Financing HIV Programming: How Much Should Low- And Middle-Income Countries and their Donors Pay? Omar Gala ´ rraga 1,2 *, Veronika J. Wirtz 3,2 , Yared Santa-Ana-Tellez 4,2 , Eline L. Korenromp 5 1 Department of Health Services, Policy and Practice; Brown University, School of Public Health, Providence, Rhode Island, United States of America, 2 National Institute of Public Health (INSP)/Mexican School of Public Health, Cuernavaca, Mexico, 3 Center for Global Health and Development, Boston University, Boston, Massachusetts, United States of America, 4 WHO Collaborating Centre for Pharmaceutical Policy and Regulation, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht, The Netherlands, 5 Department of Public Health, Erasmus MC, University Medical Center Rotterdam, The Netherlands Abstract Global HIV control funding falls short of need. To maximize health outcomes, it is critical that national governments sustain reasonable commitments, and that international donor assistance be distributed according to country needs and funding gaps. We develop a country classification framework in terms of actual versus expected national domestic funding, considering resource needs and donor financing. With UNAIDS and World Bank data, we examine domestic and donor HIV program funding in relation to need in 84 low- and middle-income countries. We estimate expected domestic contributions per person living with HIV (PLWH) as a function of per capita income, relative size of the health sector, and per capita foreign debt service. Countries are categorized according to levels of actual versus expected domestic contributions, and resource gap. Compared to national resource needs (UNAIDS Investment Framework), we identify imbalances among countries in actual versus expected domestic and donor contributions: 17 countries, with relatively high HIV prevalence and GNI per capita, have domestic funding below expected (median per PLWH $143 and $376, respectively), yet total available funding including from donors would exceed the need ($368 and $305, respectively) if domestic contribution equaled expected. Conversely, 27 countries have actual domestic funding above the expected (medians $294 and $149) but total (domestic+donor) funding does not meet estimated need ($685 and $1,173). Across the 84 countries, in 2009, estimated resource need totaled $10.3 billion, actual domestic contributions $5.1 billion and actual donor contributions $3.7 billion. If domestic contributions would increase to the expected level in countries where the actual was below expected, total domestic contributions would increase to $7.4 billion, turning a funding gap of $1.5 billion into a surplus of $0.8 billion. Even with imperfect funding and resource-need data, the proposed country classification could help improve coherence and efficiency in domestic and international allocations. Citation: Gala ´ rraga O, Wirtz VJ, Santa-Ana-Tellez Y, Korenromp EL (2013) Financing HIV Programming: How Much Should Low- And Middle-Income Countries and their Donors Pay? PLoS ONE 8(7): e67565. doi:10.1371/journal.pone.0067565 Editor: Paula Braitstein, Indiana University and Moi University, United States of America Received November 20, 2012; Accepted May 24, 2013; Published July 5, 2013 Copyright: ß 2013 Gala ´rraga et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Funding: The research was partially funded by the Bill and Melinda Gates Foundation through the INSP/Consortium for Research on HIV/AIDS and Tuberculosis (CISIDAT). Additional funding for Omar Gala ´rraga was provided by United States National Institutes of Health (NIH)/Fogarty International Center (K01-TW008016- 04). The opinions expressed in the paper do not reflect the views of any of the funding or the other organizations that supported or facilitated the study. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Competing Interests: The authors have declared that no competing interests exist. * E-mail: omar_galarraga@brown.edu Introduction An unprecedented increase in global spending on HIV/AIDS has occurred in the last decade; reaching over USD$16.8 billion in 2011 [1]. However, available funding continues to fall short of the global need to achieve global targets (such as the Millennium Development Goals); and after the rise in international funding slowed down due to the global crisis over 2009–12, it is now essentially flat or decreasing [2–4]. Better mechanisms are needed to enhance efficiency and optimize HIV allocations, on both donor and recipient sides, in relation to disease burden, as well as marginalized and vulnerable groups [1,5–7]. One way to ensure sustainable funding for HIV would be through the definition of donor obligations as a set annual amount or proportion in relation to country income level. The United Nations General Assembly Special Session (UNGASS) declaration of 2001 proposed a ‘‘target of 0.7% of their gross national product for overall official development assistance, and (…) earmarking of 0.15% to 0.20% of gross national product as official development assistance for least developed countries [8].’’ In 2002 activists from the Global AIDS Alliance argued that the Global Fund to fight AIDS, Tuberculosis and Malaria (Global Fund) should have a similar definition of donor funding obligations as that of the UN budget; and that G-7 nations should contribute three-fourths of total requirements [9]. A so-called ‘‘equitable contributions framework’’ was proposed by Oxfam, Me ´decins Sans Frontie`res (MSF) and Fund the Fund, by which the total amount of requests made by recipient countries to the Global Fund should be divided over the 37 or 47 wealthiest countries in proportion to their GDP [10,11]. Wealthier countries fell short on the 0.7% GDP commitment recommended by UNGASS [12]. Also, over recent years some donor nations have sometimes fallen short of, or delayed, the disbursement of their pledges to multilateral agencies such as the Global Fund. Since most health aid is short-term and volatile, it threatens the consolidation of long-term interventions; bilateral efforts, such as the United States Government’s President’s Emergency Plan for AIDS Relief (PEPFAR), generally PLOS ONE | www.plosone.org 1 July 2013 | Volume 8 | Issue 7 | e67565