Financing the Future: Dr. Justice Nonvignon on HIV Equity and Primary Health Care Integration

Vibrant global health conferences like AIDS 2024 leave participants energized and looking to apply what they’ve learned to their future work. Discussion about the future of HIV programming, at conferences and elsewhere, often focuses on integrating disease-focused interventions into low- and middle- income countries’ primary health care (PHC) systems. Dr. Justice Nonvignon, who recently joined Management Sciences for Health (MSH) as Technical Director for PHC Efficiency, Effectiveness, and Equity, reminds us that now “the challenge is to walk the talk.” His work with regional partners, governments, and communities is aimed at building sustainable and resilient PHC systems using innovative health economics and financing approaches and tools. Below, he answers some questions to help connect the dots between HIV programming and health financing.

What challenges do countries face integrating HIV prevention and care into their primary health care systems—and how can they address them?  

Historically, HIV programs have been delivered vertically, meaning they focus exclusively on HIV and not on the whole health system. While certain aspects of that programming for prevention and care may benefit the system as a whole, the fact that programs are designed vertically means that some work needs to happen before the services they provide truly become part of the system. This is a challenge with economic and financial implications. Much of what we know about the efficiency and effectiveness of HIV programs—which informs how they’re funded—is from evidence gathered when evaluating a vertical delivery approach. What will it cost to integrate those services into the wider health system? How can countries do it in the most cost-effective way while still improving outcomes?

My work, and that of other technical experts at MSH, can help with this process of integration. With tools like the PHC Costing Tool, evidence-based approaches such as Health Technology Assessment, and other health economics insights, we work with governments to accurately forecast the cost of managing these services domestically and make the most efficient use of limited resources.

We know that a successful transition from donor-driven and donor-funded to country-driven and country-funded must be localized. What are some recommendations you’d give to both donors and countries as they undertake this process? 

There is no such thing as a perpetual donor. That’s why it’s crucial to think about how countries can move toward designing, delivering, and funding their own health programs. Without this transition, HIV prevention and care will not be sustainable. And we need to move from talking about that to making it happen.

One of the challenges is that in many cases countries have little visibility into which donor spends what and where the money goes. One way to address this is to make sure that countries are in the driver’s seat when it comes to programming and implementation. Then they will have a better vantage point to determine what programming they can deliver out of their own resources, where the gaps are, and whether donors could help to cover those gaps. This also means countries need to drive global conversations and planning.

While governments, by their nature, will have to prioritize funding the most basic things, such as health commodities, donor funding can be useful for system-level interventions.  

Opinions vary among health officials in different countries when it comes to adopting new models for HIV services that differ from current donor-funded ones. What role do you think change management must play in those countries’ localization approach? 

Change management is important any time we’re trying to move from a longstanding status quo to a new way of doing things. In the case of HIV programming, service models have been tailored to what donors like to see for so long that those models have become institutionalized and within the comfort zone for health officers. It’s going to take time and significant effort to reconfigure this programming from externally driven vertical models to those that are integrated into PHC, driven by countries themselves. When facilitating that process, it’s important to recognize and address the challenges it may pose to staff through proven approaches such as involving stakeholders at all levels of the decision making process, sharing decisions clearly and transparently, communicating how change will affect everyone involved and in what ways, and overall being sensitive to the fact that change takes time. 

Although the HIV epidemic is largely under control, infection rates are still climbing among certain population groups. How can we ensure that health systems are cost effective but also equitable?

There can be significant inequality in access to prevention and treatment for HIV depending on where someone lives (even within a country), who they are, what they do for a living, and what attributes they have. Sometimes these inequities result from cultural norms and stigma, but they can also happen when externally driven programs focus on most of the affected population, which further isolates already marginalized groups. Health insurance and other social protection programs that attempt to resolve inequity from various angles play an important role. To correct imbalances, countries should explicitly account for equity in their public financial management—for example, by monitoring how resource allocation benefits programs that target vulnerable populations. That way, we ensure that some population groups aren’t systematically disadvantaged from accessing prevention and treatment services.

Lastly, you’ve spent years teaching public health leadership to graduate-level university students, many of whom are already working in the health system. What have you learned from them? 

One thing my students have helped me see is that theories do not really drive change; experience and context do. Health care and decision making models mainly based on textbooks are not the ones that lead to the most fundamental changes on the ground. Therefore, listening to communities and countries is core to ensuring that global-level policies and actions lead to impact on populations and country systems.