br Methods The study was a cross sectional
Methods The study was a cross-sectional, ecological analysis of country-reported HIV expenditures. We obtained the most recent available and validated data on annual country-reported HIV expenditures in SSA countries between 2012 and 2017 from the UNAIDS (http://aidsinfo.unaids.org/). Many countries use the National AIDS Spending Assessment classifications and definitions developed by the UNAIDS as framework to report HIV expenditures in a standardized way. In addition, we obtained data on the antiretroviral therapy (ART) coverage and HIV prevalence corresponding to the year of the country-reported HIV expenditure from the UNAIDS. Data on gross national income (GNI) per capita, by Atlas method (current US$) corresponding to the THZ1 Hydrochloride of country-reported HIV expenditure, were obtained from the World Bank (https://data.worldbank.org/indicator). Data on domestic general government health expenditure (GGHE-D) as percentage of general government expenditure (GGE) and GGHE-D per capita in Int$ were retrieved from the World Health Organization (http://apps.who.int/nha/database/). Thirty SSA countries with available data on all the variables were included in the study. The most recent available country-reported HIV expenditures ranged between 2012 and 2017: 2017 (7 countries), 2016 (3 countries), 2014 (6 countries), 2013 (9 countries), and 2012 (5 countries). Based on the GNI per capita, we stratified the countries into four income levels: low, lower-middle, upper-middle, and high. From the total HIV expenditure, we estimated proportions of the domestic (public and private) HIV expenditure per country. Using Spearman's rho, we conducted bivariate analyses between domestic expenditure as percentage of the total HIV expenditure and HIV prevalence, proportion of people living with HIV (PLHIV) receiving ART, GGHE as percentage GGE and GNI per capita, and GGHE-D per capita. Multivariate median regression was performed with domestic expenditure as percentage of total HIV expenditure as the dependent variable and significant correlates at the bivariate analyses as the independent variables. P-value < 0.05 was considered statistically significant. The data analysis was conducted using Stata 13.0.
Discussion In response to the HIV epidemic in SSA, external funding has been fundamental to provision of antiretroviral drugs for PLHIV, commodities, equipment, infrastructure, and training of healthcare workers to deliver quality HIV services. Although there may be a debate on the impact of the heavy investment in HIV programs on the overall health system in SSA, the role external funding has played in mitigating the burden in many countries is hardly contested. Despite the importance of external health funding, its instability makes urine unreliable. Indeed, owing to economic downturn in donor countries and competing global priorities, there has been a flatlining in external support for HIV. This potentially threatens sustainability of HIV response and progress toward ending the HIV epidemic particularly in countries that we found to be overreliant on external funding in our study. Generally, government health expenditure is low in many SSA countries, with only a few allocating up to 15% of their expenditure to health in line with the 2001 Abuja Declaration. The lack of political will to prioritize health may be a contributing factor, but more important is the poor fiscal capacity that inhibits many countries to mobilize revenues and allocate to health. Nevertheless, our findings indicate that government spending accounts for the majority of the domestic HIV expenditure. While this is commendable, private expenditure from corporations can also be an essential source of domestic funding, especially in countries with fiscal constraints in the public sector. Unfortunately, there has been limited involvement of corporate organizations in many countries partly due to influx of international donors and lack of engagement by the government. Efficient engagement of corporate organizations may involve creating platforms for regular dialog, building strong relationships, and providing organizations with program options in line with the direction of their corporate social responsibilities. Out-of-pocket spending is also an important constituent of private HIV expenditure in some countries. However, this can be catastrophic or impoverishing for the poor in the absence of financial protection mechanisms.