The economic burden of diseases in the Nordic countries: A systematic review.

BACKGROUND: Economic burden studies can provide insights into the drivers leading to increasing healthcare costs. It can also provide a more holistic view of how diseases impact the welfare of patients and their families. Having concrete estimates of the economic burden across multiple diseases can help policymakers determine which diseases are economically more burdensome. This study aimed to review and summarise comprehensively economic burden studies across multiple diseases in the Nordic countries between 2000 and 2020. METHODS: According to the 2020 PRISMA statement, a systematic literature review was conducted in PubMed, CINAHL, Academic Search Premier and Global Health databases using key terms related to the economic burden of any disease in Denmark, Finland, Greenland, Iceland, Norway and Sweden. Grey literature was also reviewed. RESULTS: A total of 10,050 potential titles and abstracts were identified and screened, and 254 full-text papers that met the inclusion criteria were evaluated by two independent reviewers. Of these, 119 articles were included in a qualitative synthesis. Twenty-nine had clearly defined comparison groups, thus able to attribute the costs to the disease. Large variations concerning methodology and cost components were noted. Across diseases, the economic burden ranged from EUR 1668 per patient annually for chronic obstructive pulmonary disease to EUR 93,041 for multiple sclerosis. However, estimates varied widely, even within each disease. CONCLUSIONS: Our review highlights the need for more comparable economic burden studies. Future studies should focus on applying robust methodology and homogeneous cost-reporting methods to inform policymakers about which diseases are economically more burdensome.

One vaccine to counter many diseases? Modeling the economics of oral polio vaccine against child mortality and COVID-19.

Introduction: Recent reviews summarize evidence that some vaccines have heterologous or non-specific effects (NSE), potentially offering protection against multiple pathogens. Numerous economic evaluations examine vaccines' pathogen-specific effects, but less than a handful focus on NSE. This paper addresses that gap by reporting economic evaluations of the NSE of oral polio vaccine (OPV) against under-five mortality and COVID-19. Materials and methods: We studied two settings: (1) reducing child mortality in a high-mortality setting (Guinea-Bissau) and (2) preventing COVID-19 in India. In the former, the intervention involves three annual campaigns in which children receive OPV incremental to routine immunization. In the latter, a susceptible-exposed-infectious-recovered model was developed to estimate the population benefits of two scenarios, in which OPV would be co-administered alongside COVID-19 vaccines. Incremental cost-effectiveness and benefit-cost ratios were modeled for ranges of intervention effectiveness estimates to supplement the headline numbers and account for heterogeneity and uncertainty. Results: For child mortality, headline cost-effectiveness was $650 per child death averted. For COVID-19, assuming OPV had 20% effectiveness, incremental cost per death averted was $23,000-65,000 if it were administered simultaneously with a COVID-19 vaccine <200 days into a wave of the epidemic. If the COVID-19 vaccine availability were delayed, the cost per averted death would decrease to $2600-6100. Estimated benefit-to-cost ratios vary but are consistently high. Discussion: Economic evaluation suggests the potential of OPV to efficiently reduce child mortality in high mortality environments. Likewise, within a broad range of assumed effect sizes, OPV (or another vaccine with NSE) could play an economically attractive role against COVID-19 in countries facing COVID-19 vaccine delays. Funding: The contribution by DTJ was supported through grants from Trond Mohn Foundation (BFS2019MT02) and Norad (RAF-18/0009) through the Bergen Center for Ethics and Priority Setting.

The health-adjusted dependency ratio as a new global measure of the burden of ageing: a population-based study.

