HIV/AIDS. The classification of Namibia as a low-middle income country, the high HIV/AIDS prevalence, as well as the high income disparity and poverty among a large part of the population, need to be taken into account in mobilizing and allocating resources. The medium and high scenarios seem to be more realistic for Namibia. They take into account the international and national policy commitments and the current progress. The scenario modeling is important to clarify the resource implications of scaling up programmes to cover a larger target group or make other additional investments. The scenarios also helped with the strategic assessment of how to roll out programmes with a focus on sustainability, efficiency and effectiveness. The approach of costing three scenarios was thought to be the most effective in facilitating the strategic planning process as well as advocacy for resource mobilization. Namibia will need an annual average of N$ 1.6 billion or N$ 1.9 billion for the medium respectively the high case scenario, which accounts for 12% and 15% of the GRN expenditure (2005). The health sector programe areas cost almost 50% of the total health expenditure, which cannot be neglected. It was apparent that the health programme areas seemed relatively well established, but the challenge is in extending their reach to districts and constituencies and tackling the infrastructure and human resource constraints. However, many of the health sector programmes are essentially externally funded, which causes concern in terms of sustainability. Some of the multi-sectoral programmes, for example food assistance, are under funded.

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Implications In terms of sustainability, the Government of Namibia (GRN) needs to invest more funds into the national HIV/AIDS response to replace external funding. Currently the Ministry of Finance (MoF) makes substantial allocations to the Ministry of Health and Social Services (health systems cost for the provision of HIV/ AIDS services), Ministry of Gender, Equality and Social Welfare (MGECW - OVC grants), and Ministry of Labour and Social Welfare (disability grants for PLWHAs), but this is by far not enough to cover the cost of the National HIV/AIDS response. External funding remains essential for the sustainability of the response. Thus, the sustainability of the national HIV/AIDS response will depend on the following factors: a) Adequate resource mobilization and resource allocation; b) Increasing programme efficiency and effectiveness; c) Tackling constraints (e.g. human resources for health sectors and expanded response); and d) Strengthening implementation capacity. Adequate resource mobilization and allocation is directly linked to strengthening the current monitoring and evaluation, including accountability and resource tracking. Namibia needs to increase investment with a more in-depth focus on prevention, in particular related to behaviour change interventions. The GRN needs to re-allocate more resources to HIV/AIDS and in collaboration with development partner look into funding mechanisms that improve the predictability of funding beyond two years and a more flexible use for allocating funding towards the HIV/AIDS programme areas. Monitoring of unit cost is a useful tool to look into cost-effectiveness and the efficiency of programmes. In order to scale up programmes, it is highly relevant to tackle the main constraint now, which is training of additional health and other professionals to improve the implementation capacity. It is also of utter importance to speed up the decentralization process in order to allocation more resources to the regions and constituencies.

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INTRODUCTION The Namibian National Strategic Plan on HIV/AIDS 2004-2009, Third Medium Term Plan (MTP III) has fulfilled many of its targets in the four years of its implementation. Therefore, the costing done at the onset of the MTP III is outdated and need arose for a revised resource estimation exercise. Following the indicators, information needed to be updated and new targets to be set. The resource estimation presented in this report builds on the initial costing done in 2003, as well as a rapid costing exercise that was carried out for the development of Namibias Global Fund Round Six Proposal in 2006. In addition, the 2006 UNGASS Political Declaration on HIV/AIDS has been taken into account and especially the strong consensus on Universal Access is reflected in the revised estimation. The revised cost estimation also fed into the MTP III mid-term review process conducted in June 2007, taking into account the most current data. The main objective of the resource needs estimation was to develop a detailed costing of the national HIV/AIDS response following the defined targets for Namibia by focusing on unit costs and bringing in various scenarios to assist decision makers in policy making and strategic planning. Thus the specific objectives of this RNE activity were to: 1. Develop a country tailored resource estimation methodology and analyze, develop and agree upon unit costs and target settings; 2. Estimate the resource requirements of Namibias Third Medium Term Plan according to the various chosen scenarios and make the resource requirements explicit; 3. Assess the resource gap based on current resource availability and the Resource Needs Estimation; 4. Contribute to an evidence base that will form an objective source for prioritization of initiatives, advocacy and decision making identified under the strategic plan, and 5. Build national capacity in the various programmes on resource estimation and develop a model composed of uncomplicated spread sheets for the multi-sectoral HIV/AIDS response programmes. The MTP III is also consistent with broader development planning taking place in Namibia. The Third National Development Plan (NDP III) provides an important development context for the MTP III. In order to ensure that this updated costing would cover the full NDP III implementation period, it covers the time frame 2007-2012. The resource estimation follows the five components of the MTP III and the subsequent 19 programme areas (see Figure 9 in Appendix II). Table 10 in appendix II shows how these 19 programme areas link to various sectors and the main umbrella organisations for People Living with HIV/AIDS (PLWHAs), civil society organisations and the private sector. The Ministry of Health and Social Services (MoHSS) was supported in the exercise by two international economists: Constella Futures Dr. Gayle Martin and Mr. Filip Meheus from the Royal Tropical Institute (KIT). Financial and technical support was provided through the European Unions HIV/AIDS Response Capacity Development Programme (HRCDP) and the Presidents Emergency Plan for AIDS Relief (PEPFAR)/ USAID.

A.

PURPOSE OF THE REPORT

This report intends to: (1) describe the intensive process to collect information and consensus building on the methodology & results; (2) explain the methodology that has been used to achieve the above-mentioned objectives; (3) document the main data inputs and data sources; (4) provide insight into the general and specific assumptions with regard to the resource estimation results; (5) share key results of the scenario modelling; (6) provide information on the resource gap analysis; and (7) discuss some of the implications and conclusions of the Resource Needs Estimation (RNE). Before proceeding, it is important to make a few comments about Resource Estimation Modelling. There are multiple purposes of modelling: (1) to clarify the implications of different approaches in order to assist with planning; (2) to deal with uncertainty1; (3) to explain why resources should be allocated for HIV by showing what may happen in the absence of the investments; and (4) to inform prioritization if total resource needs are not met. Note that modelling cannot predict the future, but it allows planners and policy-makers to consider options relevant to strategic planning and policy making. B. HIV/AIDS SITUATION AND ECONOMIC CONTEXT

Namibia has a generalised HIV/AIDS epidemic with HIV primarily spread through heterosexual transmission. From the 1992 estimate of 4.2%, prevalence rose rapidly over the following four years to 15.4% in 1996. Prevalence continued to rise, although less rapidly for the next six years to a peak of 22.3% in 2002. National prevalence showed a marginal decline to 19.7% in 2004 and then rose slightly to 19.9% in 2006. This suggests two important challenges: (1) Prevention efforts need to be consolidated and intensified; and (2) Care and treatment, as well as impact mitigation services need to be scaled up towards universal access coverage of the target populations. Since the launch of MTP III in 2004, a number of internationally guided initiatives have impacted on Namibias expanded response. The first two years of implementation have seen an unprecedented improvement in roll-out of services to the communities on prevention, treatment, care and support services. As a result, the response to the HIV/AIDS epidemic in Namibia has seen many changes. These include: a) Considerably increased funding commitments; b) The engagement of growing numbers of organizations from the public, private and civil society sectors; and c) Expansion of geographic coverage of services and programmes.

There are several sources of uncertainty: (1) Epidemic determinants (e.g., the effectiveness of prevention programs), the HIV/ response (human resource availability; pace of implementation; changes in implementation approaches over time; Financial resource availability); Macroeconomic and Market indicators (changes in commodity prices, inflation rates, interest rates).

Namibia is classified as a low middle-income country because it is endowed with rich natural resources, which has led to a relatively high per-capita income (US$2,380 per capita in 2004 - World Bank 2006). However, the 2005 Human Development Report shows that the Namibian Human Development Index dropped from 0.693 in 1995 to 0.648 in 2000 and stood at 0.627 in 2003 (UNDP 2003). The report also gives a Gini-index of 70.7 in 2003 while this same coefficient was 67 in 1998. There is no other country in the world that has a higher value related to income disparity. According to the National Household Income and Expenditure Survey (NHIES) of 1993/1994, the richest 20% of the population share 78.7% of income or consumption, while the poorest 20% share 1.4% of the income and consumption in Namibia. The report also states that 34.9% of the Namibian population lives below US$1 a day and 55.8% below US$2 a day. Namibia has a Human Poverty Index of 33 and ranks number 60 among 103 developing countries. More funding is needed to make the HIV/AIDS response sustainable through local initiatives, but external resources remain necessary taking into account the poverty challenges in Namibia. Thus, Namibias development and HIV/AIDS situation indicates a strong need to advocate for more commitment and resources both nationally and internationally to effectively address the HIV/AIDS pandemic. The Resource Needs Estimation tries to provide the most current calculations to this effect.

C.

PROCESS

The MoHSS started the revision exercise of the resource estimation in November 2006. A cost analysis working group2 was installed to review the former costing and provide overall guidance throughout the process and technical input into the costing itself. With the assistance of the EC/HRCDP project within the Ministry and the USAID/Health Policy Initiative, the consultants from Futures Group and the Royal Tropical Institute (KIT) were recruited to assist with the unit costing and scenario setting. The Resource Mobilization and Development Coordination (RM&DC) Unit in the Directorate of Special Programmes in the MoHSS worked with key ministries and stakeholders to ensure good information flow and ownership. RM&DC staff were trained on the job in the RNE process and introduced to the costing methodology together with programme managers. The idea was that programme managers and RM&DC staff could use the RNE model for future exercises. Training was achieved with several consultation sessions on the design, data input and results with the programme managers of the Government of Namibia as well as with other relevant stakeholders. The first round of consultations began in the first two weeks of December 2006. During these weeks, meetings were held with technical staff. The development of the costing sheets, calculation of unit costs and further data requirements were discussed. The technical staff were requested to provide relevant guidelines, statistics, strategic and operational plans (including budgets and expenditure sheets), and other information that could assist in the RNE. Data collection and verification took considerable time and several meetings with programmes were needed to reach consensus. The larger part of the data collection took place during a second round of meetings in the period January-February 2007. In the second tranche of consultations done in February 2007, the consultants visited Namibia from 29 January until 23 February 2007 and overlapped one week to conclude the work. The consultant from Constella Futures Group worked on elaborating different scenario settings and linked the RNE results to the MTEF and national and international funding flow information. The completion of the costing sheets was delayed as a result of the large number of stakeholders that had to be consulted as well as the data collection. Therefore a re-assignment of tasks was needed between the consultants and DSP/MoHSS staff to increase the number of additional consultancy days. A two-day Consensus Building and Scenario Setting Workshop of the Costing for the MTP III Review was organized from 14 to 15 February, 2007 for technical and managerial staff to review and comment on the draft costing sheets. All relevant HIV/AIDS stakeholders from the Government, private sector, civil society and donor agencies were invited and attendance spanned across the different programme sessions that were conducted in a parallel manner. The objective of the workshop was to review and build consensus on the data used in the costing sheets and on the target setting of the 19 areas of the MTP III as well as contributing input to the various scenarios that would be used for planning purposes. During the workshop, the objectives and overview of the costing process, as well as the Resource Needs Estimation Methodology and scenario setting were presented to the participants. The members of the costing working group and consultants facilitated the sessions during the workshop.
2

Dr. Norbert Forster, Under Secretary MoHSS (Chair); Mr. Abner Xoagub, Head Expanded National HIV/AIDS Response Support /DSP/MoHSS (Co-Chair); Mr. Ambrosius Uakurama, CHPA Resource Mobilization and Donor Coordination(RM&DC)/ DSP/MoHSS; Ms. Annemarie Nitschke, Head RM&DC, DSP/MoHSS; Ms. Julieth Karirao, CHPA/ENARS/DSP/MoHSS; Ms. Claire Dillavou, Strategic Information Liaison & Deputy PEPFAR Coordinator; Mr. Dennis Weeks, PEPFAR Coordinator; and Ms. Jeanette de Putter, Senior Technical Advisor, EC project/MoHSS. Other relevant people like Mr. Perry Mwangala, TA M&E Global Fund Programme Management Unit, DSP/MoHSS were consulted on an ad hoc basis when needed.

In the week of 19 to 23 February 2007, daily meetings were held with senior management of various relevant ministries (the Permanent Secretary (PS), Deputy PS, Directors, Deputy Directors and HIV/AIDS focal persons/points). The purpose was to brief senior management on the outcomes of the RNE, and also to examine the proposed scenarios, as costing outcomes were necessary for guidance in future planning. Due to a lack of time, some of the meetings were postponed to a later stage. During the National Aids Executive Committee (NAEC) meeting on 21 February, 2007, it was advised that the costing exercise be updated every two years, and that the current RNE Model compiling the different programme costing sheets should be used and updated as deemed necessary. This would ensure the use of up-to-date indicators and targets, unit costs, exchange rate, and policy and programme changes. The resource estimation results would be used as a strategic planning tool. The overall process took six months. The exercise consumed 60 consultancy days and quite substantial national staff time. Overall the process was judged as very positive related to extensive consultations, consensus building and ownership. D. METHODOLOGY

To estimate the costs of the various programmes identified in the MTP III, a Resource Needs Model was developed. The model was specifically tailored to the Namibian situation in collaboration with the various stakeholders using the data input style described in Appendix 11. Various scenarios were examined as seen in Appendix I. The Model is a spreadsheet that has been designed to facilitate the estimation of costs of individual programmes. The basic method of resource estimation is first to estimate the number of people in need of HIV/AIDSrelated services in the target group. A coverage target is then established to estimate the population that would actually use the service. The next step is to estimate the unit cost of providing the intervention or service and this is used to calculate the total cost of the intervention. This is illustrated in Figure 1.

Figure 1: Basic Approach to the Resource Estimation Model

# People in target population

% coverage of target population to be achieved

# of people to be reached with the intervention

Cost of intervention per person reached

Cost of intervention

 A flow chart of the structure of the Resource Needs Model is pictured in Figure 2. As illustrated, the model relies on three types of inputs _ target population size, coverage and future target setting and unit costs. Target population size: For each HIV/AIDS prevention service, the model requires the size of population that will be targeted. This is the population that could potentially have access to those services given the existing infrastructure. The estimated population sizes were based on the Central Bureau of Statistics population projections (2006) and derived from 2004/05 and 2005/06 programme data. Coverage: Coverage is the percentage of the target population that is reached by a specific prevention service in any given year. Coverage rates are intended to indicate what is feasible and necessary. Target setting was decided upon by programme experts through using current coverage based on indicators from the 2004/05, 2005/06 and 2006/07 fiscal years and the pace of rolling out programme activities. Target setting was chosen taking into account the various factors as the target population and the main capacity constraints depending on scenarios. Unit costs: They are defined as the costs required to reach one person in the target population with a particular service. Unit costs are used to calculate total costs of the service through multiplying the number of people reached by the unit cost. Figure 2: Flow chart of Data Inputs and Approach of Resource Needs Model

Target population Goals, Objectives and Interventions

Coverage and target setting

Unit Cost Required Resources

90% of high risk groups targeted with IEC

N$/US$

50% of districts develop Counselling and Support Centres 50% of HIV+pregnant women with access to PMTCT; 95% in 2012

N$/US$

N$/US$

E.

DATA COLLECTION AND VERIFICATION

A wide range of information sources were consulted. Generally, the data requirements can be divided into the following categories: Demographic data Epidemiological and Behavioural data Program and Service delivery data Economic and Financial data Other sectors and Programmes data Demographic data: This was obtained from the National Planning Commissions population projections produced in 2006 and based on the 2001 census. The MoHSS model (Spectrum), on Demographic Outcomes of HIV/AIDS provided useful data on PLWHAs and those eligible for ART, as well as on Orphans and Vulnerable Children (OVC). Epidemiological and Behavioral data: It was provided by the MTP III draft Progress Report covering 20042006, DHS, and the Sentinel Survey. There was strong reliance on the MoHSS for these data inputs. Programme and Service Delivery data: With the permission of the Ministries of Health and Social Services, Gender and Child Welfare, Labour and Social Welfare, MRLGHRD, Education, and the Office of the Prime Minister, data inputs were obtained from officials and experts who were identified in the relevant ministries. Economic & Financial data (including expenditure and unit cost data): This category of data includes two types: (1) Funding pledges & commitments data, and (2) Unit cost data for each intervention. Data on funding commitments was compiled by the MoHSS from the matrix of the Partnership Forum, and PEPFAR and Global Fund financial managers, as well as estimates from NABCOA for the private sector and NANASO3 for the civil society sector. Funding data was not disaggregated by programme. Unit costs were seldom collected but some were available from the Global Fund programme management unit in the MoHSS. The latest National Health Accounts survey had only 1999/2000 fiscal year data, and a new survey is scheduled for 2007. Household HIV/AIDS expenditure is notoriously hard to capture, but future data collection efforts should not omit this source of HIV/AIDS spending especially spending on care and treatment. Other data: A separate model was designed to estimate the human resource needs. In addition, programme plans and reports provided additional data, as well as group discussions with relevant stakeholders. Annual budgets of programmes that were being rolled out for several years contained relatively good data on unit costs, programme costs, etc. The costing exercises undertaken for OVC and the national HIV/AIDS Monitoring and Evaluation (M&E) plan were informative. These were done in 2003 and 2006 respectively and information was extracted from these exercises. Also, GTZ/NABCOA conducted a cost benefit analysis which was useful for the work place programme management unit costs. Data Verification: Several consultative meetings were conducted in order to get feedback from experts in various fields and to generate consensus building. In addition, informal consultations were done with experts to complement lacking information.
3

NANASO provided estimates based on the 2006 Cadre Exercise. Estimates of national funding of the organizations reviewed was extra-polated nation-wide.

