In January 2016 consortium of three regional networks’ three year project was supported by Robert Carr civil society Networks Fund (RCNF) to build the capacity of community-based organizations of key populations, foster exchange and partnership between different ISP groups in budget advocacy and HIV resource accountability, help them advocate for national and municipal budgets resources to be allocated to continuum of HIV care for all ISP in EECA. During project duration joint advocacy activities and community strengthening to expand funding for and accessibility of services for people who use drugs (PWUD), men who have sex with men and all trans* people (MSM and TG) and people living with HIV (PLHIV) along the continuum of HIV care in Eastern Europe and Central Asia (EECA) region were held on regional and national level.
Main achievements on regional level
EHRA worked on the budget advocacy capacities development, ECUO has been instrumental in developing advocacy plans for the communities and delivering guidance on PR and communication tools. ECOM on the other hand has launched its issue based inter-sectoral platform – Regional Platform on Policy Reform (RPPR), which consists of regional development partners and regional networks, national actors from state and civil society. This enables communities to come up with the joint strategy on how to find new and effective approaches to MSM and trans people health in EECA region. We strive to achieve situation in which all members bring in unique expertise and input.
The Regional Community Action Plan was developed with leadership from ECUO based on research and consultation with community representatives, regional networks and other stakeholders and serves as the basis for joint planning and fundraising.
In April 2017 EHRN organized the budget advocacy training in Kyrgyzstan for 28 participants from regional and national consortiums. As a result 28 community members were trained and then practically involved in advocacy on regional and national level.
The tool for community led assessment of access and quality of services was developed in close cooperation with national consortiums and then approbated by them in the first year of the project. Gaps in access to services identified by the communities, were then addressed in their advocacy work. It is planned to collect and try to unify all the existing methodologies of community led assessments during the Reginal methodological expert workshop in October, 2018.
Budget advocasy guide for community activists (BA guide short) developed by EHRA on the basis of conducted regional and national trainings for different communities is a great tool to share gained experience with members of regional networks and community leaders in EECA.
Our work together as a consortium made clear the necessity and all of the potential benefits of consortiums as a model for effective national and regional advocacy. That is why the specific training was organised and methodological guidelines (“We are different but act together”) were developed to summarize best approaches and to provide communities with practical recommendations on how to build effective consortiums working in budget advocacy.
Together with 6 other regional networks consortium members launched joint “Chase the virus, not people!” campaign at AIDS 2018 conference. EHRA, ECOM along with ECUO were the coordinating parties of the campaign. The aim of the campaign is to draw attention to the problems of key population groups, against the backdrop of the catastrophic situation with the HIV/AIDS epidemic in EECA for comprehensive support of the region by the world community. Increase the priority of actions to overcome the discrimination and stigmatization of vulnerable and communities – as a key condition for an effective response to the HIV epidemic in EECA countries.
While the perfect model and mode for transition from donor to domestic funding is yet to be discovered, there have been decisive steps taken in a number of countries to improve the situation. We work with our community organizations within each consortium individually and try to look at the situation in relation to all ISPs in the country at large. This enables building a win-win partnerships, raising stronger voice for change, gives consortia more influence on decision making level, including on funding of ISP services.
In June, 2016 members of the PUD, PLWH, MSM and transgender communities from Armenia, Kyrgyzstan and Estonia gathered together at the training “Budget advocacy and assessment of investments and priorities related to HIV prevention, diagnostics, treatment and care”, learned about the project and agreed on joint actions to collect and analyze investments and priorities related to HIV services.
In 2016 MSM, PLHIV and PWID communities from Armenia, Kyrgyzstan and Estonia conducted community led monitoring of HIV related survices, presented the results to relevant stakeholders and formulate strategic plans of national consortiums based on it.
Armenian consortium prepared the “Armenian civil society opinion on government readiness for transition to state funding”. Transition processes in the country have been advancing recently and consortium members are involved in them.
In Kyrgyzstan PLHIV, LGBT and PWUD community organizations are widely represented in the platforms that have their say on national HIV response. They are part of discussion during planning national HIV program which include transitional and reforming state procurement mechanism for ARVs.
As the result of the community mobilization, it was possible to recruit a group of new activists for the PWUD community in the North-East of Estonia. The core group of PWUD activists gained access to the resources of community assessment and mobilization in the summer of 2016. By the end of 2016, it was possible to register an NGO based on the initiative group. Estonian consortium has been actively engaged with National Institute of Health Development to work on more community based and low threshold programs for ISPs. Technical assistance provided by ECUO helped national consortium develop National Advocacy Plan of the Estonian communities.
