Financing the HIV Response in Uganda: Emerging Trends and Policy Options from National AIDS Spending Assessments

The country has scaled up access to life-saving antiretroviral therapy (ART) and new infections and annual AIDS-related deaths decreased by 43 percent and 58 percent, respectively, from 2010 to 2020. These achievements are largely due to heavy investments by development partners and the government of Uganda. Despite this progress, many challenges remain to end the epidemic in Uganda by 2030, including high levels of new infections among adolescent girls, young women, and other key population groups; low coverage of ART among children; and low male involvement in HIV programs and uptake of HIV services. A sustained commitment from the government and development partners is required for Uganda to attain UNAIDS' ambitious goal of ending AIDS by 2030. A cornerstone of this goal is reaching the "95-95-95" targets in which 95 percent of people living with HIV know their status, 95 percent of those diagnosed with HIV receive ART, and 95 percent of patients on ART achieve viral suppression by 2030. Effective and appropriate care and treatment for HIV not only reduces mortality but slows transmission of the virus, which is crucial to ending AIDS by 2030. The HIV response in Uganda is highly dependent on external funding, which has played a key role in helping to contain the spread of the epidemic. The U.S. President's Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund to Fight AIDS, Tuberculosis and Malaria together accounted for about 97 percent of total HIV spending in fiscal year (FY) 2018/19. PEPFAR contributions alone made up about 60 percent of total HIV expenditure in FY 2018/19. The current HIV funding model, which heavily relies on external sources, is not sustainable. The country needs to explore alternative ways of financing health and HIV, especially now that donor contribution is declining. The National AIDS Spending Assessment (NASA) tracking tool assesses the flow of resources and actual spending for HIV responses, providing critical information that can inform resource allocation decisions. This brief uses NASA data to describe financing of the national HIV response in Uganda and examine trends, sources, and programmatic allocations to answer critical policy questions around adequacy, sustainability, and efficiency of HIV financing in the country. The NASA is a resource tracking tool developed by UNAIDS to measure all of the resources flowing into a country to finance the national HIV response. It is based on the national health accounts framework and uses standard accounting methods to reconstruct all HIV financing transactions in a given country, tracking the flow of resources from financing source to beneficiary populations. The State of HIV Financing in Uganda: How Much is Spent on HIV? During the early years of the epidemic in Uganda, HIV expenditure was on an upward trajectory, increasing from 1,110 billion Ugandan shillings (UGX) (about US$565.2 million) in 2008/09 to UGX 2,411 billion (US$692.5 million) in 2016/17, an increase of about 23 percent. The increase was driven by increased spending from bilateral and multilateral donors, including PEPFAR and the Global Fund. However, after HIV spending peaked at UGX 2,411 billion in 2016/17, a downward trajectory emerged due to a decline in global support to the HIV response. HIV expenditure as a percentage of gross domestic product (GDP) increased from 1.2 percent in 2008/09 to about 2.2 percent in 2016/17 before embarking on a downward trend as well—it is currently estimated at 1.6 percent of GDP.