Donor support for healthcare service delivery in developing countries has been remarkable with unprecedented gains on certain fronts including HIV services [1, 2]. Health aid to Nigeria has been on the increase since the 1990s. The annual Development Assistance for Health (DAH) disbursements to Nigeria increased from $10.1 billion in 2008 to $16.1 billion in 2017 [3]. The attention given to HIV programs has been particularly striking compared to other programs. HIV donor support to Nigeria doubled as a proportion of DAH from 1990 to 2000, and HIV aid increased over fourfold between 1992 and 2005 notwithstanding competing national priorities [4, 5, 6]. Three Global Health Initiatives (GHIs) including the US President’s Emergency Plan for AIDS Relief, the Global Fund to Fight AIDS, Tuberculosis and Malaria, and the World Bank Multi-AIDS Project have been responsible for most HIV financing in Nigeria [7].
In Nigeria, there are concerns that HIV financing have continued to overshadow and could have had negative spillover effects on the delivery of other health programs including Maternal and Child Health (MNCH) services. In 2014, MNCH diseases contributed about 45% of the total Disability Adjusted Life Years (DALYS) lost to diseases compared to 6.3% for HIV, yet only 0.5% of all health-specific foreign aid was earmarked for MNCH services in Nigeria. This contrasts with an enormous 32% for HIV programs [3]. This imbalance between disease burden and financing could impact priorities and skew attention to diseases with greater funding. Thus, services for specific diseases could be scaled-up at the expense of overall health systems development. While DAH may have strengthened national health systems appreciably, there are concerns that the increasing HIV funding may have negatively impacted the delivery of non-HIV services [8].
This study expands the current body of knowledge by investigating the impact of the GHI’s HIV funding on the Nigerian health system. It evaluated the characteristics and trend of aid disbursements to Nigeria, as well as investigated the nature of the spillover effect of HIV funding on the delivery of MNCH services in Nigeria. Using multilevel analytic approaches, this study investigated what the impact of spending an extra dollar on HIV programs will have on the delivery of MNCH services in Nigeria. Findings from this study have opportunities to inform the formulation of policies that improve the effectiveness of the GHIs in Nigeria. This could facilitate the development of a national roadmap for the effective alignment of GHIs’ coordinating mechanisms with national health priorities.
Over the years, HIV programs in Nigeria have received unprecedented priorities by donors, and has sparked debates among stakeholders. HIV programs have received a disproportionate share of aid relative to its disease burden [5]. Public opinion surveys in most contexts have ranked support for HIV programs low relative to other health priorities, even among HIV patients and their network members [9]. These conversations have continued to gain momentum as there are concerns that donor support for HIV programs could be crowding-out or displacing support for other health programs [1, 6]. However, the prioritized attention given to HIV programs has been explained on the grounds of human rights; as HIV is a pandemic, and requires focused emergency interventions [10].
On the contrary, advocates of HIV programs have continued to lobby and push for increased HIV funding. They argue that allocating additional funding to HIV programs could strengthen existing health systems and improve the overall health service delivery [11]. Given that HIV patients routinely seek care at health facilities for antiretroviral medication refills, viral load checks and other related services; thus, keeping them healthier and reducing their need for, and net use of services could free-up spaces for the delivery of services to other patients [12].
Donor-driven HIV programs have recorded great successes across the globe including Nigeria. By the end of 2015, an estimated 7.5 million people were receiving antiretroviral medications, and many others were receiving HIV support and preventive services [13]. However, despite massive flow of HIV aid to global health systems, there have been increasing debates regarding the effectiveness of aid in general including the influx of new HIV funding. Critics have asserted the possibility that HIV aid might not be working and could have had unintended negative consequences on the delivery of non-HIV services [12, 14, 15]. In addition, other researchers have tested the robustness of many empirical studies and have found in real terms that aid has not been effective as it has weak associations with public policy, democracy and poverty [16, 17].
There is also an increasing debate in Nigeria about whether the scale-up investments in national health programs including HIV programs is producing the desired result of self-reliance or not. Critics found a negative association, and relate this to the interplay of socioeconomic, political, and cultural factors that play-out at the national level to affect aid effectiveness [18, 19]. They maintained that the government has abdicated most of its responsibilities to donors, and have mismanaged most funds meted for health programs [20]. Inequitable distribution and allocation of donor-driven resources stemming from corruption impact the delivery of health programs, thereby increasing aid ineffectiveness [16]. Aid works best when applied in a good policy environment. Thus, it has been argued that aid is conditionally effective with such considerations to robust public policy, transparent governance, and accountable financial management [18].
That notwithstanding, the delivery of HIV programs in most contexts have been parallel with the delivery of other health services at the national level especially in view of scaling HIV programs. The delivery of HIV programs requires large human capital for clinical and administrative roles. However, human resources for health (HRH) in Nigeria has been considered inadequate [2]. Thus, reallocating HRH to HIV programs might leave fewer healthcare workers available to carry out other health systems’ functions. In addition, the systemic vertical approach to most HIV programs further widens the gap and exacerbates the dearth of the health sector workforce. Thereby, weakening national health systems and impacting outcomes [21, 22, 23].
While multiple studies have documented the impact of aid on health outcomes for specific cases, it is not immediately clear the nature of the spillover effect of HIV aid disbursements on the delivery of non-HIV services in Nigeria. Our objective was to quantify what the impact of spending an extra dollar on HIV services will be on the delivery of MNCH services in Nigeria. We chose Nigeria because of data availability, including the presence of substantial aid disbursements to Nigeria. Prior studies have used qualitative methodologies to investigate this question in Nigeria [18, 20, 24]. Other researchers have also used quantitative approaches to evaluate this concept among facilities, districts, and regions [1, 6, 8]. Kotasadam et al. (2017) documented that the presence of active aid projects among impoverished Nigeria communities reduced infant mortality. In Malawi, aid improved self-reported quality of life including reductions in the prevalence of malaria and diarrheal diseases [26]; and in Uganda, aid reduced the overall disease burden and severity [27]. However, the focus of this study is to ascertain the nature of the spillover effect of HIV aid on the delivery of MNCH services in Nigeria. Given that the impacts of most HIV programs are likely to be felt at the national level; there is a need to investigate this further for the Nigerian health system.
Findings from this study have opportunities to inform the formulation of policies that improve the effectiveness of the GHIs in Nigeria, and therefore acts as a reference for policymakers, development organizations and other researchers. This study has opportunities to inform the formulation of improved service delivery frameworks from a healthier population perspective. Thus, using robust analytic approaches, this study investigated system-wide impacts of HIV aid disbursements on multiple MNCH outcomes in Nigeria. It evaluated the nature of the spillover effect of HIV funding on the delivery of MNCH services in Nigeria. We relied on robust multilevel regression models to estimate the relationships between HIV aid disbursements and population health measures.