F. F.1.

LIMITATIONS, GENERAL INFORMATION AND SPECIFIC ASSUMPTIONS MTP III Programme Areas

The resource estimation is based on the MTP III intervention and programme categories and 19 programme areas were identified for the Resource Needs Estimation (see Table 1). The time-frame for the estimation is 2007-2012. The following programmes are not included or could not be adequately costed either due to time constraints, data constraints, or both factors: i) - Information, Education and Communication, Behavior Change Communication and Social Mobilization (IEC, BCC & SM) (time constraint limited costing); iii) - Opportunistic Infections (data constraint not included); iv) - HIV related in-patient costs (data constraint not included); v) - Palliative Care (data constraint limited costing); vi) - Male circumcision (data constraint); and vii) - the MTP III component on Enabling Environment (time constraint limited costing, although some elements are integrated into the various programme areas).

Estimation of resources for the IEC, BCC & SM programme areas was limited due to the complexity of this area. Numerous stakeholders are active in this field and a complete costing requires more time in order to identify all activities, and mobilize and obtain the data from all stakeholders. As this is a priority area there is also need for more in-depth costing and analysis. Male circumcision is a newly focused prevention method that is currently receiving considerable attention in view of scientific advances but was not included in this analysis. Some discussion on male circumcision is provided (see Appendix V for more information). The important conclusion to be drawn based on the results of the Resource Needs Estimation is that the low scenario will not be realistic for Namibia because part of the costs are not included. HIV inpatient costs, including opportunistic infections and palliative care accounts for a substantial amount of resources that have not been captured. The February 2007 Catholic AIDS Action inpatient census indicated that 4 43% of the patients admitted to Catholic Health Services hospitals are HIV related. Extrapolating this data nation-wide will bring Namibia to an additional annual cost of N$ 244 million , or in other words 16% of the total average annual RNE cost for the medium case scenario or 13% for the high case scenario. Therefore the medium and high scenarios seem more realistic for Namibia. Table 1. Summary programme areas included in the resource estimation
MTP III Components Enabling Environment Programme Areas Comments This MTP III component was not costed. Some of the activities have been incorporated into the other programme areas below. 1. Counseling and Testing (including routine and voluntary testing) 2. Condom provision 3. Sexually Transmitted Infections (STI) 4. Blood safety 5. Post-Exposure Prophylaxis (PEP) 6. Injection safety 7. IEC, BCC, and Social Mobilisation 8. Work Place Programmes and Mainstreaming

Prevention

Estimation based on 43% of the inpatient cost for mainly internal medicine and pediatric wards following the 2006/07 MoHSS public health expenditure for referral hospitals and regional/district hospitals.

Treatment, Care & Support

9. ART, including TB/HIV and TB IEC,SM,BCC limited costing 10. PMTCT Male circumcision not covered 11. Home Based Care, Palliative care, Psychosocial support 12. PLWHAs 13. Orphans and Vulnerable Children 14. Food security & IGAs 15. Human Resources 16. Infrastructure 17. Management & Coordination of National response 18. Regional support 19. Monitoring and Evaluation Other than tuberculosis, the treatments of opportunistic infections have not been costed due to data limitations, Neither inpatient costs.

Impact Mitigation

Programme Management

The Resource Needs Estimation is based on general and specific assumptions that are important to take into account when interpreting the results of the cost analysis. F.2. General Assumptions

In this section the general approach and assumptions which have been used in the setting up of the Resource Needs Estimation Model, costing tools, as well as the assumptions underlying each scenario are listed. Fiscal year: The fiscal year in Namibia is April 1 March 31. Unless otherwise indicated, the fiscal year 2007, for example, refers to the time period April 1, 2007 to March 31, 2008. Population projections: Projections were taken from the 2005 National Planning Commission population projections that were based on the 2000/01 census. These projections might be adapted when more recent data becomes available, including more accurate vital registration. Perspective of the provider is considered: In any cost analysis the types of costs considered depend on whose perspective is adopted. The purpose of this analysis is to inform resource mobilization and resource allocation decisions. Therefore, the costs to the consumer of services are not explicitly taken into account. However, that does not mean that demand-side costs are not important or that they are not considered in the analysis. For example, one of the primary motivations for government or donor subsidization of costs of ART or condoms or expanding geographic access to various programs is driven by the desire to reduce the costs to the consumer and remove financial barriers that could prevent does not mean that demand-side costs are not important or that they are not considered the analysis. For example, one of by thecommunities. primary motivations for access to or in utilization of goods or services government or donor subsidization of costs of ART or condoms or expanding Constant unit costs assumed over the projection period: There are several reasons why one geographic access to various programs is driven by the desire to reduce the costs to the consumer remove financial barriers that could prevent access to or utilization would expect and unit costs to vary over time. One is the economic reasons (variation in exchange rate, of goods or services by communities. inflation rate and interest rates). The price fluctuations associated with drugs are very hard to predict x Constant unit costs assumed over the projection period. There are several why one expect unit costs to vary over is the economic andreasons therefore thewould RNE model was designed in time. suchOne a way that updated prices can be inserted easily. reasons (variation in exchange rate, inflation rate and interest rates). The price One might also expect unit costs to vary as programs are scaled up as a result of economies of scale. fluctuations associated with drugs are very hard to predict and therefore the RNE model was designed in such way that updated prices can inserted easily. Unit costs are defined as aaverage total costs (as be opposed to marginal costs).
One might also expect unit costs to vary as programs are scaled up as a result of economies of scale. Unit costs are defined as average total costs (as opposed to marginal costs). Figure 3: basic costing principles Figure 3 shows that initially average Figure 3: Basic costing principles costs may be high (p1) as the P Figure shows that initially average costs output is small (q1), 3 and average cost then reaches a minimum (p2 at p1 may be high (p1) as the output is small (q1), q2) and beyond that may increase andincreases averagebeyond cost then reaches a minimum (p2 as the program the optimal output (p3 at q3). As in at q2) and beyond that may increase as the most costing for strategic country plans, the program cost data increases for each beyond the optimal output p3 program does not exist to support (p3 q3). As ininmost costing for strategic p2 variation in cost byat level of output Namibia. country plans, the cost data for each program x Scaling-up: Some costs does with not scaling-up exist to support variation in cost by associated q1 q2 q3 are explicitly taken level of outputinto in Namibia. Q account when new programs are introduced. E.G. coordination and management at the national and regional level, and training of doctors and nurses to supervise and manage ART. Therefore a variation was used in the management cost percentage to cater for initial investment. x Exchange rate: The projections are generally made for the period 2007-2012. A

 Scaling-up: Some costs associated with scaling-up are explicitly taken into account when new programs are introduced. E.G. coordination and management at the national and regional level, and training of doctors and nurses to supervise and manage ART. Therefore a variation was used in the management cost percentage to cater for initial investment. Exchange rate: The projections are generally made for the period 2007-2012. A constant exchange rate is assumed over the projection period. The exchange rate used is the Interbank Exchange Rate on 1 January, 2007, namely US$1 = Namibian $7.12550 (www.oanda.com). In order to keep the model and scenarios relatively simple, exchange rate fluctuations were not taken into account. Inflation rate and Discount rate: At this stage, neither the resources required nor the resources available have been inflation adjusted or discounted. These adjustments are not always easy to interpret to non-economists, and this report includes mostly unadjusted financial results, though summary tables reflecting the adjustments have been included. Consistent programme categories: The costing for each intervention contains the following programme categories: specific programme activities, training, IEC, management and M&E. Programme management and monitoring and evaluation costs were estimated as a percentage of the activity cost. This percentage and outcomes were checked against the current overall budgets and expenditure at the national and in some cases at the regional level. Note that the costs do not include management cost of, for example, the health service delivery level. The resource estimation for the high and low case scenario resulted in respectively three percent and four percent for monitoring and evaluation which includes the national HIV/AIDS monitoring and evaluation as well as specific programme monitoring and evaluation. The overall management cost for national and regional came to nine percent and ten percent of total costs for the high and low case scenario respectively (see Appendix I, Comparison by Cost Area). The resource estimation takes into account the leveling off of these programme management costs because during initiation of the programme the costs are relatively higher compared to five years later as there are less investment costs in infrastructure and staffing. In the absence of specific data for some programmes, percentages or flat rates were used for training and IEC. Figure 4:Total Resource Needs by Cost Area for all Scenarios

Total Resource Needs by Cost Area for all Scenarios (annual average, 2007-2012, current N$ and US$)
N$2,000

N$1,800

US$250 HR (incl training)

N$1,600 US$200 M&E US$150 N$1,000 N$ (millions) N$800 US$100 N$600 US$ (millions) Management

N$1,400

N$1,200

N$400

US$50 Activities

N$200

N$0 High Medium Low

US$0

10

 Human Resources: Human resources are included as a separate category. For calculating human resource cost, full salaries (including benefits, pension etc.) were used and the number of necessary staff was calculated based on ratios of patient visits. Formal degree or curriculum training costs were also included as part of the human resource costs. On salary costs, although it was predicted that there would be a salary increase during the subsequent years, it was not taken into account. Therefore the updating of the costing every two years would ensure that the most current data was used. Training cost: Due to the specific post-apartheid context in Namibia, training costs are relatively high for 2005-08. Currently, there is substantial donor support going into training. It is assumed that this will decrease over time and extra-curriculum training should in future be concentrated on new staff recruitment. The human resource sheets in the RNE model contain the estimations for curriculum training. As Namibia is limited in training institutes, medical personnel including doctors, pharmacists, nutritionists, psychologists, etc, need to be trained outside the country. The costs were estimated based on full scholarships. F.3. Specific Assumptions The section below describes the specific assumptions underlying the programme and scenario costing. Counseling and Testing The costing was based on the UNAIDS Reference Group on AIDS Economics recommendation that the number of people in need of counseling and testing be estimated at two times the population HIV prevalence rate. In 2007 the target population is estimated to be 424,444 people while for 2012 it is 455,723 people based on the 2004 prevalence rate. The coverage in 2005/06 was 25% of the target population. The target setting for the future is based on the scaling-up of rapid testing - and the decrease of ELISA testing, recruitment and training of community volunteers to conduct the testing and the roll-out of public sector counseling and testing sites to 319 from the 250 in 2006. In addition to the public provisions, the Social Marketing Association (SMA) is operating 17 New Start centers and this number is expected to remain stable. The majority of counseling and testing is done by the public sector (about 85%). The unit costs used are the cost per person counseled for the New Start Centers as well as number of public counseling and testing sites. Detailed unit costs were obtained for the various trainings conducted by the public sector and SMA, costs of ELISA and rapid tests, and monthly remuneration to community counselors. The resource estimation was done for the following: counseling, tests, training, IEC, monitoring and evaluation (five percent of program costs), and programme management (10% of programme costs).

High scenario

The coverage rate for 2012 is set at 95% of the number of people needing tests (estimated according to the UNAIDS approach).The pace of increase between 2007 and 2012 projected a nearly logarithmic path rising fast initially and then slowing in the latter years. The coverage rate for 2012 is set at 95% of the number of people needing tests, (estimated according to the UNAIDS approach). The average annual rate of increase was assumed to be constant between 2007 and 2012, yielding a linear path. The coverage rate is set at 80% of those needing testing (estimated according to the UNAIDS approach). The pace of increase between 2007 and 2012 was assumed to be constant.

Medium scenario

Low scenario

11

Treatment of Sexually Transmitted Infections (STIs) The main objective of the STI programme is to train and supervise correct case management following the syndromic approach. The target populations are males (474,446) and females (492,461) in the reproductive age group (2007), multiplied by the STI incidence rate which provides the expected number of STIs per year. Unit costs were estimated to be N$40 per STI episode which includes drugs (about N$10), laboratory costs, partner notification, etc. The resource estimation was done for the following: diagnosis and treatment costs, training, IEC, monitoring and evaluation (five percent of program costs) and programme management (20% of program costs).
High scenario The main basis for the scenario modeling is the assumptions pertaining to reduction in STIs treated between 2007 and 2012 for the public sector. In the high scenario analysis the costs were estimated on the basis of the STI incidence being reduced from 10% to five percent. Based on an STI incidence reduction from 10% to 6.5%. Based on an STI incidence reduction from 10% to 7.8%.

Medium scenario Low scenario

Workplace Programmes and Mainstreaming The resource estimation for the public sector workplace programmes and mainstreaming was based on data from the Office of the Prime Minister (OPM). The data for the private sector workplace programmes (WPPs) came from NABCOA. The estimations for mainstreaming (MS) were based on the 28 OMAs. Unit costs were developed for small, medium and large size workplace programmes and mainstreaming programmes taking into account minimum staffing and activity funding requirements. National management costs include training, monitoring and evaluation, and impact and WPP surveys, etc. The main WPP target populations are the workers in both public and private sectors. The public sector has 99,166 employees or 79,927 (excluding parastatals) in 28 Organizations, Ministries, and Agencies (OMAs). In 2006/07, OPM estimated that 28,470 employees were reached by WPPs. The number of private sector employees is not precisely known. It is estimated that 130,000 employees are formally employed in the sector. There are 24,073 employers of which 10,000 are registered with the MTI. NABCOA estimated that about 55% of those employers have more than 20 employees of which 4,500 have between 20-50 employees and 1000 more than 50 employees. This seems to be the target group which is considerable in size in the private sector for work place programmes based on cost and benefits. In 2006/07 fiscal year, NABCOA estimated that 25,666 employees were reached. Target setting for future years was developed based on the roll-out of WPPs and information provided by key experts. An alternate unit price calculation was done for workplace programmes (N$720 per person per year), but both unit price calculations ended up with similar total cost. The bulk of the cost for WPPs, however, is generated by the investment of both public (PSEMAS) and private health insurance. Estimations of NABCOA and OPM are that about 6.5% of the investment is related to HIV, which is accounts roughly for N$ 41.6 million and N$ 32.5 million respectively. As part of the cost is included under the ART drugs and laboratory costing for human resources in the public sector, it was advised to include two percent for PSEMAS and four percent for private health insurance (due to higher consultation fees) under this costing sheet, and a five percent growth of these investments was included over the years.

12

The loss is in pension funds, and salary increases are not yet incorporated. As these programmes are in the initial roll out phase, the next costing might be able to provide more accurate information if data becomes available.
High scenario The high scenario follows the low scenario calculation but included increased investment in the health insurance for public (4%), and private (6%) (Cost for public sector Medical Aid (PSEMAS) as well as investment in private health insurance, and insurance for those that cannot afford). The scenario is based on the alternate calculation for WPP (N$720/pp). However, the number of employees in the private sector is a rough estimate, which could be slightly misleading. This scenario is calculated based on a fixed budget amount for WPP and MS for small, medium and large OMAs and private companies. It also includes investment cost in public health insurance (2%) and private health insurance (4%).

Medium scenario Low scenario

Information, Education and Communication; Behaviour Change Communication; Social Mobilisation; and Youth Skills The target population for mass media and targeted campaigns is the reproductive age population, which is roughly over one million. Then there are different target groups such as vulnerable populations like the youth, sex workers (600-7000 (2007-2012)), truck drivers (600 -100,000), prisoners and detainees (1855-3711) etc. The unit costs were obtained for mass media campaigns, targeted campaigns, social mobilisation cost per site, and My Future My Choice and Windows of Hope programmes for primary and secondary schools. Unit costs for My Future My Choice and Windows of Hope programmes were derived from the 2006/07 Ministry of Education budget for life skills programmes (N$23/pupil). The costing for out-of-school youth was based on rough estimates and the unit cost of N$30/person as the group is harder to reach. Due to lack of data on outreach to specific target groups, a flat rate was introduced by the experts in order not to lose important cost estimations. As stated earlier in the report, this latter area will need additional attention for more in-depth costing as the overall cost seems underestimated. The management cost for youth skills was estimated to be 10% of the total programme cost and the monitoring and evaluation component 5% of the programme cost. The management cost for IEC, BCC, and SM is higher due to the fact that there are many civil society actors implementing activities and therefore the percentage was estimated to be 35%. The M&E component was kept at 5% and the training component was estimated to be 20%.
Mass media campaigns High scenario 1/yr (cost of campaign one million N$ higher) Reaching 47%-80% primary and secondary schools and out of school youth from 50,000 200,000 Medium scenario 1/yr Reaching 43%-60% primary and secondary schools and no out of school youth Low scenario 1/yr Reaching 40%-40% primary and secondary schools and no out of school youth One in 2007 increasing to 5 in 2012 28 10% increasing to 40% in 2012 One in 2007 increasing to 8 in 2012 41 10% increasing to 60% in 2012 Targeted campaigns 6-8/yr Number of sites for social mobilization 55 % of risk groups reached with targeted campaigns 10% increasing to 80% in 2012

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Blood Safety The various blood products met 80% of the target population needs in 2005. Target setting from 24,156 units (93%) towards 25,881 (100%), therefore, can be gradually done over the years. The unit cost or service fee available at the blood transfusion services are two fold: a) Subsidized service fee and b) An unsubsidized one. The resource estimation used the unsubsidized one to adequately reflect the full cost to the consumer.
High scenario Medium scenario Low scenario The same assumptions were used for all scenarios.

Safe Medical Injection The target populations in this case are public hospitals, health centers and clinics (311 facilities). The coverage and target setting are based on the health facilities served (287-311). The resource estimation focused further on the number of safety boxes and protective equipment per health facility based on data from the URC.
High scenario Medium scenario Low scenario The same assumptions were used for all scenarios.

