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South Sudan has a very tight fiscal space. Sizable debt-service obligations, the reduction of legacy arrears, rising social and humanitarian expenditures, lower tax revenue mobilization contribute to the fiscal pressures that negatively affect public spending to reduce poverty, develop agriculture, strengthen human capital, and incentivize economic recovery. These are further compounded by the negative effect of climate change and natural disasters, country’s economic vulnerability to internal and external shocks combined with the impact of the war in Ukraine via global markets.

Real GDP is estimated to have declined by 5 percent in FY2020/21, after growing by 13.2 percent in FY2019/2020. GDP growth is expected to remain negative in FY23, reflecting the continued impact of floods on agricultural and oil output, with oil production projected to drop by 3.7 percent.  Despite a very small projected cash deficit (0.6 percent of GDP) in FY2022/23, fiscal financing gap is projected at SSP 235 billion (5.2 percent of GDP), amid increasing fiscal pressure.

The Government of South Sudan (GoSS) prioritizes security and infrastructure over health, education, agriculture, and other sectors, spending approx. 2% of national budget on health, and similarly, public spending on education, far below the regional and global rates. Off-budget support from international donors, which provides for most social spending, is set to decline amid shrinking aid budgets and the rising cost of providing such aid. The pattern is similar for HIV where external donors fund 97% of the approximately US$50 million annual AIDS response investments.

The UCO will liaise and collaborate with other partners, particularly the International Finance Institutions to help South Sudan to secure international and domestic funding to transition from addressing humanitarian and emergency situations and adopt macro-fiscal policies that put the country in the development trajectory. In addition, strengthen the institutional framework for debt management and revenue diversification to mitigate oil-related shortfalls and explore different pathways to reduce the projected fiscal gap, especially without large transfer reductions to Sudan.  Continue to advocate for re-prioritization of public spending for inclusive growth, prioritizing social spending, including health Continue to advocate care, addressing the on-going epidemics, and education, to boost economic development, resilience, and health security.

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The HIV response in Brazil is completely funded by domestic resources and HIV services are freely available through their UHC system. However, there are still critical factos that impact the level of funding, particularly for prevention and human rights programmes. During the previous government administration, the budget for HIV service was significantly cut and many grants for civil society and human rights programmes were impacted. During the new administration in 2023 with the return of a government more aligned to a human rights agenda. Currently the critical factors include the political opposition who continuously waging a battle against the Ministry of Health when they try to address sensitive topics like HIV, STIs, Diversity, LGBT. All of the initiatives are presented with a "sanitized" language by the Ministry. To address this issue, the Ministry is integrating HIV and other diseases under general health decrees such as the Decree calling for the Elimination of TB and other "socially" determined diseases to not draw attention. The Ministry is partnering with UNAIDS to raise awareness on prevention and other communications initiatives like the HIV Festival to draw attention to the contributions of the HIV response to health, democracy and the fight for human rights. UNAIDS is also looking at innovative financing mechanisms in partnership with ILO and the Ministry of Public Labour Defenders.

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Critical factors that hinder or slow down investment in HIV response in Ghana are:
- Low prioritization of HIV response by the President and high-level decision makers.
- Economic crisis which implicates inadequate and insufficient funding for health, HIV response and other critical matters such as education.
- Emergencies such as the migrant and refugees crisis from the north (border with Burkina Faso), some security threatens.
- Lack of coordination between the Presidential AIDS Commission, MoH and NACP (they are competing for mandates instead on agree on division of labor)
- LAck of a solid coallition of CSOs and activists working on HIV respose
- High dependande of international funds for the HIV reponse.
- Regressive context of human rights agenda (anti-LGTBIQ+ bill is being discussed at parliament.
- Challenges for acquisition of health commodities including ARVs with by government and also in supply chain mechanisms.
- CHallenges in health and HIV information systems.
- Violence against women and key populations.

As UCD my role is to advocate for a multi-sector campaigning for resurce mobilization in HIV response.

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Nuha Ceesay, UCD Malawi-Critical Issues on HIV Financing in Malawi 

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Nuha Ceesay, UCD Malawi-Critical Issues on HIV Financing in Malawi 

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The HIV response in Malawi has been evolving and the country is on track to meet the Fast Track targets by 2025. Despite this remarkable achievement, the HIV response is largely funding by external partners (95%) with the Global Fund and PEPFAR forming the biggest source of funds.

Malawi has recognized the urgent need to accelerate efforts towards Universal Health Coverage including the sustainability of the HIV and developed a new health sector strategic plan with a health sector financing plan. The Ministry identified a number of reform areas to accelerate efforts Universal Health Coverage and HIV is one of the key areas included in the benefits package.