BACKGROUND: The old-age dependency ratio (OADR), which is the ratio of older people (aged ≥65 years) to working age people (aged 20-64 years), is the most common way to assess and compare the burden of population ageing in different countries. However, the relationship between chronological age and dependency varies widely across countries. We therefore present the health-adjusted dependency ratio (HADR), a new measure of ageing burden based on the ageing-related health of the adult population. METHODS: In this population-based study we used health data for diseases and injuries for 2017 from the Global Burden of Disease project and population data for 2017 from the UN's Population Division to identify the number of adults (aged >20 years) in each country who have the same or higher ageing-related disease burden as the global average 65-year-old. We then calculated the HADR as the ratio of adults who were less healthy than the average 65-year-old (dependent population) to those in better health (supporting population) and compared the HADR with the OADR for 188 countries. We also used cross-sectional, bivariate regression analysis to investigate whether the HADR is a more powerful predictor of changes in per capita health-care expenditure than the OADR as a measure of predictive validity. FINDINGS: Many demographically younger populations have an earlier onset of ageing-related disease, and many demographically older populations have a later onset. For instance, Pakistan has an OADR of 0·09 and an HADR of 0·19, and France has an OADR of 0·35 and an HADR of 0·13. Relative to the OADR, the HADR suggests that Asia, western Europe, and North America have a lower ageing burden, whereas central Asia, southern Asia, and Africa have a greater burden. While Japan and countries in western Europe have the highest OADR, Russia, Papua New Guinea, and countries in southeast Europe have the highest HADR. Relative to the OADR, the HADR suggests that there is much less variation in the burden of ageing across countries than has previously been assumed. HADR was also more closely associated with growth in health spending than the OADR. A 0·1 increase in the HADR was associated with a 2·9 percentage points larger growth rate in per capita spending (p=0·0001), and a 0·1-point increase in the OADR was associated with a 1·8 percentage point larger growth rate. INTERPRETATION: The OADR probably overestimates the burden of population ageing in many demographically older countries and underestimates the ageing burden in many demographically younger countries, which implies that the challenges associated with ageing are more universal than previously thought, and that the world cannot easily be divided in a young and an old groups of nations. FUNDING: None.

Trends and outcomes in primary health care expenditures in low-income and middle-income countries, 2000-2017.

INTRODUCTION: As the world responds to COVID-19 and aims for the Sustainable Development Goals, the potential for primary healthcare (PHC) is substantial, although the trends and effectiveness of PHC expenditure are unknown. We estimate PHC expenditure for each low-income and middle-income country between 2000 and 2017 and test which health outputs and outcomes were associated with PHC expenditure. METHODS: We used three data sources to estimate PHC expenditures: recently published health expenditure estimates for each low-income and middle-income country, which were constructed using 1662 country-reported National Health Accounts; proprietary data from IQVIA to estimate expenditure of prescribed pharmaceuticals for PHC; and household surveys and costing estimates to estimate inpatient vaginal delivery expenditures. We employed regression analyses to measure the association between PHC expenditures and 15 health outcomes and intermediate health outputs. RESULTS: PHC expenditures in low-income and middle-income countries increased between 2000 and 2017, from $41 per capita (95% uncertainty interval $33-$49) to $90 ($73-$105). Expenditures for low-income countries plateaued since 2014 at $17 per capita ($15-$19). As national income increased, the proportion of health expenditures on PHC generally decrease; however, the fraction of PHC expenditures spent via ambulatory care providers grew. Increases in the fraction of health expenditures on PHC was associated with lower maternal mortality rate (p value≤0.001), improved coverage of antenatal care visits (p value≤0.001), measles vaccination (p value≤0.001) and an increase in the Health Access and Quality index (p value≤0.05). PHC expenditure was not systematically associated with all-age mortality, communicable and non-communicable disease (NCD) burden. CONCLUSION: PHC expenditures were associated with maternal and child health but were not associated with reduction in health burden for other key causes of disability, such as NCDs. To combat changing disease burdens, policy-makers and health professionals need to adapt primary healthcare to ensure continued impact on emerging health challenges.

Health expenditures by services and providers for 195 countries, 2000-2017.

INTRODUCTION: National Health Accounts are a significant source of health expenditure data, designed to be comprehensive and comparable across countries. However, there is currently no single repository of this data and even when compiled major gaps persist. This research aims to provide policymakers and researchers with a single repository of available national health expenditures by healthcare functions (ie, services) and providers of such services. Leveraging these data within statistical methods, a complete set of detailed health expenditures is estimated. METHODS: A methodical compilation and synthesis of all available national health expenditure reports including disaggregation by healthcare functions and providers was conducted. Using these data, a Bayesian multivariate regression analysis was implemented to estimate national-level health expenditures by the cross-classification of functions and providers for 195 countries, from 2000 to 2017. RESULTS: This research used 1662 country-years and 110 070 data points of health expenditures from existing National Health Accounts. The most detailed country-year had 52% of the categories of interest reported. Of all health functions, curative care and medical goods were estimated to make up 51.4% (uncertainty interval (UI) 33.2% to 59.4%) and 17.5% (UI 13.0% to 26.9%) of total global health expenditures in 2017, respectively. Three-quarters of the global health expenditures are allocated to three categories of providers: hospital providers (35.4%, UI 30.3% to 38.9%), providers of ambulatory care (25.5%, UI 21.1% to 28.8%) and retailers of medical goods (14.4%, UI 12.4% to 16.3%). As gross domestic product increases, countries spend more on long-term care and less on preventive care. CONCLUSION: Disaggregated estimates of health expenditures are often unavailable and unable to provide policymakers and researchers a holistic understanding of how expenditures are used. This research aggregates reported data and provides a complete time-series of estimates, with uncertainty, of health expenditures by health functions and providers between 2000 and 2017 for 195 countries.