Post-Exposure Prophylaxis (PEP) The estimation of the need was based on the total population size in Namibia and the number of PEP kits per million populations of 500. It was assumed that in 2007, 70% of the needed PEP kits would be provided, and by 2012, 100% of the needed kits would be provided. The cost estimates included the cost per PEP kit (N$1,311) and the cost of training. The training needs were estimated at 80 people trained annually in a three-day training. The resource estimation was done for the following: PEP kits costs, training, IEC, monitoring and evaluation (five percent of program costs), and programme management (50% of program costs, which includes part of the cost for the Women and Child Protection Units (WCPUs)).
High scenario Medium scenario Low scenario The same assumptions were used for all scenarios.

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Condom Promotion and Provision The target population is the reproductive population. According to the 2000 DHS, consistent condom use in marital sex or steady relationships is 17.9%. It is assumed that this percentage will double by 2012. According to the DHS, condom use in casual sex is 67% and it was assumed that this figure would also increase to 80% by 2012. Based on data from NASOMA, SMA, and MoHSS, there were 23,9 million condoms distributed and these are to be increased to 39.5 million. It is estimated that there is 10% condom wastage during storage and distribution. Cost estimation took into account variation in unit costs of male and female condoms distributed through public distribution and social marketing. Allowance was also made for costs of condom transportation, storage and logistics. The resource estimation was done for the following: male and female condoms distributed publicly and through social marketing, training (three percent of program costs), IEC (three percent of program costs), monitoring and evaluation (five percent of program costs) and programme management (30% of program costs).The programme cost includes the cost of the main civil society and private sector entities involved in the implementation of this programme area.
High scenario Medium scenario Low scenario The same assumptions were used for all scenarios.

Prevention of Mother-to-child Transmission (PMTCT) The target population is pregnant women following the crude birth rate calculations (DHS 2006, preliminary data). The number of pregnant women is estimated to be 60,574 in 2007 and 64,111 in 2012. The antenatal care service attendance is estimated to be 90% in 2007 going up to 95% in 2012.The PMTCT coverage for the pregnant women attending Ante Natal Clinics and receiving group/individual counseling is 87% in 2007 and goes up to 95% in 2012. In 2006/07 fiscal year, the women knowing their status were almost 50% and scenario target setting was done to increase the coverage of women for PMTCT prophylaxis. Unit costs were calculated for cost PCR, couple counseling, training, TBA kits, and different scenarios on prophylaxis (note scenario 1&2 [2007-2012] are women on HAART or that have met the criteria to be put on HAART according to the PMTCT guidelines incorporated in the ART costing) The resource estimation takes into account both the PMTCT current guidelines, as well as the proposed guidelines that are not yet endorsed.
High scenario The coverage rate for PMTCT prophylaxis for 2012 is set at 85% for HIV+ pregnant women accessing ANC services and receiving PMTCT (corresponding to universal access targets). The average annual rate of increase was assumed to be constant between 2007 and 2012, yielding a linear path. The coverage rate for PMTCT prophylaxis for 2012 is set at 75% for HIV+ pregnant women accessing ANC services. The average annual rate of increase was assumed to be constant between 2007 and 2012, yielding a linear path. The coverage rate for PMTCT prophylaxis for 2012 is set at 65% for HIV+ pregnant women accessing ANC services. The average annual rate of increase was assumed to be constant between 2007 and 2012, yielding a linear path.

Medium scenario

Low scenario

15

Anti-Retroviral Therapy (ART) & TB The target populations are diverse for the ART costing and were derived from the Spectrum model. The estimate for the HIV+ population is 207,216 people for 2007 going up to 257,754 people in 2012. The estimated number of people eligible for ART in 2007 is 65,941 going up to 117,611 people (cumulative) in 2012. The percentage of adults on ART is estimated to be 87%, (64% female) and for children 0 -13 years old is 14%, 0-3 are19%, and 4 -13 are 81%. There is no breakdown for pregnant women yet. About 93% of the adult population is on first line treatment. The costing includes ARV medicine, laboratory tests, IEC, training (10% in 2007- 5% in 2012), monitoring and evaluation (three percent), and programme management (15% in 2007 10% in 2012). It also includes the patients eligible for HIV/TB, IPT and CPT medicine (IPT covers 20% - 60% 2007 HIV+ population and CPT 25% of the TB patients). Unit costs were done for various treatment regimes and related laboratory tests following both the current and new guidelines and based on the number of people who could be on treatment. The TB programme cost was estimated based on the cost per patient treated (N$855) and based on a TB prevalence of 765/100,000 population.
High scenario The coverage is set at 35,422 people in 2006 (63%) and up to 93,158 in 2012 (79%), and defined as the percentage of women, men and children with advanced HIV infection receiving ARV treatment (corresponds to universal access targets). The coverage is set at 35,422 people in 2006 (63%) up to 86,818 in 2012 (74%), and defined as the percentage of women, men and children with advanced HIV infection receiving ARV treatment The coverage is set at 35,422 people in 2006 (63%) up to 83,376 in 2012 (71%), and defined as the percentage of women, men and children with advanced HIV infection receiving ARV treatment

Medium scenario Low scenario

Home-Based Care (HBC), Palliative Care and Psychosocial support The target population is calculated differently under the various scenarios (See scenario description below). HBC workers generally have three clients and provide 12 hours volunteer work per week. The turn-over of HBC workers is 15% which suggests an increased need for training and/or incentives. Training of a HBC worker varies and the average of three-week training time was taken. Cost of HBC provider incentive payments was based on average monthly reimbursement of cost and coordination fees which amounts to N$250/month for the low scenario. However, the main HBC providers experience retention problems and wish to provide in addition to the reimbursement of cost and coordination fees, a monetary remuneration of N$500 or even N$750 per month. The resource estimation included the following costs: HBC provider incentive payments, HBC provider remuneration package (which includes 2 T-shirts, 2 caps, uniform, toiletry pack, bib, name tags and bicycles), cost of HBC kits and replenishment, training, cost of psychosocial counseling by lay counselors and social workers, programme management, and monitoring and evaluation costs. Management cost covers MoHSS/PHC, Social Welfare & DSP/Palliative Care and seven main HBC providers (NGOs). For the psychosocial support and palliative care programmes only staff cost and training costs respectively were included as activities.

16

High scenario

It is assumed that the number of people needing home-based care is 43,028 in 2007 up to 47,274 people in 2012. This is based on a rough estimate, respectively 55% and 40% of the PLWHAs starting treatment and those in their last year of life. The number of HBC providers is expected to be 1.5 times as high as in 2005. Incentive payments were calculated at N$9,000 per year per person (N$750 per month). It is assumed that the number of people needing home-based care is 58,675 in 2007 up to 59,092 people in 2012. This is based on a rough estimate of respectively 75% and 50% of the PLWHAs starting treatment and those in their last year of life. The number of HBC providers is expected to be double the 2005 figure. Incentive payments were calculated at N$6,000 per year per person (N$500 per month). A different approach is used to estimate the number of people needing home-based palliative care. It is assumed that the number of people needing HBC is a combination of the following: (1) the number of people on ART and are in their last year of life; (2) the number of PLWHAs who are eligible for ART, but not starting on ART; and (3) the number of PLWHAs not eligible for ART. It is assumed that the number of people needing home-based care is 22,314 in 2007 up to 20,827 people in 2012. The number of HBC providers as per 2005 is expected to be sufficient. Incentive payments are calculated at N$3,000 per year per person (N$250 per month).

Medium scenario

Low scenario

Orphans and Vulnerable Children Target populations were taken from the updated Spectrum model and divided into primary and secondary school age. The target population in 2007 is 125,000 and this number remains stable until 2012 if Namibia reaches an 80% ART programme coverage5. The coverage of the target population was based on the number of OVC accessing some kind of grant which was almost 46% in 2006 (maintenance grants, foster care grants, children home subsidies and place of safety allowances). The costing further includes school books and uniforms, the school development fund, community development (Income Generating Activities (IGAs), multi-purpose center support, etc.)), training, monitoring and evaluation and management costs. Unit costs were based on grant amount per year per child, school development fund fee per learner, school uniform and books, support for multi-purpose centers, community development and support to CBOs. The number of OVC of primary and secondary school going age is estimated to be 66,560 and 43,520 respectively in 2007 and 70,720 and 46,240 respectively in 2012.

% of OVC accessing grants

Maintenance grant

Foster care grant

Child home Place of subsidies Safety allowance

% of OVC benefiting from Education Development Fund Secondary school Primary school 80% 60% 40%

Management cost

M&E cost

High scenario Medium scenario Low scenario

76% 60% 40%

61% 47% 31%

14% 11% 8%

3% 2% 1%

0.1% 0.1% 0.1%

80% 60% 40%

15% 15% 10%

5% 5% 5%

The MoHSS Spectrum model of 2007 estimates the number of OVCs based on an 80% ART programme coverage in 2009. The number of OVC is expected to stabilize. However, if the ART programme coverage is less the number of OVCs will increase.

17

Food Assistance and Nutrition There are different target populations such as PLWHAs, lactating HIV+ women, OVCs and primary school children that are eligible for food support. Food security is an under-funded area and comprehensive programmes have not been established yet. Currently, there is an OVC food support project covering some regions, a school feeding programme, a Food for Work programme, and a horticulture project. Part of the costing includes income generating activities (IGAs) to reduce dependency on food assistance. Unit cost data was derived from the mentioned projects and extra-polated to cover the nation. The working group composed of MoHSS/PHC, I-Tech, NANASO (nutrition), MRLGHRD (Food for Work), MoE (school feeding), MAWF/FAO (Horticulture project), MGECW/WFP (food support to 20% OVCs in need), and MGECW (IGAs) came up with a comprehensive plan which has been used for the estimations. The scenarios below include food gardens scaling up from 400 - 828 and small gardens 6,883 -14,107, and 230 IGAs per year.
# of PLWHAs eligible for food support # of OVC on food support # of primary school children benefiting from School Feeding Program 125,190-180,206 113,938-109,216 112,953-109,216 # of eligible Infants/ mothers to be reached by targeted food assistance 4,517-8,918 4,517-8,918 3,613-7,134

High scenario Medium scenario Low scenario

8,945-27,182 8,071-16,474 8,071-16,474

25,468-43,353 22,979-26,275 11,490-13,137

PLWHA Support Unit costs were derived from disability grants for six months for PLHWAs (N$2,220), the buddy system and the management and coordination costs of PLWHA networks such as Lironga Eparu.
# of PLWHAs to be covered by disability grants/yr High scenario Medium scenario Low scenario 2,357 to 17,115 2,357 to 12,836 2,357 to 8,557

18

Human Resources (HR) The HR costing was done for the health sector taking into account the number of medical doctors, nurses, pharmacists and pharmacist assistants, and laboratory technicians and laboratory assistants needed for outpatient ART/PMTCT/C&T. The calculation is based on professional/patient ratio and the number of visits by patients per year for ART, PMTCT and/or C&T. The MoHSS model developed to calculate this also included HIV/TB. Unit costs were full salaries, including benefits. In addition, as there is a shortage of medical personnel, the professional training for the above professions was taken into account based on full scholarships. The HR costing also includes social workers, record clerks and volunteers for the OVC programme; psychologists and social workers for psychosocial support; and nutritionists for the food assistance and nutrition programmes.
High scenario Medium scenario Low scenario The same assumptions were used for all scenarios.

Infrastructure Target setting was based on the number of health facilities in the public sector only. Unit costs for major and minor renovations were derived from US grain fund experiences on renovating hospitals and health centers/clinics. Experts provided information on the number of minor or major renovations/adaptations for both ART/ PMTCT/C&T as well as TB/HIV in the current 34 hospitals and the 77 clinics/health centers for ART rollout. The renovation/adaptations for ART/PMTCT/C&T targets are from 10 to 25 hospitals (2007-2012); one to 51 health centers and clinics; and for TB/HIV adaptations 0 to 30 hospitals and one to 51 health centers and clinics in 2007 and 2012 respectively.
High scenario Medium scenario Low scenario The same assumptions were used for all scenarios.

Regional Support Targets are the RACOCs and CACOC management structures. Coverage is based on whether the RACOC and CACOC structures have a plan and budget, which was high in 2006 for RACOCs but much less for CACOCs. Target setting was done on three scenarios by experts from MRLGHRD on the number of members to be trained, staff costs and management costs (including monitoring and evaluation. For RACOCs it also included activity funding/budget support. Unit costs were developed for training, management and coordinated staff and activity costs. Management and M&E costs of MRLGHRD and AMICAALL were incorporated as well.

19

High scenario

Training would target 210 (2007) to 170 (2012), RACOC members and 540 (2007) to 430 (2012), CACOC members; budget support for RACOCs ranges from N$2.7 to N$3.9 million (2007/2012). Staff costs ranged from N$912,000 to N$2.6 million for RACOCs and N$0-2 million for CACOCs; management costs were from N$684,000 to N$2 million for RACOCs and N$0-609,000 for CACOCs. The cost for national management was N$284,000 to N$862,000 (2007/2012). Training would target 100 -210 RACOC members and 350-380 CACOC members in 2007 and 2012; budget support for RACOCs from N$2 million to N$2,7 million, staff costs from N$912,000 to N$2,6 million for RACOCs and N$0 402,000 for CACOCs; and management costs from N$684,000 to N$2 million for RACOCs and N$0-121,000 for CACOCs; The cost for national management was N$284,000 to N$562,000. Training would target 100 210 RACOC members and 380-350 CACOC members respectively in 2007 and 2012; budget support for RACOCs ranged from N$2.7 to N$2.7 million, staff costs from N$912,000 to N$912,000 for RACOCs and no funding for CACOCs; and management costs from N$684,000 for RACOCs and no funding for CACOCs; There was no funding for national management as is the current situation.

Medium scenario

Low scenario

Management and Monitoring and Evaluation (M&E) Coordination and Monitoring and Evaluation costs were based on 2006/07 budgets that were incorporated for DSP/MoHSS and NANASO. Note that coordination and management costs for other main players were incorporated under various programmes (e.g. OPM, NPC and NABCOA under WPP & MS and Lironga Eparu under PLWHAs, MGECW under OVC, etc.) All programmes incorporate costing for programme monitoring and under this heading national Monitoring and Evaluation costs were derived from the recent costing exercise by MoHSS/DSP/ Monitoring and Evaluation The national HIV/AIDS Monitoring and Evaluation programme has major systems investment costs in the first two years. Further, the enabling environment component of the MTP III has not been properly costed and therefore the overall management cost is assumed to be higher.
High scenario Medium scenario Low scenario The same assumptions were used for all scenarios.

G. KEY RESULTS OF THE RESOURCE NEEDS ESTIMATION AND SCENARIO MODELING

The required resources were estimated for each scenario based on the described methodology, data inputs and scenario descriptions. Figure 5 shows the Resource Needs Estimation for the high, medium and low scenarios. Following the fact that not all programme areas could be costed and due to the relatively high estimated HIV related in-patient cost (see Section F1), the low case scenario is not realistic for Namibia. The total annual resources required for the high scenario are N$1,445 million (US$203 million) in 2007 to N$2,418 million (US$340 million) in 2012 (Figure 3, Appendix I). The resources required for the medium and low scenarios in 2012 are N$1,878 million (US$264 million) and N$1,514 million (US$213 million).

20

Figure 5: Resource Requirement for the High, Medium and Low Scenarios
Total Resources Required by Scenario (2007-2012, current N$ and US$)
N$ 2,500 US$350

US$300 N$ 2,000 US$250

N$ 1,500 US$200 High scenario Medium scenario N$ (million) N$ 1,000 US$150 US$ (million) Low scenario US$100 N$ 500 US$50

N$ 0 2007 2008 2009 2010 2011 2012

US$0

Figure 6 shows the breakdown by intervention and average annual cost on each programme area over the period of projection (2007-2012) for the three scenarios (see also Appendix I). The programme areas that account for the largest share of the total resource needs are: ART, OVC support, workplace and mainstreaming interventions, food assistance, home based care, palliative care and psycho-social support, and human resources recruitment and development. The shares vary slightly by scenario. The exact percentages are provided in the table below. Figure 6:Total Resource Needs by Programme Area for all Scenarios
Total Resource Needs by Programme Area for all Scenarios (average annnual, 2007-2012, current N$ and US$)
N$2,000 Management/Coord., M&E US$250 Regional support Infrastructure N$1,600 US$200 HR PLHA support N$1,400 Food assistance & Nutrition OVC N$1,200 US$150 N$1,000 N$ (millions) N$800 US$100 N$600 TB HBC, Palliative Care, Psychosocial support Workplace & Mainstreaming
US$ (millions)

N$1,800

IEC, BCC,SM & youth skills Safe medical injection PEP Blood safety

N$400

US$50

STI Condoms C&T

N$200

N$0 High Medium Low

US$0

ART (incl TB/HIV - IPT/CPT) PMTCT

21

Figure 7:Total Resource Needs by MTP III Component for all Scenarios
Total Resource Needs by MTP III Component for all Scenarios (average annual, 2007-2012, current N$ and US$)
N$2,000

N$1,800

US$250 Policy, Mgt, Coordination, M&E US$200 Infrastructure

N$1,600

N$1,400

N$1,200 US$150 N$1,000 N$ (millions) N$800 US$100 N$600

US$ (millions)

HR

Treatment

Mitigation

Prevention

N$400

US$50

N$200

N$0 High Medium Low

US$0

In the high scenario the share of the mitigation component of MTP III was the highest (33%), followed by treatment, care and support (32%), and prevention (24%) - (Appendix 1, Scenario Comparisons). Only six percent was required for human resources. In the medium scenario, prevention and treatment account for the largest shares 26% and 37% respectively. The share allocated for mitigation under this scenario is almost one quarter, i.e. 24%. Table 2. Share of MTP III Component for High, Medium and Low Scenarios.
High Scenario Prevention Impact Mitigation Treatment HR Infrastructure Policy, Mgt, Coordination, Monitoring and Evaluation TOTAL 24% 33% 32% 6% 2% 3% 100% Medium Scenario 26% 24% 37% 8% 2% 4% 100% Low Scenario 29% 23% 33% 9% 2% 4% 100%

How do these resource needs estimates compare with existing levels of expenditure in Namibia? Table 2 shows the resource needs estimates in relation to total GDP and government expenditure. The estimated resources required account for between four percent (medium scenario) and five percent (high scenario) of GDP (2005), and between 12% (medium scenario) and 15% (high scenario), of the total government expenditure. The per capita average annual resource needs are N$918 (129 US$) for the high, N$744 (104US$) for the medium, and N$625 (88 US$) for the low scenarios. The per capita average annual resources needs for the health sector programmes varies from N$337 (low), N$406 (medium), to N$423 (high). The per capita average annual resource needs as a percentage of the Total Health Expenditure (THE) (source: NHA 1999/2000) ranges from 39% (low), 47% (medium) and 49% (high) but is expected to be lower as the Total Health Expenditure is assumed to have increased over the years. Unfortunately at the time of the RNE, more recent NHA data was not available. However, compared to the MoHSS public health expenditure for 2005/06, the per capita share of the health sector RNE varies from 55%, 66% to 68% respectively for the low, medium and high scenarios (Appendix I), which is a considerable burden for the overall health budget portfolio.

