THE PROBLEM

Many low- and middle-income countries (LMICs) develop national strategies for HIV/AIDS. Multi-year national strategic plans (NSPs) articulate a set of objectives, interventions, targets, and timeframes for programs responding to a country’s HIV/AIDS epidemic. These plans impact the health and productivity of communities by guiding the decisions that governments, development agencies, nongovernmental organizations, and communities make for years at a time. Developed in a time when HIV was considered a global “emergency” and funding for HIV programs was rapidly increasing, the first generation of NSPs in the early 2000s typically did not focus on issues of economic efficiency or financial constraints. But, within a decade, as programs matured and as bilateral and multilateral donor investments in HIV/AIDS plateaued or decreased, consideration of cost became more salient. Today, most NSP development processes include an estimation of resource needs required to implement the strategy, some examination of opportunities to improve efficiency of resource allocation, and consideration of financial sustainability.

Despite the increasing importance of economic aspects of strategic planning, reviews of NSPs have often identified weaknesses in this area. Challenges that limit the quality of costing exercises include the availability of financial data linked to programmatic data, insufficient integration of the costing exercise with other aspects of NSP development process, and inconsistency in analytical methods.

THE PHAROS SOLUTION

We created a roadmap — published in Gates Open Research — to support organizational change initiatives aiming to improve capabilities and practices related to the analysis of HIV intervention costs and the management of cost information. Such organizational change initiatives may benefit a country as it prepares for greater local ownership of strategy development and improved management of HIV/AIDS program implementation. The roadmap provides a structured approach to diagnosing the status quo situation, and then to identifying, prioritizing, and sequencing actions within an action plan for the change initiative. Aiming to be both simple and useful in a wide range of settings, while also recognizing that readers of this roadmap represent and work in diverse contexts within their respective organizations and countries, our approach balanced prescriptiveness and flexibility.

The document is informed by country-level work we performed with a large consortium and with support of a grant from the Bill & Melinda Gates Foundation (no. OPP1212592). The consortium included: members of national AIDS councils (Kenya, Malawi), researchers (Harvard University, USA; HE2RO at University of Witwatersrand, South Africa), and consultants (Pharos Global Health Advisors, USA; independent experts based in Kenya, Zimbabwe, and Mozambique). Between 2019 and 2021, we supported HIV costing activities for national planning (Zimbabwe and Mozambique) and conducted assessments of the local capacity and practices for generating and using cost analyses in strategic decision making in other countries (South Africa, Kenya, Zimbabwe, and Mozambique).

LOOKING AHEAD

Readers and users of the roadmap may include government representatives, bilateral and multilateral donors, international and local implementing partners, and other stakeholders. The roadmap includes a guide and some tools for carrying out an assessment of a country’s current “ecosystem” for costing HIV programs. As well, this roadmap provides real-world examples from several countries in addition to describing the characteristics of a well-performing system that exemplifies best practices.

We aim to provide insights and instructions that enable organizations responsible for HIV strategy to undertake initiatives to assess strengths and weaknesses in local systems for generating and using cost data and analysis to inform strategic planning, and then develop and implement plans to improve these systems.

Status: Completed, July 2021 – March 2022

Team Members Involved: Robert Hecht, Stephen Resch, Joseph Corlis, Nathan Isaacs, Grace Chen

For more information, contact Robert Hecht at [email protected].