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HIV Response Sustainability Assessment�2024��Sustaining the HIV Response for the Long Term

Proposed High Level Outcomes for a Sustainable HIV Response

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Context: Uganda made significant progress in reducing new HIV infections & AIDS mortality in recent years, but meeting 2030 targets is contingent on bending the epidemic curve significantly during 2023-30

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Rationale for Long-term HIV Programme Sustainability

Currently there over 1.4 million PLHIVs who are receiving ART, that will live health and productive lives for several decades to come
However, If we don’t meet the 2030 targets and more new HIV infections occur, the number of PLHIV will be higher as shown in the blue bars
That is why we need to meet our 2030 targets and sustain the gains for decades to come

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Risks of Not Sustaining Gains ……….

Continued reduction of new HIV infections will be necessary after 2030 through sustained HIV prevention for the general population services

Not sustaining efforts could lead to a second wave as shown in the blue curve which forecasts new infections if condom use dropped by 50% during 2030 – 35, up to 40,000 additional infections could occur during 2030 – 50. Reversal in other interventions could result in more pronounced spikes

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Declining HIV Resources Amidst Low Domestic Funding and Restricted Fiscal Space and HIV Funding Gap of approx. 25% in 2023

These graphs present a high level summary of the macro-economic situation in the country and Health and HIV funding landscape

The first graph shows that Uganda has maintained high economic growth of over 5% of GDP over recent years except during 2020 due to the COVID-19 pandemic lockdown. Economic growth has since recovered and IMF forecasts continued economic growth over the next short term. This puts Uganda in good position to raise increased domestic revenue to support its health and HIV services

The next graph on the right shows that despite steady economic growth, Uganda allocates a small share of its budget to health services. This is far below the 15% allocation target under the Abuja Declaration. To sustain the HIV response, Uganda will need to significantly increase its funding allocation to health services and move closer to the Abuja target

Graph in the LHS shows the trends in HIV funding by source during 2014/ - 2020/21. External financing is the predominant source, but it has been falling since 2016. The domestic financing constitutes a small percentage, and recent increases are not matching the decline in external funding. There is need for increase in domestic funding to close the funding gap (25% in 2023), and compensate for the drop in external funding.

The last graph shows the restricted fiscal space for Uganda to adequately fund health and HIV services on account of its high debt. Debt servicing consumes a high proportion of Govt expenditure that is almost 4 – 5 times the spending on Health. This limits fiscal space for health. Uganda will need to negotiate restructuring of its debts for instance through debt-to-health swaps, etc in order to free up some resources for health and HIV services

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HIV Response Sustainability �

the state where Uganda is able to maintain and increase HIV programme performance and health outcomes for people living with, affected or at risk of HIV for decades to come, delivered within the broader national financial, political, legal, social and health ecosystems in the country

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The Response Sustainability Assessment

As part of developing the HIV response sustainability roadmap, we assessed the sustainability of the response across five domains, which are further divided into 21 sub-domains – across 125 programme elements

Political Leadership
Enabling environment and policies
Services and Solutions
Sustainable and Equitable Financing
Systems

The structured participatory assessment was conducted in July – August 2024 based on the UNAIDS tool
Following that, stakeholders have agreed on HLOs to be achieved in order to sustain the HIV response for the long term
We now present the draft High Level Outcomes

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�High Level Outcomes

Increased domestic funding for EMHS of UGX 200 billion annually .

Increase in domestic funding for ART from USD $ 62 M to USD $ 135 M by 2030.
Increase in domestic funding to meet 50% of the cost of Co infection drugs by 2030

Lowered unit cost of production of locally manufactured ARTs from 18$ per ARV patient to 11$ per ARV patient.

High coverage of new cost effective interventions ( Injectable ART, DSDM, SMC)

Pathways of Change

High level advocacy for increased funding for EMHS & ARTs + tracking of the funding ,
Traceability & visibility of ARTs bought through different funding streams.

Lower cost of production of ART, negotiate for regional market, get FDA approval.
Feasibility studies for new technologies , mobilization of resources , targeted implementation of new technologies, phased uptake of injectable ART,
Regular review of treatment algorithms , service delivery models.

Health Technologies

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�High level Outcomes �

Harmonized procurement of supplies and commodities guided by the PPDA by 2030
Functional electronic integrated logistics information management system in 80% of health centre III facilities by 2030
Increased 95% availability of
a basket of 41 tracer commodities from 78% in 2021/2022 to 85% by 2030
ARVs from 81% in 2021/2022 to 85% by 2030
Wastage of drugs and supplies reduced by 5 % by 2030.

Pathways of Change

High level negotiations with partners for joint procurement.
Review of PPDA to identify and address bottlenecks
Funding for expanding LMIS infrastructure, upskilling of HW.
Increased funding for EMHS, adequate district regional warehouses, upskilling of HSC staff, tracebility & visibility of commodities, recruitment of pharmacists, continuous supervision by pharmacists to curb irrational transcribing

Procurement & Supply Chain

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High level Outcomes

Increased recruitment & upskilling of lab personnel.
LMIS system that is integrated with the HMIS & EMR in 80% of HC III’s by 2030
Increased funding & more efficient use of lab resources

Increased GoU funding for reagents and equipment and operations by 2030
Harmonized use of lab resources ( equipment , personnel)
Unified sourcing system for lab commodities by 2030

50 % of laboratories accredited.

