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

Speeches Shim

USAID supported the Government of Vietnam by providing technical assistance to the Ministry of Health and Vietnam Social Security to integrate HIV services into Social Health Insurance and the public health system.
USAID supported the Government of Vietnam by providing technical assistance to the Ministry of Health and Vietnam Social Security to integrate HIV services into Social Health Insurance and the public health system.
@HFG, Image by Linh Pham

As many PEPFAR-supported countries approach sustained epidemic control, there is a need to ensure the financial sustainability of programs providing life-saving services to people living with HIV/AIDS. Sustainable financing interventions will help countries sustain epidemic control over the long term. The COVID-19 pandemic has resulted in economies contracting and domestic fiscal space narrowing. As a result, government spending will be impacted and this could affect the HIV response because governments will have less ability to fund all priorities. Sustainable financing work will be important for finding efficiencies and allow country governments to make evidence-based decisions when programming health resources.

USAID Impact

As part of its overall approach to sustainable financing, USAID has led the coordination and implementation of PEPFAR’s Sustainable Financing Initiative (SFI), which aims 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 have 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.


Botswana Dominican Republic Namibia Tanzania
Cambodia Ethiopia Nepal Uganda
Cameroon India Nigeria Vietnam
Côte d’Ivoire Kenya Rwanda Zambia
  Asia regional program Caribbean regional program  
The Sustainable FInancing Initiative is making a difference in 16 countries and 2 regional programs.
The Sustainable Financing Initiative worked globally across 3 technical pillars

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:

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Public Financial Management:
Public Financial Management (PFM) helps mobilize country resources for the health and HIV response and 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.

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Private Sector Engagement: Public health facilities are often faced with constraints to provide quality health care services to 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.

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Financial Protection: Depending on the country, health insurance plans vary on benefits and eligibility available for PLHIV. Financing work on analysis and advocacy adds HIV services into existing health insurance plans, enrolls more PLHIV into health insurance, contracts HIV providers with plans, increases the efficiency of HIV commodity procurement, and increases domestic funding for HIV through the insurance plans. During the COVID-19 pandemic, financial risk protection for PLHIV is of even greater importance.


As SFI comes to an end in 2021, USAID is focusing on supporting PEPFAR country governments and USAID Missions to continue to support and expand sustainable financing activities in the areas of PFM, private sector engagement, and financial risk protection. USAID is also working with Missions and country governments to ensure sustainable financing work is included in country budgets. USAID will broaden its focus to several areas:

  • 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;
  • Increased use of a total-market approach to grow and strengthen commercial 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.

2020 Achievements

A few key achievements in 2020 include the following:

Public Financial Management:

  • Policy/advocacy support to the Government of Kenya resulted in a $114 million budget allocation to HIV commodities over a 5 year period, $80 million of which was ultimately expended.
  • SFI’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 Tanzania and Uganda and initiation in Kenya, Mozambique, and Namibia.
  • 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 51 HIV facilities contracting with the state insurance scheme and 223,000 individuals enrolled, who will now qualify for HIV testing services under the scheme.

Additional Resources

The Sustainable Financing Initiative:

SFI Technical Areas:

Last updated: September 13, 2021

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