A statement by the Dr. Ruth Laibon Masha, Chair of the HIV Multi-sector Leadership Forum at the 54th meeting of the UNAIDS Programme Coordinating Board (PCB) on 27 June 2024.
When I was asked to speak at this segment of the UNAIDS PCB, I was honored.
But this invitation triggered a series of consultations. I have been privileged to serve in multiple capacities for the HIV response and in my reflection, I realised there has been something off about the current approaches to this important progressive movement for a single disease in our lifetime.
My consultation processes began with the question, ‘what is this agenda about?’ I reflected on Mark Heywood notes for input to ICASA Symposia, 9 December of Michel Sidibe, World AIDS Day statement, 2013: The end of AIDS? Reality or Myth? “For the first time we can see an end to an epidemic that has wrought such staggering devastation around the world. For the first time we can say that we are beginning to control the epidemic and not that the epidemic is controlling us. The world is poised to end AIDS….”
To consider whether we are getting to the end of AIDS, we have to reflect what AIDS looked like in the beginning. We reflected and queried, “Do the targets roadmaps reflect this concepts or are they pathways to get there?” We also reflected on the diverse terminologies we are applying as we navigate the sustainability discourse.
1. Explored the dictionary meanings of the words that are used in this discourse: sustainability, transition, country-ownership, resilience
2. Found that the common actors in the literature in relation to these words are, UNAIDS, Global Fund for HIV, Tuberculosis and Malaria, PEPFAR and USAID, and their descriptions of these words,- and finally
3. I engaged with colleagues from the HIV Multisector Leadership Forum, a community of practice of Director Generals of National AIDS Coordinating Agencies, across Africa, Asia and Latin America, hosted by the Global HIV prevention Coalition, as well as other forum such as the Africa HIV Control Working Group that is headed by Dr. Izukanje.
My reflections and statement today are informed by the above and in particular, by countries.
1. We acknowledge and appreciate the financial, technical and human resource investments over the last 3 decades from global and country level to the HIV response had incredible results for both people, communities and health systems.
2. The agenda on sustainability is more than two-decades old and has been coined in different terminologies over that period, - country ownership, country innovative financing, country investment cases, country efficiency studies, country transition plans and the current discource of country sustainability roadmaps. But has remained elusive.
When I posed questions ‘What does a future HIV programme look like when it is sustained for each country?’ and ‘Why, after decades of investments, has the sustainability agenda remained elusive?’ The responses were varied, but I consolidated the following challenges-
i. A collective lack of shared vision, common understanding or common end goals of ‘sustainability’.
Stakeholder opinions of sustainability differed. For some, it was about global guidance documents, donor driven country plans, new sets of targets, replacement of funding streams, co-financing, working with less money or end of aid? However, there is consensus that true sustainability has remained elusive.
ii. The sustainability discourses are often characterised by a 'one-size-fits-all' approach overlooking the diverse contexts of each country including unique macro-economic, political, legal, and social environments that guide its public health investments. They fail to account for three key transitions that are experienced uniquely by each country.
Epidemic transitions- the interaction between HIV epidemics and syndemics—such as drug and substance abuse disorders, poverty, tuberculosis and sexually transmitted disease and other social determinants are experienced differently in each country. Emerging efficacious technologies and monitoring science for AIDS has been adapted differently leading to varying progress. Although we have made overall gains in life expectancy and quality, annual new HIV infections seem to be stagnating at 1.3million people globally and this manifests uniquely across geographies and populations. Despite this, we are leaving HIV primary prevention behind. This is a real threat to sustainability.
Demographic Transitions- Country experiences with HIV incidence, quality of life or all-cause mortality among persons living with HIV are influenced by demographic shifts. For instance, new infections in general population remain largely in women, but are now seen in the ages above 24 years and ageing PLHIV facing non-communicable diseases.
Economic transitions- The effects on health are shaped by a country’s fiscal policy, allocation priorities and funding for health care. At the global level, evolving directions in the ODA landscape impact donor policies at country level in terms of aid, grants and loans and attendant conditionalities. The reliance of health, and specifically HIV on ODA, means that countries are susceptible to these changes.
iii. Countries lack clear information on the true costs of managing HIV services utilising national systems. Available figures consolidate spent accrued through donor and NGO funded models which typically include expensive overheads and administrative complexities. This often inflates costs of HIV programs to potentially beyond what many countries can afford. For example, in Kenya, in 2023, 67% of resources deployed in the HIV programme are managed by non-governmental organistations whose costs included negotiated indirect cost rates. These inflated figures complicate the understanding of the true financial burden of national HIV management, and minimize ability to negotiate for resources from national budgets.
iv. In the current HIV funding architecture, there has been resistance to fund national central systems for data management, surveillance, diagnostics, and supply chains that will eventually be required to run sustainable and integrated HIV services. Further, current funding modalities are unlikely to harness efficiency gains that could be directed towards national systems because the flow of resources from donors through INGOs, through NGOs until acutal service delivery is expensive and resource inefficient.
v. Co-financing requirements pressure governments to move scarce resources from underfunded health diseases or systems to supplement already heavily funded donor programmes. The challenge for sustainability herein is the weakened health systems.
vi. While the success of the HIV response appreciates the role of communities -grassroots networks of persons living with HIV, and key population; health volunteers, mentor, mothers- they are increasingly loosing access to global resources. In the sustainability discourse, they stand to lose even more as many nations lack adequate frameworks that allow government funding for communities evolving public-private partnerships for procurement of services in many countries.
vii. Over time, the multi-sector approaches that begot our success have been devalued, despite our on-going and future reliance on other sectors such as education, labour, public service finance, social protection, legal and technology for sustained positive outcomes.
viii. Sustainability has routinely been presented to countries as an intervention with short term program outputs and targets reportable to donors, as opposed to being a country-led process that is embedded within government agenda setting and policy making institutions.
