Innovative financing for HIV response in sub–Saharan Africa

BACKGROUND: In 2015 around 15 million people living with HIV were receiving antiretroviral treatment (ART) in sub–Saharan Africa. Sustained provision of ART, though both prudent and necessary, creates substantial long–term fiscal obligations for countries affected by HIV/AIDS. As donor assistance for health remains constrained, novel financing mechanisms are needed to augment funding domestic sources. We explore how Innovative Financing has been used to co–finance domestic HIV/AIDS responses. Based on analysis of non–health sectors, we identify innovative financing instruments that could be used in the HIV response. METHODS: We undertook a systematic review to identify innovative financing instruments used for (1) domestic HIV/AIDS financing in sub–Saharan Africa (2) international health financing and (3) financing in non–health sectors. We analyzed peer–reviewed and grey literature published between 2002 and 2014. We examined the nature and volume of funds mobilized with innovative financing, then in consultation with leading experts, identified instruments that held potential for financing the HIV response. RESULTS: Our analysis revealed three innovative financing instruments in use: Zimbabwe’s AIDS Trust Fund (a tax/levy–based instrument), Botswana’s National HIV/AIDS Prevention Support (BNAPS) International Bank for Reconstruction and Development (IBRD) Buy–Down (a debt conversion instrument), and Côte d'Ivoire's Debt2Health Debt Swap Agreement (a debt conversion instrument). Zimbabwe’s AIDS Trust Fund generated US$ 52.7 million between 2008 and 2011, Botswana’s IBRD Buy–Down generated US$ 20 million, and Côte d’Ivoire’s Debt2Health Debt Swap Agreement generated US$ 27 million, at least half of which was to be invested in HIV/AIDS programs. Four additional categories of innovative financing instruments met our criteria for future use: (1) remittances and diaspora bonds (2) social and development impact bonds (3) sovereign wealth funds (4) risk and credit guarantees. CONCLUSION: A limited number of innovative financing instruments contributed a very modest share of funding toward domestic HIV/AIDS programs. Several innovative financing instruments successfully applied in other sectors could be used to augment domestic financing toward HIV/AIDS programmes.