Cross-sectoral co-financing: Taking a multi-payer perspective in the financing and economic evaluation of structural HIV interventions

Background: Global HIV resource needs estimates are ever-increasing. There is growing interest in creating domestic fiscal space and prioritising the most cost-effective interventions. Concurrently, structural drivers and barriers are undermining the efficiency of HIV programmes to deliver on ambitious treatment and prevention targets. Yet, limited HIV resources are being channelled to interventions addressing these upstream factors. Conventional priority-setting and financing frameworks that only consider HIV outcomes and budgets, are further hampering investments in structural interventions that tend to be implemented in other sectors, for other objectives. Opportunities to factor in synergies with non-HIV investments tend to be missed, due to a lack of data on their multiple outcomes; the dominance of single outcome economic evaluation frameworks; and weak incentives for joint financing between sectors. The aim of this thesis is to develop and explore the application of a novel methodological approach for both fiscal space analysis and economic evaluation that considers multiple intervention benefits and multi-sectoral payers. Methods: The research uses a mixed methods approach, including case studies, econometric analysis, economic evaluation, and qualitative interviews, with data from selected countries in sub-Saharan Africa. Results: A ‘co-financing’ approach is developed for factoring non-HIV benefits and payers in HIV resource allocation. It is compared to other economic evaluation approaches, and to a unisectoral conceptualisation of cost-effectiveness thresholds. This approach is then used to explore the potential for creating fiscal space for HIV through co-financing of health system and broader development investments. Co-financing is also applied to the economic evaluation of a food support intervention for people initiating antiretroviral therapy. Finally, the institutional feasibility of adopting a co-financing framework in real-world HIV resource allocation is investigated from the perspective of policy-makers in Tanzania. Conclusion: Co-financing across sectors and budgets could optimise resource allocation and prevent welfare loss, but it will require strong cross-sectoral coordination and institutional incentives.