Universal Health Service Coverage under threat? A study of the effects of PEPFAR HIV funding on UHC

Introduction: While the effects of the US government's sudden pause of foreign aid on the global HIV response have been well documented, little is known about the likely impact on universal health coverage (UHC) in recipient countries. This study assesses the association between PEPFAR funding and the universal health service coverage index.Methods: Using data on PEPFAR investments in 24 countries between 2004 and 2020, the study applied fixed and time effects panel data regression on the main UHC index and its sub-indices for non-communicable diseases (NCDs), reproductive, maternal, newborn and child healthcare (RMNCH); and service capacity and access. Gross domestic product (GDP) per capita, government health expenditure as a percentage of current health expenditure (CHE), private health expenditure as a percentage of CHE, and government efficiency were included as control variables.Results: The UHC index tripled in some countries over the study period, coinciding with PEPFAR investments, which prioritised HIV treatment. However, GDP per capita doubled, government health spending increased marginally, while out-of-pocket payments declined in the same time period. The study found positive associations between PEPFAR funding and the UHC index (0.11, p < 0.01), RMNCH (0.036, p < 0.1), and NCDs (0.038, p < 0.05). GDP per capita, government health expenditure, and government efficiency were also positively associated with UHC indexes. Time effects were established for the main UHC index and the NCDs sub-index.Conclusions: We conclude that PEPFAR funding for HIV was instrumental in driving UHC in recipient countries. The abruptness of the funding cuts was destabilising to HIV programs across the globe and threatened to upend hard-won gains in ending AIDS as a public health threat. Without renewed PEPFAR support, continued global solidarity, and greater domestic financing, health systems risk setbacks threatening the health of current and future generations, as well as global health security. Safeguarding current progress requires PEPFAR funding restoration, host governments' commitment to growth-oriented policies, efficient use of available resources, integration of HIV into UHC, stronger South-South cooperation to reduce aid reliance, and donor alignment with national health goals.