The study’s primary goal was to map and describe funding mechanisms and main sources of funding of the community response to HIV and AIDS. The specific objectives were to:
- Identify the main sources of global funding of the community response;
- Document different funding mechanisms for the community response to HIV and AIDS;
- Describe the flow of funds from key funding sources;
- Identify the percentage of the budgets of civil society organisations (CSOs) covered by each of the main sources of funding; and,
- Describe the allocation of funds across the continuum of prevention, treatment and support, care, mitigation, policy and advocacy.
This study is descriptive in nature. The purpose was not to analyse the relative efficiency of different channels (e.g. CSOs versus government agencies) or provide a cost-benefit analysis of interventions. The following are key conclusions.
- Background and findings from the literature
- Donor funding flows
- The World Bank’s Multi-Country HIV/AIDS Program for Africa
- The Global Fund to Fight AIDS, Tuberculosis and Malaria
- US President’s Emergency Plan for AIDS Relief (PEPFAR)
- Department for International Development, United Kingdom
- Funding from four key donors, and its context
- Country funding profiles
- Survey of CSOs involved in AIDS responses
- Study conclusions
- Sources of data and methodology
Increased funding has reached civil society to respond to AIDS
As a result of donors prioritising both the scale-up of AIDS responses and the involvement of multiple sectors of implementers in developing countries, new and important funding flows have reached civil society in the past nine years. From 2001, the World Bank Multi-Country AIDS Program for Africa emphasised a community response as part of country and regional projects, with likely funding commitments to CSOs in Africa averaging $55 million annually from 2001 through 2013. MAP’s efforts resulted in an apparent mobilisation of local CSOs, with relatively small individual funding amounts spread through a large number of civil society organisations.
From early 2003, the Global Fund has also prioritised civil society involvement within its model of scaling up responses in developing countries. By June 2010, 18 percent of Global Fund disbursements for AIDS grants have been through civil society Principal Recipients (PRs), or more than $150 million on average per year. Most CSO PRs have exceeded performance targets. Indigenous organisations, rather than international NGOs, have managed 57 percent of Global Fund disbursements received by civil society PRs. Geographically, the funding flow through CSO PRs is not aligned with global funding patterns, and this has been addressed by the Global Fund by encouraging systematic inclusion of CSO PRs in all proposals.
From 2003, US PEPFAR has largely relied on partners with demonstrated capacity to deliver the top priority of rapid scale-up. While most funding passes through relatively large international organisations, it is also estimated that 11 percent of the funding flow reaches indigenous civil society organisations (net of clinical activities for treatment and blood safety), amounting to an annual average of approximately $270 million a year.
From 2004, DFID’s first AIDS strategy committed the UK government to spend $2.5 billion on AIDS in developing countries, and in 2008 its second AIDS strategy committed $11 billion to more general strengthening of health systems. DFID’s support to civil society engagement in AIDS responses is estimated at $55 million on average per year.
There are some challenges in putting this funding in context, but it is possible to say the annual average when all four donors have been active has been almost $500 million a year for civil society AIDS activities across all countries. While certainly higher in some years, it is still a relatively modest contribution to effective AIDS responses when compared to the funding needs for AIDS responses in low- and middle-income countries – estimated at $22 billion for 2008 – and the amounts being made available from different sources. 2.
Despite growth, there have been important signs of funding uncertainty and these continue
On the ground, as indicated by country profiles, it is only in recent years that positive developments in civil society AIDS funding have been effectively in place. In Peru, India and Kenya funding continues to be subject to change: there are relatively recent examples of successes in involving more CSOs in the AIDS response, alongside examples of funding fluctuations or funding stream close-out. Both positive and negative developments for recipients reinforce long-standing complaints from civil society regarding the predictability of funding beyond the short term.
There are indications of changes in donor priorities that have occurred and are continuing. Examples include a reduction in the World Bank MAP’s relative contributions, although its funding is still important in some countries. The Global Fund continues to change aspects of its funding system. While PEPFAR has made attempts to broaden the number of partner organisations, it also has a new emphasis on country government ownership for programme sustainability, and its most recent HIV/AIDS budget has been flat-lined in 2010 after more than doubling every two years since 2005. DFID’s more recent emphasis on health systems strengthening has replaced AIDS-specific priorities. The effects of these various changes on civil society’s access to funding flows, and on its contributions to AIDS responses in lowand middle-income countries, are not yet known.
During the past nine years the role of CSOs within AIDS responses has been positively influenced by donor priorities, including the World Bank’s and the Global Fund’s systematic prioritisation of funding community responses. It will be important to understand the impact of future changes in donor priorities, especially on advances that have been made in funding the involvement of indigenous civil society organisations in AIDS responses.
Country level funding mechanisms are important for civil society responses
From the recipients’ level there are clear indications of the importance of country funding mechanisms that are accessible to civil society organisations. Indigenous CSOs in particular appear to be well-served by these funding streams, including the Global Fund grants through PRs and other country funding mechanisms. While some information from country profiles shows concentration of funding among a small number of recipients (in Kenya and Peru), some funding streams have successfully strengthened dispersal through country mechanisms (Peru and India). There are examples of funding that has expanded the number of CSOs involved, and indigenous organisations in particular, while data on the resulting AIDS activities indicate these mechanisms are funding community responses.
A CSO survey reached a fairly homogenous sample of indigenous organisations involved in AIDS at grassroots level, and showed country level funding mechanisms provide on average 37 percent of annual revenue for AIDS activities. This includes 21 percent from the Global Fund and 16 percent from country based funding mechanisms and government contracts. Another fifteen or sixteen percent average annual revenues are from each of three other categories: the organisations’ own private fundraising, funds from “other” bilaterals and multilaterals (i.e. not the “big four” reviewed here), and unspecified foundations or charities. At the same time, while country funding mechanisms were individually important to average annual income, they do not often dominate budgets. This is consistent with findings in the literature: when funding mechanisms are strong and decentralised they are more successful in reaching organisations in a broad-based manner.
The findings confirm that civil society organisations fill certain roles
The country profiles and survey results confirm the main rationales for funding civil society and its complementary role in AIDS responses. In Kenya, national AIDS spending was dominated by treatment and care, but half of CSO funds were allocated to prevention. In India, some larger prevention programmes fully rely on local CSO implementers, while Global Fund financing to CSO PRs appears to have increased the use of different funding channels, filled gaps in delivering the national strategy, and diversified AIDS activities. In Peru, a third of CSO projects targeted key populations such as transgender people, men who have sex with men and sex workers, which have not been the focus of Governmental prevention activities.
The survey respondents were mostly indigenous organisations, and most of these are small, voluntary CSOs. The bulk of their annual prevention spending – 71 percent on average – was for work with key populations at high risk and targeted prevention for groups such as women, youth and migrants. Treatment spending was focused on support to people living with HIV (72 percent) rather than drug procurement (14 percent). Most care and support funds deliver programming for adults living with HIV (52 percent on average) and for orphans and vulnerable children (another 22 percent).
There is an important gap in regular data
Despite certain stakeholders’ recognition of the importance of the community response, regular monitoring systems have not specifically tracked its funding or its outputs. This appears to be true both at donor and country levels. This lack of regular information could be a risk for ensuring continued funding of CSOs’ contributions to AIDS responses, especially while donor priorities for AIDS continue to be discussed and funding flows continue to change.