The Cost of Complacency: A Harm Reduction Funding Crisis
Author:
Catherine Cook, Sustainable Financing Lead, Harm Reduction International
Article Type:Article Number: 3
The Global AIDS Strategy 2023-2028 calls for an ‘intensified harm reduction response’ as crucial to ending AIDS as a public health threat by 2030. Harm Reduction International’s new report The Cost of Complacency: A Harm Reduction Funding Crisis explores the state of harm reduction funding in low- and middle-income countries, from both donors and domestic funding. This article summarises the report findings, with particular emphasis on the Global Fund, the largest donor for harm reduction in low- and middle-income countries.
Introduction
Harm reduction encompasses a range of health and social services and practices that aim to minimise the negative health, social and legal impacts associated with drug use, drug policies and drug laws. Harm reduction services, such as needle and syringe programmes (NSP) and opioid agonist therapy (OAT), are proven to be effective and cost-effective HIV prevention interventions.
People who inject drugs are 15 times more likely to acquire HIV compared to the general population, although this differs substantially across regions with four regions showing higher than average risk: the Middle East and North Africa (MENA) (88 times higher), Latin America (46 times higher), Asia Pacific (42 times higher) and Eastern Europe and Central Asia (EECA) (19 times higher). UNAIDS reports that new HIV epidemics appear to be emerging in some regions, such as MENA and EECA. This is mainly due to a lack of prevention services for key populations and to the barriers posed by punitive laws, violence, social stigma and discrimination.
The current state of harm reduction funding in low- and middle-income countries
Harm Reduction International (HRI) has monitored the harm reduction funding landscape since 2007. Our latest research identified $151 million in harm reduction funding from both donors and domestic budgets in 2022. This is just 6% of the $2.7 billion that UNAIDS estimates to be required for an adequate harm reduction response by 2025.
Harm reduction funding accounted for only 0.7% of total HIV funding in 2022 (from donors and domestic budgets). While the overall HIV response has a 29% funding gap, for harm reduction this gap is 94%. Furthermore, this gap has hardly changed since 2019, when it stood at 95%.
Domestic funding for harm reduction
In 2022, our research identified domestic investment in harm reduction in 27 low- and middle-income countries, amounting to $49.7 million, representing around one-third of all harm reduction funding identified in 2022. It is clear that while countries are investing in their HIV responses, they are not yet investing in harm reduction, which represented just 0.4% of all domestic funding for HIV in 2022.
While there are data quality issues, we appear to have gone backwards since 2019 in terms of sustainability, with fewer countries investing and a lower total amount.
As Figure 1 shows, we found some substantial decreases in the countries that were investing the most in 2019. These 10 countries accounted for 85% of all identified domestic funding in 2019 but only 74% in 2022. We did also find some increases in domestic funding at country level, which may be due to the influence of Global Fund co-financing, such as in Serbia and Indonesia.
Figure 1: Countries with the highest domestic investment in 2019 and funding identified in 2022
Donor funding for harm reduction
Since HRI’s monitoring work began, the number of donors supporting harm reduction in low- and middle-income countries has remained small, particularly when compared to the number of donors that fund HIV programmes more broadly. In 2022, we identified $101.6 million in donor funding for harm reduction from eleven donors. This amounted to 67% of total harm reduction funding that year. This is a greater share and a greater amount than in 2019, when donor funding was 52% of total harm reduction funding (see Figure 2).
Figure 2: Amount of harm reduction funding ($ millions) by funding source in 2019 and 2022
Since 2007, we have documented the steady decline in bilateral funding and increasing dependency on multilateral funding. Harm reduction is now more reliant on the Global Fund than ever before, as the source of 73% of all donor funds in 2022, compared with just 31% in 2007. In 2022, only three governments were making bilateral investments of over $100,000 in harm reduction, with the US government providing $8 million and the French and Dutch Governments contributing $3.5 million and $1.5 million respectively. Overall, this shift has had a detrimental impact on the amount of donor support available. Donor funding for harm reduction has halved in real value over the past 15 years. Had funding levels remained stable, rising in line with inflation, low- and middle-income countries would have received $202 million from donors in 2022.
It is also of great concern that investment from donors that have provided key support for advocacy and legal and policy reform has diminished, emphasising the fragility of donor funding and its vulnerability to political shifts. For example, in 2019, the Dutch Government accounted for 8% of identified harm reduction funding but this reduced to 1% in 2022. Open Society Foundations (OSF) has been a crucial funder for harm reduction and drug policy advocacy, but recent organisational changes have reduced this support.
Investing in community-led responses
Community-led responses are recognised as integral to the HIV response within donor strategies and global targets, but there is currently no mechanism in place to hold donors accountable on their investments. The majority of donors do not record data on their funding for community-led organisations. Where there is funding, it is minimal and does little to support sustainable community-led programmes. This is despite clear evidence of the positive impact of community-led harm reduction during COVID-19 lockdowns and in Ukraine, particularly when organisations were provided with flexible and enhanced funding.
The pivotal role of Global Fund
The importance of the Global Fund cannot be overstated; it is a crucial source of support for harm reduction service provision, as well as advocacy and the legal and policy reform required to reduce the barriers that prevent people who use drugs from accessing services. It plays a vital role in introducing and increasing access to harm reduction services through its country partnerships. Global Fund country grants provide a lifeline to sustain and scale-up harm reduction programmes for people who use drugs. Global Fund support for community strengthening and advocacy is now more important than ever. Relatively low cost but high impact support including through multi-country grants and other catalytic investments are essential to ensure that people who use drugs are not left behind. The Global Fund also has a key role in building sustainable responses through co-financing, matching funds and other tools to catalyze government financial ownership of national harm reduction programmes.
The Global Fund estimates that $74.5 million was budgeted for harm reduction in 2022, representing 73% of donor funding for harm reduction. Harm reduction programmes in low- and middle-income countries are now more reliant on the Global Fund as a source of funding than ever before. As a result, any reduction in harm reduction funding from the Global Fund is likely to dramatically and disproportionately affect harm reduction programmes, resulting in service closures and a reversal of gains made in preventing HIV among people who use drugs. As GFAN, HRI and others emphasised in the lead up to the 7th replenishent, ensuring a fully funded Global Fund going forward will be paramount for harm reduction.
Recommendations
Harm reduction donors and governments must make substantial additional investments to meet global goals to end AIDS as a public health threat by 2030. As emphasised in a recent report by the UN Special Rapporteur on the Right to Health, governments and donors should divest from the unjust drug war and related punitive drug law enforcement and invest in programmes that prioritise community, health and justice.
Funding for advocacy should be increased to help drive the drug law and policy reform required for sustainable harm reduction responses. Global Fund multi-country grants, catalytic investments and strategic initiatives are crucial sources of support.
International donors and governments must invest in community-led organisations as part of national health systems to create and protect resilient and sustainable harm reduction programmes. Dedicated funding streams are necessary to bypass structural barriers.
International donors should support governments to establish the financing mechanisms required for domestic funding of harm reduction.
Harm reduction needs to be viewed as broader than disease prevention. Strong health systems require strong harm reduction community systems.
Conclusion
Governments have committed to ending AIDS and tuberculosis, eliminating viral hepatitis and providing universal access to healthcare by 2030. These goals cannot be reached while prevention programmes for key populations, including people who use drugs, continue to be woefully underfunded. A sustainable HIV response for people who use drugs requires far greater investment in community-led programmes, advocacy and law and policy reform. More than ever, harm reduction in low- and middle-income countries is dependent on a fully funded Global Fund that ensures the voices of people who use drugs are heard in grant-making processes and maximises opportunities to support harm reduction.
