Abstract
BackgroundSub-Saharan Africa is heavily dependent on global health initiatives (GHIs) for funding antiretroviral therapy (ART) scale-up. There are indications that global investments for ART scale-up are flattening. It is unclear what new funding channels can bridge the funding gap for ART service delivery. Many previous studies have focused on domestic government spending and international funding especially from GHIs. The objective of this study was to identify the funding strategies adopted by health facilities in Uganda to sustain ART programs between 2004 and 2014 and to explore variations in financing mechanisms by ownership of health facility.MethodsA mixed-methods approach was employed. A survey of health facilities (N = 195) across Uganda which commenced ART delivery between 2004 and 2009 was conducted. Six health facilities were purposively selected for in-depth examination. Semi-structured interviews (N = 18) were conducted with ART Clinic managers (three from each of the six health facilities). Statistical analyses were performed in STATA (Version 12.0) and qualitative data were analyzed by coding and thematic analysis.ResultsMultiple funding sources for ART programs were common with 140 (72%) of the health facilities indicating at least two concurrent grants supporting ART service delivery between 2009 and 2014. Private philanthropic aid emerged as an important source of supplemental funding for ART service delivery. ART financing strategies were differentiated by ownership of health facility. Private not-for-profit providers were more externally-focused (multiple grants, philanthropic aid). For-profit providers were more client-oriented (fee-for-service, insurance schemes). Public facilities sought additional funding streams not dissimilar to other health facility ownership-types.ConclusionOver the 10-year study period, health facilities in Uganda diversified funding sources for ART service delivery. The identified alternative funding mechanisms could reduce dependence on GHI funding and increase local ownership of HIV programs. Further research evaluating the potential contribution of the identified alternative financing mechanisms in bridging the global HIV funding gap is recommended.
Highlights
IntroductionThe dramatic expansion in antiretroviral therapy (ART) coverage in Sub-Saharan Africa (SSA) depended substantially on Global Health Initiatives (GHIs) notably The Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) established in 2002 and The President’s Emergency Fund for AIDS Relief (PEPFAR) commissioned in 2003 [1, 2]
Within the framework by Shediac-Rizkallah & Bone [27], our findings suggest that Not-for-profit (PNFP) providers were inclined towards a ‘supply side’ strategy of financial sustainability by relying more on external donor funding channels to sustain antiretroviral therapy (ART) programs
Alternative funding mechanisms In the context of calls for identifying alternative funding schemes to bridge the funding gap for attaining ART scale-up targets, we found that private philanthropic organizations and individual donors were important sources of additional funding for ART programs in Uganda
Summary
The dramatic expansion in antiretroviral therapy (ART) coverage in Sub-Saharan Africa (SSA) depended substantially on Global Health Initiatives (GHIs) notably The Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) established in 2002 and The President’s Emergency Fund for AIDS Relief (PEPFAR) commissioned in 2003 [1, 2]. In 2015, international funding remained steady at $ 10.8 billion, compared to 2013, $ 11.2 billion was raised indicating a 3.3% decline [5] Against this backdrop of uncertainty in the long-term sustainability of international funding for ART service delivery in SSA and shifting donor priorities, there are amounting calls for alternative funding streams [6, 7]. There are renewed calls for locally-led alternative funding streams for bridging the resource gap for meeting ART scale-up targets in Sub-Saharan Africa [4, 6, 8]
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