The focus is on consensus to be achieved through a myriad of working groups. While stakeholder engagement is essential, it should complement, not substitute, effective leadership and management execution that is necessary to transition programmes to national management. Appreciating the above observations, the HIV multisector leadership Forum recommends three strategic shifts for the on-going globally led sustainability discourse.
Our first shift is driven by the question, ‘What is required for a country to successfully plan for a sustainable HIV response? It demands that we adopt a country-centric approach to sustainability planning. A comprehensive understanding of the country context against which HIV sustainability planning is undertaken is the priority. Prior to roadmap formulation an appraisal of the HIV epidemic in relation to country syndemics is a pre-requisite in order to align the roadmap with country realisties. This must be accompanied by a programme alignment assessment to review the HIV programme alignment with the country’s macroeconomic political, governance, social, legal and health systems, institutions, capabilities and priorities. Each country also needs clarity of the real costs of its HIV programmes as conditional to aligning this with the country’s fiscal realities in the planning process. With these understandings, a country can initiate the formulation of its sustainability roadmap. This knowledge forms the basis of practical re-modelling decisions on how to integrate HIV services into primary, secondary or tertiary healthcare, or into UHC financing models without loosing gains made. It also will inform budget negotiations with national treasuries or parliaments.
The second shift is driven by the question, ‘What is required for a country to successfully manage its HIV response?’ It focuses on transitioning from a global-led appraoch to real country-stewardship of the transition process. Creating the reality of country leadership requires a collective willingness from donors, governments and communities to re-design the architecture of HIV financing and programming to:
a) Equip countries with resources to strengthen foundational systems in health, education, legal and social protection sectors. Strong systems will be necessary to sustain the gains made when countries inherit and manage HIV programmes through national systems. There is demonstrable evidence that country systems can be applied for responsiveness and efficiency. The COVID-19 pandemic showed us this potential. For instance, nations repurposed donor funded HIV and TB diagnostic infrastructure to generate daily COVID surveillance data. HIV programmes did not benefit from these lessons as they still rely on quarterly and annual data reviews.
b) Institutionalize HIV within national political and financial management processes such as annual budget outlook papers, medium term expenditure frameworks, annual budget making processes and parliamentary reporting systems in order to maintain visibility and long-term prioritization of HIV, as well as increased potential for mobilizing domestic resources. a) Define country specific health sector integration frameworks that define what is non/integratable, types and pathways to integration and realizable benefits and efficiencies informed by costs.
b) Recognize that a multi-sector approach is imminent for safeguard gains made in the HIV response within a sustainable response. For instance, as donors cut human resources funding, stating that these staff will be absorbed, as is currently happening, in the sustainability roadmaps is not sufficient. Action will be required with the Government agencies responsible for public service personnel administration who are located outside of the health sector. Other examples include addressing challenging legal environments which requires action with the justice sector; or ICT and data commissioners who are key to maintaining confidentiality for persons living with HIV.
The third shift engaged with the question, ‘Who is at the driver's seat? Who is accountable for a sustainable HIV response?’ and thus, we call for mutual accountability between countries, communities, donors and global health institutions. Donors and governments need to conduct structured multi-lateral negotiations and trade-offs in each country, guided by a detailed analysis of potential donor-country conflict or HIV response critical areas such as financing frameworks, supply chains, prioritization of funding and programmes during transition, commodity security, data ownership, human resources integration and research.
Countries need predictability and adaptability in funding as this will strongly influence a country’s ability to safeguard gains made in treatment diagnostics, incidence reduction, community services and supply chain security. In particular, transparency and disclosure by donors regarding the short- and medium-term transitions in funding levels, priorities and timelines must take precedence in the sustainability discourse in order to mitigate potential future shocks. These discussions should involve key sectors, including national treasuries and Ministries of foreign affairs. We propose a mutual accountability framework to monitor the fidelity of donors, communities and governments to transition commitments.
It is clear that attaining a sustainable HIV response goes beyond developing well written roadmaps at country level. It is about willingness to change by the global north, countries and communities. It is about investing in country systems to build resilience in order to sustain gains made. It is about country stewardship in practice. Each country requires an institutionalized Stewardship function for this long-term transition process.
On our part, the National AIDS Coordinating Authorities are committed to providing stewardship in our countries. We have set up a thought leadership group who are progressing the development of tools that can be adapted for country epidemic appraisals, programme alignment, and development of a framework for costing for services.
Consolidated thoughts from the Community of Practice of the National AIDS Authorities of the HIV multi-sectoral leadership forum