Fund the medicines or fund the programs that support people to go on treatment? That's the choice countries are now facing amid Global Fund shortfalls. With money tight, countries are slashing civil society-led HIV and TB programs in an attempt to maintain basic and essential services, according to preliminary research being conducted by the Open Society Foundations. The programs most frequently on the chopping block are efforts to reach highly vulnerable populations.
In November 2011, the Global Fund to Fight AIDS, TB and Malaria faced US$2.2 billion in unpaid donor pledges and cancelled its Round 11 of funding. The cancellation was the most dramatic outcropping of years of broken donor promises.
In 2009, Global Fund donors reneged on almost 15 percent of pledges. A year later, almost a quarter of donor pledges failed to materialize, according to former Global Fund Executive Director Michel Kazatchkine's November 2011 report to the board.
To ascertain the civil society impacts of Global Fund shortfalls, the Open Society Foundations conducted research in three countries that had planned to apply for Round 11: Swaziland, Malawi, and Zimbabwe.
In Swaziland, the country's Round 11 application−like that of Namibia–would have been the first to include HIV prevention programming aimed at criminalized, most-at-risk populations of sex workers and men who have sex with men. The country would have also addressed the needs of people who inject drugs.
Through interviews with nearly 45 representatives from civil society groups, Global Fund Country Coordinating Mechanisms, HIV and TB programs, and UN agencies, we discovered that countries are facing funding gaps for essential services such as HIV and TB testing and treatment, prevention of mother-to-child transmission services (PMTCT), and support for orphaned and vulnerable children.
Civil society activities the first to go
To free up funding for these initiatives, all three countries are cutting the kinds of complementary, civil society-led activities identified as "critical enablers" in the UNAIDS Strategic Framework.
Swaziland has now halted HIV prevention programs, with the exception of PMTCT and medical male circumcision, and may re-program phase II of its current Global Fund money to shift more money towards ARV stocks, according to Vusi Nxumalo, a CCM member and vice chairperson of the Swaziland National Network of People Living with HIV and AIDS.
Malawi and Zimbabwe have already cut civil society activities under their Phase II renewals to shift money towards medicines, HIV testing kits, and PMTCT.
Zimbabwe's recently approved Round 8, Phase II renewal has slashed funding for behavior change communication in communities and schools (-54%); institutional capacity building and efforts to strengthen networks of people living with HIV (-27%); and support for orphaned and vulnerable children (-17%). Civil society organizations that implement these programs were not consulted about the funding cuts.
"The removal of behavior change communication is not justified," said Joyce Siveregi, deputy director for programs at the Zimbabwe AIDS Network.
"Whilst they are saying, ‘Focus on low-cost, high-impact interventions,’ for a program to be effective you really need it to be well integrated," Siveregi told the Open Society Foundations. "I thought this was what the Investment Framework was all about."
A little bit of history repeating
It's not the first time countries have had to cut civil society programming to preserve drug stocks and diagnostics.
In 2009, the Global Fund mandated a 10 percent "efficiency gain" in Round 8. Research by the Open Society Foundations found that during grant negotiations, most countries felt resources for commodities such as medicines, lab equipment, and infrastructure could not be reduced. Instead, gains were achieved by decreasing resources devoted to programmatic components such as education campaigns, prevention activities, and outreach services targeting marginalized and vulnerable groups.
According to the latest survey, about 80 percent of civil society organizations interviewed said organizational funding had declined in the past two years, with several, longstanding organizations citing funding cuts of up to 30 percent.
To cope, organizations have scaled back or cut both staff and the kinds of programs they were forced to cut in 2009—most prominently community systems strengthening, human rights programming, and community mobilization efforts.
Community organizations, like groups operated by and for people living with HIV, have been the most impacted by programming cuts.
"We are losing the community structures that we've built up,” Nxumalo told the Open Society Foundations. “If there comes a time when there is money for HIV, we're going to have to go back into communities and build these structure all over again."
Now that the Global Fund has announced that it has $1.6 billion available to begin investing in new programs, it needs to prioritize investments in the communities it was set up to serve.