Associations Between Practices and Behaviors at the Health Facility Level and Supply Chain Management for Antiretrovirals: Evidence from Cameroon, Namibia, and Swaziland.

BACKGROUND: While measuring, monitoring, and improving supply chain management (SCM) for antiretrovirals (ARVs) is understood at many levels of health systems, a gap remains in the identification and measurement of facility-level practices and behaviors that affect SCM. This study identifies practices and behaviors that are associated with SCM of ARVs at the hospital level and proposes new indicators for measurement. METHODS: We performed an in-depth literature review to identify facility-level practices and behaviors and existing indicators that are associated with SCM. We used the United States Agency for International Development's 2013 National Supply Chain Assessment Toolkit to define 7 supply chain function areas to frame the study. Qualitative, semistructured key informant and focus group interviews were conducted in hospitals with health professionals from Cameroon, Namibia, and Swaziland to understand facility-level practices and behaviors. RESULTS: Using the results from 54 key informant and focus group interviews from 12 hospitals, we identified 30 practices and behaviors that may affect ARV SCM at the facility level. The following practice areas were particularly associated with SCM: order verification, actions taken when ARV stock is received, changes in prescription and dispensing due to ARV stock-out, actions to ensure patient adherence, and communication with other affiliated facilities and higher-level SCM. We subsequently developed measurable indicators for future research. CONCLUSION: This study characterizes facility-level practices and behaviors that can affect ARV SCM. It also identifies gaps in their measurement. While this study uses ARVs as a tracer medicine to understand gaps in practices at the facility level, many of the findings are more broadly applicable to other medicines in an integrated setting. This study provides real-world evidence and the groundwork for further research to characterize the link between 30 facility-level practices and behaviors and ARV SCM at the facility and central levels.

Measuring population ageing: an analysis of the Global Burden of Disease Study 2017.

BACKGROUND: Traditional metrics for population health ageing tend not to differentiate between extending life expectancy and adding healthy years. A population ageing metric that reflects both longevity and health status, incorporates a comprehensive range of diseases, and allows for comparisons across countries and time is required to understand the progression of ageing and to inform policies. METHODS: Using the Global Burden of Diseases, Injuries, and Risk Factors Study 2017, we developed a metric that reflects age-related morbidity and mortality at the population level. First, we identified a set of age-related diseases, defined as diseases with incidence rates among the adult population increasing quadratically with age, and measured their age-related burden, defined as the sum of disability-adjusted life-years (DALYs) of these diseases among adults. Second, we estimated age-standardised age-related health burden across 195 countries between 1990 and 2017. Using global average 65-year-olds as the reference population, we calculated the equivalent age in terms of age-related disease burden for all countries. Third, we analysed how the changes in age-related burden during the study period relate to different factors with a decomposition analysis. Finally, we describe how countries with similar levels of overall age-related burden experience different onsets of ageing. We represent the uncertainty of our estimates by calculating uncertainty intervals (UI) from 1000 draw-level estimates for each disease, country, year, and age. FINDINGS: 92 diseases were identified as age related, accounting for 51·3% (95% UI 48·5-53·9) of all global burden among adults in 2017. Across the Socio-demographic Index (SDI), the rate of age-related burden ranged from 137·8 DALYs (128·9-148·3) per 1000 adults in high SDI countries to 265·9 DALYs (251·0-280·1) in low SDI countries. The equivalent age to average 65-year-olds globally spanned from 76·1 years (75·6-76·7) in Japan to 45·6 years (42·6-48·2) in Papua New Guinea. Age-standardised age-related disease rates have decreased over time across all SDI levels and regions between 1990 and 2017, mainly due to decreases in age-related case fatality and disease severity. Even among countries with similar age-standardised death rates, large differences in the onset and patterns of accumulating age-related burden exist. INTERPRETATION: The new metric facilitates the shift from thinking not just about chronological age but the health status and disease severity of ageing populations. Our findings could provide inputs into policymaking by identifying key drivers of variation in the ageing burden and resources required for addressing the burden. FUNDING: National Institute on Aging of the National Institutes of Health.

