Transitioning from international to

domestic funding

Experiences in the Asia-Pacific

June 27 , 2019

Outline

• PEPFAR priorities on HIV epidemic control and strategies for Asia

• Funding gaps of HIV response in selected countries

• Barriers and bottlenecks for transitioning

• Promising practices

• Ways forward

PEPFAR priorities on HIV epidemic control and strategies for Asia

Reach 90/90/90 targets and achieve full PrEP

access to the highest risk key populations (KP)

by 2020

• Expand KP networks and KP- and community-led

approaches

• Strengthen KP organizations, participation and

leadership at local and regional levels to sustain

epidemic control

• Advance regional connectivity and expertise

through technical assistance, knowledge sharing

and proven implementation practices

• Support a country's journey to self-reliance:

increase and optimize domestic investments for

KP programming as well as innovate financing

mechanismsSource: Mplus Foundation, Chiang Mai, Thailand

“Civil society plays a critical role in the HIV response.”

• We would not have a global HIV response

if not for civil society groups that

demanded it

• Support from donors has been inadequate

• We can all do more to support efforts of

networks of KPs and civil society groups

• “Fast-track” success depends on

partnerships that put effective tools within

reach of individuals and communities with

the greatest needs

4

Ambassador Birx

Source: SWING Foundation, Bangkok, Thailand

Rationale for financial transition

• High levels of donor dependence on HIV funding in the region and for

KP programs in particular

• Program sustainability and inclusive national coverage ultimately

require full domestic financing – government budgets and private sector

funding

• Domestic funding is increasing but it is inadequate

• Current donor funds are time-bound and limited. They are vulnerable to

changes in donor priorities.

• The future outlook for donor funding is uncertain.

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HIV expenditure (% reliance on external sources)

Health expenditure (% reliance on external sources)

The situation (1): Governments’ commitment to health and dependency

on external sources

Prepared by www.aidsdatahub.org based on Global AIDS Monitoring Reporting and Global Health Expenditure Database at https://apps.who.int/nha/database/Select/Indicators/en (accessed April 25, 2019)

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The situation (2) - Evidence from four countries

The Global Fund SHIFT program:

• National HIV financing assessments in Indonesia, Malaysia, Philippines and

Thailand (2017): Increasing domestic financing of national HIV

responses

• 2014/5: Malaysia 96%, Thailand 89%, Philippines 74% and Indonesia

57%

• In aggregate, only around 10% spent on MSM/KPs

• Bulk of prevention spending on KPs is from donors

• Civil society access to domestic financing remains a challenge in all

countries except Malaysia

• In Indonesia, MSM programming receive 99.7% of their funding from

international sources and in the Philippines, it is 100% for MSM

prevention investment

• International partners usually provide direct funding to CBOs7

Barriers and bottlenecks for transitioning

Countries are at different places when it

comes to transitioning:

• Transitioning from external to domestic

financing has been constrained by lack of

political will, stigma and discrimination

and competing priorities

• Private sector engagement is

limited/emerging

• Data are limited on how money is being

spent

• Traditional government health budgets

are often not well adapted to provide

funding to CBOs that support health

service provision for key populations

8

• Absence of enabling laws

and policies

• Government attitudes

toward CSOs may include

lack of trust, concerns of

financial management and

governance and lack of

ownership

• Stringent registration

criteria

• CSO accreditation

• CSO technical

capacity/reputation

Social contracting – Effective across the services cascade

9

Definition: Mechanisms that allow for government funds to flow directly to

civil society organizations to implement specific activities

Service access/uptake

Support along the cascade

Some countries that employ social contracting approaches

10

Asia

• China

• India

• Malaysia

• Thailand

• Vietnam (feasibility analysis)

Europe

• Belarus

• Bosnia and Herzegovina

• Macedonia

• Moldova

• Montenegro

• Netherlands

• Serbia

• Ukraine

Americas

• Dominican Republic

• United States

Africa

• Namibia

Central Asia

• Kyrgyzstan

• Tajikistan

• Uzbekistan

Examples of social contracting in the region

11

China India Malaysia

Initiated 2013 1997 1993

Scope National, provincial and prefectural State level National level

Services • Outreach

• HIV testing

• PrEP

• Linkage/referral to ART• Adherence support

• Outreach

• Opioid substitution therapy

• HIV testing

• STI diagnosis/treatment

linkage/referral to ART/TB

• Adherence support

• Advocacy

• Collectivization

• Outreach

• Harm reduction

• Shelter care

• Adherence support

Management • National HIV/STI Association

• Provincial AIDS Bureaus

• Prefectural/county leadership

• Chinese Centers for Disease

Control

• ART Hospitals

• National AIDS Control

Organization (NACO)

• State AIDS Control Societies

(SACS)

• District AIDS Prevention and

Control Units

• Malaysia AIDS Council (MAC)

Executive Director in

collaboration with MOH

Promising practices: Thailand

Public sector expenditures for KP HIV

prevention have increased

significantly since 2016

• Improved systems and legal

frameworks for enhancing

contributions of KP community-based

organizations

• Accreditation and reimbursement

processes and standards for CBOs

and private clinics

• Management of CBO contracts

through provincial sub-grants

• Inclusion of PrEP in Universal

Coverage

Challenges: determining appropriate

and acceptable costs for services for

sustainability

12

NHSO funding trends from 2018 to 2019

313%

156%

305%

152%

-3%

152%

75%-26%

-28%

40%

13

PrEP uptake in public and community (KP-led) sites through FY 19 Q1

Public sector PrEP new cases

FY 17-FY19 Q1*

KPLHS PrEP new cases

FY 16 Q2-FY19 Q1

*Other PrEP users (discordant & other KPs) excludedSource: Thailand-US Collaboration and Thai Red Cross AIDS Research Centre

Initial PrEP uptake much higher in community sites

14

Long way to go: PrEP for epidemic impact needs far higher scale-up

15%

Public sector sites

85%

KP-led sites

2020

6,000 to 118,000 leap to reach national target

How did we get there?

