A Global Fund multi-country program in Southeast Asia helps countries SHIFT towards sustainable HIV financing
Sustainable HIV Financing in Transition (SHIFT) is a two-year regional advocacy program (2017–2018) that aims to enable and empower civil society, including communities of HIV key populations, to advocate for sustainable HIV financing, especially in light of the changing international HIV funding landscape. The four countries involved in the program are Malaysia, Indonesia, the Philippines and Thailand.
Malaysia and Thailand are classified by the World Bank and the Global Fund as upper-middle-income. Indonesia and the Philippines are classified as lower-middle-income and may graduate to upper-middle-income status before too long. The Global Fund projects that the Philippines will become an upper-middle-income country in the 2020–2022 allocation period and that its malaria component will become ineligible for Global Fund support at that time.
Malaysia is currently eligible for Global Fund support only for its HIV program. The Fund expects that Malaysia will graduate to high-income status by 2019 and therefore become ineligible for Fund support. Thailand has said that its current TB/HIV grant (from its 2017–2019 allocation) will be its last, though technically Thailand is expected to remain eligible for the next allocation period (2020–2022).
Thus, it makes sense that for all four countries involved in SHIFT, transition planning would be a top priority.
In three of the four countries, there is a gap between the proportion of new HIV infections represented by key populations and the proportion of HIV prevention funding for these populations. In Thailand, key populations account for more than 50% of new HIV infections but only 22% of what has been spent for HIV prevention programs. In Philippines, the proportions were 95% and 18% respectively. In Indonesia, they were 50% and less than 10%, respectively. Only in Malaysia was the gap relatively small: Key populations account for 70% of new infections and 62% of prevention program funding.
One of the rationales for creating SHIFT was the need to ensure that limited resources are allocated effectively to meet the needs of key populations. The SHIFT program has three objectives:
- to support civil society organization (CSO) advocacy for sustainable HIV financing in the four countries and in regional and international platforms;
- to enhance the capacity and technical skills of civil society and communities of HIV key and vulnerable populations to advocate for increased allocative efficiency in HIV financing, increased domestic HIV funding, and improved fiscal space for CSO HIV programs; and
- to facilitate access to, and use of, strategic information on HIV financing.
In terms of structure, the SHIFT program is composed of a principal recipient (PR) –– the Australian Federation of AIDS Organizations –– and six sub-recipients (SRs). There are two regional SRs: the Asia Pacific Council of AIDS Service Organizations (APCASO), and the Asia Pacific Coalition on Male Sexual Health (APCOM); and four national SRs: ACHIEVE (the Philippines), the Indonesian AIDS Coalition, the Malaysian AIDS Council and the Thailand National AIDS Foundation.
SHIFT program activities at the national level have included forums and dialogues on HIV financing; capacity building assessments; training workshops on technical and advocacy skills related to HIV financing; and analysis of existing legislation and other relevant topics. A situation assessment on HIV financing was prepared in each country to inform and support the work of CSOs in advocating for sustainable HIV financing. All four countries have now developed technical assistance plans for rolling out advocacy activities and supporting capacity building on HIV financing.
Activities at the regional level have included the preparation of a framework on HIV financing and transition; forums and dialogues (including a forum on lessons learned and good practices); and creation of an online knowledge management hub for both CSOs and government. (The hub is expected to be operational in the near future.)
The regional forums, hosted by country partners, focused on specific topics in relation to HIV financing, such as: understanding what the existing CSO funding mechanisms and opportunities are at country level for communities to engage in discussions around budget allocation for an effective HIV response; the cost of criminalization of certain key populations, including the negative impact this has on the HIV response; and transition planning for those countries shifting from international donor support to domestic financing.
A baseline assessment was carried out in mid-2017. Fifty-seven people in the four program countries were interviewed, from Global Fund principal recipients, SHIFT sub-recipients, country coordinating mechanisms (CCMs), ministries of health, development partners, key populations and CSOs.
The assessment found that while all four countries have established national mechanisms to fund CSOs with domestic resources, in all of the countries (except Malaysia) the funding mechanisms are difficult to access due to increasingly stringent accessibility criteria.
Although all participating countries (except the Philippines) had developed a transition plan to manage the withdrawal of Global Fund support for HIV programming, only some the interviewees were aware of these plans and none of them were able to describe the content of their country’s plan.
Most CSO representatives interviewed for the assessment were very interested in the topic of HIV financing but felt that they lacked the necessary knowledge and skills to engage.
The assessment also found that traditional HIV advocacy has focused on scaling up service delivery and putting in place an enabling environment, but that very few HIV CSOs have been involved in HIV financing advocacy, especially at national or district levels.
Further, the assessment found that there were large gaps in expenditure data disaggregated by key population, as well as gaps in epidemiological data for key populations. The report on the assessment said:
“It is therefore worrisome that as transitions have already been initiated in several countries for some years already, yet there are still critical expenditure and epidemiological data gaps that must be addressed in order to make effective (and evidence-based) decisions that will generate sustainable HIV responses. It is indeed hard to conceive how the transition process as promoted by the Global Fund can achieve sustainable outcomes if up-to-date baseline data to measure progress against national objectives is not yet available.”
The assessment observed that swapping out international donors and substituting their funds with domestic resources would likely compromise the fundamental capacity and value of CSOs in terms of advocacy and watchdogging –– “functions that the Global Fund, other donors and development partners acknowledge as necessary to achieving sustainable HIV responses.”
Finally, the assessment stated that some Asian governments “tend to perceive CSOs with suspicion, even as dangerous opponents, given that successes generated by CSOs imply a certain loss of face for Asian governments who have essentially failed to meet the needs of their citizens.”
The report on the assessment is available here.
The program encountered delays in signing grant agreements and lining up county partners. Grant management has been challenging as there were six SRs working across four countries. In addition, selling the importance of engaging in the program and obtaining buy-in from communities and CCMs took more time than originally envisaged.
Other challenges included packaging information in a way that is both practical and strategic; and aligning SHIFT’s activities with national HIV strategic plans and activities.
On 5–6 September 2017, SHIFT organized a regional forum in Kuala Lumpur, Malaysia on financing mechanisms for CSOs and key population networks. Participants included teams from SHIFT’s PR and six SRs, CCMs in the four participating countries, the UNAIDS Asia Pacific HIV and AIDS Data Hub, and the AIDS division of the Malaysian Ministry of Health (MOH).
The objectives of the forum included (a) to showcase the Malaysian model for civil society HIV financing; (b) to identify best practices and explore other possible models; and (c) to develop advocacy strategies.
In addition to providing a valuable opportunity for networking, the forum generated useful strategies for how CSOs can better engage with their CCMs. Malaysian participants were reassured by the presentation from the head of the AIDS division in the MOH that the ministry strongly believes that communities are a crucial part of the HIV response and was looking for ways to collaborate.
For more information, please contact Greg Gray at AFAO.