Elise Lang | Palladium - Aug 26 2019
Donor Support for AIDS is Decreasing: What's Next?

A home-based HIV test, rural Malawi. Credit: © 2017 Nandi Bwanali/ONE COMMUNITY

Elise Lang recently attended the UNAIDS' Geneva meeting to discuss the future of financing HIV. Here she shares her reflections on what it will take to achieve sustainable financing and enduring results. 

In many countries, HIV is no longer considered an emergency. Incidence has decreased and people are being tested and connected to care at higher rates; it is no longer seen as the looming epidemic that it was 20 years ago.

While there has been considerable success, this does not mean that funding is no longer needed. HIV program costs remain significant and country governments are not prepared to replace donor funding at the same rate it is stagnating and decreasing. Developing country governments still face constrained resources, HIV case finding is becoming more costly (as incidence declines), and anti-retroviral treatment costs remain too expensive for many low- and middle-income country governments to cover alone.

To reach the ambitious Sustainable Development Goals in the age of stagnating and uncertain donor support, we need sustainable financing. This past April, I joined over 75 attendees at the UNAIDS' Geneva meeting to discuss the future of financing HIV.

Everyone at the meeting agreed on four critical components that needed to advance sustainable financing for HIV:

1. HIV needs to be included in broader discussions of universal health coverage and health financing and not siloed. HIV advocates need to be health advocates.

2. Civil society organizations need continued support, not only for service delivery to key populations, but also in their role as watchdogs. Public funding for NGO-led HIV programs (also known as "social contracting") is an opportunity for governments to support civil society, but funding for advocacy also needs to come from non-governmental sources.

3. Public health professionals and policy makers need to continue to advocate for reform and support for key population groups and creating an enabling environment to reach them with high-quality services. Given the current political climate and an increase in criminalization and human rights abuses, the need to protect the progress made and ensure continued progress and outreach to key populations is more important than ever.

4. The private sector, including private healthcare providers and facilities and private corporations, needs to be engaged through more targeted and concerted efforts, particularly given constrained government resources.

Political Will and Leadership

Political will and leadership are essential to moving these initiatives forward and creating lasting commitments and strategies to finance HIV programming. There have already been several efforts by development partners to make catalytic investments to spur domestic resource mobilization on the path to sustainability and self-reliance. The Health Policy Plus (HP+) project has seen first-hand that developing impact models, conducting costing and efficiency analyses to inform advocacy, and developing the capacity of civil society organizations to advocate may be essential to realizing progressive policy reform. But if high-level decision-makers are not on board, change will never be realized.

Many times, these catalytic activities are successful and have a positive impact. In Kenya, for example, advocacy efforts with the National Treasury and Parliament resulted in the restoration of a budget line item of USD 20 million for HIV commodities in fiscal year 2015/16, with additional commitments through 2021. Two years later, the Ministry of Health successfully advocated to the National Treasury for an additional USD 4 million for anti-retroviral therapy and test kits.

But sometimes these catalytic successes are not enough. Development partners have the opportunity to do more to create social value by coordinating and aligning incentives to encourage government decision-makers and develop concrete plans for reducing donor dependence. For example, if one donor pushes a country government to take over a percentage of the commodity cost, while at the same time another donor continues to fund at the same level or without increasing co-financing requirements, there is little incentive for the country government to make an effort to correct inefficiencies or mobilize new resources to support HIV.

It was clear from participant examples from Latin America, Thailand, and Cambodia that the road to reducing donor dependence is long. It requires early development of a clear transition plan agreed upon by all parties and funding for that plan. It requires following multi-year policy pathways to, for example, integrate HIV services in Thailand’s national health insurance benefit package. It requires open dialogue and rapport between the ministries of health and finance, and transparency and accountability of the budget.

While living with HIV today is different than decades ago, there were still almost two million new infections worldwide in 2017. Incidence is increasing in Eastern Europe and the Middle East and we are far from reaching the UNAIDS 90–90–90 targets, let alone the 95–95–95 targets. Without conscious collaboration efforts, political will, catalytic investments, aligned incentives, and targeted service delivery efforts, we risk losing the progress we’ve gained.

This article originally appeared on Medium and was adapted with permission.