THE PROBLEM

While tremendous progress has been made over the past decade in raising the efficiency and financial sustainability of AIDS programs in low and middle income countries (LMICs), much remains to be done to achieve the global 95-95-95 targets and the elimination of HIV. Many countries most affected by HIV have increased their domestic financing through a combination of traditional (ie. health budgets) and innovative (ie. earmarked levies and health insurance revenues) sources over the past decade. This is putting many MICs in a strong position to transition from external financing while maintaining and expanding their efforts at epidemic control and elimination of HIV. Other countries that still depend heavily on donors and are unlikely to transition any time soon have committed to generate additional domestic funds for HIV.

In parallel, and conscious of the vigorous competition for scarce donor health and HIV assistance and of highly constrained fiscal space at home, LMIC countries have been working to identify ways to raise the efficiency of resource use for HIV. Efforts to streamline procurement and supply of drugs and other commodities, targeted testing and counseling strategies, adoption of prevention and treatment protocols that require fewer human resources, and integration of HIV into primary care services have helped to lower the cost of implementing HIV programs by 10-20% or more in some countries.

At the same time, there is much more to be done to advance this efficiency and sustainable financing agenda. Progress is challenged by numerous factors such as limited knowledge of best practices, entrenched bureaucracies, limited political will, incomplete coordination and most recently, the Covid-19 pandemic which is generating severe macroeconomic and fiscal impacts in many countries with high HIV burdens. Covid-19 is likely to reduce government budgets and disposable incomes normally fueled by remittances, increase unemployment, and add further stress to domestic allocations and spending decisions for health and HIV. Treatment and prevention could be disrupted, exacerbating the human toll of the epidemic.

Nevertheless, the newfound emphasis on increasing funding for health and social sectors presents an opportunity for UNAIDS to positively influence the funding available for HIV control through fiscal stimulus and debt moratoria. Covid-19 can spark a global movement to invest in health systems and infrastructure and strengthen the global HIV response.

THE PHAROS SOLUTION

Pharos Global Health Advisors has been engaged by UNAIDS to create a set of tools and methods for conducting analysis and policy dialogue on sustainable HIV financing and efficiency, extract key lessons from country case studies to inform support for high-burden countries in pursuit of global targets for 2030, and assist UNAIDS to articulate its stance on sustainable financing and efficiency in light of Covid-19.

In 2021, Pharos completed a synthesis of progress on HIV response efficiency and sustainability, including the UNAIDS contribution. This paper highlighted lessons learned with regards to a) cross-cutting themes in sustainability and efficiency, b) best practice solutions, and c) recommended ways to carry out the analysis and country dialogue to maximize influence on current and future work on HIV and health financing in the context of Covid-19. An excerpt of this synthesis report is attached to this page.

LOOKING AHEAD

This optimization of ongoing efforts to improve efficiency in HIV spending can have big payoffs for countries and institutions committed to achieving the global 2030 goals for ending HIV. This UNAIDS engagement has also spurred the recent publication in The BMJ by Shahid M, Bharali I, Hecht R, et al.

Status: Complete, September 2020 – June 2022
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Team Members Involved: Claire Young, Grace Chen, Robert Hecht

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