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Options and Opportunities
  1. Key Information
  2. Financing Essential HIV Services: A New Economic Agenda
  3. RethinkHIV: Smarter Ways to Invest in Ending HIV in Sub-Saharan Africa
  4. RethinkHIV

Future treatment costs remain unaddressed with short-term funding cycles. There is a moral obligation to maintain treatment for those who need it, and considerable resources have been implicitly pre-committed to lifelong HIV treatment and care. In countries such as Swaziland and Uganda, the fiscal liability the commitment to lifelong treatment creates is substantial—and for the next two decades may be up to three times annual gross domestic product GDP [6].

In most low- and middle-income countries, domestic financing is pivotal to funding the HIV response. While external financing accounts for two-thirds of HIV investment in sub-Saharan Africa, more than two-thirds of general health expenditure is financed from domestic sources, funding the health systems upon which HIV services rely [7]. However, the amount of revenue governments can raise from taxes is constrained due to the risk of excessive taxation dampening nascent economic growth. It can therefore be challenging to identify additional domestic budgetary flexibility for investments in HIV, without compromising fiscal stability [8].

Nevertheless, there is potential from the positive economic growth and rising domestic tax revenues forecast in a number of sub-Saharan African countries [9]. External borrowing can also generate revenue, particularly where there are economic returns to HIV programmes [12]. However, for many low-income countries with high debt-to-GDP ratios, the room to absorb additional lending remains limited [8]. Governments' capacity to generate revenue is higher than reflected in tax revenue estimates, particularly in oil-producing countries that directly collect profits from oil production.

However, most of these countries had data on tax revenue expressed in percent of non-oil GDP only and were therefore excluded for comparability e. The remaining countries where oil was a source of revenue were Cameroon and Cote d'Ivoire, although for the latter, most of the oil revenue was through taxes except a small contribution from oil company dividends. Tax revenues are from the latest year available between the five-year period from to For Uganda and Madagascar, this meant using the IMF projected estimates for , rather than the actual value, while for Kenya, it meant using the IMF estimate for — Economic constraints in high-income countries appear to be resulting in a flat-lining of development assistance to health DAH [13].

Non-health development priorities are dominating the post agenda for sustainable development, with only one out of 11 thematic groups addressing health [14]. Moreover, the value of providing development assistance to middle-income countries is being challenged, leaving some high-prevalence countries, such as South Africa, with the prospect of funding much of their own HIV response [15].

The financing for HIV may be better sustained, planned for, and absorbed if it becomes part of the broader shift towards investing in the shared responsibility for universal coverage of essential health services [16]. A long term approach, fully embedded in national expenditure frameworks, may also reduce any substitution effect, whereby external financing replaces domestic financing for HIV [17]. Countries are ordered from lowest to highest adult HIV prevalence estimates.

HIV spending is from the latest year available — , while health expenditure data are estimates. Innovative revenue streams are currently being explored in several countries. The development of social health insurance could help attract further household resources and may be an important new source of financing in middle-income countries as development assistance scales down [16].

However, none of these options is without challenges. Earmarking restricts the ability of governments to allocate funds efficiently across sectors, and may create a disincentive to use broader tax revenues to fund the HIV response. Health insurance presents considerable challenges in terms of ensuring sustainability, equity, and financing the care of chronic illness. Each of these options therefore needs to be carefully evaluated within the broader framework of health financing reform and on a country-by-country basis. Financing the HIV response must also be achieved without damaging investments in health systems more broadly and other development sectors that are essential for social welfare in turn addressing a number of the barriers to scaling up the HIV response [5].

An HIV programme may have important external benefits for sexual and reproductive health; maternal and child health; or provide the necessary health system platforms for managing chronic conditions [23]. Similarly, investments in strengthening health systems or addressing related co-morbidities that compound HIV vulnerability or worsen treatment outcomes are critically important to individuals living with HIV.

This amount exceeds the relative burden of HIV disability-adjusted life years DALYs [24] and is at least partly due to the relatively high costs of HIV treatment compared to treatment for other prevalent diseases.

Key Information

There remains a difference between the amount spent on the HIV response across countries with a similar GDP per capita and HIV prevalence Figure 3 , and more work is required to understand the optimal level of domestic resourcing for HIV, given competing health sector priorities. Ministries of finance and donors can be reluctant to allocate more resources to the health sector, when funds remain unspent. Even with political will, limited capacity to effectively spend funds in the health sector can lead to chronic under-spending [25] , further illustrating the importance of ensuring that key bottlenecks in broader health systems are fully addressed.

