Cambodia has made headlines with its successful fight against HIV. According to UNAIDS, between 2005 and 2013, new HIV infections dropped by 67% and more than two-thirds of the 75,000 persons living with HIV have access to ARVs. This success draws in large part on two decades’ worth of sustained funding from international donors to support HIV prevention, treatment, care, and support programs. But with external resources declining, Cambodia is looking to new and cost-effective ways to maintain the gains and make further progress to eliminate new infections.
With the Global Fund’s transition to the new funding model, this exercise was unexpectedly fast-tracked. Early in 2014, the Phase II agreement of the existing Round 9 HIV grant was signed, covering a period of two years through December 2015. However, due to the formula used for allocating resources under the NFM, the country coordinating mechanism (known as “CCC” in Cambodia) was informed in March 2014 that no additional funding will be available for its HIV component until the end of 2017; Phase II funds would have to be stretched to cover almost four years of activities, not two.
The national program and its partners were suddenly faced with critical choices in its AIDS response. The concept note for the HIV grant reprogramming was due, critical for ensuring the continuity of prioritized services until end-2017. Initially planned for October 2014, it was finally submitted at the end of January 2015 after intensive reprogramming.
An invitation was cast sector-wide for participation in the country dialogue from July 2014 on – beyond the usual stakeholders in the three diseases. The dialogue allowed participants to brainstorm where synergies can be had and how to best optimize resources to last for a longer timeframe. Examples of synergies discussed include integration of HIV into broader health community systems that advance other medium term agenda, such as in sexual and reproductive rights and sexual and gender-based violence.
“It was an abrupt decline in available external funding,” said Dr. Ouk Vichea, Deputy Director of the National Center for HIV/AIDS, Dermatology and STD (NCHADS). “There needed to be strict prioritization of services and interventions.”
In the absence of other new funding, a massive overhaul and downsizing of the complement of interventions was required. This was achieved through collaboration among stakeholders such as NCHADS, CCC members, implementers, civil society, and partners, resulting in a lot of tough choices and a lot of disappointment.
The government has had to increase its own budgetary allocation to HIV. In order to comply with the NFM rules on counterpart financing, the government agreed to an investment that will gradually increase over the life of the HIV grant. In addition to covering some operational costs, the government committed an additional $1million in 2015, $1.2 million in 2016, and $1.5 million in 2017 for HIV treatment.
The process of reprogramming triggered strategic and epidemiological analyses and discussion on how to optimize resources.
The belt-tightening also prompted closer engagement between NCHADS and civil society, specifically in finding, testing and treating hard-to-reach populations at higher risk of HIV: people who inject drugs, men who have sex with men, transgender people and those in the sex work industry known as “entertainment workers,” where the epidemic is concentrating.
This aligns perfectly with the NFM’s emphasis on engaging civil society and key populations, which has helped not only to encourage dialogue between government and non-government entities, but also to give civil society the clout and standing it needed to become equal partners in decision-making. Positive steps were taken in finalizing Cambodia’s Harm Reduction Strategic Plan.
Yet, challenges remain in relation to the low coverage of prevention services for PWID, and, in particular, low uptake and retention rates of the methadone program.
Another priority was to find financing synergies. From the country dialogue came the idea of lining up with the national push for universal health coverage and building on the existing Health Equity Fund and other social protection mechanisms. With external funding reduced, the HIV home-based care model had to be redesigned: PLHIV who were stabilized on antiretroviral treatment were registered to benefit from broader health and social protection allowances (e.g. for travel, food, care, vocational training, peer support and funeral costs), while the most vulnerable PLHIV will continue to receive more dedicated HIV-specific care support.
Ultimately, it was an intensive exercise by stakeholders in forging national consensus for a more sustainable response. Partners, government and civil society had to act decisively and quickly on the austerity measures, so as to maintain the hard-won momentum in the program even as Cambodia reached a new phase where national funding will have to progressively take over from external resources.
Cambodia appears to have successfully backed away from a financial cliff, instituting cost savings and becoming bolder about looking for other sources of funding.
The HIV/AIDS community can only hope that the government and development partners will continue funding the national response. In the face of decreasing funding from its largest donors, all parties must work together to ensure continued and sustained progress. The reprogramming was a factor in introducing, scaling up and/or strengthening creative approaches to HIV prevention, treatment and care. It united stakeholders in a common goal: sustaining gains and, with less funds, optimizing resources. It triggered new opportunities for integration and efficiencies. In the end, a few building blocks were set for a more sustainable future response, but as a low-income country with a high disease burden, Cambodia still needs continued support from donors.