Sustainable Financing: Controlling the HIV/AIDS Epidemic through Shared Responsibility

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Caption: A healthcare provider counsels a patient on how to take their HIV medication.
Credit: GHSC-PSM 

As many PEPFAR-supported countries approach sustained epidemic control, there is a need to ensure the financial sustainability of the HIV response which provides life-saving services to people living with HIV/AIDS. Sustainable financing is critical for countries to facilitate the delivery of HIV services through routine primary healthcare  and sustain epidemic control over the long term. The economic downturns caused by the COVID-19 pandemic added severe constraints to countries with already vulnerable health systems struggling to finance their health sectors. Many country governments borrowed to maintain the delivery of essential health services and finance the COVID-19 response. Now, and just as countries were emerging from the economic shock of the COVID-19 pandemic, the prices of food and energy have skyrocketed and supply chains are disrupted by world events. This matters for  the HIV response because higher interest payments on public debt limit government capacity to fund all priorities. Sustainable financing work in both the public and private sectors will be important for finding efficiencies in how existing resources are used, identifying the potential for new sources of financing for health, and supporting country governments to make tough choices based on evidence when prioritizing and programming health resources.

USAID Impact

As part of its overall approach to sustainable financing, USAID led the coordination and implementation of PEPFAR’s Sustainable Financing Initiative (SFI), which aimed to increase domestic resources through improved public financial management and effective advocacy, to reduce financial risk to people living with HIV/AIDS (PLHIV), and to advance private sector engagement in support of sustainable HIV/AIDS services. A unique cross-cutting initiative, SFI deployed technical expertise from USAID staff and implementing partners to innovate, pilot, and scale new financing approaches to help countries achieve and sustain an AIDS-free generation. SFI’s efforts helped selected PEPFAR countries expand domestic financing of HIV/AIDS services through improving the management of existing and newly committed resources, leveraging the unique advantages of the private sector, and expanding health insurance benefits for those living with HIV.

Investing $47.8 million over six years, SFI supported 16 countries and two regional programs to further mobilize their own resources to address the needs of people living with HIV/AIDS.

USAID focuses on three approaches to mobilize and more effectively use domestic resources for HIV/AIDS. The mix of these interventions was uniquely tailored to each country’s context. Sustainable financing interventions supported through SFI include:

Public Financial Management: Public Financial Management (PFM) helps national and sub-national governments mobilize, allocate, spend, and account for public resources. Sound PFM is essential for the health and HIV response to ensure that spending is in keeping with budget ceilings, that budget resources are aligned with government priorities and deliver good value for money for the public. USAID helps governments to maximize the impact of existing investments by providing technical assistance and training on budget allocation and execution to government officials and other stakeholders at the national, sub-national, and local levels. USAID’s work also improves data systems that are used to support evidence-based advocacy, policy change, and decision-making that lead to better financial planning, budget monitoring, and spending for HIV.

Private Sector Engagement: Public health facilities are often faced with constraints to provide quality health care services to people living with HIV (PLHIV), while private health facilities remain relatively untapped resources. Sustainable financing work on policy/advocacy efforts, training, and capacity building enables the private sector to deliver high-quality HIV services to vulnerable populations. USAID’s work also unlocks innovative financing options to help private HIV service providers access capital so that they can serve more people. Through effective collaboration with the private sector, sustainable financing work helps more PLHIV to get the care they need.

Financial Protection: When direct payments for health services do not expose people to financial hardship, financial protection is achieved. Many countries design health insurance plans to advance financial protection, which is a foundational element of universal coverage. Health insurance plans are one way that countries can pool resources for health and ensure prepayment for healthcare, so that people do not face high out-of-pocket spending at the time of care. However, depending on the country, health insurance plans vary on benefits and eligibility available for PLHIV. Adding HIV services into existing health insurance plans, enrolling more PLHIV into health insurance, contracting HIV providers with plans can be achieved through advocacy efforts supported by strong analytics, and can facilitate country efforts to improve the equity, quality, and affordability of service delivery for PLHIV.

