THE PROBLEM

Namibia is globally recognized as having one of the strongest HIV treatment programs and is one of the few countries on course to meet its 90-90-90 goals, with 86% of all PLHIV 15-64 years aware of their status, 96% of those aware on antiretroviral treatment (ART), and 91% of those on ART virally suppressed. New HIV infections have also declined from over 10,000 annually in 2010 to less than 6,000 in 2018, and prevention of mother to child transmission is nearly universal, with over 95% of pregnant women living with HIV on ART.

Despite these impressive achievements, the future of Namibia’s AIDS epidemic remains uncertain. The two main funders, PEPFAR and the Global Fund, have indicated that they plan to draw down their support to focus on other countries with weaker programs, with PEPFAR funding declining up to 10% per year from 2020 to 2024 and Global Fund support likely only to continue through the next funding cycle (2021-2023) and ending thereafter. At the same time, the government has faced slow economic growth and severe fiscal constraints over the past few years, with limited signs of improvement in the near future. In all, total funding for HIV is expected to fall by almost 30% by 2025, compared to 2018 levels.

Given the large burden HIV still places on society and the growing urgency to counter declining donor funds, sustainability planning has increasingly become more integrated into the HIV response framework in Namibia. Policy makers see sustainability planning, both from a financial and programmatic angle, as the critical step to achieving HIV epidemic control and simultaneously making progress on other health priorities, such as expanding universal health coverage in a resource limited setting. An update of the Namibia Investment Case from the Investment Case 1.0 undertaken in 2015-2016 has been identified a critical input to developing the national sustainability plan, because it will explore what the required resource levels and funding gaps would be over the next 10 years under different assumptions of program targets, efficiency, and external and domestic financing.

THE PHAROS SOLUTION

The Ministry of Health and Social Services, with support from UNAIDS, requested Pharos to lead this update of the HIV Investment Case in Namibia, building on Pharos’s robust investment case expertise and recent experience in Tanzania. The overall objective of Investment case 2.0 (IC 2.0) was to analyze options for Namibia to achieve its HIV/AIDS targets and goals under uncertain and likely declining donor financing, and to make recommendations that can be used in the national HIV sustainability plan, the next national strategic framework annual budgets, and the operational plans of PEPFAR and the Global Fund. The IC 2.0 findings can also be used by Ministry of Health and Social Services to advocate with the Ministry of Finance for funds to fight AIDS.

In collaboration with Avenir Health, six investment scenarios — two target-driven and four resource-constrained transition– were defined and modelled to inform sustainability planning:

• The Constant Coverage (CC) scenario was a baseline reference point that conveys the costs of inaction.
• The National Strategic Framework (NSF) scenario explored Namibia’s current national HIV targets and priorities for achieving 90-90-90 and 95-95-95 in the NSF 2017-2021/22, and calculated the related costs of achieving these targets using the current mix of interventions and unit costs, without any savings or reallocation of funds across activities.

Given the anticipated decline in donor funds, a series of transition scenarios examined future possibilities for the Namibia HIV program based on varying countermeasures by the government.

• “Transition to Domestic Responsibility with Minimum Response” (“Transition Minimum”) was a hypothetical worse-case scenario meant to illustrate what the impact of declining donor funding would be if there is no increased fiscal effort or program adaptation by the Government – an unlikely scenario but one that highlights the risks and losses that Namibia could incur if it does not act decisively to expand national resources to fight HIV.
• “Transition with Technical Efficiencies” (“Transition + Efficiencies”) showed how Namibia can enhance its HIV response by improving service quality and effectiveness (e.g. retention on ART improving viral suppression) and reducing costs of major interventions, thereby channeling savings to cost-effective services with unmet needs.
• “Transition with Optimization” (“Transition + Optimization”) demonstrated how limited funds can be stretched further by allocating resources to services with the highest cost-effectiveness to reach populations with the highest burden and at the greatest risk of new infections.
• “Transition + High Domestic Resource Mobilization” (“Transition + High DRM”) illustrated the additional benefits that increased domestic funds can have, when combined with technical efficiencies and optimization (reallocation) to help Namibia stay on track to reach its national HIV Strategy goals and targets on the path to controlling the epidemic.

Initial stakeholder consultations and feedback on this framework and scenarios were collected in July 2019. We conducted modeling and analysis in the fall of 2019, and a first draft of the investment case was presented in December 2019.

LOOKING AHEAD

The final validation meeting for the IC 2.0, originally planned for spring 2020, had been delayed due to the strains of the Covid-19 pandemic. Despite this setback, the IC 2.0 framework and analysis will become even more critical as Namibia emerges from its Covid-19 response and both domestic and external resources for health are even more constrained. Pharos remains in communication with the Namibia UNAIDS office to support efforts to disseminate and present the IC 2.0.

Status: Completed, June 2020
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Team Members Involved: Lindsey Hiebert, Steve Cohen, and Robert Hecht.

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