Capitalising on Global HIV/AIDS Funding: The Challenge for Civil Society and Government

Abstract

After years of passionate advocacy informed by solid policy work on the ground, the global response to HIV/AIDS is better resourced. Poor countries can absorb considerably higher levels of aid than they currently receive, but recent increases in funding have generated a number of concerns. This paper analyses the capacity of NGOs, community-based organisations and governments to ensure that the influx of funds has a significant effect on the HIV epidemic and people's lives. Limited absorptive capacity may be an obstacle to the uptake of funding. To avoid community-based organisations being over-stretched by AIDS and to ensure capacity is maintained, HIV-positive staff must be enabled to continue their work through access to antiretroviral therapy and related services. Equally challenging, given that donors are increasingly using governments as intermediaries to fund civil society organisations, is increasing the capacity of developing country governments to disburse funds effectively. If donors do not accept that governments and civil society organisations need technical support in order to accept, distribute and account for increases in funding, there is a danger that home-grown responses will be replaced with imported solutions. The community sector is the glue that holds responses to HIV/AIDS together; now it needs to adapt to new partnerships with government and other emerging HIV/AIDS service providers.

Résumé

Après des années de plaidoyer passionné fondé sur un solide travail politique sur le terrain, la lutte mondiale contre le VIH/SIDA dispose de meilleures ressources. Les pays pauvres peuvent absorber des niveaux nettement plus élevés d'assistance, mais les accroissements récents du financement ont suscité certaines préoccupations. L'article analyse la capacité des ONG, des organisations à assise communautaire et des gouvernements de s'assurer que l'afflux de fonds améliore sensiblement la lutte contre l'épidémie et la vie de la population. Une capacité d'absorption limitée peut s'opposer à l'accroissement du financement. Pour éviter que les organisations communautaires ne soient mises à rude épreuve par le SIDA, et pour garantir le maintien de la capacité, le personnel séropositif doit continuer à travailler grâce à l'accès à la thérapie antirétrovirale et aux services liés. Tout aussi difficile, étant donné que les donateurs utilisent de plus en plus les gouvernements comme intermédiaires pour financer les organisations de la société civile, il convient d'accroı̂tre la capacité des gouvernements des pays en développement d'allouer efficacement les fonds. Si les donateurs ne reconnaissent pas que les gouvernements et les organisations de la société civile requièrent un appui technique pour accepter, distribuer et comptabiliser les hausses de financement, les solutions nationales risquent d'être remplacées par des approches importées. Le secteur communautaire assure la cohésion des réponses au VIH/SIDA ; il doit s'adapter aux nouveaux partenariats avec les pouvoirs publics et d'autres prestataires de services émergents en matière de VIH/SIDA.

Resumen

Después de años de realizar vehementes esfuerzos de gestorı́a y defensa informados por medio de un trabajo sólido de formulación de polı́ticas en este tema, la respuesta mundial al VIH/SIDA cuenta con mejores recursos. Los paı́ses pobres pueden asimilar niveles de ayuda financiera considerablemente más altos de los que reciben actualmente, pero los recientes aumentos en el financiamiento han generado varias inquietudes. En este artı́culo se analiza la capacidad de las ONG, las organizaciones comunitarias y los gobiernos de garantizar que el flujo de fondos tenga un efecto significativo sobre la epidemia del VIH y la vida de las personas. Una capacidad limitada de asimilación puede ser un obstáculo a la captación de financiamiento. Para evitar que las organizaciones comunitarias se extralimiten por el SIDA y para garantizar que se mantenga la capacidad, se debe facultar al personal VIH-positivo para que continúe su trabajo mediante el acceso a la terapia antirretroviral y a los servicios complementarios. Igual de desafiante, dado que los donantes emplean cada vez más a los gobiernos como intermediarios para financiar a las organizaciones de la sociedad civil, es aumentar la capacidad de crear gobiernos en cada paı́s con el fin de desembolsar los fondos de manera eficaz. Si los donantes no aceptan el hecho de que los gobiernos y las organizaciones de la sociedad civil necesitan apoyo técnico para poder aceptar, distribuir y explicar los aumentos en el financiamiento, existe el peligro que las respuestas formuladas a nivel local se sustituyan con soluciones importadas. El sector comunitario es el elemento que mantiene unidas las respuestas al VIH/SIDA; y ahora necesita adaptarse a las nuevas alianzas con el gobierno y a otros prestadores de servicios de VIH/SIDA emergentes.

