·       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.

 

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: 

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.

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.

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.

 

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. 

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.

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. 

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.  

 

 

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.