• Innovative financing opportunities to increase the volume of private capital available to support HIV programs and services;
• Continued diversification of funding streams to ensure the sustainability of key population civil society organizations;
• Grow and strengthen markets for HIV services and commodities in order to improve the sustainability of the HIV response by improving the availability, affordability, and quality of privately-financed and delivered HIV services and products.

2022 Key Achievements

Public Financial Management:

• USAID’s financial support and technical leadership for Activity Based Costing and Management (ABC/M), an S/GAC-led initiative that captures a holistic picture of real costs of the HIV program more routinely, led to its implementation in Kenya, Mozambique, and Namibia and the analysis of early findings in Tanzania and Uganda. USAID brought together 99 stakeholders and policymakers from eight sub-Saharan African countries (Tanzania, Kenya, Uganda, Mozambique,

Eswatini, Namibia, Lesotho, and Botswana) to establish and launch a Regional Technical Network (RTN) that will focus on issues of HIV and broader health financing. This first RTN meeting held in Dar es Salaam addressed Optimizing Alignment, Efficiency, and Effective Use of HIV and Broader Health Resources. 

• In Namibia, USAID is supporting the Government of the Republic of Namibia (GRN) to progress towards universal health coverage. Through technical assistance to and in collaboration with the Ministry of Health and Social Services (MOSS), USAID outlined an iterative process to support budgetary allocation decisions aligned with regional populations and needs as prioritized in the essential health services package. USAID also assisted GRN to identify health sector budgeting reforms which could improve the efficiency of how financial resources for health are allocated.
• Resource Alignment: PEPFAR, in partnership with The Global Fund, launched the Resource Alignment collaboration in 2017. This multi-year effort has allowed countries to better understand the funding landscape and to make strategic decisions about resources. It has also helped to avoid duplication by donors, drive efficiency, ensure spending is in line with program priorities to ultimately ensure financial and programmatic sustainability of HIV programs.

Private Sector Engagement:

• An additional nine countries formed partnerships with networks of private pharmacies, clinics, and labs to provide ARVs, PrEP and viral load testing through the decentralized drug distribution (DDD) program. These countries rapidly scaled DDD in response to COVID-19 to ensure patients could safely access medication.
• In India, SFI supported the design of a strategic purchasing partnership with the Government to increase availability and affordability of HIV services and commodities in the private sector.
• In Kenya, SFI supported the development of a policy framework for private sector health services, which will provide a platform for greater engagement of the private sector in Kenya’s HIV programs and support Kenya’s goals for universal health coverage.
• Within PEPFAR’s Asia Region, SFI is supporting the development of a financial sustainability framework for key population civil society organizations, including private sector approaches such as social enterprise--models where CSO develop funding streams beyond government funding to become financially independent.

Financial Protection:

• In Nigeria, SFI supported development and endorsement of a National Blueprint for HIV Integration in health insurance plans. In Lagos state, support to implement this roadmap resulted in 230 HIV facilities contracting with the state insurance scheme and 686,267 individuals enrolled, who will now qualify for HIV testing services under the scheme.  Efforts are now underway to support a similar scale-up in Kano state.
• USAID continues to support the Government of the Republic of Cameroon as it prepares for the 2023 roll out of its national universal health coverage (UHC) program.  USAID has supported a range of key functions, from the development of a UHC investment case, a consolidated package of services, and health facility accreditation tools to strategic communications support. 
• USAID continues to support the Vietnam Administration of AIDS Control (VAAC) to integrate all HIV treatment facilities into Vietnams’ social health insurance scheme

Additional Resources
The Sustainable Financing Initiative:

• SFI Global Brief - 2021
• SFI Infographic - 2021
• SFI Final Report - 2021

SFI Technical Areas:

• Public Financial Management - 2021
• Private Sector Engagement - 2021
• Financial Protection - 2021