Key Words:

• HIV/AIDS
• non-governmental organisations
• community-based organisations
• international donor funding
• government–NGO partnerships
• governance

After years of passionate advocacy informed by solid policy work on the ground, we are finally in a position where the global response to HIV/AIDS is better resourced and politically supported. In his State of the Union address in 2003, US President Bush announced his Emergency Plan for AIDS Relief (PEPFAR) that pledges US$15 billion, including nearly $10 billion in new funding, to fight the HIV/AIDS epidemic over the next five years. The UK has in 2004 firmly committed £1.5 billion ($2.6 billion) for HIV/AIDS between 2005 and 2008. Meanwhile, the Global Fund for AIDS, TB and Malaria continues to garner financial commitments too, with current projections suggesting that some US$900 million will be available for the fourth round of grant funding. While still not enough, these new millions–and the political sea-change that they represent–are very welcome. However, this situation presents a number of urgent and complex dilemmas for the community sector.

This paper is a reflection on some of the pitfalls that the community sector must avoid and questions it must answer in order to ensure best use of the new HIV/AIDS money. It explores ways to address the blockages that prevent funds reaching community-based organisations on the ground and discusses whether it is a lack of capacity to absorb or to disburse funding in effective ways. It then moves on to analyse the type of funding that is necessary to respond effectively to the pandemic, and asks whether an emergency response can fund what is essentially long-term development work and if so, how. Finally, the paper questions the different types of partnerships between government and civil society actors responding to HIV/AIDS; are these “marriages of convenience” or committed relationships, and how well will they fare in the future response to HIV/AIDS?

These are all issues which we in the International HIV/AIDS Alliance are struggling with at the moment.* Having supported community responses in partnerships with NGOs and community-based organisations from over 40 countries, we believe that future success in curbing the epidemic depends on how we collectively answer these questions.

Tackling uptake: absorptive capacity

“Absorptive capacity” is used in this text to refer to the ability to deal effectively with sudden inflows of capital. In the present HIV/AIDS context, we can interpret it as referring to the capacity of organisations and sectors to use the forthcoming influx of funds in a way that has a significant effect on the epidemic and on people's lives.

At the macroeconomic level, the issue of insufficient absorptive capacity for HIV/AIDS money is hotly debated; some question its very existence.¹ It is clear that, whether real or imagined, it is creating an obstacle between donors and those people who could best utilise the funds. Absorptive capacity issues raise a number of specific challenges for the community sector which need to be addressed if we are to do justice to the current financial pledges to HIV/AIDS and if we are to lobby effectively for the increased funding that is necessary for the response. Although there is growing evidence that poor countries could absorb considerably higher levels of aid than they currently receive, there do appear to be challenges in how this money reaches the community or the individual, the level where money is desperately needed. Increases in funding to community-based organisations can, on occasion, lead to “bottlenecks”. However, there is no reason why this should be accepted as an inevitable outcome and, when it does occur, used to trumpet the hopelessness of community action on HIV/AIDS. The HIV/AIDS sector must question why these bottlenecks are an excuse for inaction. What is being offered as an alternative to this method of aid expenditure and for what reason? What can be done to overcome such blockages? If we do not address these questions, there is a danger that the pressure to scale up HIV/AIDS interventions quickly may lead to locally-rooted community action being replaced with less effectively mobilised action on a wider scale.

There are a number of concrete steps that can be taken to alleviate the problems associated with the absorptive capacity of the community sector. One of the most important is the facilitation of access to antiretroviral therapy (ART) and related services. The impact of the rise in morbidity and mortality associated with AIDS undermines community action and community sector capacity, through absenteeism and death of staff and volunteers. However, in countries like Brazil, increased spending on commodities and access to treatment has helped relieve systems that were formerly over-stretched by HIV/AIDS, and acted as an important first step in capacity maintenance. This includes enabling HIV-positive staff to continue their work, and helps to preserve institutional knowledge.²

Another reason given for delays in spending is that community actors do not have the professional knowledge and skills and the all-important personal compassion, creativity and commitment to respond effectively to HIV/AIDS. From our experience, the ongoing provision of, and investment in, relevant and high quality technical support is crucial for increasing the capacity and effectiveness of community-based organisations. This is because practical skills (e.g. peer education and home-based care), appropriate attitudes (e.g. being non-judgmental) and organisational development (e.g. strategic planning and budgeting), form the bedrock of effective community action on HIV/AIDS. However, compassion, creativity and commitment are difficult skills to imbue through the exchange of knowledge. So in addition to more traditional technical support, there is an urgent need to foster and support existing and emerging leaders in the response to the pandemic. These local field workers, activists, policymakers and members of community- and faith-based organisations can be aided in their work through financial, political and technical and emotional support.

