Stakeholders’ Perspectives on the Financial Sustainability of the HIV Response in Nigeria: A Qualitative Study

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Abstract
Background: Countries in sub-Saharan Africa, including Nigeria, continue to depend on donor funding to achieve their national HIV response goals. The Government of Nigeria has made limited progress in translating political commitment to reduce donor dependency into increased domestic investment to ensure the sustainable impact of the HIV response. We explored the context-specific factors affecting the financial sustainability of the HIV response in Nigeria. Methods: Between November 2021 and March 2022, we conducted document reviews (n=13) and semistructured interviews with purposively selected national and subnational stakeholders (n=35). Data were analyzed thematically using the framework of health financing functions comprising revenue generation, pooling, and purchasing. Results: Stakeholders reported that there is a low level of government funding for the HIV response, which has been compounded by the weak engagement of Ministry of Finance officials and the unpredictable and untimely release of budgeted funds. Opportunities for domestic funding include philanthropy and an HIV Trust Fund led by the private sector. Integration of HIV treatment services into social health insurance schemes has been slow. Commodity purchasing has been inefficient due to ineffective coordination. Government stakeholders have been reluctant to support one-stop-shop facilities that target key and priority populations. Conclusion: Opportunities exist in the government and private sectors for improving domestic health financing to support transitioning from donor support and ensuring the financial sustainability of the HIV response in Nigeria. To ensure that domestic financing for the HIV response is stable and predictable, the amount of domestic funding needs to increase and a framework that incorporates donor transition milestones must be developed, implemented, and monitored. Key Findings The financial sustainability of the HIV response in Nigeria faces a variety of challenges, including heavy reliance on donor funding that is declining, a low level of domestic funding, and a low level of private-sector financing. In an effort to improve financing sustainability, integrating HIV testing and treatment services into social health insurance schemes has been slow due to concerns over the high cost of antiretroviral drugs. Purchasing of HIV treatment and prevention commodities has been inefficient because of the lack of an integrated procurement and supply chain management process. Despite the high costs associated with providing HIV treatment in hospitals, decentralizing treatment to primary health care centers and shifting tasks to less specialized staff has been slow. Key Implications Decision-makers and donors can use these findings to develop and implement a plan to increase domestic resource mobilization. The findings can help guide the implementation of a country-owned sustainable HIV response framework that incorporates donor transition milestones, ensures evidence-informed integration of HIV services into universal coverage schemes, initiates policy change to enable public financing of the community-led response, prioritizes HIV care and treatment, and addresses inequalities in future resource allocation decisions.

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