Although willing, the macro economic challenges as a result of slow growth, inflation, high cost of living, geopolitical context and consistent episodes of climate and weather related disasters continue to strain efforts by the country to substantially increase domestic resources.

Discussions to introduce a national health insurance scheme are at advanced stage but not at a level that can fundamentally bridge the funding gap. The reliance on external sources, especially the Global Fund and PEPFAR is a reality.

As UNAIDS Country Director, I engage in the advocacy for sustainable by pushing the priorities of the Global AIDS strategy and 2021 Political Declaration. The continuous and support to ensure that the national strategies are fully aligned with the Global AIDS Strategy  remain my priority areas .

I also worked closely with PEPFAR during the COP planning and implementation process.

On the Global Fund where I serve as Second Vice Chair of the Country Coordinating Mechanism , I continue to advocate and support the allocation of resources in key areas with the apparent gaps.

Perhaps one key areas that requires more attention is the need to further look  at efficiencies in service delivery. This remains a big conversation.

Under the leadership of government and in close collaboration with PEPFAR and the National AIDS Commission, I am actively engaged and participation in the development of the sustainability road map.

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Iran for many years has support its response mainly thru domestic resources. However, in recent years, investment is threatened by impact of sanctions which has led to an economic decline. Under such circumstances due to resource scarcity, priorities compete with each other. Stigma and discrimination just add to the complexity of issue. therefore, one of the main mission of UCO is to keep HIV on the priority list.

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Previously In recent Years Zambia Economy used to be Classified as Intermediary Income Country but the since 2022 the country has reclassified as Low Middle-Income Country. Zambia Economy is more driven by Mining and Agriculture Sectors. These 2 sectors have been affected by different Global issues. Climate Change has affected Agriculture Production as Zambia has been facing Floods and Droughts. COVID 19 and the Wall in Ukraine has also impacted the economy including the Mining Sector. The other Factor affecting the Economy is the huge Debt the country has accumulated, and Debt services are reducing investment in different sectors including Health. Looking Health sector with different outbreaks linked with these different Floods and Draughts has reduced the Capacity of the Country to increase Investment in HIV/AIDS response. The National Aids Spending Assessment supported by UNAIDS in 2018 and in 2022 give the same results as the domestic funding for HIV/AIDS response has slightly increased from 8% to 10%. 90% of HIV/AIDS response are provided by Donors particularly PEPFAR and GFATM.

For the Coming Years, there is opportunities to increase domestic Funding and also the new Government is investing in Social sectors such Education with Free Education Policy for primary and secondary Education levels which will have more returns on preventing new infections among young people particularly Girls by Keeping them in school until end of Secondary Education and Increase their Chance to complete Tertiary Education. The second opportunity is the Decentralization with Increased Financial allocation to the Community Development Funds is offering a window to support HIV Prevention program at community levels. UNAIDS together with PEPFAR and GFATM is supporting the National AIDS Council and Ministry of Health for the development of Zambia HIV/AIDS Sustainability Framework which will include social Contracting with community led organizations and integration of HIV/AIDS in other health services for more efficiencies. Zambia has recently reached an agreement with WB and IMF on the debt restructuring which will offer the government to invest more in social sectors including health. The commitment is to reach Abuja Declaration in 2024 (15% ) from 10% in 2023.

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Mozambique borders Tanzania, Malawi, Zambia, Zimbabwe, South Africa, and Eswatini. Its long Indian Ocean coastline of 2,500 kilometers faces east to Madagascar.

About two-thirds of its estimated 33 million (2022) people live and work in rural areas.

Mozambique is still grappling with a military insurgency in parts of the gas-rich province of Cabo-Delgado; the four-year conflict has caused an estimated 4,000 deaths and displaced nearly one million people. About four million people are likely to face high levels of food insecurity because of the combined effects of climate shocks and the conflict, which is also threatening the economic potential of lucrative Liquified Natural Gas investments in the area.

It is estimated that overall, more than 60% of people live in poverty and more than one million people have been displaced by the conflict in Cabo Delgado.

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As a lower middle-income country and with HIV competing with equally important health programs, HIV is just a hard sell to the government. Furthermore, COVID19 pandemic has exacerbated the funding situation- most funds being reprogrammed to pandemic response resulting to plummeting of HIV service uptake.