Another way of making the most of the increase in funding is by continuing to use our collective imagination to identify and catalyse non-traditional actors. There is under-utilised capacity in existing development NGOs, and these organisations can, with the appropriate technical guidance, absorb some of the new funding. Programmes which have the potential to make the greatest difference can be expanded by the formation of strategic partnerships with community actors. Sevanilayam, Alliance India's lead partner in the state of Tamil Nadu, has been working with communities on development programmes for more than two decades. Over the last few years it has integrated health programmes into its existing development work and established community health centres where there was no previous access to primary health care. This has significantly increased the services available within the local community and Sevanilayan is now a “centre of excellence” for training village health care providers in home-based care.

Freeing up funding: the capacity to disburse

In parallel to absorptive capacity, we need to address the equally pressing question of “disbursement capacity”. In the context of aid for HIV/AIDS, this refers to the ability of governments and international donors to disburse funds to all sectors so as to have a significant effect on the epidemic and on people's lives. In the context of this paper, we are looking at disbursement capacity specifically to support community responses.

International donors have a number of disbursement strategies to choose from. Smaller donors might concentrate on a small number of sites, or on “demonstration projects” or on funding advocacy. Larger donors, and any donor that is trying to support the significant scale-up of impact, tend to pursue a combination of routes. These can include dramatically increasing their own field support capacity; focusing their support on governments to provide government programmes; funding and supporting governments to become intermediaries to support community-based implementers; and funding and supporting non-governmental intermediaries to support community-based implementers (typically through contracts to large international NGOs, but sometimes through national or indigenous intermediaries). In general, donors do not have the technical or administrative capacity to assess, fund and monitor hundreds of thousands of community-based projects around the world and so some type of intermediary is usually employed to take on this role.

There is an increasing dependence by international donors on governments as intermediaries, and this brings with it a new question of capacity. It is not just the disbursement capacity of donors that is limited, but also the disbursement capacity of southern governments. Few governments have systems in place for large-scale funding support to NGOs and community-based organisations, let alone also for ensuring they get technical assistance and carrying out monitoring and evaluation. Even when these systems are in place, governments are rarely willing to fund civil society actors who may critique their policies and hold them to account. In addition, governments are also subject to their own biases and moral viewpoints. This can make it difficult for them to work with organisations that are working with communities vulnerable to HIV infection (such as sex workers and men who have sex with men), especially those whose behaviour may be highly stigmatised or even illegal. Finally, government systems usually work best in promoting a roll-out of standardised approaches rather than in supporting innovation and diversity. All of this makes it more difficult for them to disburse funding for HIV/AIDS.

From the recipient countries' point of view, more money in the pipeline has also triggered many questions. National AIDS agencies are asking how they can be expected to cope with all the visitors, requests for separate accounts and different indicators that are expected alongside the additional money. The “Three Ones” is an attempt by donors and national governments to make progress on this issue.³ This is a strategy supported by UNAIDS and others, which promotes one national AIDS strategy, one national governing body and one way to monitor and report on progress. With the active involvement of civil society in their development and management, such strategies have great potential for harmonising national systems and, in turn, reducing duplication and increasing efficiency and disbursement capacity to community-based organisations. The downside to the “Three Ones” approach is the risk of increasing “sub-contracting” relationships in order to increase disbursement capability. This could undermine the independence of community-based organisations by curtailing their ability to get funding from a variety of sources, using a variety of strategies.