Stigma and ignorance about HIV in South Africa - BBC News

It is now critical to take advantage of the wider benefits generated by some HIV investments and adopt new co-financing approaches between HIV and broader development programmes. For example, programmes that improve livelihood opportunities or help keep young girls in school may yield HIV as well as development benefits [20]. However, at present, the sector-specific perspectives that dominate priority-setting are not designed to recognise and harness such opportunities [26]. Interventions with direct HIV outcomes may, for example, appear more attractive than interventions that could have more structural and long-term benefits for the health or government system as a whole [27].

Approaches through which various sectors pool funds or engage in joint budgeting to fund interventions with multi-sectoral benefits can be found in high-income countries [28] , and are worth exploring. Advocacy pleas for continued funding for the HIV response will also no longer be sufficient without parallel demands for increased efficiency in their use [5]. Improving efficiency is about preventing more new infections and saving more lives by doing the right things for the right populations, as well as delivering quality services at the lowest cost.

Good governance is a pre-requisite given that sustaining financing from both domestic and external financing sources is hard to justify when a substantial leakage of funds exists [29].

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Blueprint HIV programmes may have resulted in inefficiencies in resource allocation between different HIV interventions, and left some highly vulnerable groups under-served [30]. Increased attention needs to be placed on prioritising those interventions with proven effectiveness resulting in the best patient and population-level outcomes within the resources available.

While there has been success in recent years in improving the efficiency of HIV service providers [2] , programme costs still require careful scrutiny. Reducing the distortions and duplication inherent in parallel management systems [27] —originally necessary to initiate the rapid scale-up of HIV services—could help redirect scarce resources towards direct service delivery. Improved organisational structures for example providing integrated service platforms and community-based delivery may also reduce costs to the health system and patients [5] , [31] , but these gains have yet to be demonstrated at scale.

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  • RethinkHIV: Smarter Ways to Invest in Ending HIV in Sub-Saharan Africa.
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Adjusting to this new and complex reality will require a concerted global effort to support countries to fully institutionalise their response within domestic governance structures, and move beyond a silo HIV approach. Domestic finance ministries, who will increasingly be at the front-line of the fight against HIV, will need to be supported with new economic, epidemiological, and developmental evidence on how to harness each of these potential areas for increased financing in a way that reflects their national contexts.

This effort will not be without major technical, political, and economic challenges.

Financing Essential HIV Services: A New Economic Agenda

The magnitude of the conflict between current commitment levels and long term fiscal liabilities is substantial. Increasing domestic financing, improving efficiency, and adopting a bold and innovative financing framework will be central to success. However, none of these options are easy for governments to implement. Increasing domestic financing, particularly in low-income countries, will require creative solutions to ensure the poor are not negatively affected. In some middle-income countries, efforts to increase domestic financing will require a paradigm shift in the HIV community; moving away from highlighting resource needs, towards participating in national planning processes and offering solutions that resonate with those working in broader development policy.

RethinkHIV: Smarter Ways to Invest in Ending HIV in Sub-Saharan Africa

Efforts to improve efficiency will require impartiality to examine trade-offs from spending in one area of HIV response compared to others, some of which may be unpalatable to different domestic interest groups. HIV programmes will need to conduct an open, critical examination of their relative costs compared to other development programmes.

In order for donors to champion additional external financing, collaboration, rather than competition, with other development orientated interest groups will be required. The relationship between donors and national governments will need to be carefully navigated and may become increasingly complex as governance becomes central to any offer of co-financing.

Finally, the same level of innovation that has produced some of the best HIV technologies will now be required to fund and sustain their use. To address these challenges there is now an accentuated need for more and better evidence that speaks to the needs of policymakers at the country level.

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  • Options and Opportunities.

Key evidence gaps include: better understanding how the HIV response can interact with the broader health system and other development sectors; the accurate estimation of the magnitude of the current and future fiscal commitments and financing gaps; and evaluating opportunities for optimising efficiency in service delivery and new financing modalities. The site uses cookies to offer you a better experience. By continuing to browse the site you accept our Cookie Policy, you can change your settings at any time. In stock online Free UK delivery Usually dispatched within 24 hours.

Quantity Add to basket. This item has been added to your basket View basket Checkout. Your local Waterstones may have stock of this item. In this book, Bjorn Lomborg brings together research by world-class specialist authors, a foreword by UNAIDS founding director Peter Piot and perspectives from Nobel Laureates and African civil society leaders to identify the most effective ways to tackle the pandemic across sub-Saharan Africa.

There remains an alarming lack of high-quality data evaluating responses to HIV. We still know too little about what works, where and how to replicate our successes.


This approach provides a provocative fresh look at the best ways to scale up the fight against this killer epidemic. This pioneering work shows how economic analysis can contribute to a prioritisation for spending in this vital area. It will be invaluable to those funding both research activities and healthcare programmes in Africa. Added to basket. How to Survive a Plague. David France. Somebody I Used to Know. Wendy Mitchell. Never Enough. Judith Grisel. Tove Ditlevsen. Drugs Without the Hot Air.

David Nutt.