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The investment in the response to HIV in Morocco faces several challenges, the most significant being the mobilization of necessary funds. The response to HIV/AIDS in Morocco requires about $20 million per year, financed by a combination of public spending (50%), the Global Fund (GF) (40%), and other donors (10%).

A major challenge lies in the mobilization of funds for prevention activities targeting key populations, often managed by non-governmental organizations (NGOs). The transition of the Global Fund poses a significant risk: if alternatives are not found to finance NGO programs, prevention activities for key populations risk coming to a halt.

This situation is further complicated by the stigma and discrimination faced by key populations, including sex workers, men who have sex with men, and people who inject drugs. This makes it harder to access and deliver services, and underscores the critical role NGOs play in reaching these populations and providing essential services, making their funding all the more crucial.

To address these challenges, a process has been initiated to search for alternative financing, including social contracts and advocacy to mobilize funds from other actors, such as bilateral cooperation and other donors. However, the broader economic context also plays a role: economic challenges make it harder to allocate sufficient public funds to health, including HIV prevention and treatment. This makes external funding, including from the Global Fund, particularly important, but also particularly risky if that funding is reduced or withdrawn.

In summary, the main hindrance to investment in the response to HIV in Morocco is the dependence on external donors, particularly the Global Fund, combined with the stigma faced by key populations and the broader economic challenges. Developing sustainable financing strategies, which may include a mix of domestic public funds, external donor funds, and innovative financing mechanisms, is crucial to ensure that the response to HIV in Morocco is adequately funded and can be maintained over the long term.

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Addressing challenges in HIV investments

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Addressing challenges in HIV investments

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It is often said that there was greater ownership and investment in HIV by the government before Pakistan started to receive significant financial support from the GF, which is now by far the largest funding source for HIV. HIV is not seen as a political priority by the government or donors, who have moved away from funding HIV over the last decade. As UCD, I am trying to 1) advocate for greater ownership by the government including increasing domestic funding for HIV and greater engagement and leadership in GF-related processes (FR development and grant implementation), and 2) sensitizing development partners about the growing HIV epidemic, which is an exception in the AP region to mobilize greater engagement (e.g. joint advocacy efforts) and hopefully new/renewed investments.

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Hindering factors for investment n the HIV response in Tanzania- Martin Odiit

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Hindering factors for investment n the HIV response in Tanzania- Martin Odiit

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Tanzania has a low medium income economy with several competing priorities for the national budget. The economy has recently faced the effects of COVID-19 pandemic and the Ukraine war. The HIV response is highly donor dependent. There is a need to advocate for a phased transition with gradual increment in domestic investment to ensure sustainability of the response. In this regard, the government and partners are constituting a sustainability working group that will be guided by a framework. The other hindering factor is poor mobilisation of the private sector to contribute to the HIV response. This will be addressed as part of the sustainability framework. Some HIV and AIDS interventions are stand alone and need to be mainstreamed and integrated into other health and development functions of government and the private sector as a way of increasing domestic investment. There is also room for improved efficiencies in applying the existing resources.

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What hinders investment in the HIV response in Guatemala?

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What hinders investment in the HIV response in Guatemala?

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Other pressing national priorities (high levels of malnutrition, unemployment, migration, violence etc) make it difficult for leaders to prioritize health and access to HIV services. In addition, political instability and changes in government priorities (with a presidential mandate of maximum 4 years) disrupt long-term investment in HIV programs.

Guatemala has a very low revenue collection rate and struggles with limited financial resources allocated to healthcare. HIV response requires consistent funding for prevention, treatment, and care services.

Inadequate healthcare infrastructure and personnel, and inaccessibility of some remote areas in the country are a barrier to further investments.

Donor fatigue for the HIV response and for Guatemala.

Community leadership is rather ineffective in advocating for more national resources for the HIV response and for social contracting. A few CSOs have gained expertise in delivering HIV services but there is no common advocacy agenda and efforts among civil society actors.

A lack of comprehensive and up to date data, and stigma associated with the HIV response and people most at risk from key populations hinder adequate resource allocation.