Guidance from World Health Organization (WHO), United Nations Office on Drugs and Crime (UNODC) and Joint United Nations Programme on HIV/AIDS (UNAIDS) suggests that reversing an HIV epidemic requires 60% of all people who inject drugs (PWID) to be reached regularly by a needle syringe program (NSP), and that 40% of all opiate users be enrolled in opioid substitution therapy (OST).
Governments of Central and East Europe and Central Asia (CEECA) provide less than 15% of harm reduction funding needed in the region, which indicates region’s strong dependency on international donors who support both NSP and OST. At the same time, many of the countries in the CEECA region are becoming ineligible to receive donor funding due to increasing GNP per capita level. There are no more countries in CEECA that are classified as low-income – the funding priority for key donors such as the Global Fund to Fight AIDS, Tuberculosis and Malaria.
Epidemics among PWID cannot be reversed without greater and sustained state funding of harm reduction. Investments are needed to improve service quality and coverage level of both NSP and OST. Governments and other domestic sources have responsibility for meeting these investment needs. Their increased and sustained engagement is essential because the Global Fund is swiftly withdrawing from the region to concentrate on supporting low-income countries across the globe.
One of the key priorities of Eurasian Harm Reduction Association (EHRA) is to build capacity of PWID communities in CEECA in budget advocacy – a process enabling civil society organizations and communities to monitor and influence state decisions for the allocation of public funds towards harm reduction programs and better solutions safeguarding people’s health.
Budget advocacy by communities may have the greatest impact on actions of authorities, and in its turn, on the lives of people. With that in mind we believe that:
- It is crucially important to engage PWID community in planning through estimating the unmet needs for harm reduction services and defining priority items for a policy agenda change and financing;
- Allow for direct financing of civil society through social contracting or similar mechanisms, to deliver harm reduction and HIV and TB services to PWID, is the most evident way for the governments to sustain services and funding;
- An important consideration is that cost-effectiveness can best be obtained not by cutting services, but by making them more efficient through their optimization.
Increasing national funding should go hand in hand with reversing harsh prohibition laws and change of enforcement policies that discriminate PWID. Otherwise scale-up in funding would not convert to increased program coverage.
On 21 May – 4 June, 2018 EHRA conducts online Regional Meetings of it’s members to elect new Steering Committee representatives in the following regions:
- Russia (Russia);
- South-Eastern Europe (Albania, Bosnia-Herzegovina, Bulgaria, Croatia, Kosovo, Macedonia, Montenegro, Romania, Serbia).
All members (individual and organizational), who are from the above-mentioned regions and who are approved by the Steering Committee have a right to vote in the Regional meetings.
If you have any questions, please contact General Secretary of the Regional meetings – Eliza Kurcevič firstname.lastname@example.org
A social contracting mechanism which would allow the government to contract with NGOs to deliver prevention programs to key affected populations in Belarus is “under construction.” It is a slow process and there are still some uncertainties about how well it will function.
A mechanism allowing the government to co-finance social services and projects being implemented by NGOs has existed in the Republic of Belarus for a number of years and has been regulated under the Social Services Law. However, under this law, it is not possible to financially support the provision of NGO-based HIV prevention services among key affected populations.
An analysis carried out by Belorussian NGO “ACT” in 2016 (on file with the author) identified the following barriers to government financing of NGO-based HIV prevention activities imposed by the Social Services Law:
- subsidies are provided only for salaries;
- subsidies for social projects are provided only where the government commits to paying 50% of the costs (or less); the NGO commits to paying at least 50% of the costs; and the NGO possesses funds to cover its share;
- subsidies were available only for services to be provided to “citizens in difficult life situations”; people who inject drugs (PWID), sex workers and men who have sex with men (MSM) are not considered to fit this definition under the legislation;
- the Social Services Law does not cover health care; there is no legislation covering social contracting for health care and, therefore, HIV prevention services;
- “outreach worker” is not among the types of jobs listed in the Belorussian official job classifier, so it is not possible to include salaries for them within social contracting under the Social Services Law; and
- under the Social Services Law, services can be provided only upon the written consent of the recipient of the services, so services cannot be accessed anonymously, which effectively makes it impossible to provide services to key affected populations.
It is important to mention here that under the new funding model introduced by the Global Fund in 2013, before the grant confirmation (previously called the grant agreement) is signed, a Framework Agreement outlining all of the terms and conditions of the grant has to be signed between the Global Fund and the relevant government. The grant confirmation becomes an integral part of the Framework Agreement.
“Introduction of the social contracting mechanism for HIV prevention into legislation became possible mainly due to the fact that the Framework Agreement signed between the Global Fund and the Belorussian Government in October 2015 has the status of law in the Republic of Belarus. The grant agreement which was signed by the Global Fund and the principal recipient on behalf of the Ministry of Health is an integral part of the Framework Agreement. Therefore, the obligation to establish the relevant social contracting mechanism was confirmed by the Belorussian government legislatively,” explained Elena Fisenko, Head of the HIV division of the Global Fund Grants Management Department in the Republican Theoretical and Practical Centre for Medical Technologies, Informatization, Management and Economics of Healthcare of the Republic of Belarus.