Estimating the distribution of morbidity and mortality of childhood diarrhea, measles, and pneumonia by wealth group in low- and middle-income countries.

BACKGROUND: Equitable access to vaccines has been suggested as a priority for low- and middle-income countries (LMICs). However, it is unclear whether providing equitable access is enough to ensure health equity. Furthermore, disaggregated data on health outcomes and benefits gained across population subgroups are often unavailable. This paper develops a model to estimate the distribution of childhood disease cases and deaths across socioeconomic groups, and the potential benefits of three vaccine programs in LMICs. METHODS: For each country and for three diseases (diarrhea, measles, pneumonia), we estimated the distributions of cases and deaths that would occur across wealth quintiles in the absence of any immunization or treatment programs, using both the prevalence and relative risk of a set of risk and prognostic factors. Building on these baseline estimates, we examined what might be the impact of three vaccines (first dose of measles, pneumococcal conjugate, and rotavirus vaccines), under five scenarios based on different sets of quintile-specific immunization coverage and disease treatment utilization rates. RESULTS: Due to higher prevalence of risk factors among the poor, disproportionately more disease cases and deaths would occur among the two lowest wealth quintiles for all three diseases when vaccines or treatment are unavailable. Country-specific context, including how the baseline risks, immunization coverage, and treatment utilization are currently distributed across quintiles, affects how different policies translate into changes in cases and deaths distribution. CONCLUSIONS: Our study highlights several factors that would substantially contribute to the unequal distribution of childhood diseases, and finds that merely ensuring equal access to vaccines will not reduce the health outcomes gap across wealth quintiles. Such information can inform policies and planning of programs that aim to improve equitable delivery of healthcare services.

Poverty reduction and equity benefits of introducing or scaling up measles, rotavirus and pneumococcal vaccines in low-income and middle-income countries: a modelling study.

INTRODUCTION: Beyond their impact on health, vaccines can lead to large economic benefits. While most economic evaluations of vaccines have focused on the health impact of vaccines at a national scale, it is critical to understand how their impact is distributed along population subgroups. METHODS: We build a financial risk protection model to evaluate the impact of immunisation against measles, severe pneumococcal disease and severe rotavirus for birth cohorts vaccinated over 2016-2030 for three scenarios in 41 Gavi-eligible countries: no immunisation, current immunisation coverage forecasts and the current immunisation coverage enhanced with funding support. We distribute modelled disease cases per socioeconomic group and derive the number of cases of: (1) catastrophic health costs (CHCs) and (2) medical impoverishment. RESULTS: In the absence of any vaccine coverage, the number of CHC cases attributable to measles, severe pneumococcal disease and severe rotavirus would be approximately 18.9 million, 6.6 million and 2.2 million, respectively. Expanding vaccine coverage would reduce this number by up to 90%, 30% and 40% in each case. More importantly, we find a higher share of CHC incidence among the poorest quintiles who consequently benefit more from vaccine expansion. CONCLUSION: Our findings contribute to the understanding of how vaccines can have a broad economic impact. In particular, we find that immunisation programmes can reduce the proportion of households facing catastrophic payments from out-of-pocket health expenses, mainly in lower socioeconomic groups. Thus, vaccines could have an important role in poverty reduction.

The Equity Impact Vaccines May Have On Averting Deaths And Medical Impoverishment In Developing Countries.

With social policies increasingly directed toward enhancing equity through health programs, it is important that methods for estimating the health and economic benefits of these programs by subpopulation be developed, to assess both equity concerns and the programs' total impact. We estimated the differential health impact (measured as the number of deaths averted) and household economic impact (measured as the number of cases of medical impoverishment averted) of ten antigens and their corresponding vaccines across income quintiles for forty-one low- and middle-income countries. Our analysis indicated that benefits across these vaccines would accrue predominantly in the lowest income quintiles. Policy makers should be informed about the large health and economic distributional impact that vaccines could have, and they should view vaccination policies as potentially important channels for improving health equity. Our results provide insight into the distribution of vaccine-preventable diseases and the health benefits associated with their prevention.