22

However, we need to be careful with the interpretation as cost are included for civil society (e.g. in HBC provision) and private sector (condom production) as well. Nevertheless, the civil society sector is currently financed mainly by the donor community and public sector provisions need to be made to take over some of these cost (outsourcing). During the RNE it was noted that most health sector programmes are heavily dependent on external funding. From the sustainability point of view, it would be useful to allocate more national resources towards these programmes. In conclusion, the total cost for the national HIV/AIDS response is substantial but necessary to reduce the impact of HIV/AIDS on the overall development. When comparing the total annual average RNE for the MoHSS health sector programmes with the total RNE for the non-MoHSS programme areas, the medium scenario attributes 56% of the cost to the health programmes and 44% for non-health. The high scenario attributes 48% and 52% for health and non-health respectively. The costly programmes for the health sector are ART, HBC, and Human Resources, and for the non-health sector OVC, Work Place Programmes, Mainstreaming, and Food Assistance.

Table 3. Comparison of Resource Needs Estimates with selected economic indicators (in millions)6
High scenario Average Annual Resource Needs Estimate (2007-2012, million) GDP (2005, million) Average Annual Resource Needs Estimate as % of GDP Government Expenditure (2005, million) Average Annual Resource Needs Estimate as percentage of Government Expenditure 15% 5% N$12,700 US$1,783 12% 10% N$1,920 US$270 N$38,744 US$5,439 4% 3% Medium scenario N$1,554 US$218 Low scenario N$1,306 US$183

These comparisons are incomplete but are purely to benchmark the estimated resources required and to get a sense of the order of magnitude of the resource needs. For example, not all RNE will be financed from government expenditure. However, this is an important benchmark to consider when considering sustainability.

23

Table 4. Comparison of per capita Resource Needs Estimates with Health Expenditure (in millions)
High scenario Per capita Average Annual Resource Needs Estimate (2007-2012) N$918 US$129 N$423 Medium scenario N$744 US$104 N$406 Low scenario N$625 US$88 N$337

Per capita Average Annual Resource Needs Estimate for Health Sector (2007-2012)

US$59 Per capita Total Health Expenditure (THE)(1999/00) N$858 US$141 Per capita Average Annual Resource Needs Estimate for Health Sector (2007-2012) as a % of THE 49%

US$57

US$47

47%

39%

H. RESOURCE GAP ANALYISIS Given the existing resource availability based on pledges and commitments from various funding partners, external and domestic, the resource gap was assessed. The estimates based on pledges and commitments are cited in Table 4. According to the data collected for 2005, 63% of the resources come from external or donor sources. The resource gap for Namibia at the time that the RNE was conducted was based on funding pledges and commitments. There was no compiled data on funding disbursements in-country, which is more accurate to estimate the resource gap. At the end of 2007, more accurate data will be available through the MoHSS/ DSP funding database, and therefore the resource gap may increase in the future. It is also important to realize that funding commitments beyond two years are hardly available, and therefore one needs to be careful with funding projections over two years. For 2010 - 2012 the gap is high as there are no funding commitments yet. In monetary terms, the cumulative resource gaps over period 2007-2009 for the high and medium scenarios are: N$485 million (US$82 million) and N$228 million (US$54 million). Table 5. Committed resources for HIV/AIDS (2005)
N$ millions 2005 Government External Total N$249 N$426 N$675 US$35 US$60 US$97 US$ millions

Figure 8 shows the projected resource gap through 2012 taking into account the estimated resource needs for 2007 to 2012. The share of the resource needs estimate for the high scenario that can be funded with the available resources in 2007 is 76%. The medium scenario appears more affordable and 88% of the resource needs seem covered. These percentages decrease to 66% and 80% in 2009. It is important to note that this assumes that the resources provided on paper are available for programmes and that these can be re-allocated where needed. This is however not always the case as funding is programmed and it is administratively cumbersome to reallocate. Currently some of the MTP III areas are grossly underfunded. 24

Figure 8: Resource Gap Analysis for all Scenarios (20072012).

Resource Gap Analysis for all Scenarios (2007-2012, current N$ and US$)
N$2,500 N$2,000 N$1,500 N$1,000 N$500 N$0 2007 N$ (millions) N$500N$1,000N$1,500N$2,000N$2,500US$3512008 2009 2010 2011 2012 US$51US$ (millions) US$349

Resource requirement

US$249

US$149

US$49

US$151-

Resource gap

US$251-

High scenario

Medium scenario

Low scenario

Resources available

The Resource Gap Analysis suggests that even for the medium scenario additional resources need to be mobilized for implementation. As Namibia is categorized as a low middle income country and therefore expected to contribute substantial national funding to HIV/AIDS, it is not always easy to advocate for more external resources. The Namibian Government is struggling with one of the highest income disparities in the world and a large percentage of the population is living below the poverty line. Re-allocation is not always that self-evident. Nevertheless, resources from both donors and the Government of Namibia need to be continually mobilized. The resources needed until 2012 continue to increase in efforts to honor national and international commitments. Further, resources need to become more effectively distributed towards priority areas and to reach the decentralized level (regions and constituencies). Cost-effectiveness arguments are now routinely part of assessments of the merit of HIV interventions. Cost is an important determinant of the cost-effectiveness of an intervention. The cost variation may be for legitimate reasons (e.g. small scale given the population size, or considering geographic catchment areas). Namibia has relatively high factor costs for human resources, equipment and logistics, transport, and physical infrastructure. Yet, there may also be some in-efficiencies that would need detailed investigation and strategic rethinking of programme implementation. For example, mobile testing might be more costeffective for some scarcely populated areas. It is therefore important that the cost per person reached be monitored in order to identify inefficiencies and separate these from legitimate causes of cost variation. If fewer resources become available following the RNE medium scenario, some programmes will remain inadequately resourced and national and international commitments cannot be honored. At the same time, it is useful to look at the various programmes in more detail and see where efficiency gains can be accomplished through more focus on cost effective interventions, etc. Lack of clarity on funding projections below two years is hampering financing strategies for both external and internal donors.

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1. I.1

CONCLUSIONS AND IMPLICATIONS Conclusions

The MTP III has been implemented for almost four years and a mid-term review was done in June/July 2007. A revised resource estimation was needed based on the current achievements, the dynamic nature of the epidemic, and addressing constraints in HIV/AIDS programmes. Therefore the main objective of the resource estimation was to develop a detailed costing of the national HIV/AIDS response following the RNE methodology reflecting the target population of an intervention, the current coverage (2005/06) and targets (2012/13) for Namibia and the calculation of unit costs. Various scenarios (low, medium and high) were costed to assist decision makers in policy making and strategic planning. The process included a wide range of stakeholders. Several meetings with programmes were conducted to collect and verify data, and consensus building through workshops. The overall exercise took six months. Namibia is faced with its own HIV prevalence situation and development context. Namibia remains one of the highest prevalence countries in the world, and the 2006 sentinel surveillance did not indicate any promises regarding a decrease. At the same time is Namibia classified as a low middle-income country with one of the highest income disparities in the world. The increase of national resources towards financing the epidemic should be possible but will consequences for the sectors where resources are reallocated from. The MTP III progress report, covering the 2004 and 2005 fiscal years indicates clearly that the health sector programmes are well under way to reaching their set targets. Therefore the data inputs and target setting was easier as in other HIV/AIDS sector programmes that are lagging behind. The longer programmes are implemented the better the monitoring data could become and the easier the costing. During the costing exercise it also became apparent that these health programme are largely externally funded, creating an issue around sustainability. Further, the challenge of extending their coverage towards districts and constituencies is directly related to tackling the infrastructure and human resource constraints. Other programme areas as, for example, food security and nutrition and health systems infrastructure seem to have insufficient resources and lack institutional capacity at the national and regional level. Namibia is serious is in political commitments to increasing coverage of HIV/AIDS programmes. The government of Namibia has endorsed global and regional commitments for HIV/AIDS implying universal access as in the UNGASS II (2006) political declaration and most recently in the AU summit (2007). These commitments have been instrumental in rolling out the National HIV/AIDS response, developing programme strategies and mobilizing and reallocating internal and external resources. The resource needs estimation incorporated these commitments and the current situations on the ground in the target setting and scenarios. Taking into account the international and national policy commitments and the current national HIV/ AIDS response progress, the resource estimation was done with incorporating scenario setting (low, medium and high). This scenario setting was important to show the resource implications on scaling up programmes to cover a larger target group or increasing investment, as well as rethinking strategically of how to roll out programmes with a focus on sustainability, efficiency and effectiveness. The cost of the MTP III components of treatment, care and support, and mitigation is substantial and there is a need to strategize on financial sustainability. What is needed for implementation planning is a strategic response i.e., one that makes optimal use of available resources. In Namibias case, it was identified that costing three scenarios would be most effective in facilitating the strategic planning process as well as advocacy for resource mobilization over time. Taking into account the limitations in the costing, as not all costs were included, the low scenario seems not to be an option for Namibia. 26

Especially the HIV related inpatient cost that is expected to be a substantial amount in addition to the current cost, which is estimated to be 13% or 16% of the total average annual cost in respectively the high and medium scenario. With the medium case scenario, Namibia tried to be as realistic as possible given the amount of funding and capacity constraints. The high scenario is what comes closest to the Universal Access goals. The final results of the high, medium and low case scenarios are highlighted in the report. The average annual resources required for the medium scenario is 1,6 billion or 1,9 billon N$ for respectively the medium and high scenario. These average annual resources are estimated to be around 4% (medium) and 5% (high) of the GDP (2005), or 12% (medium) and 15% (high) of the 2005 government expenditure. The per capita average annual RNE for health sector programmes as a percentage of the total health expenditure is expected to be around 47% (medium) and 49% (high) or slightly lower as we expect the total health expenditure to have increased since 1999/2000. The RNE report outlines in detail the general and specific underlying assumptions for the individual programmes areas. The programmes needing substantial resources are ART, OVC support, Workplace programmes, HBC, Food support, and Human resources management. When breaking the programmes into the MTP III components, the shares of prevention, care and treatment, and mitigation are relatively balanced, with slightly more cost for the two latter ones. By looking down at the breakdown of the 19 programmes together, the share of monitoring and evaluation comes to 3% (high) and 4%(medium), and of management is around 9% (high/medium). The share of human resources is 11% for the medium and 8% for the high scenario. The resource gap for Namibia at the time that the costing was conducted did not have accurate data on external funding disbursements in-country, this report intends to be modest in drawing conclusions. At the end of 2007, more accurate data will be available in the MoHSS/DSP funding database. Therefore, based on ongoing data collection for 2006/07 on disbursements, the gap analysis and percentages may change in the future. However, it is clear that for both the medium as well as the high scenario additional resources are needed. Thus, this also means if an increase in funding from the GRN or other development partners is not mobilized, the scaling-up of the current programmes will not be possible. In 2005, almost 63% of the HIV/ AIDS response seemed to be funded through external sources and some of the MTP III programme areas are heavily externally funded and some seem grossly under-funded. It seems evident that the Government of Namibia needs to contribute more to the overall response in order to ensure sustainability. Costeffectiveness through monitoring unit cost will enhance programmes rate of efficiency. The fact that the most commitments are made for two years of less, poses challenges for long-term planning. Also the committed resources are often relatively tied and cannot easily made available for programmes areas that are under-funded. This requires to look into more long-term and flexible funding mechanisms. I.2 Implications

The sustainability of the national HIV/AIDS response will depend on different factors: a) resource mobilization and resource allocation; b) increasing programme efficiency and effectiveness through creating economies of scale; c) tackling constraints (e.g. human resources and human capacity development); and d) strengthening implementation capacity. To make the HIV/AIDS response sustainable, it is important to increase and/or maintain investments in prevention. As much emphasis has been put on scaling up treatment services and much success has been achieved, the need to invest in prevention is apparent in the data given. A more detailed costing exercise for this particular area is needed. The implementation of prevention is done by a wide range of stakeholders and the weak national coordination needs to be addressed structurally to reach effectiveness. 27

Focus on investing in national and regional coordination, BCC and high risk behaviors, and secondary prevention. An increased commitment of resources by the GRN is necessary to ensure a sustainable response. Currently the Ministry of Finance makes substantial allocations to the MoHSS (HIV/AIDS Health Sector Programmes and Health Systems), MGECW (OVC grants), MoLSW (disability grants for PLWHAs), but this is by far not enough. At the same time, the development partners will need to strategize co-funding for the current rolled-out programmes and more effective and efficient allocation of those resources. The partners need to follow-up on the Rome Declaration related to aid effectiveness. In collaboration with the Government of Namibia they need to explore improved funding mechanisms for both central and regional levels to facilitate better implementation of service delivery. Funding mechanisms need to become more aligned and easier to administer. Basket funding seems to be a best practice to date, and possibilities around scaling this method up and incorporating a larger proportion of the donors needs to be addressed. Cost-effectiveness arguments need to routinely part of assessments of the merit of HIV interventions. Cost is an important determinant of the cost-effectiveness of an intervention. It lends itself to sustainability and to programme efficiency. The cost variation may be for legitimate reasons (e.g., small scale given the population size, or in large geographic catchment areas). Namibia has a relatively high cost factor in terms of human resources and logistics. But, there may also be some inefficiencies that would need detailed investigations and strategic rethinking of programme implementation. For example will mobile testing be more cost-effective for sparsely populated areas? It is therefore important that the cost per person reached/ unit cost be monitored in order to identify inefficacies and separate these from legitimate causes of cost variation. Increased support for HIV/AIDS programming will depend on whether value for money is demonstrated in the way current resources are utilized and whether accountability is guaranteed. It is thus critical that the current health management information systems and monitoring and evaluation be strengthened, which includes resource tracking. The resource tracking also needs to be closely linked to health indicators. The Ministry of Finance and NPC need to enforce the use of the MTEF coding for more effective tracking of HIV resources. Adequate responses depend on managers and service providers having the necessary information to respond effectively. Capacity-building will remain a high cost until the root determinant of this problem is addressed: the overall human capacity development of Namibians. An investment in basic secondary education as well as bursaries for tertiary education outside of the country needs to be prioritized. Many students migrate soon after graduation abroad or to the private sector, therefore a retention policy needs to be attached to scholarships and bursaries subsidized by both the GRN and development partners. Namibia needs to be less dependent of foreign professionals. The human resource estimates in this Resource Needs Estimation exercise are limited to the salary costs of additional posts that need to be created and the formal training requirements. Extra-curriculum training accounts for more than five percent of total resource needs estimate. Over the period of the projection, there is a slowing down on resources needed for training. However, extra-curriculum training still remains a substantial part of some programmes (more then 10% for IEC, BCC, and Social Mobilisation; Home Based Care, Regional Support and Management and Coordination), often due to high rates of staff turnover. Successful implementation of the response to HIV is about more than just money. Institutional capacity building and investments in national level systems and infrastructure is being done but at regional and district level this is still needed. While this report primarily stresses financial issues, tackling the implementation capacity constraints is crucial for the current programme roll-out as well as sustainability.

28

The overall cost will still increase as some programmes need to be set up and rolled out, e.g. food assistance. Yet this is expected to decrease over time after the initial investment is made. Implementation capacity must therefore grow at the same pace in order to effectively utilize increases in financial resources and ensure coverage of services, at least in the initial years. Due to the sparsely populated nature of Namibia, scaling up effective programmes that reach the entire population is necessary, but will also have significant cost implications. Decentralizing services and increasing management capacity requires investment. Yet the current ongoing decentralization process in Namibia is slow. It is needed to expedite the current decentralization process in order to learn and understand how the GRN can effectively contribute to the HIV/AIDS response in terms of better management capacity, resource mobilization & resource allocation, and monitoring and evaluation in order to bring the services closer to the target groups at less cost. Currently, there are no funding mechanisms (e.g. regional basket or pooled funding) in place to allocate resources closer to service delivery. In terms of cost and tackling constraints, it would seem decentralization may be a worthy investment for the GRN to explore in order to attain the maximum level of programme effectiveness and coverage.