This obligation on the part of the government resulted in the inclusion in early 2016 of a number of HIV-related activities, including those focused on key affected populations (KAPS), into Sub-Program 5 (“HIV prevention”) of the Governmental Program “Health of Nation and Demographic Security of the Republic of Belarus” for 2016–2020 –– implying that the provision of governmental subsidies to NGOs for implementation of the activities would start in 2017. Necessary funds were budgeted for these purposes, but this was done before the legislation to allow for social contracting was actually being developed.
Protracted process of the mechanism introduction
To ensure the development and introduction of the proper social contracting mechanism in the health care sphere allowing NGOs to receive governmental funding for HIV prevention activities among KAPs, the process of changing the relevant legislation (The Law on Prevention of Socially Communicable Diseases and HIV) was initiated in 2016. It took more than a year to adopt the necessary amendments and pass the new version of the law –– the process was completed only in July 2017. Moreover, an additional six months were needed to prepare and enact all necessary subordinate legislation once the law comes into effect on 19 January 2018.
Initially, this mechanism was expected to start working by the end of 2016, but this never happened.
“Changes in legislation happen very slowly. It is really fast that in two years we managed to have legislation changed and prepare all regulations and procedures for approval of the social contracting mechanism in health care. It could have been done in 2016 only if relevant changes in legislation had been launched in 2014–2015,” said Valery Zhurakovski, an expert in the NGO “ACT,” a local organization advocating for introduction of the social contracting mechanism in health care, and particularly in the sphere of HIV prevention since 2010.
Consequences of the delay for HIV prevention programs
The government’s Program for HIV Prevention 2016–2020 included a plan to start funding NGOs to deliver services through a social contracting mechanism starting in 2017. It was expected that the Global Fund would remain the main donor of these programs in 2016, and that its share of the funding would then start to decline, finally ending by 2019 –– whereas government funding through the social contracting mechanism would start increasing in 2017, and would continue to grow, thus ensuring a smooth transition from the Global Fund’s support of HIV prevention programs among key affected populations to full government funding by 2020 (see table). But this didn’t happen in reality.
Table: Planned budget of the Governmental Program of HIV Prevention for 2016–2020
|Objectives of the program: Reduction of HIV transmission among populations with high risk of infection (injection drug users and their sexual partners; male and female sex workers; MSM; prisoners; adolescence practicing high risk behaviors.|
|Ordering party||Sources of funding||Amount of funding (Belarus rubles)|
|Oblast government, Minsk government||Local budgets||162,641,400||548,300||17,087,400||33.612,800||53,804,900||57,598,000|
Because the social contracting mechanism was not yet developed, the funds being planned for 2017 under the Governmental Program on HIV Prevention for 2016–2020 for support of NGO-based HIV prevention activities were spent on other needs that the regional governments deemed important.
Nevertheless, a government financial contribution to prevention services for key populations in 2017 was partly ensured through supporting the work of 10 HIV prevention units based in government healthcare facilities that provided anonymous counselling to people who use drugs. This partially reduced the additional financial burden on the Global Fund grant in 2017 caused by the necessity to ensure the provision of a decent level of prevention services in the absence of government funding through the social contracting mechanism.
“As it is clear that in 2018 prevention services will again not be fully covered by government funding through the social contracting mechanism, the Ministry of Health decided to considerably increase its purchase of ARVs from the governmental budget in 2018. Thus, funds initially budgeted for that purpose within the Global Fund grant could be reprogrammed to support prevention services among affected populations,” Fisenko said.
Social contracting mechanism
According to the government’s draft “Regulations on the conditions and procedures of social contracting in the area of socially communicable diseases and HIV prevention” (on file with the author), social contracting will be implemented by providing NGOs with “subsidies” from local budgets for services and (or) projects aimed at preventing socially communicable diseases and HIV. (In Belarus, all official documents use the term “subsidies” to describe the funding available through social contracting.) Subsidies for the implementation of projects will be granted under condition of partial co-financing by the NGOs, likely at the level of 20%. The subsidies may cover a wide range of expenses, including: NGO employees’ salaries; administrative expenses (i.e. rent, stationery, bank expenses, office equipment maintenance); project activities; and the purchase of items to be distributed (such as syringes, needles, sterile napkins, motivation packs, lubricants, condoms and information materials).