15

Evolution of PrEP in Thailand: the journey towards financing

Nov. 2010 Jul. 2011 Dec. 2012 Oct. 2014 Dec. 2014 May 2015 Jan. 2016

Thailand provided

sites for early PrEP

clinical trials, i.e.

iPrEX

HPTN 052, 96%

prevention efficacy

with immediate ART

The 1st Test & Treat

project in MSM and

TGW in 4 provinces

National guidelines

recommended ART

regardless of CD4

count and PrEP

PrEP-30 (about US$ 1 per

PrEP dose) starts at Thai

Red Cross AIDS Research

Centre (TRCARC); Now

PrEP-15

Implementation

science in community

and government

clinics

Princess

PrEP

The Princess PrEPUSAID LINKAGES and

Thai Princess support

PrEP scale-up through

key population-led health

services in 2015 (free

PrEP)

Steps towards successful transitioning

16

Establishing new frontiers in SRH with private sector

17

Thai Red Cross Anonymous Clinic

service model expanded to

Bangpakok (BPK) Private Hospital

Group (of 8 hospitals throughout

Bangkok)

Improvements in Social Health Insurance (SHI) to cover ARV in

Vietnam

GVN = Government of Vietnam | HIS = Health Information System

USAID SHIFT Support to Sites

Before Implementation After Implementation

• Trained sites on information systems,

checked HIS functionality

• Developed SOPs for sites on patient

flow, reimbursement processes,

treatment protocols

• TA on estimating ARV needs, handling

shipments etc.

• Advocate for ARV copay from local

budget

• On-site to support

information systems

• On-site to support clinics in

prescribing SHI-covered

ARVs

• On-site to support data

collection for reimbursement

• GVN selected 188 sites to begin implementation, covering 48,000 patients

• 6 of USAID SHIFT’s 31 HIV treatment facilities were selected, covering 3,866 patients

18

Hanoi

Quang

Ninh

HCMC

Tay

NinhDong

Nai

Tien Giang

Provincial support for ARV coverage increased

19

Dong Nai

Hanoi

HCMC

Quang Ninh

Tay Ninh

Tien Giang

Support for SHI Card

Purchasing

Support for ARV

Co-Payment

USAID SHIFT covering copays

PPC issued a decision to cover 100% of premiums for PLHIV and

ARV copay

PPC decision allocated $86,000 in 2019 to DOH to cover 100% of

premiums for PLHIV and ARV copay

PPC decision allocated $69,000 in 2019 DOH budget

PPC decision allocated $69,000 in 2019 DOH budget

PPC = Provincial People’s Committee

DOH issued guidance on copays

PPC issued a decision to support for HCM residents only.

USAID SHIFT covering copays

for non-residents

USAID SHIFT covering copays

for non-residents

LESSONS LEARNED

20

SUCCESSES

• Government convinced to support ART

through SHI for predominantly PWID

PLHIV population

• $ 62,377 already requested via eClaim

CHALLENGES

• System of co-payments and

coordination between provinces

and districts still needs

improvements

Most people living with HIV have social health insurance in Vietnam

21

“The health staff at the clinic told patients that

SHI-covered ARVs will replace donor-

supported ARVs, counseled us on the

benefits of participating in SHI, explained

about personal information security and other

benefits, and supported us with enrolling in

SHI. Now, most people living with HIV have

social health insurance.”

- Person living with HIV at USAID SHIFT-

supported site

Ways forward

• Financial transitioning from donor to domestic financing

needs to be planned as early as possible and

enabled in national laws, policies and guidelines

• Success in achieving the UNAIDS 90-90-90 goals by

2020 will be associated with our capacity to put “fast-

track” solutions in the hands of those in which they can

have the greatest impact – key populations and civil

society organizations

• Need to explore a variety of financing mechanisms to

channel funds to HIV programs, including private

sector engagement

22

• Social contracting is a promising financing strategy for governments to provide funding to CBOs

and KP-led organizations for health service delivery; Countries can learn from each other on

various strategies, e.g. grants, reimbursements per person tested, treated

• Social contracting can also be used to engage with CBOs to rapidly implement emerging and

more effective interventions, e.g. index testing, PrEP

Acknowledgements

• Dr Steve Mills and Dr Michael Cassell, FHI 360 (USAID LINKAGES

and SHIFT Programs)

• Dr Nittaya Phanuphak and Krittaporn Termvanich, Thai Red Cross

AIDS Research Centre

• Mplus Foundation

• SWING Foundation

• Rainbow Sky Association

• Nisha Gupta, USAID/RDMA

• Dr Eamonn Murphy, UNAIDS

• The Global Fund SHIFT Program

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