HIV Experts Agree that Political Will and Leadership is Essential for Continued Sustainability

By Elise Lang, Health Policy Plus, Palladium

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A community engagement facilitator provides home-based HIV testing service to a woman in rural Malawi. Photo: © 2017 Nandi Bwanali/ONE COMMUNITY, Courtesy of Photoshare.

At UNAIDS’ three-day meeting convened in Geneva this April, I had the privilege of joining more than 75 experienced professionals to learn and discuss how major HIV donors and country-based leaders are approaching sustainable financing in the age of stagnating and uncertain donor support and ambitious targets to attain the Sustainable Development Goals. Among all the challenges to sustainably finance HIV, there was one area that appeared as a make-it-or-break-it input: political will.

In many countries, HIV is no longer considered an emergency. Incidence has decreased and people are being tested and connected to care and therefore it is no longer seen as the looming epidemic that it was twenty years ago. But at the same time, donor funds are stagnating and decreasing and developing country governments still face constrained resource envelops while HIV case finding becomes more costly (as incidence declines) and anti-retroviral treatment costs remain too expensive for many low- and middle-income country governments to cover alone.

As a result, there have been several efforts by development partners to invest in catalytic investments to spur domestic resource mobilization. The Health Policy Plus (HP+) project — and its predecessor the Health Policy Project (HPP) — both led by Palladium, have had the opportunity to implement country technical support in collaboration with these development partners. HP+ has seen first-hand that while 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, 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, HPP/HP+ advocacy efforts with the National Treasury and Parliament resulted in the restoration of a budget line of $US20 million for HIV commodities in fiscal year 2015/16, with additional commitments through 2021. Two years later, with HP+ support, the Ministry of Health successfully advocated to the National Treasury for an additional US$4 million for ARVs 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.

As countries move toward their visions for universal health coverage and improving sustainable financing, there were several areas that the meeting participants agreed were crucial:

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 needs to be engaged through more targeted and concerted efforts, particularly given constrained government resource envelops.

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, incentives, and targeted service delivery efforts, we risk losing the progress we’ve gained.

USAID-funded project strengthening and advancing health policy priorities in family planning/reproductive health, HIV, and maternal health

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