Social contracting will be implemented on the local (oblast) level. The contracting will be managed by the oblasts, particularly the health care committees which will be responsible for announcing tenders. Funds will be provided via the relevant government programs –– in the case of HIV prevention, the Governmental Program on HIV Prevention for 2016–2020. For each tender, the process will produce a winning bid (or bids) from among the NGOs that participated, after which the oblast will arrange for contracts to be signed and the subsidies to be provided.
It is expected that contracts with the implementers could be for a period of up to five years, depending on the framework and timelines of the government programs. However, Fisenko told Aidspan that funding will most likely be provided one year at a time.
The draft regulations do not mention specific target groups. ACT’s Valery Zhurakovski explained: “The epidemiology can vary from oblast to oblast and thus it will be up to each oblast to determine what the target groups are for the funding.”
According to the draft criteria for evaluating the tender proposals (on file with the author), among the factors to be considered are (a) the work experience of the organization in the area of socially communicable diseases and HIV prevention; and (b) experience working with the representatives of the target groups –– i.e. the intended recipients of the service.
Potential obstacles for the introduction of the social contracting mechanism
Experts outlined some of the problems that may be encountered when introducing the social contracting mechanism. One potential problem is related to decision to implement the mechanism at the oblast level rather than the republican (i.e. central government) level. “In local budgets, funds are allocated first to certain obligatory budget lines,” explained Irina Statkevich, CCM member, and Head of the local NGO “Positive Movement.” “Social contracting is not one of those lines. Thus, in the event of a budget deficit, funding within the local budget would be spent first on the priority areas, and the activities to be supported within the social contracting mechanism can appear to have no financing at all if there are not enough funds left over.”
Another possible problem is that the majority of the local bureaucrats have no previous experience with social contracting, especially in the area of HIV prevention for key affected populations. And the idea to allocate funds to support the work among such groups as PWID, MSM and sex workers may seem as a quite a revolutionary idea for most of them.
“I am not sure about authorities’ readiness to name in tendering specifications the target groups in a way we do,” Zhurakovski said. “There was no precedent up to now to have them in official documents.”
Zhurakovski added: “Also, in some places, local authorities consider the grown-up working population to be the target group for HIV prevention programs. In such cases, workplace interventions to prevent HIV may become the priority for them. That’s why some local bureaucrats may decide to allocate part of funds planned within the government program for these purposes.”
According to Elena Fisenko, an additional problem is that the budget for 2018 has already been set, based on laws and regulations already in effect. The amendments to the law introducing social contracting in prevention of socially communicable diseases and HIV are effective only as of January 2018. Thus, no oblast government has budgeted funding for social contracting for 2018. “In practice, it will mean that approximately in February or March 2018, oblast governments will have to change their already approved budgets which, in any case, can be done only on a quarterly basis. And the best-case scenario is that money for social contracting will appear in local budgets starting from the second quarter of 2018,” said Fisenko.
The role of civil society
The importance of the role of civil society representatives in the introduction of the social contracting mechanism for socially communicable diseases and HIV prevention in Belarus deserves to be mentioned separately. On the one hand, experts who contributed to this article highlighted the transparency of the process of developing the social contracting mechanism by the authorities, as well as the possibility for NGO representatives to participate in this process. On the other hand, for a number of years, civil society representatives were actively advocating for adoption of this law and also for keeping to the principles of NGOs work in providing prevention services to key affected populations within the framework of this mechanism. The NGO “ACT” merits a special mention as it has been leading the advocacy work on social contracting in HIV prevention for many years and had vast experience in dealing with the Ministry of Labour and Social Protection in the context of social contracting implementation under the Law on Social Services. For this reason, the representatives of ACT took an active part in development of all key documentation on social contracting in Belarus, including the development of relevant legislation, bylaws, drafts of resolutions of the Council of Ministers, and so on.
It should also be mentioned that advocacy activities of ACT with respect to a social contracting mechanism have been financed for a number of years from Global Fund grants. This can serve as a good example for how the Global Fund could successfully contribute in middle-income countries to the transition from donors’ support of HIV prevention services for key affected populations to national funding.
“Our work is focused not only on the social contracting. We are also advocating for the creation of the enabling environment for the work of NGOs in the country in general, including exploring other options for attracting funding –– such as foreign grants or donations, charity and also changes in the approach for the taxation in this sphere,” Zhurakovski said. “We are in active on-going communication with the relevant department regarding the possibility of changing the procedure for NGOs for registration of foreign grants or donations in Belarus by lowering the threshold. We work closely with the Ministry of Finance, the revenue authority and Parliament regarding changes in the approach to taxation of local fundraising. We understand that a social contracting mechanism is not able to solve all the problems and cover all needs. Organizations will nevertheless need other resources and it is necessary to make it easier for them to get the access to the resources needed as well as to facilitate this process.”