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Advocating for increased domestic funding for HIV/AIDS: A road map for sustaining the HIV response in Nigeria

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The global call to fast-track the end of the HIV epidemic by 2030 and embark on the “Treat All” policy for all persons living with HIV has made it imperative for national authorities to find innovative ways of financing their HIV responses for the long-term good of their people. During the recent years of the response, the number of people on ART globally has increased significantly and continuing them on treatment while starting more people on treatment comes with a high price tag. The fast track targets include accelerated response and thus, the requirement to front load investments for greater gains in the coming years. Funding for the HIV response in Nigeria at the national and sub-national levels, comes from a mix of public, private and international funding sources. According to the most recent National AIDS Spending Assessment (NASA) done by NACA in collaboration with UNAIDS and other partners, the total expenditure on HIV and AIDS in 2014 was $632,378,599 of which $447,769,523 (about 70%) was from international funding sources. Domestic funding accounted for only about 27% of the total expenditure. Over the years, international funding has continued to be disproportionately higher than other sources.

The United States President’s Emergency Plan for AIDS Relief (PEPFAR), through the U.S. Agency for International Development (USAID), funds the Strengthening Integrated Delivery of HIV/AIDS Services (SIDHAS) Project being implemented in Nigeria. The project aims to improve stewardship by Nigerian institutions for the provision of sustainable, high-quality, comprehensive HIV/AIDS and TB services. It uses a continuous quality improvement approach to build the technical, institutional and financial capacity of Government of Nigeria (GON) and civil society organizations (CSOs), to coordinate, plan, manage and deliver HIV, TB and related services.

The current PEPFAR 3.0 approach emphasizes a sustainability action agenda, which outlines that sustainability conversations need to be initiated and concerted efforts need to be put in place while countries are working toward achieving sustainable epidemic control, rather than wait till the end. This can be achieved only through engagement with, and involvement of other international and local partners, including the investment of greater local resources. SIDHAS, implemented by FHI 360, has pushed this agenda to the forefront of interactions with various levels of government in Nigeria.

In March 2015, the project provided technical assistance to enable states to develop and monitor a set of milestones to measure progress towards the achievement of sustainability of the HIV response.  The set of milestones was evaluated quarterly for the state level ministries, departments and agencies (MDAs) responsible for the HIV response. The sustainability milestone assessments include 23 questions across four major domains: program management, quality assurance, monitoring and evaluation, and coordination. The tracking of the milestones allows for continuous engagement between SIDHAS staff and government stakeholders on issues key to sustainability. It also allows for SIDHAS to provide supportive interventions during or in between assessments. The interventions may be in the form of capacity building and/or advocacy visit to key officers within government.

In order to address the sustainability issues identified, the SIDHAS Project, through a collaborative process, supported the development of Sustainability Road Maps (SRMs) in 13 states covered by the project, and 13 federal tertiary institutions. The goal of the SRM is to build a systematic, operational framework within which the leadership and funding of the HIV response in the state is gradually transitioned from donor agencies and implementing partners, to respective state governments, to assure sustainability in the long term. This will involve getting all states and federally funded tertiary institutions to take ownership of the planning, budgetary allocations, funds release and implementation of donor supported HIV/AIDS interventions. Each SRM was guided by key sustainability milestones derived through consensus building and input from subject matter experts.

Between the 23rd and 27th January 2017, SIDHAS collaborated with National Agency for the Control AIDS (NACA) and eight out of 13 states to present memos for increased domestic funding for HIV/AIDS services to the 59th National Council on Health (NCH) in Umuahia, Abia State. The council adopted the prayer – “The earmarking of at least 0.5 to 1% of the monthly federation allocation to states for financing the implementation of the HIV/AIDS sustainable road maps.”  All other states were also charged to develop sustainability road maps.

Today, domestic funding of HIV/AIDS services is already evident in several states, such as in Bauchi state where the cost of haematology and biochemistry tests have been subsidized for clients in Abubakar Tafewa Balewa University Teaching Hospital; other states such as Jigawa, have procured and distributed haematology and chemistry reagents for HIV/AIDS-related laboratory investigations, as well as rapid test kits for HIV Testing Services (HTS). Adamawa, Yobe and Rivers State Governments have also procured and supplied data capturing tools to health facilities in their states.

In order to build on these and earlier commitments by state governments, the SIDHAS Project Advisory Committee (PAC), chaired by the NACA Director General, Dr. Sani Aliyu, recently began a series of advocacy visits to supported state governments, starting with Edo and Anambra States, to deliberate with stakeholders on the most effective means to improve domestic funding of the HIV response in line with recommendations of the road map. The visit was led by the Honourable Minister for Health, represented by Dr. Evelyn Ngige, the Director Public Health in the Federal Ministry of Health (FMOH), also a member of the SIDHAS PAC.

In Anambra State, the Deputy Governor responded to the prayers made during the advocacy, by committing to the following:

  • That the state government through the Ministry of Economic Planning would ensure up to one percent (1%) of federation allocation which is estimated approximately at NGN 374,239,850.72 be included in the annual budget for HIV/AIDS response to support the funding of the sustainability roadmap which stands at NGN 390,818,213.00 annually.
  • The state Health Insurance Scheme would be reviewed to include HIV/AIDS services as well as to review user fees associated with PMTCT services in public health facilities in the State
  • Viable public-private partnerships with renowned and indigenous pharmaceutical companies such as Juhel, Orange Drugs, Emzor etc. would be explored for the manufacturing of HIV and malaria commodities such as RTKs, ARVs, laboratory reagents, insecticide treated mosquito nets.

In Edo State, the governor stressed the state government’s commitment towards quality health care, ownership and sustainability of other supported activities. He requested that the advocacy team support the state to identify a list of fundable activities across the health sector that the government can execute in the next six months. AHNi Edo worked with key stakeholders in the state to identify a list of health and non-health sector related health activities across HIV, TB, and Malaria that when implemented would ensure sustainability and delivery of quality care to clients.

From inception of the SIDHAS project to date, more than 15 million Nigerians have been reached with HIV/AIDS services and more than 200,000 adults and children are currently receiving ART.  The commitment of the 13 state governments to using the roadmaps to increase funding for the HIV/AIDS response in their states, is therefore critical for consolidating on the gains so far achieved in controlling the epidemic.

 

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