THE PROBLEM

Over the past twenty-five years, Tanzania has made significant progress in reducing new HIV infections and averting AIDS-related deaths by expanding prevention, testing, and treatment services. The number of new HIV infections has fallen from 120,000 annually in 2000 to 65,000 in 2017, and the number of AIDS-related deaths recorded in recent years is less than half the number in 2010.

Looking to 2030 and the next phase of the response, Tanzania has committed to reaching epidemic control and achieving ambitious Fast Track and 95-95-95 targets. To meet these goals, the national program will have to address major challenges and overcome new constraints. Only 61% of People Living with HIV (PLHIV) are aware of their status – much needs to be done to find the missing infections and link these PLHIV to treatment. The HIV financing outlook is also worrisome as donors are now signaling that their contributions have likely reached a ceiling and may decline in the future, at a time when external funding accounts for 90% of the more than $500 million being spent each year to fight AIDS and the Tanzania government is only contributing 10% of the total.

As Tanzania seeks to sustain its national program and achieve ambitious coverage goals for 2030, policy makers will have to be prepared to close coverage gaps with current or possibly lower financial resource levels. Uncertainty about the future of donor funding must also be taken into account, as the two main sources — PEPFAR and the Global Fund – have signaled that their support may decline in the coming years.

THE PHAROS SOLUTION

The Government of Tanzania through its National AIDS Council and with support from UNAIDS, requested assistance from Pharos and Avenir Health in updating and creating a new Investment Case relevant to changing national conditions and suitable as an input to shaping government policy and strategy, government budgeting and Global Fund grant proposals. An investment case was published in 2016 to help guide policy and investment decisions for maximizing impact, but constrained resources did not factor in the analysis and the resulting “price tag” turned out to be too high to be implemented. The new IC 2.0 developed by Pharos needed to be a high-quality product that could build consensus among stakeholders about the path forward and inform key processes such as the costing of the Multi-Sectoral Framework and the Health Sector HIV and AIDS Strategic Plan, Tanzania’s next grant request to the Global Fund, and the PEPFAR COP. Stakeholders asked Pharos to develop scenarios that would be ambitious but also consider stagnant or falling donor funds and a tight fiscal environment within Tanzania.

Based on wide consultation involving Government, USG, Global Fund, private sector and NGOs in November 2018, it was agreed that IC 2.0 should:

• Explore various options and make a strong case for continued investment in high impact, highly efficient HIV program areas that would enable the country to achieve its goals as spelled out in key national documents (e.g. NMSF, HSHSP) and sustain these outcomes over time.
• Present realistic long-term scenarios that estimated coverage, impact, cost, value for money, and financing arrangements, to aid consensus and decision-making.
• Explore opportunities for greater allocative efficiency across prevention interventions and increase technical efficiency gains that could generate savings under conditions of highly constrained resources
• Provide evidence-base for key messages regarding: The value of financial investments in HIV response; the cost and affordability of these investments; the consequences of inaction or failure to implement certain levels of investment; and the importance and value of enabling policies (related to gender, legal and regulatory environment, etc.)

During the first half of 2019, the Pharos team modeled five scenarios proposed by the Tanzania AIDS Commission, National AIDS Control Program, and key partners including PEPFAR and the Global Fund: (1) maintaining Constant Coverage; (2) implementing Tanzania’ current National Strategy; (3) making the most of the funds needed for Constant Coverage through Optimization (4) Optimizing impact with Declining Donor Funds; and (5) Optimizing impact with falling donor support but with the Government stepping in to Mobilize extra Domestic Resources.

The IC 2.0 was presented and validated at a stakeholders meeting hosted by TACAIDS in July 2019 in Dodoma, Tanzania. The final version consists of both a full technical report and a shorter, advocacy document.

LOOKING AHEAD

As time counts down to 2030, Tanzania faces stark choices for its HIV response. The country needs to adopt measures to optimize the value of every dollar spent, achieve the maximum impact in preventing new infections and put more PLHIV on ART. At the same time, the Government must mobilize additional domestic funding to sustain and deepen its HIV program, especially in the face of likely declines in donor financing. IC 2.0 provides Tanzania with the options to design its HIV roadmap for the coming decade.

Status: Completed, August 2019
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Team Members Involved: Lindsey Hiebert, Stephen Resch, Carl Schutte, and Robert Hecht.

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