The Alliance's partners are working with innumerable NGOs and community-based organisations that are doing highly effective work and are ready to do more, but they lack access to even minimal resources, even in countries where the millions are pouring in. For example, in Burkina Faso, People Living with HIV/AIDS networks and community groups with huge potential and capacity to contribute to ART service provision are confronted with enormous difficulties accessing resources because of the way they are being made available, and they are not alone in this. Although there is no single model for supporting communities, the experience of the Alliance and best practice would suggest that the use of national peer NGO support providers, with the local experience and capacity to provide support to NGOs and community-based organisations needs to be encouraged and resourced. The vast experience of existing national NGOs in providing support to community-based organisations appears to have been under-utilised in existing funding mechanisms. Interestingly, recent analysis by the Global Fund of 25 of its grants that had reached the one-year mark shows there has been better disbursement performance when the money goes directly to civil society. These data show that civil society Principal Recipients achieved higher median disbursements, reaching 85% of targets, compared to a median 57% of targets reached by governments.⁴

The Global Fund for AIDS, TB and Malaria has also recognised that the programmes it supports financially often do not include enough human capacity-building, and it now explicitly invites countries to include this in their bids. Although this may not go far enough in addressing the problem, other well-developed NGOs and donor countries need to make similar adjustments. Absorptive capacity and disbursement capacity are clearly interlinked and impact on each other. Governments and civil society organisations need technical support in order to accept, distribute and account for increases in funding.⁵ If donors do not accept this, there is a very real danger that home-grown responses will be replaced with imported solutions. Yet where national responses to AIDS have had successes, it has largely been due to the fact that affected communities and people living with HIV/AIDS have been instrumental in setting priorities and in planning and implementing interventions; importing solutions would be not only disappointing but negligent.

Emergency relief vs. community development

We have finally reached the point where the HIV/AIDS pandemic is becoming recognised as the global emergency that it undoubtedly is. It is ironic, therefore, that this focus and the resultant funds are creating many tensions for the community sector. NGOs and community-based organisations are struggling to balance demands for quick results with a desire to spend new funding in the most appropriate way. Donors are often tempted by the “lowest hanging fruit”, i.e. programmes that can show near-instant results. This is perhaps unsurprising given the financial, political and ethical pressures they are under.

However, there is no magic bullet; successful responses to the epidemic are the ones that are comprehensive and comprised of simultaneous interventions. Effective action on HIV/AIDS is multi-sectoral and requires partnership between actors from different government ministries and civil society. For example, through community consultations in urban and rural areas of Zambia, we have learned that for one person with HIV to reach the point of putting an antiretroviral medicine in their mouth for the first time–and to continue to do so several times a day for the rest of their life–the community and country needs to have a functional network of human, material and infrastructure resources. These include a counsellor to support the person to have an HIV test, a self-help group to share information and support their self-esteem, trained health workers to prescribe and monitor the treatment, a laboratory to do necessary monitoring tests, an advocate to persuade the government to provide the treatment free, and a supportive family and community to help the person to continue to adhere to the treatment and to sustain protective behaviours.⁶

Action on HIV/AIDS and broader development agendas are solidly and intrinsically linked. This type of work is characterised by incremental relationship-building and the maximising of local resources. In countries as varied as Mongolia and Mexico, the Alliance and many others would not have had a fraction of their impact if it were not for the work that had gone before them. For example, the work of NGOs with vulnerable populations such as people living with HIV/AIDS, injecting drug users, sex workers and men who have sex with men is more complex and more time-consuming than simply purchasing commodities or offering services. Effective community action moves beyond the behaviour change of individuals to the creation of a social environment that supports healthy behaviours. Work to increase the social capital of affected communities can encompass interventions to deal with constructs such as trust, reciprocity, local democracy, citizenship, civic engagement, social relationships and access to information and power. It is multi-faceted, context specific and changes over time. Building systems to provide this type of community support is not work that can be accomplished overnight; it demands a long-term approach.

Although nobody can deny the long-term nature of comprehensive interventions and health systems strengthening, there are areas where the HIV/AIDS sector could add significant value relatively quickly. For example, it is now ten years since the International Conference on Population and Development and yet there is still some way to go until we reach a point where HIV/AIDS services are meaningfully integrated into sexual and reproductive health care. In some countries a robust network of clinics offers a ready-made infrastructure from which services such as voluntary counselling and testing, services for the prevention of vertical transmission and antiretroviral treatment could be offered. While it is important not to underestimate the investment in terms of time and money that would be needed to scale up these services, they do present an under-utilised opportunity for the roll-out of HIV/AIDS services.

We have a responsibility to explain, to both donors and taxpayers, the reality of community action on HIV/AIDS and why quick fixes do not work. However, we should also think innovatively about where partnerships can speed up action and prevent the creation of unnecessary vertical services. What we all need is a strong and steady flow of resources to foster both existing and potential efforts, to enable them to grow at a steady pace. We need not just more funding, but predictable funding, that will enable us to plan and invest. Our success depends on our ability to recognise and support urgent and rapid scale-up with sustained, long-term approaches.