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South Africa’s economy has been exposed to a slowing global economy and volatile markets. The domestic economy contracted severely from the effects of the COVID-19 pandemic, exacerbated by low economic growth, extreme unemployment, high debt servicing costs, the national energy crisis, and unexpected shocks, such as unrest and floods in some parts of the country in 2021. The government is expecting economic growth in the medium-term as the economy recovers and due to implementation of stimulus measures and structural reforms, but fiscal space for health is expected to remain constrained over the NSP period 2023-2028, despite better-than-expected revenue-collection estimates in 2022. The government’s austerity approach to spending in the past few years has resulted in cuts to the baseline budgets of all government programmes that do not have special protection and the introduction of measures to realise efficiencies, including through centralised procurement, more effective contract negotiations and strengthened in-year monitoring of budget execution and improving human resource efficiency. Between 2019-20 and 2022-23, the annual value of the health budget declined by approximately R3.2 billion. According to analysis the government will spend about R332.80 less per health user in 2023 in real terms than it did in 2019. Budget allocations to the HIV and TB conditional grants for the 3-year 2022 MTEF period show a small decrease in real terms. A total of R81.8 billion of the components for the DOH conditional grant components for HIV, TB, community outreach services and HPV immunisation for the 3-year 2022 MTEF period is more than R6 billion less than what was allocated under the 2019 MTEF. The Department of Basic Education’s HIV and Life Skills programme as well as the Department of Social Development’s HIV programme also reflect similar baseline reductions, both showing declines in funding in real terms over the medium-term. Although recent allocations to South Africa from both PEPFAR and the Global Fund have increased, as they support South Africa to intensify efforts to reach the goals of the NSP PEPFAR funding is expected to flatline. As an UMIC, South Africa is encouraged to increase domestic funding in key areas and to systematically plan for the transition of selected externally funded functions to the public sector. Of particular concern is that development partners are a major source of funding for South Africa’s key and vulnerable population interventions, human rights interventions, VMMC and that they also invest significant funds in health systems strengthening, including health information management systems, quality improvement, CHCWs and contracting of NGOs for community outreach services. Despite increasing resource needs, fiscal space for increased spending on health over the period will remain constrained. South Africa and its external and private sector partners will need to invest smarter, and in harmony, based on economic evidence; and just as importantly spend efficiently to ensure that the NSP’s outcomes are achieved

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HIV response in Chad is 90% dependent of external funding mainly the Global Fund and this is the same for many other health programmes. Investment in HIV response and health sector is facing many challenges due to huge competing priorities the country must deal with.

The first one is the security: the security sector consumes more than one third of the national budget as the country faces some internal conflicts (rebels’ groups in various part of the country) and manage the impact of external conflict such the Sudan’s war which led to more 350 000 refugees in the eastern part of the country.

Second factor is the political instability in the context of a protracted political transition: This situation affects the economic growth therefore reducing the fiscal space.

The third factor is the donors’ fatigue and the lack of good governance: It has been difficult to mobile resource with in-country donors as they all claimed to contribute to the Global Fund so more investment at country level. The country also faces some governance issues with the management of resources in terms of rationalization and prioritization, where to invest for more impact.

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The implementation of the 2021-2025 NSP in Togo will require a budget of 87 billion CFA over the five years. The question of the sustainability of the HIV response is a fundamental issue in Togo. 69% of funding depends on international donors and the capacity to mobilize domestic resources is quite limited.

Constraints on possibilities of an increase of international and national funding. The difficult international financial context with the emergence of new priorities in the sub-region as well as the real impact of security threats on the resources of the states of the sub-region can influence the achievement of the objectives of mobilizing domestic and international resources for the HIV response.

Promising, but limited possibilities:

Health Sector Efficiencies:

1.                   The country has made the choice since 2019, to switch to the TLD1 protocol and has already begun the implementation of a transition plan to allow a gradual consideration of TLD in ARV treatments. In addition to this, the country is also implementing the differentiated approach to care through Multi-Month Dispensation (DMM) (3-6 months). The latter measure allows a significant reduction in the costs associated with care, particularly at the laboratory, human resources and nutritional levels, thus allowing the entire health system to achieve economies of scale.

2.                   The integration of HIV services into health services has improved considerably in Togo, raising hopes for a reduction in the direct costs of providing services to PLHIV. There has been a decrease in the supply of services dependent on autonomous structures (NGOs and faith-based health structures) from 60% in 2009 to about 30% in 2018, this decrease being offset by an increase in services by public health structures. Although this integration of HIV into care does not mean for the moment, a reduction in costs, it presents an interesting perspective on the pooling of resources with a real reduction in costs.

3.                   The sustainability of the response will depend in part on the effectiveness of performance management approaches at the health human resource level. This is why investing in a complete reform of the vocational skills acquisition system is an innovative approach for the new NHP. The issue of sustainability is also linked to the country's ability to put in place a comprehensive health financing strategy as part of a universal health coverage approach where each priority disease is adequately funded and managed.

Efficiencies in the health sector: there is certainly work to be done in terms of fiscal space.

