What's the issue?

Upstream structural barriers undermine the potential of HIV programmes to deliver on ambitious targets to prevent new infections and save lives. Interventions addressing these upstream factors are considered beyond the remit of the HIV response and too expensive for the HIV budget. This reflects conventional priority-setting and financing frameworks that consider only HIV outcomes and budgets. 

With shrinking international HIV funding on one hand, and the wide range of priorities established by the Sustainable Development Goals (SDGs) on the other hand, development interventions with multiple outcomes provide an opportunity for greater value for money. Yet, opportunities to realise synergies with non-HIV investments tend to be missed due to:

• a lack of data on their multiple outcomes 
• the dominance of single outcome cost-effectiveness frameworks 
• weak incentives for joint financing between sectors. 

Cross-sectoral co-financing is an innovative solution that can increase efficiency in the allocation of government, donor and other budget-holders’ resources. 

Co-financing is a financing approach whereby two or more sectors or budget holders, each with different development objectives, co-fund an intervention or broader investment area which advances their respective objectives simultaneously. 

Co-financing could provide a new way of financing high-impact interventions that can achieve benefits across the interconnected SDGs and targets.

What have we found?

1. Interventions to address the social determinants of health can yield multiple benefits across sectors
   Compelling evidence suggests that HIV-risk and service uptake are associated with poverty, food insecurity, low levels of schooling, gender-based violence, problematic alcohol use and stigma, among other upstream determinants. Investments in other non-health sectors that address these structural barriers and drivers can therefore be good HIV investments.

2. Structural interventions tend to be underfinanced and under-implemented, because their multiple benefits are often under-valued and unaccounted for in investment analyses
   Interventions to address the social determinants of health do not tend to be prioritised and receive limited funding, due to a focus on proximal determinants of health. Commonly applied economic analyses (including standard cost-effectiveness analyses) do not do justice to interventions with non-health costs or benefits.

3. Cross-sectoral co-financing is an innovative solution that can increase efficiency in the allocation of government, donor and other budget-holders’ resources
   Various joint budgeting/co-financing mechanisms are being implemented in high-income countries for health promotion and health/social care for specific vulnerable groups (for example, the elderly), however limited research has been conducted in resource constrained settings. STRIVE has identified institutional barriers and enablers to co-financing mechanisms according to national policy-makers/ budget holders.

What impact have we had?

The United Nations Development Programme (UNDP) – a STRIVE affiliate institution who was closely involved in the development of the co-financing approach – has developed a work stream on the operationalisation of cross-sectoral co-financing in seven countries in sub-Saharan Africa, as an innovative financing mechanism to strengthen universal health coverage and human development. 

This has involved the development of training materials for policy-makers, as well as the training of multi-sectoral government teams from South Africa, Tanzania, Malawi and Ethiopia. Further support is being provided to these countries, as well as Kenya, Zambia and Ghana, in translating co-financing models into high impact, cost-effective innovations in programming and financing structures. 

These implementation trials were implemented over a two-year period from 2017 to 2019. The outcomes provide further information on the barriers and enablers of engaging in co-financing models, along with additional evidence of the gains possible from a co-financing approach in practice. 

Key resources

• Report: Inter-sectoral co-financing: Financing across sectors for universal health coverage in sub-Saharan Africa
• Guidance note: Financing across sectors for sustainable development goals
• Technical brief: Co-financing for development synergies
• Impact case study: Co-financing for HIV and development synergies
• Report: Incorporating structural interventions in country HIV programme planning and resource allocation
• Learning lab: Co-financing for Universal Health Coverage: lessons from the UNDP-STRIVE pilot in seven sub-Sahara Africa countries
• Journal publication: Financing structural interventions: going beyond HIV-only value for money assessments