Pathways of Change

Expanding capacity – adequate personnel with appropriate skills, fully equipped labs with required commodities, internet, computers upskilling of HWs - a roadmap for expansion with targets, costs, implementation plan
Interoperable systems – LMIS & EMR& HMIS
Efficient systems – harmonized procurement & implementation – review of PPDA, negotiation with partners , PPP to promote efficient use of expensive equipment and under used equipment
Quality services – Streamlined Governance and leadership, Expand National & international accreditation, functional QA/QC systems in all facilities

Laboratory Systems

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Options for increasing fiscal space

Budget re-prioritization -an increase in the health sector's share of the government budget to 10% or 12% or 15% - an additional USD 2.66 Billion, USD 3.79 Billion and USD 7.07 Billion, by 2030.
Private wings of public hospitals with improved governance and management - UGX 32 Billion (USD 8.5 Million) annually from all the NRHs, RRHs, GHs, and Specialized hospitals (USAID/UHSS Activity)
if partly retained e.g 50% could be a major source of revenue.

Other Financing mechanisms

Debt to health swaps, blended financing, bonds for health, trust funds

Sin taxes. A 10% increase in taxes on cigarettes, alcohol, and sugary beverages is estimated to generate nearly USD 100 million per year, which could be earmarked for the health sector.
Motor third party insurance. An average of UGX 2.9 Billion (USD 773,333) is projected as potential revenue per annum through MTPL premiums alone over the period FY2022/2023 to FY2026/2027, if a MTPL guarantee fund were to be established some of this could be earmarked for health
Improving the efficiency of health spending - annual savings of around USD 60 million ( 12.8% of public expenditure) at current spending levels (estimated to be USD 360 million between 2024/25 and 2029/30).

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High Level Outcomes to be achieved for a Sustainable Response

Sustainable and Equitable Financing	Increased domestic resources with a tax to GDP ratio of 15% by 2030. Increased Government financing from innovative financing sources and other non tax revenue from 8% of total government revenue to 15% by 2030. Increased Govt domestic allocations for health and HIV to progressively attain the 15% Abuja Declaration target Current development partner contributions to the HIV response maintained at (80%) in the short term (2030) and scaled down gradually to cover 50% of the funds required for the response in the long term (2040). Atleast 80% of development partner funds for health channelled through on budget support or virtual pool Increased efficient and effective use of resources to enable the saving of US$ 60 million annually .

Under Sustainable and Equitable Financing of the HIV Response, Uganda will need to find fiscal space to accommodate increased spending on Health and HIV as an investment good.

First, there is need for mobilisation of more domestic revenue through various sources (blended financing, debt to health swaps, bonds, earmarking funds from mineral and oil extraction etc) and increased allocation to health. We recommend an annual increase of 1% of domestic budget till the target of 15% is attained

Secondly, Uganda’s HIV response will continue to need external funding, and Govt should start negotiation with external partners to maintain funding levels for the medium term

More efficient use of the external funding should also be explored through such avenues as bringing it on budget, or at the very least put in place mechanisms for virtual pooling of resources

Lastly, sustainability of the HIV response might also benefit from increased efficiencies and effective use of current resources that could yield up to US$ 60 million annually according to one recent assessment of fiscal space for health

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High Level Outcomes to be achieved for a Sustainable Response


Sustainable financing systems	Effective social accountability systems at national and subnational levels by 2030 Enhanced capacity for financial management at higher level health facilities (RRH, hospitals and HC IVs) Efficient tax administration system Effective system for virtual pooling development partner funds

As we transition services to local structures and HIV integrate services into primary care, strengthening the systems that by them selves have existing vulnerabilities will be grucial.

Financing systems will need to be strengthened through: implementation of the health financing strategy, implementation of social accountability systems at all levels, enhancing capacity for financial management at all levels, and instituting virtual pooling systems for all HIV resources. Government needs to take a lead on negotiation for virtual pooling of resources with development partners and put in place the systems for doing so.

Uganda’s Laboratory services that were strengthened by the HIV programme and were leveraged during recent epidemics will need to address the current vulnerabilities. More efficient funding and resource utilisation will be needed to increase HR capacity, expand electronic laboratory management information systems integrated with HMIS and EMRs in facilities, and nationawide scale up of the QA/QS systems as well as the laboratory accreditation system that should extend to private sector laboratories

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�Pathways of Change �

Investment case analysis for increased investment in health as an investment good - priority focus on high impact interventions & reducing high DX burden through health prevention & promotion
High level advocacy & evidence based negotiations between MoH & MoFPED & Devt partners
Expanded capacity to implement &monitor - blended financing & private sector funding
Implementation & monitoring of other financing initiatives – NHIS, SIN taxes
Enhanced Tax administration
Debt restructuring & reduced borrowing
Long term commitments on donor & GOU funds +timely tracking of commitments
Implementation framework for virtual pooling of development partner funds
Harmonized procurement –drugs, supplies, equip.

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Next Steps

Rationalise and sequence the HLOs taking into account overlaps, feasibility, time sequencing and cost.
Develop HIV Sustainability Roadmap
Submit Sustainability Roadmap for approval by JSC
Policy Dialogue