Modest improvements in skilled birth attendants at delivery with increased Mutuelles coverage in Rwanda.

Background: We revisit the question of the role health insurance coverage played in increasing use of skilled birth attendants (SBA) at delivery in Rwanda. Previous studies have suggested that enrollment in Mutuelles health insurance increased the odds of using an SBA by up to 163%. Methods: We take advantage of latest Rwanda Demographic Health Survey (NISR M, Macro O. Rwanda Demographic and Health Survey 2010. National Institute of Statistics of Rwanda and Ministry of Health, 2012.) to increase the sample size and extend the time frame of analysis to 5 years (2005-10). We also adopt a stronger matching method, coarsened exact matching, to control for model dependence. Results: We find that although enrollment in Mutuelles insurance increases use of SBAs at delivery, the size of the effect is an order of magnitude lower than previously published (12-18% versus 78-163%). We also find that the effect of education on use of SBA is similar in magnitude to that of Mutuelles insurance enrollment. Conclusions: Our findings lead us to conclude that Mutuelles only had a modest effect on increasing use of SBA at delivery and therefore insurance alone may not be the 'magic bullet' that solves the problem of non-use of SBA at delivery.

Dynamic modeling approaches to characterize the functioning of health systems: A systematic review of the literature.

Universal Health Coverage (UHC) is one of the targets for the United Nations Sustainable Development Goal 3. The impetus for UHC has led to an increased demand for time-sensitive tools to enhance our knowledge of how health systems function and to evaluate impact of system interventions. We define the field of "health system modeling" (HSM) as an area of research where dynamic mathematical models can be designed in order to describe, predict, and quantitatively capture the functioning of health systems. HSM can be used to explore the dynamic relationships among different system components, including organizational design, financing and other resources (such as investments in resources and supply chain management systems) - what we call "inputs" - on access, coverage, and quality of care - what we call "outputs", toward improved health system "outcomes", namely increased levels and fairer distributions of population health and financial risk protection. We undertook a systematic review to identify the existing approaches used in HSM. We identified "systems thinking" - a conceptual and qualitative description of the critical interactions within a health system - as an important underlying precursor to HSM, and collated a critical collection of such articles. We then reviewed and categorized articles from two schools of thoughts: "system dynamics" (SD)" and "susceptible-infected-recovered-plus" (SIR+). SD emphasizes the notion of accumulations of stocks in the system, inflows and outflows, and causal feedback structure to predict intended and unintended consequences of policy interventions. The SIR + models link a typical disease transmission model with another that captures certain aspects of the system that impact the outcomes of the main model. These existing methods provide critical insights in informing the design of HSM, and provide a departure point to extend this research agenda. We highlight the opportunity to advance modeling methods to further understand the dynamics between health system inputs and outputs.

Economics in "Global Health 2035": a sensitivity analysis of the value of a life year estimates.

BACKGROUND: In "Global health 2035: a world converging within a generation," The Lancet Commission on Investing in Health (CIH) adds the value of increased life expectancy to the value of growth in gross domestic product (GDP) when assessing national well-being. To value changes in life expectancy, the CIH relies on several strong assumptions to bridge gaps in the empirical research. It finds that the value of a life year (VLY) averages 2.3 times GDP per capita for low- and middle-income countries (LMICs) assuming the changes in life expectancy they experienced from 2000 to 2011 are permanent. METHODS: The CIH VLY estimate is based on a specific shift in population life expectancy and includes a 50 percent reduction for children ages 0 through 4. We investigate the sensitivity of this estimate to the underlying assumptions, including the effects of income, age, and life expectancy, and the sequencing of the calculations. FINDINGS: We find that reasonable alternative assumptions regarding the effects of income, age, and life expectancy may reduce the VLY estimates to 0.2 to 2.1 times GDP per capita for LMICs. Removing the reduction for young children increases the VLY, while reversing the sequencing of the calculations reduces the VLY. CONCLUSION: Because the VLY is sensitive to the underlying assumptions, analysts interested in applying this approach elsewhere must tailor the estimates to the impacts of the intervention and the characteristics of the affected population. Analysts should test the sensitivity of their conclusions to reasonable alternative assumptions. More work is needed to investigate options for improving the approach.