29

Appendix I: Summary RNE Sheets

Table 6: RNE Summary High Scenario

2007 11,519,922 286,453,125 51,370,376 31,188,602 4,546,396 19,324,667 3,341,173 1,192,011 84,657,087 134,143,540 193,426,602 6,322,352 209,149,668 201,562,295 17,643,413 87,340,902 29,375,000 6,178,376 65,864,435 15,657,028 48,540,879 $232,873,462 30,625,000 109,007,766 25,610,914 256,482,826 234,531,014 255,392,146 309,009,642 29,536,723 117,682,478 32,500,000 12,274,898 52,954,966 $254,418,127 6,494,626 6,665,396 193,771,794 189,599,643 154,798,202 187,328,079 86,617,396 88,583,605 91,418,714 223,382,241 183,418,315 6,833,092 280,332,078 362,230,079 33,172,333 128,121,653 32,500,000 13,167,768 47,710,463 1,143,115 1,143,115 1,192,011 3,999,476 4,408,754 4,502,868 20,705,000 20,705,000 20,705,000 4,280,768 3,959,425 3,582,367 3,149,593 20,705,000 4,594,829 1,143,115 93,259,524 262,915,722 205,138,966 6,996,951 305,272,009 420,232,848 40,501,915 125,446,078 30,625,000 13,087,768 43,210,463 $279,981,487 $307,5684,023 38,056,735 41,619,263 48,147,642 51,160,150 59,120,737 65,133,982 70,925,618 71,983,262 356,210,855 379,743,332 428,175,581 476,271,962 13,059,291 13,931,534 14,737,110 15,879,682 17,128,822 524,770,842 73,017,852 53,458,480 2,661,105 20,705,000 4,683,795 1,143,115 95,100,336 304,846,432 220,250,471 7,155,472 330,211,941 481,296,733 55,089,827 135,581,453 30,625,000 17,107,768 43,210,463 $339,479,069 2008 2009 2010 2011 2012 % 0.75% 21.32% 3.41% 2.29% 0.19% 1.07% 0.22% 0.06% 4.69% 11.02% 10.31% 0.35% 14.02% 17.66% 1.75% 6.12% 1.62% 0.67% 2.62% 100.00%

High Scenario (total cost)

PMTCT

ART (incl TB/HIV - IPT/CPT)

C&T

Condoms

STI

Blood safety

PEP

Safe medical injection

IEC, BCC,SM & youth skills

30

Workplace

HBC

TB

OVC

Food assistance

PLWHA support

HR

Infrastructure

Regional support

Management/Coord., Monitoring and Evaluation

TOTAL (N$)

1,444,599,942 1,658,713,421 1,812,171,981 1,994,254,933 2,191,574,838 2,418,044,907

TOTAL (US$)

$202,3813,207

MTP III components 341,283,774 $47,914,204 428,355,376 $60,138,376 486,202,079 $68,259,869 87,340,902 $12,262,141 29,375,000 $4,124,075 72,042,811 $10,114,381 $232,873,462 $254,418,127 $9,013,003 $9,157,884 $8,546,940 $279,981,487 64,197,907 65,229,864 60,878,231 $4,299,567 $4,562,806 $4,562,806 30,625,000 32,500,000 32,500,000 $15,304,040 $16,521,917 $17,987,515 $17,611,880 30,625,000 $4,299,567 56,298,231 $7,903,936 $307,684,023 109,007,766 117,682,478 128,121,653 125,446,078 $78,126,087 $80,868,136 $86,823,457 $96,648,356 556,477,275 576,008,371 618,426,988 688,407,879 $72,531,031 $83,385,421 $94,869,088 $107,006,773 516,624,755 593,938,511 675,734,490 766,006,773 866,598,501 $121,655,256 752,176,786 $105,601,130 135,581,453 $19,034,827 30,625,000 $4,299,567 60,318,231 $8,468,320 100.0% $339,479,069 3.3% 1.6% 6.1% 32.0% $53,599,734 $59,921,963 $67,191,680 $73,677,506 $80,409,970 33.4% 381,780,719 426,812,757 478,593,571 524,790,878 572,744,936 23.7%

2007

2008

2009

2010

2011

2012

Prevention

Mitigation

Treatment

HR

Infrastructure

Policy, Mgt, Coordination, Monitoring and Evaluation

31

TOTAL (N$)

1,444,599,942 1,658,713,421 1,812,171,981 1,994,254,933 2,191,574,838 2,418,044,907

TOTAL (US$)

$202,813,207

Comparison by cost area 1,245,763,788 $174,897,798 174,355,206 $24,478,430 63,599,274 $8,928,958 174,995,154 $24,568,275 72,394,471 $10,163,751 $11,727,393 83,531,992 95,359,000 $13,387,834 $23,586,376 $24,974,564 168,001,272 177,889,077 $9,546,393 $9,400,617 $9,352,476 186,989,392 $26,252,194 106,119,254 $14,898,510 67,997,146 66,958,811 66,615,912 $24,500,511 $26,037,657 $28,267,201 174,512,485 185,461,281 2001,341,904 218,713,496 $30,706,069 70,963,939 $9,962,913 200,295,126 $28,120,240 116,071,419 $16,295,734 $196,784,847 $219,568,648 $243,812,151 $270,689,847 1,401,661,077 1,563,945,764 1,736,627,630 1,928,072,346

2007

2008

2009

2010

2011

2012

% 80%

Activities

1,052,943,766

$147,827,018 157,539,180 $22,117,560 79,265,626 $11,128,421 154,851,370 $21,740,208 57,189,586 $8,029,076

Management

9%

Monitoring and Evaluation

3%

HR (incl training)

8%

HR (excl training)

5%

32 $232,873,462 $254,418,127

TOTAL (N$)

1,444,599,942 1,658,713,421 1,812,171,981 1,994,254,933 2,191,574,838 2,418,044,907 $279,981,487 $307,684,023 $339,479,069

100%

TOTAL (US$)

$202,813,207

Table 7: RNE Summary Medium Scenario

2007 11,344,002 279,061,224 57,053,119 31,188,602 5,127,810 19,324,667 3,341,173 1,192,011 51,038,985 107,137,540 189,880,901 6,322,352 198,627,417 88,688,932 17,643,413 87,340,902 29,375,000 6,098,376 65,864,435 13,596,468 48,540,879 $196,106,519 30,625,000 109,007,766 24,077,516 100,524,300 109,768,477 26,651,611 117,682,478 32,500,000 9,279,777 52,954,966 $209,485,551 211,093,770 223,560,124 6,494,626 6,665,396 195,213,278 194,446,027 126,441,902 157,553,964 192,119,420 162,440,456 6,833,092 236,026,477 118,511,204 28,777,266 128,121,653 32,500,000 9,511,468 47,710,463 $222,258,206 56,124,840 61,216,595 63,114,751 1,143,115 1,143,115 1,192,011 3,999,476 4,408,754 4,502,868 20,705,000 20,705,000 20,705,000 20,705,000 4,594,829 1,143,115 68,081,108 230,089,760 184,615,479 6,996,951 248,492,831 127,706,408 34,447,176 125,446,078 30,625,000 9,196,468 43,210,463 $241,283,521 4,952,883 4,731,527 4,463,741 4,149,526 38,056,735 41,619,263 48,147,642 51,160,150 59,120,737 63,102,106 67,009,564 70,099,774 334,420,654 350,782,500 397,477,917 443,009,510 490,722,623 73,017,852 53,458,480 3,788,881 20,705,000 4,683,795 1,143,115 73,047,464 270,379,173 198,094,875 7,155,472 260,959,185 137,297,252 45,591,068 135,581,453 30,625,000 13,096,468 43,210,463 $263,716,582 12,690,532 13,354,094 13,937,977 14,847,052 15,845,491 2008 2009 2010 2011 2012 % 0.88% 24.69% 4.19% 2.84% 0.29% 1.32% 0.27% 0.07% 4.01% 11.65% 12.09% 0.44% 14.79% 7.34% 1.91% 7.56% 2.00% 0.65% 3.24%

Medium Scenario (total cost)

PMTCT

ART (incl TB/HIV - IPT/CPT)

C&T

Condoms

STI

Blood safety

PEP

Safe medical injection

IEC, BCC,SM & youth skills

Workplace

33

HBC

TB

OVC

Food assistance

PLWHA support

HR

Infrastructure

Regional support

Management/Coord., Monitoring and Evaluation

TOTAL (N$)

1,255,650,861 1,396,829,476 1,492,125,776 1,583,102,972 1,718,616,677 1,878,403,111 100.00%

TOTAL (US$)

$176,285,884

MTP III components 286,747,909 $40,257,695 304,959,762 $42,957,305 475,264,477 $66,724,295 87,340,902 $12,262,141 29,375,000 $4,124,075 71,962,811 $10,103,149 $8,723,712 $8,737,386 62,137,347 62,234,744 $4,299,567 $4,562,806 30,625,000 32,500,000 32,500,000 $4,562,806 57,221,931 $8,033,617 $15,304,040 $16,521,917 $17,987,515 109,007,766 117,682,478 128,121,653 $75,269,249 $77,482,612 $79,568,522 $89,097,132 125,446,078 $17,611,880 30,625,000 $4,299,567 52,406,931 $7,357,620 536,128,558 551,893,923 566,751,465 634,621,940 $46,988,673 $50,080,339 $53,061,035 $56,629,728 335,695,586 359,980,212 383,314,948 410,646,415 443,847,505 $60,927,343 695,972,971 $97,710,450 135,581,453 $19,034,827 30,625,000 $4,299,567 56,306,931 $7,905,157 $45,380,295 $51,641,756 $58,290,615 $65,265,017 $72,453,042 323,235,220 367,834,418 415,192,975 464,870,314 516,069,251

2007

2008

2009

2010

2011

2012

% 25.5%

Prevention

Mitigation

24.0%

Treatment

37.2%

HR

7.6%

Infrastructure

2.0%

34 $196,106,519 $209,485,551

Policy, Mgt, Coordination, Monitoring and Evaluation

3.9%

TOTAL (N$)

1,255,650,861 1,396,829,476 1,492,125,776 1,583,102,972 1,718,616,677 1,878,403,111 $222,258,206 $241,283,521 $263,716,582

100.0%

TOTAL (US$)

$176,285,884

Comparison by cost area 883,019,784 $141,838,543 142,235,501 $19,969,015 63,599,274 $8,928,958 180,705,708 $25,370,003 72,394,471 $10,163,751 $11,727,393 83,531,992 95,359,000 $13,387,834 $24,265,475 $24,981,949 172,838,366 177,941,678 $9,546,393 $9,400,617 $9,352,476 189,154,789 $26,556,203 106,119,254 $14,898,510 67,997,146 66,958,811 66,615,912 $19,823,486 $20,468,052 $21,871,917 141,198,925 145,790,043 155,789,509 167,077,821 $23,456,729 70,963,939 $9,962,913 203,620,146 $28,587,053 116,071,419 $16,295,734 $155,850,197 $167,407,588 $183,502,925 $201,709,888 1,010,288,993 1,110,091,338 1,192,412,440 1,307,056,467 1,436,741,205

2007

2008

2009

2010

2011

2012

% 76%

Activities

$123,970,706 133,555,947 $18,750,458 79,265,626 $11,128,421 159,809,503 $22,436,300 57,189,586 $8,029,076

Management

9%

Monitoring and Evaluation

4%

HR (incl training)

11%

HR (excl training)

6%

35 $196,106,519 $209,485,551

TOTAL (N$)

1,255,650,861 1,396,829,476 1,492,125,776 1,583,102,972 1,718,616,677 1,878,403,111 $222,258,206 $241,283,521 $263,716,582

100%

TOTAL (US$)

$176,285,884

Table 8: RNE Summary Low Scenario

2007 11,168,082 277,115,987 54,867,449 31,188,602 5,209,225 19,324,667 3,341,173 1,192,011 49,228,270 128,618,151 56,976,221 6,322,352 184,733,434 71,858,846 13,479,714 87,340,902 29,375,000 5,814,685 65,864,435 5,639,685 48,540,879 $168,373,055 30,625,000 109,007,766 16,400,390 82,270,418 90,564,769 17,268,371 117,682,478 32,500,000 5,434,685 52,954,966 $176,832,734 183,305,806 181,878,177 6,494,626 6,665,396 53,944,073 52,297,266 145,190,137 161,302,748 180,286,318 52,735,790 6,833,092 180,450,548 98,535,660 18,686,435 128,121,653 32,500,000 5,454,685 47,710,463 $188,544,070 51,950,144 54,677,919 54,312,094 1,143,115 1,143,115 1,192,011 3,999,476 4,408,754 4,502,868 20,705,000 20,705,000 20,705,000 20,705,000 4,594,829 1,143,115 56,914,468 202,684,345 54,062,665 6,996,951 179,022,919 106,774,371 21,169,216 125,446,078 30,625,000 5,139,685 43,210,463 $198,804,823 5,124,998 5,003,628 4,845,115 4,649,458 38,056,735 41,619,263 48,147,642 51,160,150 54,907,811 57,006,478 59,177,456 60,682,335 329,661,446 343,656,297 385,627,912 427,253,511 471,465,511 62,175,986 53,458,480 4,416,658 20,705,000 4,683,795 1,143,115 59,516,843 224,157,844 55,694,667 7,155,472 177,595,290 115,343,674 27,180,643 135,581,453 30,625,000 5,139,685 43,210,463 $212,530,130 12,321,774 12,776,654 13,138,845 13,814,422 14,562,161 2008 2009 2010 2011 2012 % 0.99% 28.58% 4.45% 3.36% 0.37% 1.57% 0.33% 0.09% 4.17% 13.30% 4.16% 0.52% 13.87% 7.22% 1.46% 8.98% 2.38% 0.42% 3.85%

Low Scenario (total cost)

PMTCT

ART (incl TB/HIV - IPT/CPT)

C&T

Condoms

STI

Blood safety

PEP

Safe medical injection

IEC, BCC,SM & youth skills

36

Workplace

HBC

TB

OVC

Food assistance

PLWHA support

HR

Infrastructure

Regional support

Management/Coord., Monitoring and Evaluation

TOTAL (N$)

1,103,019,205 1,199,289,279 1,259,545,966 1,342,963,586 1,416,048,979 1,513,811,738 100.00%

TOTAL (US$)

$154,857,311

MTP III components Prevention 22.5% 33.2% 9.0% 2.4% 48,350,148 $6,788,072 4.3% 100.0%

% 28.6%

Mitigation

Treatment

HR

Infrastructure 71,679,120 $10,063,321 54,180,564 $7,606,628 58,389,651 $8,197,558 53,165,148 $7,464,069

2007 304,137,629 $42,699,107 270,071,994 $37,916,496 340,414,560 $47,792,172 87,340,902 $12,262,141 29,375,000 $4,124,075 48,350,148 $6,788,072

2008 333,399,189 $46,807,256 281,976,614 $39,587,833 390,100,146 $54,767,732 109,007,766 $15,304,040 30,625,000 $4,299,567

2009 358,643,560 $50,351,415 289,711,317 $40,673,739 402,618,960 $56,525,298 117,682,478 $16,521,917 32,500,000 $4,562,806

2010 386,307,349 $54,235,245 297,672,642 $41,791,462 445,196,794 $62,502,972 128,121,653 $17,987,515 32,500,000 $4,562,806

2011 416,348,121 $58,452,791 306,966,506 $43,096,265 488,313,126 $68,556,248 125,446,078 $17,611,880 30,625,000 $4,299,567

2012 444,819,880 $62,450,056 320,119,607 $44,942,882 534,315,650 $75,014,727 135,581,453 $19,034,827 30,625,000 $4,299,567

Policy, Mgt, Coordination, Monitoring and Evaluation

37 2008 846,844,578 $118,891,923 134,100,999 $18,826,980 57,814,544 $8,116,817 160,529,157 $22,537,335 72,394,470 83,531,991 2009 912,516,938 $128,111,930 130,971,226 $18,387,578 61,414,856 $8,622,279 154,642,946 $21,710,946 57,189,585

TOTAL (N$) TOTAL (US$)

1,103,019,205 1,199,289,279 1,259,545,966 1,342,963,586 1,416,048,979 1,513,811,738 $154,857,311 $168,373,055 $176,832,734 $188,544,070 $198,804,823 $212,530,130

Comparison by cost area Activities

% 74% 10% 4% 12% 95,359,000 106,119,254 116,071,418 8% 100%

Management

Monitoring and Evaluation

HR (incl training)

2007 759,386,396 $106,613,316 128,145,379 $17,990,846 74,864,180 $10,510,484 140,623,250 $19,742,665

2010 983,571,905 $138,087,623 133,247,902 $18,707,210 61,070,776 $8,573,972 165,073,003 $23,175,264

2011 1,051,660,627 $147,646,873 140,890,509 $19,780,186 58,813,053 $8,257,002 164,684,790 $23,120,761

2012 1,125,052,386 $157,950,638 149,859,440 $21,039,371 61,784,274 $8,674,143 177,115,637 $24,865,978

HR (excl training)

TOTAL (N$) TOTAL (US$)

$8,029,076 $10,163,751 $11,727,393 $13,387,834 $14,898,510 $16,295,734 1,103,019,205 1,199,289,279 1,259,545,966 1,342,963,586 1,416,048,979 1,513,811,738 $154,857,311 $168,373,055 $176,832,734 $188,544,070 $198,804,823 $212,530,130

