Engaging the private sector to increase access to HIV services and increase sustainability of the HIV response

Addressing the HIV/AIDS investment gap through stronger public financial management systems: a human-centered approach

BACKGROUND

UNAIDS estimated that US$29 billion will be required by 2025 to meet HIV/AIDS service demands, with 53 percent expected to come from domestic sources. The PEPFAR-funded, USAID-implemented Sustainable Financing Initiative for HIV/AIDS (SFI), starting in 2014, supported domestic resources mobilization efforts and activities to strengthen countries' public financial management (PFM) systems, positively contributing to much-needed increase in domestic resources for health and HIV.

PROGRAM APPROACH

SFI was implemented in 12 countries, supporting activities to build the capacity of governments to mobilize domestic resources for HIV, improve budget absorption, and maximize resource use and develop and use evidence for advocacy to increase domestic government funds for HIV/AIDS. SFI measured impact by agreed upon indicators and estimated return on investment (ROI).

RESULTS

Eight countries focused on building capacity to improve budgeting and execution of health and HIV/AIDS funds; five experienced increases in budget allocation and spending. Kenya country governments spent an additional US$180 million and US$8.7 million on health and HIV, respectively. This contributed to US$60 mobilized and spent for every SFI dollar invested. Eight countries focused on using evidence to advocate for more domestic resources for health and HIV/AIDS from government budgets, increase budget execution, and identify areas for efficiency. Cambodia saw an increase in government commitments for ARVs from US$1.5 million annually from 2018-2020 to US$5 million by 2023.

LESSONS LEARNED

Robust data are needed for evidence-based advocacy to increase domestic government funding for HIV/AIDS and to strengthen PFM systems for more efficient and effective resource use; institutionalizing capacity building efforts allows for locally-led technical assistance; policy-related work is a multi-year endeavor; PFM success can be stymied by political transitions, political will, and donor commitments; COVID-19 brought new challenges and new opportunities; measurable results can lead to greater impact; and results are not necessarily solely project attributions with possible inflation of ROI estimates given there was no counterfactual.

CONCLUSION

Strengthening PFM systems can increase domestic resources for health and HIV through increased revenue and improved efficiency; closing the investment gap to end the HIV/AIDS epidemic by 2030.

Integrating HIV/AIDS services into financial protection systems to increase sustainability of the HIV/AIDS response

Begun in 2014, the Sustainable Financing Initiative (SFI) was dedicated to mobilizing domestic resources for the HIV response. Among its three programmatic pillars was a focus on ensuring financial protection for people living with HIV (PLHIV). SFI's activities were founded on a strong understanding of and alignment with partner government priorities, as well as costing and actuarial analyses, which allowed for the development of context-specific approaches for improving financial protection for PLHIV. SFI implemented financial protection activities in a total of nine countries; the five countries with the most substantial investments are discussed in this paper. In Vietnam, SFI's support helped the country to integrate almost all outpatient HIV treatment facilities into the public health system, attain enrollment of 90% of PLHIV into Social Health Insurance (SHI), and increase domestic funding for HIV through SHI. In Cambodia, SFI supported the development of a guiding framework for integration of HIV/AIDS services into the existing health system; key achievements included a policy change that expanded eligibility for the country's Health Equity Fund, allowing all PLHIV to access free health services. In the Dominican Republic, SFI support led to the inclusion of antiretroviral drugs in the family health insurance benefit package, increased enrollment of PLHIV in health insurance, and expanded care options through non-governmental organizations. In Nigeria, SFI's support helped to enroll more than 600,000 people and empanel 216 health facilities into the Lagos State Health Insurance Scheme. In Cameroon, SFI support helped the government achieve stepwise progress on key building blocks of its planned new universal health coverage system; SFI contributed to the development of a consolidated package of services, standardized care and service protocols, and accreditation criteria. SFI's investments in financial protection demonstrated that with strong political will; long-term engagement with partner governments; and focused technical assistance for advocacy, policy reform, and implementation support, HIV services can be successfully integrated into financial protection systems. Such integration can promote increased, long-term domestic financing for HIV while also protecting PLHIV from financial risk.

Innovative approaches to HIV/AIDS financing: lessons learned from the Sustainable Financing Initiative (SFI)

INTRODUCTION

As of 2018, domestic resources covered 56% of the total financing for the HIV/AIDS response in low- and middle-income countries (UNAIDS, AIDSInfo - Global data on HIV epidemiology and response, 2021). This has not been sufficient to close the financing gap as donor funding, such as PEPFAR, flatlines or declines in many countries. The Sustainable Financing Initiative (SFI) was a PEPFAR-funded, USAID-led initiative aimed at leveraging the rapid economic growth in many focus countries to increase domestic funding for HIV/AIDS.

METHODS

SFI worked with ministries of health and finance, the private sector, and other critical stakeholders to implement innovative health financing solutions aimed at increasing domestic spending on HIV/AIDS. Three core areas were emphasized in SFI's approach: improved public financial management, integration of HIV services into social health insurance schemes, and greater private sector engagement in the financing and delivery of HIV services. SFI supported these areas through advocacy, evidence generation, strategic engagement with country governments, the use of metrics to measure results, willingness to take measured risks, and the readiness to stop funding activities that did not yield results. Through new partnerships and ways of doing business, SFI worked to increase the efficiency and sustainability of the HIV response. A core principle underlying SFI was to make system changes that would lead to sustained long-term increases in domestic spending on HIV/AIDS.

RESULTS

SFI invested PEPFAR funding across sixteen countries and two regional programs to leverage domestic resources for HIV/AIDS and improve approaches to health financing. With an investment of $47.8 million, SFI generated an estimated $393 million in domestic resources for HIV. Additionally, SFI interventions yielded significant results globally, generated lessons learned and made strides towards improving sustainability of HIV programming.

CONCLUSION

By implementing innovative approaches to HIV financing and how interventions are designed and implemented, PEPFAR funding can leverage additional resources from host-country governments and the private sector for a more sustainable HIV response.