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Barriers to investment in the HIV response in Paraguay - Alberto A Stella MCO Southern Cone

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Barriers to investment in the HIV response in Paraguay - Alberto A Stella MCO Southern Cone

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Although the HIV response in Paraguay has been progressively assumed by the government, local funding is mainly for treatment, without sustained strategic actions in prevention and human rights to promote social environments free of stigma and discrimination. These actions are almost entirely dependent on foreign funds (Global Fund, some bilateral, UNOSUDA/UNJT)
The intersecting world crises have had an impact on countries like Paraguay, whose social development agenda has multiple competing priorities and, although macroeconomic indicators are positive and the Paraguayan economy is stable, the distribution is profoundly inequitable and social investment (health, education, transportation, security) is very insufficient. Thus, a social context of profound inequalities is generated with excluded and multidimensionally poor sectors of the population.
The high levels of stigma and discrimination in conservative governments have given rise to environments with deep gender inequities and homotransphobia. On the other hand, inadequate financing of health systems affects the response to HIV, which makes it difficult to provide quality HIV services, decentralized and linked to the first level of care.
However, Paraguay benefits from the Global Fund and this is an opportunity to strengthen the health system by focusing on combined prevention services. UNAIDS and UNJT accompanies this effort and works with the state on a transition plan towards greater sustainability.

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What factors hinder the investment in HIV response in Mali?

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What factors hinder the investment in HIV response in Mali?

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Below factors constitute the mains constraints and obstacles which hinder the investments in the health sector and particularly in the HIV response in Mali:

1. Mali is classified as a low incomes revenues country. That means the GDP is also low with a high level of the debt service.
2. Since 2013, the country faces a huge security and humanitarian situation which heavily affect the economic growth.
3. It has been decided to prioritize the security and defense department in the objective to deal with the growing insecurity across the country. Other departments including the HIV response are left behind.
4. The country intercurred economic sanctions from the ECOWAS which caused losses of financial resources and reduce the fiscal space and the possibility to mobilize more domestic resources as well.
5. the health system financing is inadequate, and the Public Financing Management is not designed to be equitable enough to address the needs of the health system including HIV
response.
6. The Covid-19 pandemic combined with the debt service reduced the potential domestic resources available for the AIDS response.
7. The AIDS response in Mali is funded up to 80% from external resources while donors have significantly reduced the support to Mali as the country is transitioning to democratic
elections which started and will end next year.

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Hindering factors to invest in HIV response in Mali

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Hindering factors to invest in HIV response in Mali

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Below factors constitute the mains constraints and obstacles which hinder the investments in the health sector and particularly in the HIV response in Mali:

1. Mali is
classified as a low incomes revenues country. That means the GDP is also low
with a high level of the debt service.
2. Since 2013, the
country faces a huge security and humanitarian situation which heavily affect
the economic growth.
3. It has been
decided to prioritize the security and defense department in the objective to
deal with the growing insecurity across the country. Other department including
the HIV response are left behind.
4. The country
intercurred economic sanctions from the ECOWAS which caused losses of financial
resources and reduce the fiscal space and the possibility to mobilize more
domestic resources as well.
5. the health
system financing is inadequate, and the Public Financing Management is not designed
to be equitable to address the needs of the health system including HIV
response.
6. The Covid-19
pandemic combined with the debt service reduced the potential domestic
resources available for the AIDS response.
7. The AIDS
response in Mali is funded up to 80% from external resources while donors have significantly
reduced the support to Mali as the country is transitioning to democratic
elections which started and will end next year.

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Barriers to investment in the HIV response: Richard AMENYAH (Jamaica)

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Barriers to investment in the HIV response: Richard AMENYAH (Jamaica)

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·       Funding and budgetary constraints due to high debt/GDP ratio are major barriers even though the country is categorized as an upper middle-income country.

·       Global poly crises (food, fuel and financial) due to climate change, Russia-Ukraine war, effect of the covid pandemic have resulted in shifts in donor priorities leading reduce international financing especially PEPFAR and Global Fund resources for HIV programs.

·       Negative attitudes and misconceptions about HIV can lead to reluctance among individuals, communities, and even governments to invest into HIV programs.

·       Inadequate legal and policy frameworks could limit investment in the HIV response especially punitive laws which criminalize LGBTQI+ populations can limit access to HIV prevention and healthcare services, hindering effective responses.

·       Inadequate health systems financing can be a disincentive to investment in the HIV response which can compromise the health systems capacity to deliver quality HIV services including securing HIV commodity security and other essential medicine for long term care and treatment for HIV patients.