Table 9: RNE Scenario Comparison

Average Annual Low 1.0% 28.5% 4.5% 3.4% 0.4% 1.6% 0.3% 0.1% 4.2% 13.3% 4.2% 0.5% 13.9% 7.2% 1.5% 9.0% 2.4% 0.4% 3.8% 100.0% 117,196,722 31,041,667 12,912,268 50,248,611 1,919,893,337 $269,541,563 33,592,521 338,469,071 269,148,143 229,793,301 113,749,429 29,531,342 117,196,722 31,041,667 10,129,838 50,248,611 1,554,121,479 $218,189,377 6,744,648 6,744,648 197,600,965 187,448,503 211,235,703 180,620,293 173,706,590 54,285,114 6,744,648 181,164,362 94,224,623 19,030,795 117,196,722 31,041,667 5,437,185 50,248,611 1,305,779,792 $183,323,687 89,939,444 62,103,957 54,433,290 1,159,414 1,159,414 1,159,414 4,255,149 4,255,149 4,255,149 25,530,894 6,956,481 539,636,662 1,267,414,215 1,185,605,791 40,467,890 1,614,888,856 2,030,814,424 201,555,124 703,180,330 186,250,000 77,473,606 301,491,669 11,519,360,022 $1,617,249,375 20,474,944 20,474,944 20,474,944 122,849,667 3,696,609 4,535,728 4,874,847 22,179,653 43,938,479 43,938,479 43,938,479 263,630,873 65,258,638 64,900,526 58,136,253 391,551,828 389,403,153 263,630,873 27,214,367 122,849,667 25,530,894 6,956,481 372,623,743 1,083,721,758 1,124,691,016 40,467,890 1,378,759,804 682,496,575 177,188,049 703,180,330 186,250,000 60,779,025 301,491,669 9,324,728,872 $1,309,136,264 408,604,283 382,579,071 372,463,444 2,451,625,697 2,295,474,428 14,376,060 13,669,858 12,963,656 86,256,362 82,019,150 High Medium Low High Medium Low 77,781,938 2,234,780,665 348,817,515 263,630,873 29,249,082 122,849,667 25,530,894 6,956,481 326,599,737 1,042,239,541 325,710,682 40,467,890 1,086,986,172 565,347,738 114,184,770 703,180,330 186,250,000 32,623,110 301,491,669 7,834,678,753 $1,099,942,123 Cumulative

Scenario Comparisons

High 0.9% 24.6% 4.2% 2.8% 0.3% 1.3% 0.3% 0.1% 4.0% 11.6% 12.1% 0.4% 14.8% 7.3% 1.9% 7.5% 2.0% 0.7% 3.2%

Medium

PMTCT

0.7%

ART (incl TB/HIV - IPT/ CPT)

21.3%

C&T

3.4%

Condoms

2.3%

STI

0.2%

Blood safety

1.1%

PEP

0.2%

Safe medical injection

0.1%

IEC, BCC,SM & youth skills

4.7%

38

Workplace & Mainstreaming

11.0%

HBC, Palliative Care, Psychosocial support

10.3%

TB

0.4%

OVC

14.0%

Food assistance & Nutrition

17.6%

PLHA support

1.7%

HR

6.1%

Infrastructure

1.6%

Regional support

0.7%

Management/Coord., M&E

2.6%

TOTAL (N$)

100.0%

100.0%

TOTAL (US$)

MTP III Components 25.5% 63,785,843 24.0% 90,022,019 37.1% 86,054,506 7.5% 16,453,720 2.0% 4,358,065 $4,358,065 4,358,065 2.4% 31,041,667 31,041,667 31,041,667 $16,453,720 16,453,720 9.0% 117,196,722 117,196,722 117,196,722 703,180,330 98,722,320 186,250,000 26,148,388 $80,975,377 60,859,858 516,327,036 33.2% 612,949,896 576,772,222 433,493,206 3,677,699,378 $52,377,372 41,334,779 540,132,111 $314,264,234 3,460,633,334 $485,852,260 703,180,330 $98,722,320 186,250,000 $26,148,388 22.5% 641,209,734 373,074,071 294,419,780 3,847,258,404 2,238,444,428 $55,548,070 52,499,312 382,715,057 $333,288,419 28.6% 454,334,439 395,658,348 373,942,621 2,726,006,635 2,373,950,086 2,243,655,728 $382,715,057 1,766,518,680 $540,132,111 2,600,959,236 $516,327,036 703,180,330 $98,722,320 186,250,000 $26,148,388

High

Medium

Low

High

Medium

Low

High

Medium

Low

Prevention

23.7%

Mitigation

33.4%

Treatment

31.9%

HR

6.1%

Infrastructure

1.6%

39
3.9% 8,867,410 100.0% 269,541,563 1,919,893,337 8,476,774 1,554,121,479 218,189,377 4.3% 63,160,879 60,378,449

Policy, Mgt, Coordination, M&E

3.3%

55,685,796 7,817,953 1,305,779,792 183,323,687

378,965,275 53,204,462 11,519,360,022 1,617,249,375

362,270,694 50,860,643 9,324,728,872 1,309,136,264

334,114,779 53,204,462 7,834,678,753 1,099,942,123

TOTAL (N$)

100.0%

100.0%

TOTAL (US$)

Comparison by cost area Low 74.3% 208,930,052 8.9% 26,017,905 3.8% 9,719,963 10.8% 24,873,643 6.2% 12,417,050 100.0% 269,541,563 High N$918 $129 N$8,366 $1,175 N$423 $59 N$5,460 $767 Medium N$744 $104 N$6,786 $953 N$406 $57 N$4,149 $583 218,189,377 1,919,893,337 1,554,121,479 12,417,050 7.7% 88,444,287 88,444,287 88,444,287 12,417,050 1,305,779,792 183,323,687 Low N$625 $88 N$5,709 $802 N$337 $47 N$3,182 $447 25,366,164 22,525,492 11.7% 177,170,232 180,678,365 160,444,798 9,719,963 8,792,449 58,319,780 1,063,021,391 149,241,857 530,665,721 74,502,299 11,519,360,022 1,617,249,375 4.1% 69,233,451 69,233,451 62,626,947 415,400,709 20,723,276 19,122,029 156,107,428 9.9% 185,320,592 147,607,958 136,202,576 1,111,923,552 885,647,746 124,339,656 415,400,709 58,319,780 1,084,070,190 152,196,983 530,665,721 74,502,299 9,324,728,872 1,309,136,264 162,379,974 132,883,717 1,253,580,310 974,279,846 1,488,169,062 1,156,601,705 946,505,472 8,929,014,371 6,939,610,227 High Medium Low High Medium Low 5,679,032,830 797,302,305 817,215,455 114,732,171 375,761,683 52,754,697 962,668,786 135,152,950 530,665,721 74,502,299 76.5%

High

Medium

Activities

79.7%

Management

9.0%

M&E

2.9%

HR (incl training)

8.3%

HR (excl training)

4.8%

40

TOTAL (N$)

100.0%

100.0%

7,834,678,753 1,099,942,123

TOTAL (US$)

Per capita AIDS RNE

per capita total RNE

per PLHA total RNE

per capita health sector total RNE

per PLHA Care and Treatment RNE

Per capita AIDS RNE High Medium Low

% Total RNE per GDP and Gvt expenditure and % Health sector RNE/MoHSS expenditure N$38,744,000,000 5.0% 4.0% 3.4%

GDP and Government Expenditure

GDP (million, 2005)

N$38,744

$5,439 N$12,700,000,000 15.1% 12.2% 10.3%

Gvt expenditure (million, 2005)

N$12,700

$1,783 N$1,334,858,637 68.5% 65.8% 54.5%

MoHSS Public Health Expenditure (PHE) (million, 2005/06)

N$1,335

$187

41

Per capita Health Expenditure

Total per capita

N$1,446

$203

Public per capita

N$1,007

$141

Per capita Health Expenditure High scenario Medium scenario Low scenario

Average Annual Resource Needs Estimate (20072012, million) N$1,920 N$1,554 N$1,306 $270 GDP (2005, million) $5,439 N$38,744 $218 $183

42
5.0% 4.0% 3.4% N$12,700 $1,783 15% 12% 10%

Average Annual Resource Needs Estimate as % of GDP

Government expenditure (2005, million)

Average Annual Resource Needs Estimate as % of Gvt expenditure

Per capita Health Expenditure High scenario Medium scenario Low scenario

Per capita Average Annual Resource Needs Estimate (2007-2012) N$918 N$744 N$625 $129 $104 $88

Per capita Average Annual RNE for health sector (2007-2012) N$423 N$406 N$337 $59 N$858 $141 $57 $47

43
49% 47% 39% 68% 66% 55%

Per capita Total Health Expenditure (1999-2000)

Per capita Average Annual RNE for Health Sector (2007-12) as % of THE

% Average Annual RNE for Health Sector (2007-12) as % of MoHSS PHE (2005/06)

Appendix II. MTP-III Components, Programme Areas & Main Sectors Figure 9: MTP III National Programme Goals

MTP3 III National Programme Goal

1 Enabling Environment

2 Prevention

3 Treatment, Care, & Support

4 Impact Mitigation

5 Programme Management

1.1 Capacity development: Leadership 3.1 Capacity development: Treatment, care and support
3.1.1 Capacity Development 3.1.2 IEC to support expanded treatment, care & support programmes

2.1 Capacity development: prevention 4.1 Capacity development: Local responses

5.1 Developing of HIV/AIDS management capacity

5.1.1 Human resource planning 5.1.2 Human resource development 5.1.3 Quality assurance 5.1.4 Capacity development of service providers

1.1.1 Sustained leadership commitment

2.1.1 Capacity development

2.2 Target vulnerable populations

1.2 PLWHA involvement

2.2.1 Target BCI for vulnerable populations

1.2.1 Increase participation

44
3.2 Treatment and Care services
3.2.1 Laboratory services for HIV/AIDS management 3.2.2 Drugs & supplies systems 3.2.3 PMTCT+ services 3.2.4 Management of opportunistic infections 3.2.5 Collaborative TB/HIV/AIDS services 3.2.6 Provision of HAART 3.2.7 Home-based care 3.2.8 Access to care for vulnerable populations

2.2.2 Prevention of transmission in health care settings

5.2 Management & co-ordination

5.2.1 Management structures

1.3 Policy & law reform

2.3 Target young people

2.3.1 BCI in schools

1.3 1 National policy Development & law reform

2.3.2 BCI for youth

4.2 Services for OVC & PLWHA

5.2.2 Resource mobilisation & flow mechanisms 5.2.3 Information flows 5.2.4 Mainstreaming 5.2.5 Management processes

1.3.2 Sectoral & Institutional policies

2.4 Target the general population

1.4 Interventions to reduce stigma discrimination

4.3 Addressing poverty

5.3 Programme monitoring & evaluation

5.3.1 Monitoring & evaluation

1.4.1 Social mobilisation to combat discrimination

1.4.2 Actions to prevent & address discrimination

2.4.1 Social mobilisation & awareness 2.4.2 Workplace programmes 2.4.3 Expand condom provision 2.4.4 Strengthen STI management 2.4.5 Voluntary counselling & testing 2.4.6 Safety of blood transfusion products

4.3.1Addressing poverty, food security, nutrition & housing

5.4 Surveillance and operational research

2.5 Interventions to reduce Vulnerability

5.4.1 Multi-sectoral HIV/AIDS research coordination

55

5.4.2 Surveillance & Research

2.5.1 Addressing vulnerability

45

Table 10. Main Sectors in the Multi-Sectoral Response Ministry or Sector Examples of Programs, Activities and Interventions All Sectors & Office of the Prime Workplace interventions + Mainstreaming Minister and National Planning Youth Life Skills Program IEC,BCC,Social Mobilisation (mainly civil society) School Fee Exemptions for OVC Learners (through School Education Development Fund) Loans for formal training for selected health professionals School Feeding Program for OVC Learners Food Support for PLWHAs Agriculture Food gardens Grants for OVC (Maintenance; Foster Care; Children Home Gender and Social Welfare Subsidies; Place of Safety) and OVC Food Support Regional and Local Government Regional Support Disability grants to PLWHAs

Labor and Social Welfare

Information and Broadcasting

Health and Social Services

IEC/BCC/SM: Mass Media, Targeted Campaigns ART, C&T, PMTCT, HBC, Psychosocial support, Palliative Care, PEP, Injection Safety, Blood Safety, Loans for formal training for health professionals Work Place programmes for private sector Civil society coordination (HBC, Nutrition, IEC/BCC/SM & OVC support), monitoring and evaluation civil society, PLWHAs coordination, buddy support

NABCOA

NANASO

LIRONGA EPARU

Appendix III. Consultative Meeting Attendance List Attendance List of Consensus Building and Scenario Setting The Revised MTP III Costing Exercise 14 & 15 February 2007 at GZ Conference Centre
Title Undersecretary, NAEC Chair Director, DSP Deputy Director, HSR Dep. Director: PP& HRD Deputy Director Deputy Director-Child Welfare Media Officer Chair AIDS Committee Inspector Industries Systems Administrator National Coordinator OVC National Coordinator Programme Manager EC Senior Tech. Advisor (KIT) Deputy Director Chief Health Program Chief Health Program Regional Technical Advisor TA-HIS Project Coordinator Capacity Project CHPA 2066111 2066310 0812719295 261122 081248 3272 235226 378750 0812632703 2032830 0812092757 224149 2032825 0812524813 2032289 0811272801 2032282 0812857250 224149 224149 2032731 303799 2032725 2087622 2839111 2833167 0812526806 2975019 2032502 0811283491 2032272 0812691205 2032273 0811221406 2032038 0811284273 Work Phone Cellphone Email Name nforster@mhss.gov.na shihepoe@nacop.net gorasebm@nacop.net bkatjivena@mhss.gov.na fnauyala@mrlgh.gov.na handjamba@mgecw.gov.na ildefonsina@yahoo.com muzumay@mawrd.gov.na unt@web.com.na kstrauss@mol.gov.na coordinator@nanaso.com Natprog-ovc@redcross.org.na pjvanwyk@africaonline.com.na deputterj@nacop.net broussardd@nacop.net xoaguba@nacop.net owosess@nacop.net ormelh@nacop.net hblake@nacop.net damesynm@nacop.net fsoroses@globalfund.com.na eaziz@intrahealth.org

Organization

Name

MoHSS

Dr. Norbert Forster

MoHSS

Ms. Ella Shihepo

MoHSS

Dr. Marcus Goraseb

MoHSS

Ms Bertha Katjivena

MRLGHRD

Fenni-F Nauyala

MGECW

Ms. Helena Andjamba

MIB

Ritha Jodo

MAWF

Ms Uaeta Muzuma

MoLSW

Mr. Tjikuzu Tjirarakanua

46

MoLSW

Mr. Kay Strauss

NANASO

Mr. Michael Mulondo

Nam Red Cross

Ms. Diana E.Iyambo

NABCOA

Mr. Peter Van Wyk

MoHSS/DSP/EC

Dr. Jeanette De Putter

CDC

D. Brossard

MoHSS

Mr. Abner Xoagub

MoHSS

Ms Sandra Owoses

MoHSS/DSP/EC

Mr. Hermen Ormel

CDC

A. Blake

CDC

Mark Damesyn

MoHSS/GF

Florence Soroses

Capacity

Emad Aziz

MoHSS/FHD

M.Diergaardt

Appendix III. Consultative Meeting Attendance List - continued Attendance List of Consensus Building and Scenario Setting The Revised MTP III Costing Exercise 14 & 15 February 2007 at GZ Conference Centre
Title Work Phone 224149 224149 224149 2032828 377 854 23818 244 936 233151 Cellphone

47
228016 248365 2046335 256427 2032873 2046208 2032875 2032874 2032869 244936 2032220 256427

256427 256427 0811296943

Organization MoHSS/DSP MoHSS/DSP MoHSS/DSP MoHSS/DSP Project Hope MoHSS SMA Pharm Services USAID NASOMA NASOMA URC RPM+MSH CHS WHO NASOMA MoHSS/DSP UNICEF MoHSS/GF MoHSS/CDC MoHSS/DSP Futures Group KIT Group MRLGHRD SMA MoHSS NASOMA MEO TA Monitoring and Evaluation Statistician CHPA Admin Assistant Pharmacist Coordinator ART Logistics Pharmacist Monitoring and Evaluation Advisor Bookkeeper HR,Admin & Sales Manager Deputy Coordinator Senior Technical Advisor Chief Medical Officer HIV/AIDS Country Officer Project Manager NA VCT Prog Coordinator Project Officer Manager--Condoms TA - VCT Nursing Coordinator Senior Economist Health Economist DPS Research Manager Deputy Director Workplace

Name Dalleen Witbooi Dr.K.Masupu Dumeni Ephraim Anna Jonas Aina Nghipangelwa Indongo Lazarus Elize Biermann Pharm-Idris T.Koppenhaver R.de Klerk E.Neidel L.Nisbet David Mabiriu D.M.Kangudie Olufemi Oke Otilie Lambert Sara Fuller Taimi Amaambo W.Hausiku Edington Dzinotyiweyi Fransina Tjituka Gayle Martin Fillip Meheus Erica Ndiyepa Liezel Wolmarans HCR Beukes Sabina Nghiyolwa