Marriages of convenience or committed relationships: confrontation or collaboration?

Twenty years of the HIV/AIDS epidemic have left valuable examples of strong, confrontational civil society advocacy producing badly needed policy changes and strong collaborative efforts between governments and civil society, with impressive results.

The work of the Treatment Action Campaign (TAC) in South Africa is a good example of change through campaigning activism. TAC was established in 1998 with the objective of campaigning for greater access to treatment for all South Africans, by raising public awareness and understanding about issues surrounding the availability, affordability and use of HIV treatments. TAC works through a combination of direct action to hold their government and pharmaceutical companies to account, excellent communications and media work, the creation of a critical mass of members, and strategic alliances with trade unions, employers, religious bodies, women's and youth organisations, and lesbian and gay organisations. Their work has been influential in the South African government's decision to adopt a comprehensive plan for HIV/AIDS treatment and prevention. TAC continues working to ensure that this plan is driven forward from the level of policy to appropriate implementation.

A less well known project to secure access to services for people living with HIV/AIDS is run by AidsNet in Chiang Mai, Thailand. AidsNet supports partnerships between the government and groups of people living with HIV/AIDS in Upper Northern Thailand. Through the positive groups, members access services such as psychosocial support, children's education, medical care and income-generation projects.⁷ The recognition by local government that the epidemic could only be overcome by working closely with HIV-positive people was crucial to the success of this endeavour, together with the support of other NGOs, which enabled the groups to access sustained technical and financial assistance.

Unfortunately, there are also many examples where the lack of dialogue and respect between governments and civil society gets in the way of a good response. There have been “marriages of convenience” where national governments have simply funnelled money to NGOs without any real strategy, simply because this has become a political and administrative necessity, perhaps a prerequisite for getting money for their own governmental programmes. However, effective use of the new funding for HIV/AIDS requires real collaboration between government and civil society, which presents quite a serious challenge to traditionally uncomfortable bedfellows.

Governments and international organisations will have to decide what type of civil society they feel can best contribute to a successful response and how they are going to relate to and support them. Civil society needs to retain its diversity and continue playing a variety of roles, but individuals, organisations and networks will have to decide where to position themselves and also learn to adapt to changing environments. One of the strengths of the Treatment Action Campaign is its ability to respond to shifting government positions whilst remaining absolutely within its original remit. Other NGOs can learn from this flexible style. New tensions are likely between service delivery, advocacy and holding governments to account. More money may also affect their role in catalysing and leading social movements, raise larger questions about inefficiency, and exactly how and to whom they are accountable. Finding solutions to these problems as they arise, and learning from the experiences of our peers around the world, are key challenges for us all and ones we can no longer ignore.

Conclusion

In this paper we have tried to present questions that come up in our daily work supporting community action on AIDS. The paper is intended to generate debate and explore different perspectives rather than necessarily offering concrete solutions to the challenges that have been created by recent funding pledges.

The community sector has an immense amount to offer. We are the glue that holds responses to HIV/AIDS together. Without our skills, insights, imagination, commitment and energy, the million-dollar budgets and high-tech drugs will fail. However we have much to learn and a lot to adapt to, and we need support to do this. Maybe what is needed is a little humility, an acceptance that we cannot do it all alone. Pride in our past work and achievements should not be allowed to obscure the fact that we will need to adapt to new partnerships with government and other emerging HIV/AIDS service providers.

We might also need a call to action. Now is not the time for complacency. We can pat ourselves on the back for a reasonably good effort with yesterday's epidemic. And we can actively learn from our response to today's. But now is the time to prepare, by re-energising, re-equipping, re-focusing and re-positioning ourselves for the pandemic of tomorrow.

Acknowledgements

This paper is a revised version of a paper prepared by the Policy Team, International HIV/AIDS Alliance, for the International AIDS Conference satellite meeting, Questioning the Community Sector: Are We Making a Difference?, Bangkok, July 2004. Thanks to Sarah Middleton Lee, independent consultant, for her help drafting this paper. Thanks also to Kieran Daly for his work on civil society involvement in funding mechanisms for HIV/AIDS, which was drawn on extensively for this paper.

Notes

* The International HIV/AIDS Alliance supports community action on HIV/AIDS in over 20 countries, some heavily affected by AIDS and others threatened by emerging epidemics.