Understanding and improving the one and three times GDP per capita cost-effectiveness thresholds.

Researchers and policymakers have long been interested in developing simple decision rules to aid in determining whether an intervention is, or is not, cost-effective. In global health, interventions that impose costs per disability-adjusted life year averted less than three and one times gross domestic product per capita are often considered cost-effective and very cost-effective, respectively. This article explores the conceptual foundation and derivation of these thresholds. Its goal is to promote understanding of how these thresholds were derived and their implications, as well as to suggest options for improvement. These thresholds are intended to reflect the monetary value of the benefits to affected individuals, based on their preferences for spending on health vs spending on other goods and services. However, the current values were not rigorously derived, which means that their application may lead to inappropriate conclusions regarding which interventions should be adopted as well as misallocation of resources across health and other investments. Improving the basis for these cost-effectiveness thresholds is of particular importance in low- and middle-income countries, given the limited resources available and the significant needs of their populations.

Changing HIV treatment eligibility under health system constraints in sub-Saharan Africa: investment needs, population health gains, and cost-effectiveness.

OBJECTIVE: We estimated the investment needs, population health gains, and cost-effectiveness of different policy options for scaling-up prevention and treatment of HIV in the 10 countries that currently comprise 80% of all people living with HIV in sub-Saharan Africa (Ethiopia, Kenya, Malawi, Mozambique, Nigeria, South Africa, Tanzania, Uganda, Zambia, and Zimbabwe). DESIGN: We adapted the established STDSIM model to capture the health system dynamics: demand-side and supply-side constraints in the delivery of antiretroviral treatment (ART). METHODS: We compared different scenarios of supply-side (i.e. health system capacity) and demand-side (i.e. health seeking behavior) constraints, and determined the impact of changing guidelines to ART eligibility at any CD4 cell count within these constraints. RESULTS: Continuing current scale-up would require US$178 billion by 2050. Changing guidelines to ART at any CD4 cell count is cost-effective under all constraints tested in the model, especially in demand-side constrained health systems because earlier initiation prevents loss-to-follow-up of patients not yet eligible. Changing guidelines under current demand-side constraints would avert 1.8 million infections at US$208 per life-year saved. CONCLUSION: Treatment eligibility at any CD4 cell count would be cost-effective, even under health system constraints. Excessive loss-to-follow-up and mortality in patients not eligible for treatment can be avoided by changing guidelines in demand-side constrained systems. The financial obligation for sustaining the AIDS response in sub-Saharan Africa over the next 35 years is substantial and requires strong, long-term commitment of policy-makers and donors to continue to allocate substantial parts of their budgets.

Long-term financing needs for HIV control in sub-Saharan Africa in 2015-2050: a modelling study.

OBJECTIVES: To estimate the present value of current and future funding needed for HIV treatment and prevention in 9 sub-Saharan African (SSA) countries that account for 70% of HIV burden in Africa under different scenarios of intervention scale-up. To analyse the gaps between current expenditures and funding obligation, and discuss the policy implications of future financing needs. DESIGN: We used the Goals module from Spectrum, and applied the most up-to-date cost and coverage data to provide a range of estimates for future financing obligations. The four different scale-up scenarios vary by treatment initiation threshold and service coverage level. We compared the model projections to current domestic and international financial sources available in selected SSA countries. RESULTS: In the 9 SSA countries, the estimated resources required for HIV prevention and treatment in 2015-2050 range from US$98 billion to maintain current coverage levels for treatment and prevention with eligibility for treatment initiation at CD4 count of <500/mm(3) to US$261 billion if treatment were to be extended to all HIV-positive individuals and prevention scaled up. With the addition of new funding obligations for HIV--which arise implicitly through commitment to achieve higher than current treatment coverage levels--overall financial obligations (sum of debt levels and the present value of the stock of future HIV funding obligations) would rise substantially. CONCLUSIONS: Investing upfront in scale-up of HIV services to achieve high coverage levels will reduce HIV incidence, prevention and future treatment expenditures by realising long-term preventive effects of ART to reduce HIV transmission. Future obligations are too substantial for most SSA countries to be met from domestic sources alone. New sources of funding, in addition to domestic sources, include innovative financing. Debt sustainability for sustained HIV response is an urgent imperative for affected countries and donors.