Email Name witbooid@nacop.net masupuk@cdc.gov dumenie@nacop.net jonasa@nacop.net Hope_ovc_pm@iway.na lindongo@mhss.gov.na Elize.biermann@sma.org.na ridris@cms-namibia.com tkoppenhaver@usaid.org Romandi.deklerk@nasoma.com elmarie@nasoma.com lydiaN@urc-na.com dmabiriu@msh.org.na kangudie@iway.na oke@na.afro.who.int otilie@nasoma.com fullers@nacop.net tamaambo@unicef.org hausikuw@nacop.net dzinotyiweyie@nacop.net tjituka@nacop.net gmartin@futuresgroup.com f.meheus@kit.nl endiyepa@mrlgh.gov.na Liezel.wolmarans@sma.org.na hbeukes@mhss.gov.na Sabina@nasoma.com

Appendix III. Consultative Meeting Attendance List - continued

Attendance List of Consensus Building and Scenario Setting The Revised MTP III Costing Exercise 14 & 15 February 2007 at GZ Conference Centre
Title Work Phone Cellphone Email Name

Organization

Name

48

URC SCMS MoHSS/DSP WHO MoHSS/DSP MoHSS/DSP MoHSS WHO MoHSS/DSP MoHSS/DSP NANASO LifeLine UNICEF OPM GTZ NANASO MoHSS/DSP UNDP MoHSS/DSP MGECW WFP PEPFAR ACT UNDP OPM MGECW MoHSS/DSP MoHSS/PHC

Frantz Simeon Joseph Ngidari Annatjie Tobias Tuoyo Okorosobo S.K.Tobias I.C.Pietersen D.J.Tjiho James Chitsva Wilhelmina Kafitha Patrick Githendu Eliezer Hamburee Sumitra M. Matthew Dally A. Kessler Lauckner Kathrine L.Larsdotter L.N.Indongo B.O.Koranteng Juliet Karirao Lucia Eises Mallika Alulua Claire Dilla Julia Amukwaya Sarah Mwilima Emelda Ucham Brigitte Nshimyimana Gebhardt Timotheus Aira Shikuambi

Chief of Party Lead Resident Advisor CHP Health Economist SHPA Ass VCT Coordinator AG Dir THC+ CSS MR Tech Officer SHPA OI & PC Pharmacist Officer Director: Finance & Admin P.O.OVIS PHRM Programme Manager Nutrition Advisor Pharmacist Senior Policy Advisor CHPA-Mainstreaming Control Social Worker Programme Officer Senior Liaison Senior Counselor National Program Officer Liaison Officer Social Worker CHPA CHPA-CBHC

237022 228016 2032277 2046336 2032871 2037874 2032391 2046337 2032867 2032863 261122 226889 2046111 2873154 2032761 261122 2032348 2046234 2032276 2833182 2046401 273753 259590 2046326 2875011 2833137 2032829 2032723

frantzs@urc-nam.com jngidari@pfscm.org tobiasa@nacop.net okorosobot@na.afro.who.int tobiass@nacop.net pieterseni@nacop.net dtjiho@mhss.gov.na chitsvaj@na.afro.who.int kafithaw@nacop.net githendup@nacop.net e.hamburee@nanaso.com sumitra@lifeline.org.na mdalling@unicef.org akessler@opm.gov.na Kathrin.lauckner@gtz.de nutrition@nanaso.com lindongo@mhss.gov.na beyam.afron.koranteng@undp.org kariraoj@nacop.net leises@mgecw.gov.na Mallika.ahluwalia@wfp.org cdillvou@usaid.gov jamukwaya@aidscare.com Sarah.mwilima@undp.org eucham@opm.gov.na briuza@yahoo.com timotheusg@nacop.net ashikuambi@globalfund.com.na

Appendix III. Consultative Meeting Attendance List - continued Attendance List of Consensus Building and Scenario Setting The Revised MTP III Costing Exercise 14 & 15 February 2007 at GZ Conference Centre
Title Project Manager CHPA Senior Project Secretary Work Phone Cellphone 2873019 2032276 081317 7945 2032275 Email Name kmarenga@opm.gov.na uakuramaa@nacop.net kuschm@nacop.net

Organization OPM MoHSS/DSP MoHSS/EC

Name Kapenda Marenga Uakurama K.Ambrosius Marlina Kusch

49

Working Group Members

DESIGNATION OFFICE PHONE OFFICE FAX MOBILE E-MAIL

NAME

COSTING WK GROUP MoHSS/DSP Chief: Enars Senior TA - MoHSS/DSP/EC MoHSS DSP - RMDC MoHSS/DSP/RMDC Under Secretary: MoHSS Deputy PEPFAR Coordinator USAID Namibia M & E Advisor MoHSS/DSP Mainstreaming MoHSS/DSP: Director Royal Tropical Institute, Amsterdam Futures Group USG PEPFAR Coordinator 273713 2032830 224155 081 129 4082 2032830 224155 2032273 224155 2032276 224155 273740 081 127 3023 081 228 4714 081 122 1406 273753 081 122 1844 2032038 081 128 4273 2032278 224155 081 1490038 2032276 224155 081 317 7945 2032830 224155 081 209 2757 2032825 224155 081 252 4813 xoaguba@nacop.net deputterj@nacop.net uakuramaa@nacop.net nitschkea@nacop.net nforster@mhss.gov.na cdillavou@usaid.gov Mfeinberg@usaid.gov kariraoj@nacop.net shihepoe@nacop.net f.meheus@kit.nl gmartin@futuresgroup.com weeksd@state.gov

Mr. Abner Xoagub

Ms Jeanette de Putter

Mr.Uakurama Ambrosius

Ms. A. Nitschke

Dr.Norbert Forster

Dillavou Claire

Feinberg Madeleine

Ms. Juliet Karirao

Ms.E.Shihepo

Mr.Meheus Filip

Ms.Gayle Martin

50
PMTCT/Global Fund CDC CDC MoHSS PHC - FHD WHO Health Economist 2032725 2046336 2032731 224149 VCT Coordinator VCT Coordinator TA -VCT Research Manager 2032872 2032873 2032828

Mr. Dennis Weeks

PMTCT Working Group 234956 226959 081 127 9112 081 309 4457 fsoroses@globalfund.com.na netherdam@na.cdc.gov

Ms.Florence Soroses

Mark Netherda

Dr. Magari

M.Diergaardt

Tuoyo Okorosobo

okorosobot@na.afro.who.int

VCT Working Group 300539 300539 300539 081 124 3688 081 243 4032 081 239 9993 pieterseni@nacop.net fullers@nacop.net dzinotyiweyie@na.cdc.gov Liezel.wolwerans@sma.org.na

Ms. Ismelda Pietersen

Ms. Sara Fuller

Mr. Edington Dzinotyiweyi

Ms. Liezel Wolmarans

ART Working Group HSR: Deputy Director HSR - CHPA - HIV-AIDS Senior Medical Officer Pharmacist CDC: Deputy Director CDC Capacity Project RPM+MSH Senior Technical Advisor CHS:Chief Medical Officer Deputy Director: MoHSS 2032220 248365 228016 303799 224149 224149 2032863 300539 081 302 1652 2032864 300539 081 124 8735 2032867 300539 081 269 8392 2032868 300539 081 269 1205 gorasebm@nacop.net bockm@nacop.net hamunimeh@nacop.net githendup@nacop.net broussardd@nacop.net hblake@nacop.net eaziz@intrahealth.org dmabiriu@msh.org.na kangudie@iway.na hbeukes@mhss.gov.na

Dr. Marcus !Goraseb

Ms. Ria Bock

Dr. Ndapewa Hamunime

Mr. Patrick Githendu

Ms.Dawn Broussard

A. Blake

Emad Aziz

David Mabiriu

D.M.Kangudie

H.C.R.Beukes

Policy & Planning WG Acting DD: HRD/PP Control Officer Deputy Director: HRD/PP AG Dir - THC + CSS 2032391 2032502 272286 272286 2032511 272286 2032535 272286 081 3044 789 081 2481 473 081 1283 491 vanzyle@mhss.gov.na mphamana@mhss.gov.na bkatjivena@mhss.gov.na dtjiho@mhss.gov.na

Ms.Van Zyl

Ms.Hamana

Ms. Bertha Katjivena

51
MoHSS/HRD MoHSS/HRD MoHSS/HRD MoHSS/HRD 2032506 2032504 2032515 2032573 MoHSS/HRM MoHSS/HRM 2032181 2032184 Central Medical Stores (CMS) Central Medical Stores (CMS) ART Logistics Pharmacist (CMS) 233151 233151 233151

Ms.D.J.Tjiho

Training & Scholarships WG 272286 081 1222 2029 273286 274286 272286 081 1244 948 cusiku@mhss.gov.na kmutirua@mhss.gov.na wabwiti@yahoo.com julianangombe@yahoo.com

Ms.Celine Usiku

Ms.Kautoo Mutirua

Mr.Protasius Nghilendele

Ms.Julia Nangombe

Salaries & Benefits WG 220462 220462 081 124 0451 081 236 0249 lnashixwa@mhss.gov.na atjipura@yahoo.com

Ms.Lydia Nashixwa

Mr.A.J.Tjipura

CMS:Pharmaceutical WG 236483 236483 236483 081 212 8919 ghabimana@cms-namibia.com dsheehama@cms-namibia.com ridris@cms-namibia.com

Mr.G.Habimana

Ms.Sheehama Diana

Mr.Pharm-Idris,R.A

Ms.Lema Harriet Central Medical Stores (CMS) MoHSS: Pharmacist Lead Resident Advisor: SCMS 228016 203818 lindongo@mhss.gov.na jngidari@pfscm.org 233151 236483 hlema@cms-namibia.com

Mr.Indongo Lazarus

Joseph Nghidari

Disability Grants: MoL&SW Deputy Director: MoL&SW System Administrator: MoLSW Inspector Industries 2066111 212323 2066310 212323 081 271 9295 2066111 212323 081 122 8162 ebiwa@mol.gov.na kstrauss@mol.gov.na unt@web.com.na

Mr.A.E.Biwa

Mr.K.Strauss

Mr.Tjikuzu Tjirarakanua

Training Working Group MoHSS/DSP / TSC MoHSS/DSP / TSC I-TECH Country Director MoHSS/DSP: TSC 2032277 224155 246085 221391 2032277 224155 2032278 224155 081 229 3664 081 246 7055 081 287 9002 thomasa@nacop.net tubaunduleg@nacop.net lizo@u.washington.edu tobiasa@nacop.net

Ms.Thomas Albertina

Mr.Tubaundule Godfrey

Ms.Liz Stevens

Ms.Annatjie Tobias

52
ACT CAA CAA MoHSS/PHC MoHSS/DSP NRCS - OVC - Nat Coordinator Namibia Red Cross Society MoHSS/HSR: Nursing Coordinator WHO HIV/AIDS Country Officer NANASO: Officer NANASO National Coordinator 2032723 2032867 235226 235226 2032869 2046335 261122 261122 276358 238169 259590 MoHSS/DSP/ TB 2032867

HBC & Palliative Care WG 218673 218665 276364 234968 300539 081 298 4162 081 208 4101 081 129 2433 081 269 9624 081 129 9310 jamukwaya@aidscare.com caaka@mweb.com.na tuafi@caa.org.na shikuambia@nacop.net kafithaw@nacop.net Natprog-ovc@redcross.org.na hiv-aidscord@redcross.org.na 300539 tjituka@nacop.net oke@na.afro.who.int e.hamburee@nanaso.com 081 248 3272 coordinator@nanaso.com

Ms.Julia Amukwaya

Ms.Verie Kasume

Ms.Nghixulifwa Tuafi

Ms.Aira Shikuambi

Ms.Wilhelmina M.Kafitha

Ms.Diana Iyambo

Rosemary Nalisa

Fransina Tjituka

Dr.Olufeni Oke

Eliezer Hamburee

Mr.Michael Mulondo

TB Working Group 224155 081 257 9397 indongor@nacop.net

Ms.Rosalia Indongo

300539 300539 256424

081 269 1205 081 255 2848 081 291 3804

Condoms & STI WG Dr. Marcus !Goraseb Ms.Sarah Tobias Farirayi Nyambiya Elize Biermann R. De Klerk E.Neidel Otilie Lambert W.Hausiku Liezel Wolmarans Ms.Sarah Tobias 2032868 2032871 256427 244936 256427 257427 256427 2032875 244936 2032871 300539 300539 gorasebm@nacop.net tobiass@nacop.net farai@nasoma.com elize.biermann@sma.org.na romandi.deklerk@nasoma.com elmarie@nasoma.com otilie@nasoma.com hausikuw@nacop.net liezel.wolmarans@sma.org.na tobiass@nacop.net

HSR: Deputy Director HSR - SHPA - STI Condoms NASOMA: Manager Finance SMA Coordinator NASOMA: Bookkeeper NASOMA: HR, Admin & Sales Manager NASOMA: Project Manager MoHSS/GF: Manager Condoms SMA: Research Manager MoHSS/HSR: Condoms

WG On Psychosocial Support Ms.Laura Cronje MoHSS 2032609

081 288 3483

lcronje@mhss.gov.na

Statistics Working Group Mark Damesyn Mark Netherda Mr.Pharm-Idris,R.A CDC - TA HIS CDC Central Medical Stores(CMS) 224149 224149 233151 226959 226959 236483

081 128 0159 081 309 4457 081 212 8919

damesynm@na.cdc.gov netherdam@na.cdc.gov ridris@cms-namibia.com

53
GM (Technical Operations) Manager: Corporate Affairs 2954200 2954200 2954200 222860 2032282 2975188 2975037 2975008 2975104 2975019 2032276

NIP Working Group Harold T.Kaura Esegiel Gaeb Mrs.de Waal-Miller

255566 255566 255566

081 127 5945 081 127 5782

harold.kaura@nip.com.na esegiel.gaeb@nip.com.na

Regional Support Working Group Andrew Harris Advisor: MRLGHRD Hermen Ormel Regional Tech Advisor: MoHSS/DSP E.K.Ndiyepa MRLGHRD: DPS Ms.E.U.Kamutuezu MRLGHRD: Chief Development Planner Ms.A.A.Campbell Accountant: MRLGHRD Mrs.T.N.Iitenge SHRP:MRLGHRD Fenni-F Nauyala Deputy Director: MRLGHRD Erica Ndiyepa MRLGHRD Deputy PS

222864 224155 258131 2975279 297 5159 297 5096 2975096

081 210 6206 081 285 7250 081 128 3721 081 270 0185 081 295 5705

aharris.lep46@london.edu ormelh@nacop.net endiyepa@mrlgh.gov.na ekamutuezu@mrlgh.gov.na acampbell@mrlgh.gov.na Tiitenge@mrlgh.gov.na fnauyala@mrlgh.gov.na endiyepa@mrlgh.gov.na

Workplace & Mainstreaming WG Ms.Juliet Karirao MoHSS/DSP - Mainstreaming

224155

081 228 4714

kariraoj@nacop.net

224155 225076 378777 081 300 4874 081 231 3027 2873028

081 240 7024

Mr.Gebhardt Timotheus Mr.A.Kessler Ms.Heita Aina Kapenda Marenga Matthew Andreas Alexia Krug von Nidda Mr.Juegen Haas Mr. Abner Xoagub Mr.Peter van Wyk Sabina Nghiyolwa Katherine Lauckner B.O.Koranteng Sarah Mwilima Emelda Ucham 2032829 2873154 378756 2873019 2873031 2037128 2032761 2032825 378750 256427 2032761 2046234 2046326 2875011 224155 378777 081 280 2496 081 252 4813 081 263 2703 gebhardt@nacop.net akessler@opm.gov.na ainah@nabcoa.org kmarenga@opm.gov.na mandreas@opm.gov.na alexia.ded@iway.na haag.ded@iway.na xoaguba@nacop.net peterj@nabcoa.org sabina@nasoma.com kathrin.lauckner@gtz.de beyam.afron.koranteng@undp.org sarah.mwilima@undp.org eucham@opm.gov.na

MoHSS/DSP WPP OPM NABCOA OPM OPM DED DED - HIV AIDS Expert MoHSS/DSP Chief: Enars NABCOA NASOMA: Workplace GTZ: Programme Manager UNDP Senior Policy Advisor UNDP National Program Officer OPM Liaison Officer

54
2975190 261122 2087463 276563 2087622 2046364 2046401 237022 237022 2046337 225851 225851

Food Security & Nutrition WG Manfred Menjengua Linda Larsdotter Paulina Shiyelekeni Albert Fosso Uaeta Muzuma Baton Osmani Mallika Alulua 226049 261778 2087786 276552 2087594 2047065

Deputy Director: MRLGHRD Nutrition Advisor: NANASO Project Coordinator: MAWF Horticulture Project Coordinator: FAO HIV/AIDS Focal Person - MAWF UNWFP: Head of Programme WFP: Programme Officer

081 127 3312 081 232 5791 081 216 4073 081 213 9240 081 253 9971 081 303 6371

mmenjengua@mrlgh.gov.na nutrition@nanaso.com shiyelekenip@mawrd.gov.na albert.fosso@ho00.hsw.ch muzumau@mawrd.gov.na baton.osmani@wfp.org mallika.alulua@wfp.org

081 203 3814 081 129 6943

Injection Safety & PEP Costing WG Frantz Simeon URC Ida Bouwer URC L.Nisbet URC: Deputy Coordinator James Chitsva WHO: MR Technical Officer

FrantzS@urc-na.com IdaB@urc-na.com lydian@urc-na.com chitsvaj@na.afro.who.int

Bood Transfusion Services (BTS) WG Mrs.C.J.Gouws Admin Manager: NAMBTS Mrs.R.Mosiane Lab Manager: NAMBTS

