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Ending AIDS and Pursuing Universal Health Coverage: 6 lessons for approaching and analyzing financing integration from South Africa

Ending the AIDS epidemic by 2030 seems more within reach than ever, but governments and their partners are facing complex decisions about how to finance their HIV response while also pursuing universal health coverage (UHC) to ensure healthy lives and promote well-being for all.

One option many governments are looking at is the integration of vertically funded programs like HIV into their national health insurance programs. This approach could increase value for money in resource-constrained environments, but there are also trade-offs. Without concerted analysis and dialogue, actions to pursue either independently will likely miss opportunities for efficiency (for instance, in financing care for an HIV patient’s other chronic disease) or even do harm (such as losing private-sector HIV service providers or failing to sustain financing for HIV prevention).

South Africa is an important case in point. Home to the world’s largest HIV burden, the country has rapidly scaled up its epidemic response: the government now provides life-sustaining treatment to more than 3 million people and has embraced the UNAIDS “fast-track” 90-90-90 treatment goals. If achieved, the targets will mean that most of the nearly 7 million South Africans living with HIV will be able to live long and productive lives, and be less likely to transmit the virus.

Last year, the Department of Health also released its long-awaited White Paper on National Health Insurance, which proposes ambitious reforms meant to achieve UHC and alleviate deep and persistent health inequities. If realized, the NHI White Paper’s vision could improve access, efficiency, and quality throughout the health system, and cover 85 percent of South Africans currently lacking insurance.

In South Africa and elsewhere, accelerating the HIV response and implementing UHC policies will pay significant dividends in terms of lives saved and livelihoods safeguarded, but how can they fit together?

At the Results for Development Institute, we have been working to expand the knowledge base on HIV financing integration, both globally and in individual countries like South Africa. To date, much of the work on sustainable financing and integration focuses on resource needs. For example, the South African HIV and TB Investment Case and the White Paper project funding gaps based on established goals for HIV and NHI, respectively (see Figures 1 and 2).

Estimating funding needs, while critically important to policy design and advocacy, only addresses one piece of the financing integration puzzle. Because resource mobilization is just one of three health financing functions, we assessed the integration between how funds for HIV and other health needs are collected, pooled, and used to purchase services and commodities. We found considerable variation in the level of integration from one health financing function to the next, both across countries but also within them (see Figure 3).

Descriptive frameworks are valuable, but we wanted to better understand how HIV financing integration factors into a country’s ongoing policy processes. So, on behalf of UNAIDS and in consultation with the South African government, we conducted a thought experiment about whether and how to integrate financing as part of NHI implementation. This work and our experience tackling similar questions in other countries yield some useful lessons to approach policy design and future analysis of integration.

6 Lessons for Approaching and Analyzing Financing Integration

Our work has unearthed a handful of important considerations for HIV financing integration. These may also be relevant to other vertically funded interventions that will be integrated into national health insurance programs. Our in-country consultations have also highlighted valuable methodological approaches to understanding integration within a real-time policy discourse.

Analysis

  1. Unpack financing integration: Integration is no simple thing. Unpacking financing integration along the three health financing functions (plus possibly service delivery) is a useful way to make the complex concept digestible to policymakers and explore practical options for reform.
  2. Present different policy options: Presenting different policy options to government officials—even as a set of illustrative and qualitative choices—stimulates useful debate. The two-dimensional depiction of five integration scenarios in our South Africa study (Figure 4) resonated more with many stakeholders than the pages upon pages of detailed analysis.
  3. Neutrality is key: Neutrality among these options can be key to facilitating an open-minded and productive debate on reforms. Discussions about integration understandably make HIV program managers and advocates nervous. Framing analysis in terms of feasibility, and providing inputs to discussion while retaining neutrality among multiple proposed options, can assuage concerns about change. Highlighting expected risks to the sustainability or effectiveness of HIV programs is also valuable.

Policy design

  1. De-emphasis of non-personal services is a risk: A looming risk from financing integration is the potential de-emphasis of non-personal HIV services, such as behavior change campaigns and other prevention efforts. Agencies like South Africa’s proposed NHI Fund typically pay for personal services delivered in clinics. Consequently, if South Africa integrates financing, it will need new mechanisms to coordinate different types of HIV-related activities between the Fund, the national and provincial AIDS councils, and the Department of Health.
  2. Integration could lead to greater efficiency: To bolster efficiency, integrating and improving the manner in which HIV and other services are purchased is most promising. Efficiency is a key concern for policymakers, and other experts have written extensive guidance on how to design provider payment systems to improve quality and efficiency (for example here and here).
  3. HIV programs could offer a foundation for UHC: HIV programs can serve as foundations for UHC decision-making and progress. In some cases, governments and development partners (like PEPFAR and the Global Fund) have made large-scale investments in systems for HIV financing, service delivery, and governance that could be adapted to the rest of the health system. These include population coverage approaches, benefits design processes, effective purchaser-provider splits and engagement of private sector providers, and perhaps most clearly of all, good planning and monitoring systems.

Ending the AIDS epidemic and achieving universal health coverage by 2030 are critical goals for global health and country health systems like South Africa’s, but they are also constrained by limited resources and complicated by conflicting trade-offs. Unpacking current integration of HIV and non-HIV financing across the three health financing functions is a useful and necessary starting point to get the best of both worlds.

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