225854 225854

cgouws@bts.com.na rkmosiane@bts.com.na

OVC Working Group Matthew Dallint Doris Roos Brigitte Nshimyimana Celeste Zaahl Joyce Nakuta Rollette Bessinger Helena Andjamba Lucia Eises Ms.Aina Nghipangelwa Taimi Amaambo Sumitra M 2046111 2046252 2833137 2833179 2833164 269572 2833167 2833182 377854 2046208 226889 081 290 2096 081 129 5219 2046206 2046206 229569 229569 229569 269574 229569 081 337 3707 081 276 8865 081 237 4468 081 241 4165

PO - OVCs - UNICEF PO - Child Protection - UNICEF Social Worker - MGECW Control Social Worker - MGCEW Control Social Worker - MGCEW Program Manager - CAFO Acting Director - MGCEW MGCEW - Control Social Worker Admin Assistant: Project Hope UNICEF Project Officer LifeLine: Director Finance & Admin

mdalling@unicef.org droos@unicef.org briguza@yahoo.com celestez@mgecw.gov.na jnakuta@mgecw.gov.na programcafo@iway.na handjamba@mgecw.gov.na leises@mgecw.gov.na Hope_ovc_pm@iway.na tamaambo@unicef.org sumitra@lifeline.org.na

M & E Working Group 224149 226959 081 129 5523 081 337 8181 2032289 224149 224149 2032828 273740 224155 226959 226959 224155 081 127 2801 witbooid@nacop.net mahym@unaids.org marelize.gorgens@gmail.com owosess@nacop.net masupuk@cdc.gov dumenie@nacop.net jonasa@nacop.net tkoppenhaver@usaid.gov

Dalleen Witbooi

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2032273 2834138 2839111

Mary Mahy Marelize Gorgens-Albino Ms.Sandra Owoses Dr.K.Masupu Mr.Efraim Dumeni Ms.Anna Jonas

Todd Koppenhaver

MoHSS/DSP Monitoring and Evaluation Officer UNAIDS Monitoring and Evaluation Advisor World Bank MoHSS/DSP CHP Monitoring and Evaluation MoHSS/DSP TA Monitoring and Evaluation MoHSS/DSP Statistician MoHSS/DSP USAID/Namibia Monitoring and Evaluation Advisor

Management and Coordination Ms. Ella Shihepo Mr. Michael Mulondo Ms. Anna Jonas Mr.Vekondja H.Tjikuzu

Director Special Programmes National Coordinator NANASO M and E Officer MoHSS/DSP NPC Deputy Director PRP: NHRP

224155

081 122 1406

shihepoe@nacop.net

226501

081 122 8298

vtjikuzu@npc.gov.na

IEC,BCC,SOC Bastian Schwartz Fedney Kabunga Claire Dillavou Ritha Jodo

NawaLife MIB Deputy Director PEPFAR MIB: Media Officer

ildefonsina@yahoo.com

Appendix IV. Circumcision: What do we know to date? Scientific evidence. Ecological studiesi and epidemiological studiesii,iii,iv,v,vi have highlighted the potential protective effect of male circumcision in preventing HIV transmission to uninfected males having sex with womenvii . The biological plausibility of this protective effect has been supported by laboratory studiesviii,ix and clinical trials studies have now confirmed the efficacy of male circumcision against HIV transmission.x,xi Following the 60% efficacy (95% CI: 32% -76%), demonstrated in the South African study, two clinical trials in Uganda and Kenya recently revealed a protective effect of 53% and 48% respectively of male circumcision on HIV transmission. Impact. Countries in the Southern Africa region vary in HIV prevalence, and it is uncertain whether male circumcision as an HIV intervention should be recommended in all these countries. However, some evidence from multi-country modeling xx (Williams et al. (2006)) found that the largest benefit from male circumcision as an HIV prevention intervention (measured in terms of reduction in HIV incidence) is likely to occur in countries with a high HIV prevalence and moderate to low levels of male circumcision (Figure 10, Figure 11). Figure 10: Relationship between HIV prevalence and reduction in HIV incidencexii
10

1 0 0.1 10 20 30 40 50

0.01 Reduction in incidence (percent per year - log scale) 0.001 HIV prevalence (%)
Source: Adaptated from Williams et al. 2006

Figure 11: Relationship between male circumcision prevalence and reduction in HIV incidencexiii
10

1
0 20 40 60 80 100

0.1 scale) 0.01 Reduction in incidence (log 0.001 Prevalence of MC (%)

Source: Adaptated from Williams et al. 2006

Coverage. The clinical trials have focused on the impact of male circumcision on susceptibility to HIV infection (i.e., the probability of infection from an infected female partner to the circumcised male), but have shed very little light on the impact of male circumcision on HIV infectiousness (i.e., the probability of infection from an infected circumcised male to a sexual partner)xiv . The magnitude of the latter effect will determine the size of the secondary effect of male circumcision. It is therefore possible that the relationship between coverage and impact is not linear, but associated with a sharper decrease in infections averted as coverage increases. 56

 Age at circumcision. Assuming implementation barriers limit the ability to roll out male circumcision to all men, what age group should be targeted to afford the greatest impact in terms of new infections averted? There is no conclusive information available concerning the relationship between HIV risk and age at circumcision, and some studies have yielded contradicting results.xv Risk compensation (or behavioural disinhibition). This is increase in HIV risk behaviour (e.g. lower condom use, increase in number of sex partners, increase in frequency of sex, etc.) in response to perceived protection from circumcision. This is a vexing issue raised in relation to new HIV prevention technologies (e.g. vaccines, male circumcision, microbicides etc). xvi In addition to clinical safety, risk compensation is the most important factor raised in debates about male circumcision. Moving from science to planning for implementation. The accumulating scientific evidence is slowly being supplemented with qualitative and quantitative policy analysis to ensure that the necessary information is available for decision-makers to make resource allocation and affordability decisions. Examples are: acceptability studiesxvii,xviii,xix impact studiesxx, cost-effectiveness analysesxxi, expert consultationsxxii, as well as a detailed cost analysis and impact study currently being undertaken by the Health Policy Initiative.xxiii Cost. Some cost data has been reported, although none of these studies are formal costing studies. Orange Farm (South Africa) $55; Rakai (Uganda) $69; Kisumu (Kenya) $25. It should be noted that these costs are not directly comparable because it is unclear what is included in the studies. For example, indirect costs are often not fully reflected; donations (especially clinicians time), often not costed; and variation by provider type and level of health facility not reflected as well as the scale of service delivery is unclear. A cost study of male circumcision in three Southern African countries has found that uncomplicated circumcisions usually require four visits: pre-surgical examination and IEC; surgical procedure; and two follow-up visits (2-3) and seven days post-surgery. A fifth visit at 21 days post-surgery is recommended but seldom occurs in uncomplicated cases. Male circumcision is usually done under local anaesthesia by all except private providers who generally use general anaesthesia. Waiting time between the first and second visit ranges between one to eight weeks reflecting some capacity constraints. Antibiotics are routinely prescribed by some providers but not in all cases. Dressings are not reapplied by all providers at post-operative visit. Costs to the patient at non-private providers range between US$4.8 to US$41.5. The unit cost analyses are being completed. The results of this study will provide accurate unit cost estimates that are critical for cost-effectiveness analysis and affordability assessment in order to inform resource allocation and resource mobilization for Male Circumcision as an HIV intervention.

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BIBLIOGRAPHY
Auvert B, Buve A, Lagarde E, Kahindo M, Chege J, Rutenberg N, Musonda R, Laourou M, Akam E, Weiss HA. 2001. Male circumcision and HIV infection in four cities in sub-Saharan Africa. AIDS. Vol. 15, suppl. 4, pp. S31-S40. ii Gray R, Kiwanuka N, Quinn T, Sewankambo N, Serwadda D, Mangen F, Lutalo T, Nalugoda F, Kelly R, Meehan M, Chen M, Li C and Wawer M, for the Rakai Project Team. 2000. Male circumcision and HIV acquisition and transmission: cohort studies in Rakai, Uganda. AIDS, 14:2371-2381. iii Mehendale SM, Shepherd ME, Divekr AD, et al. 1996. Evidence for high prevalence and rapid transmission of HIV among individuals attending STD clinics in Pune, India. Indian J Med Res; 104:317-35. iv Cameron DW, DCosta LJ, Maitha GM, Cheang M, Piot P, Simonsen JN, Ronald AR, Gakinya MN, Ndinya-Achola JO, Brunham RC and Plummer FA. 1989. Female to male transmission of human immunodeficiency virus type 1: risk factors for seroconversion in men. Lancet, 334(8660): 403-407 v Weiss HA. 2002. Update of current epidemiological evidence on male circumcision and HIV. In USAID/AIDSMark, 2003. Male Circumcision: Current Epidemiological and Field Evidence; Program and Policy Implications for HIV Prevention and Reproductive Health, Conference Report, Washington DC. http://www.usaid.gov/pop_health/aids/TechAreas/research/index. html, pp 14-15. Weiss HA, Thomas SL, Munabi SK, and Hayes RJ. 2006. Male circumcision and risk of syphilis, chancroid and genital herpes: A systematic review and meta-analysis. Sex. Transm. Inf., 82:101-110. vi Siegfried N., Muller M., Deeks J., Volmink J., Egger M., Low N., Weiss H., Walker S. and Williamson P.: HIV and male circumcisionA systematic review with assessment of the quality of studies. Lancet Infect Dis. 2005; 5:165173. Siegfried N., Muller M., Deeks J., Volmink J., Egger M., Low N., Weiss H., Walker S. and Williamson P.: Male circumcision for prevention of heterosexual acquisition of HIV in men, Cochrane Review, 2006. vii The effect has not been demonstrated for homosexual sexual exposure. viii Szabo R, Short RV. 2000. How does male circumcision protect against HIV infection? BMJ 320: 15921594. ix Patterson. BK. 2002. Recent research on the physiology and uptake of HIV in the human foreskin. Update of current epidemiological evidence on male circumcision and HIV. In USAID/AIDSMark, 2003. Male Circumcision: Current Epidemiological and Field Evidence, Program and Policy Implications for HIV Prevention and Reproductive Health. September 18, 2002 Conference Report. Washington DC. http://www.usaid.gov/pop_health/aids/TechAreas/res earch/index.html, pp 16-17. x Auvert B, Taljaard D, Lagarde E, Sobngwi-Tambekou J, Sitta R, and Pure A, 2005. Randomized, Controlled Intervention Trial of Male Circumcision for Reduction of HIV Infection Risk: The ANRS 1265 Trial. PLoS Medicine, Vol. 2 (11):1112-1122 Online at: www.plosmedicine.org. xi National Institutes of Health/National Institute of Allergy and Infectious Diseases: Questions and Answers: NIAIDSponsored Adult Male Circumcision Trials in Kenya and Uganda, Bethesda, 2006. International AIDS Society: Statement on New Studies Showing that Male Circumcision Substantially Reduces the Risk of HIV Infection Among Men, 2006. xii Williams, BG., James O. Lloyd-Smith, Eleanor Gouws, Catherine Hankins, Wayne M. Getz, John Hargrove, Isabelle de Zoysa, Christopher Dye1, Bertran Auvert, The Potential Impact of Male Circumcision on HIV in Sub-Saharan Africa, PLOS Medicine, 3(7): 2006: 1032-1040. Online at: www.plosmedicine.org. xiii Ibid. xiv A Gates-funded study by Ron Gray that is currently underway in Rakai will be able to measure the impact on infectiousness (Personal Communication, December 2006). xv Bailey RC, Plaummer FA. and Moses S.: Male circumcision and HIV prevention: current knowledge and future research directions, Lancet Infectious Diseases 2001; 1: 223231. xvi Cassell M.M., Halperin D.T., Shelton J.D. and Stanton D.: Risk compensation: the Achilles heel of innovations in HIV prevention? British Medical Journal, 332: 2006: 605-607. xvii Halperin DT, Fritz K, McFarland W, Woelk G. Acceptability of Adult Male Circumcision for Sexually Transmitted Disease and HIV Prevention in Zimbabwe. Sexually Transmitted Diseases April 2005; 32:4:238-239. xiii Soori N et al. Dynamics of male circumcision practices in Northwest Tanzania. STI 2001; 28:214-8. Bailey RC et al. The acceptability of male circumcision to reduce HIV infections in Nyanza Province, Kenya. AIDS Care 2002; 14:27-40. xix Kebaabetswe P et al. Male circumcision: An acceptable strategy for HIV prevention in Botswana. Unpublished manuscript (Also Abstract accepted for 2002 Barcelona AIDS Conference.) Fritz K et al. The feasibility of adult male circumcision for HIV prevention in Zimbabwe. (Submitted) xx Williams et al 2006 xxi Kahn J.G., Marseille E., and Auvert B.: Cost-effectiveness of Male Circumcision for HIV prevention in a South Africa setting. PLoS Medicine, 3(12):2349-2358. Online at: www.plosmedicine.org. xxii AIDSMark Project: Male Circumcision: Current Epidemiological and Field Evidence, Program and Policy Implications For HIV Prevention and Reproductive Health; Conference Report, 2002, Population Services International, Washington DC xxiii Cost and Impact of Male Circumcision in Lesotho, Swaziland and Zambia.
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Appendix V. Source and other References Reference Materials collected from Technical and Financial staff contacted on indicators, targets and unit costs Costing DSP Office Working Group: Ref Material 1) Plan for National Multisectoral Monitoring and Evaluation of HIV/AIDS 2006/7 - 2008/9 MoHSS Solitaire Press; Copyright MOHSS/DSP 2) National Malaria Policy, April 2005 Rep of Namibia: Copyright MoHSS/DSP 3) Namibian HIV/AIDS Situation and Gap Analysis Executive Summary, July 2006 MoHSS/DSP - RME 4) The GLOBAL FUND Round Six Proposal Form, May 2006 PMTCT Working Group: Ref Material 1) Guidelines for PMTCT: Dec 2004 2) Revised PMTCT - Plus Programme 2004 - 2013 3) Current ARV tender estimates 4) Food Security Worksheet 5) Global Fund Round 6 6) Proposed Guidelines for PMTCT, 2nd Edition, Nov 2006 7) Costs of Tests NIP 8) Costs of Drugs CMS VCT Working Group: Ref Material 1) VCT current status & gap analysis (2004-2013), Revised 5/7/2006 2) VCT Centres Reports 3) Government NPC,CBS, Population Projections 2001 - 2031, Jan 2006 4) NIP, Jan 2007 5) CMS, Jan 2007 ART Working Group: Ref Material 1) ART Circular of Lab Tests 2) ART Prog: Current Status Report & Gap Analysis 3) ART Cost Estimation Questionnaire 4) Projected ARV Quantification Figures FY 07/08 5) Table 4: Info on Health Professionals in Posts FY 05/06 Policy & Planning Group HRM/HRD: Ref Material 1) Estimates of Infrastructure Needs 2) HSS Current Status & Projections 3) Draft IMAI Roll-out Plan, June 2006 4) Facilities Report 2004 5) A record of all facility centers, hospitals & clinics. Training & Scholarships HRM/HRD: Ref Material 1) Info on Health Related Students under Training, 2006 2) HRD Action Plan for Support from CDC/I-tech, 2007

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Salaries & Benefits HRM/HRD: Ref Material 1) MoHSS Health Personnel Salary Scales for 1999 & 2006 2) Summary of Posts on Proposed staff Establishment MoHSS 2006 & 2007 3) Circular: Salary Budget Adjustment 2005/2006 MoHSS 4) Package of Medical Officers, Nurses & Pharmacists 2005 Disability Grants: MoL&SW: Ref Material 1) List of Regional Pension Offices (MoL) 2) Disability Grant 3) MoL: Funeral Benefit Programme 4) MoL: Re-registration of Pensioners 5) MoL: Old Age Grant 6) MoL: Customer Service Charter, Division - Social Welfare HBC & Palliative Care WG: Ref Material 1) Prepared by NEDICO Copyright: MOHSS/PHC 2) HBC: General Issues across all 13 Regions 3) HBC Volunteers & Clients as per Constituency - CAA 4) Community - Based Health Care - Report of an Assessment of Comm Volunteers, Dec 2006 5) Red Cross database 6) NANASO database 7) CAA database & info 2006 8) HBC Working Group 9) HBC Worksheet 10) HRM: Salary & Benefit Database TB Working Group: Ref Material 1) The National Strategic Plan on TB 2) National Guidelines for the Management of TB 3) WHO TB database Condoms & STI Working Group: Ref Material 1) Guidelines on STI 2) Strategy on Distribution of Condoms 3) NASOMA,SMA,DHS databases 4) Fillips Worksheet, STI workgroup on workshop 5) Global Fund Round 6 costing Food & Security Working Group: Ref Material 1) MGECW/WFP - out of school food distribution to OVC 2006 2) MoHSS/PHC - PMTCT data of 2006 3) MoHSS/PHC - PMTCT progress report(Jan-Dec 2006) 4) MGECW & WFP estimates 5) Civil society Guidelines WPP & Mainstreaming Working Group: Ref Material 1) The Namibian Labour Market - workers experiences and perceptions (LARRI), June 2004 2) The number of workers in public sector - source OPM 2006 3) The number of offices, ministries & agencies --source OPM 2006 4) The number of workers formally employed in private sector --source NABCOA,2006

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OVC Working Group: Ref Material 1) The NPC Central statistics 2) 2001 Census 3) Spectrum Projections from OVC Costing Study 4) MGCEW brochure on SWG, 2003 5) MGCEW 2005 OVC Costed Plan STI Working Group: Ref Material 1) STI Status & Gaps 2) Global Fund Round 6 Costing

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