Background Report Prepared for UNICEF for the ADB-UNICEF Workshop on the Role of Non-State

APRIL 2010

HIV/AIDS and Non State Provision of Prevention, Treatment, Care and Support Services for Women and Children in Asia Pacific

Background Report Prepared for UNICEF for the ADB-UNICEF Workshop on “The Role of Non-State Providers in Delivering Basic Services for Children”

DRAFT NOT FOR CITATION Disclaimer This draft paper was developed by Ms. Doris D’Cruz Grote, Independent Consultant and former Coordinator, Country Coordination Mechanism, The Global Fund for AIDS, Tuberculosis and Malaria, Geneva.

This draft paper will be finalized jointly by the HIV/AIDS team of the ADB and UNICEF based on inputs and comments received at the Workshop on ‘The Role of Non-State Providers in Delivering Basic Social Services for Children’ and by drawing upon good practices on the value-added of NSPs in selected countries in the region.

2 Table of Contents

Executive summary 1

Part 1: Introduction 4 Rationale and objectives Regional context of HIV/AIDS and its response

Part 2: Current status of the role of NSPs in the national 6 HIV responses in Asia 1. Role of non-governmental organizations, community – based organizations 2. Role of Faith Based Organisation 3. Role of the private sector 4. Coordination, networking and technical support for NSP 5. Challenges faced by NSPs

Part 3: Analysis of financial support to the Non-State 23 Providers for HIV/AIDS prevention and treatment in the region 1. Global Fund’s contribution to supporting the participation of Non State Partners in HIV/AIDS national responses 2. Overview of financial support globally to HIV/AIDS response 3. Overview of international financial support to service delivery for HIV/AIDS prevention, treatment and care in Asia 4. Review and analysis of financial support to NSPs for service delivery in the countries in East Asia and the Pacific 5. Review and analysis of financial support to NSPs for service delivery in the countries in South Asia

Part 4: Conclusion and the way ahead 37

iii Abbreviations AIDS Acquired Immunodeficiency Syndrome ADB Asian Development Bank APCASO Asia Pacific Council of AIDS Service Organizations APN+, Asia Pacific Network of People Living with HIV/AIDS CBO Community Based Organisation CCM Country Coordinating Mechanism CDC Center for Disease Control GTZ German Technical Cooperation FBO Faith-Based-Organization FHI Family Health International GFATM The global Fund for AIDS, TB and Malaria HIV Human Immunodeficiency Virus IDU Injecting Drug User ILO International Labour Organization MTCT Mother-To-Child Transmission MSM Men having Sex with Men NAC National AIDS Councils/Committees NGO Non-Government Organization NSP Non-State Provider PPP Public-private partnerships PEPFAR President’s Emergency Plan for AIDS Relief RCC Rolling Continuation Channel TBCA Thai Business Coalition on AIDS UNAIDS Joint United Nations Programme on HIV/AIDS UNGASS United Nations General Assembly Special Session WHO World Health Organization

Terminology The definitions in the paper are taken from UNAIDS Non-State Partners (NSPs) are broadly defined as profit, non-profit, formal and non- formal entities such as Non Governmental Organizations, Community Based Organizations, Faith Based Organisations Civil Society: made up of ordinary citizens who organize themselves outside of government and the public service to deal with specific issues and concerns that normal governmental process cannot address by itself. This includes people living with and affected by HIV/AIDS, and the organizations of these people, Non-Governmental Organisations, Community-based Organisations, Faith-based organizations Private Sector refers to for-profit business entities of all sizes or their philanthropic foundations excluding not-for-profit, nongovernmental and faith-based organizations. Public sector refers to governments and government institutions Public-Private Partnerships: partnerships of private companies and development agencies, to business relations of the private sector with public organizations or the privatization of public services and the public-private mix of health care provision12.

iv Executive summary

This background paper was commissioned by UNICEF to review the current status of the role of Non-State Providers (NSP) in meeting the prevention, treatment, care and support goals of HIV/AIDS programme priorities in Asia and what mechanisms exist to regulate and ensure that quality services are delivered by non-state actors.

The reports, reviews and analysis indicated that, as in other regions, early civil society initiatives laid the foundation on which national responses were built in many countries in Asia. Civil society engagement and activism brought the voices and issues of marginalized communities and human rights, and social protection to the forefront of AIDS agenda. In Thailand, NGOs have been a key force in pushing the government towards action. More recently, the participation of civil society in the development of the National AIDS Strategy and the Law in Vietnam resulted in the inclusion of substitution therapy.

Thailand's experience supports the widely held belief that policy development should be a joint effort of government officials and representatives of the NGOs. The true engagement in policy and decision making is still limited in a number of other countries. Government dominance, NSPs’ lack of experience in engaging in national processes are among the barriers for a true participation in national decision making processes. Despite these challenges and even in countries with restrictive legal framework, NSPs have been in forefront of service delivery both in prevention and in the provision of care, particularly among the most vulnerable and hard-to-reach populations.

The private sector has been active mainly in the area of service delivery through workplace programmes. In some countries partnerships between the government and the pharmaceutical companies have been formed for service delivery in prevention, treatment and care but these are still rather limited in scope and reach. Trade Unions and Business Coalitions have contributed to establishing corporate and workplace policies and to developing minimum standards. But the potential of the private sector in terms of resource mobilization and for strengthening leadership, management and governance has not been fully exploited.

Opportunities for technical support are being provided by international partners and by the UNAIDS Technical Support facilities, and the HIV/AIDS Alliance technical hubs. In addition to these, a number of regional networks such as Asia Pacific Network of People Living with HIV/AIDS APN+ Asia Pacific Council of AIDS Service Organizations APCASO, Asia Interfaith Network on HIV & AIDS (AINA) & Business coalitions provide support to national networks and organizations and have developed guidelines and Codes of Practice.

In terms of financial allocation to the national response, the countries in the region with the exception of China, India and Thailand are still donor dependent. PEPFAR and the Global Fund are the two major donors in the region both of whom have increased availability of resources to NSPs. The Global Fund has made major contributions to promoting NSP participation through making inclusion of NSPs in Country Mechanisms a requirement and putting in place policies which increased substantially the amount of funds going to NSPs for programme implementation. The dependency on donor funds

1 and the limited domestic financing of the national response have negative implications for the sustainability in particular of care and treatment service delivery.

Despite recent progress made in availability of funds and technical support, NSPs in the region are confronted with a number of challenges. With few exceptions, the countries of the Asia Pacific region are hampered in their response to HIV/AIDS by weak institutional mechanism, limited organizational capacity in programmatic and financial management and low technical capacity of community actors. This not only constrains service delivery but also limits their ability to effectively use what funds are available. A major limitation to quality service delivery is the absence of accreditation processes and minimum standards, which would also serve to hold NSPs accountable to the communities they serve.

Based on the findings of this review, this paper proposes the following actions for moving forward in strengthening NSP role in the national response to HIV/AIDS.

1. Participation in national coordination, planning and policy development - Establish policies and procedures for an open participatory selection/election of NSP representation and for genuine participation in national mechanisms. Provide the training and the resources necessary to optimize participation in formal governmental environments. True participation would facilitate dialogue and joint planning, contribute to the development of a comprehensive coherent policy framework and evidence based, impact- oriented and sustainable, long term plan with clearly defined roles for NSPs.

2. Conducive policy and legal framework for public-private partnership - Advocate for the removal of restrictive laws and regulations and create an enabling environment through policy frameworks to facilitate the engagement of NSPs in the national response particularly for service provision to those most at risk such as injecting drug users IDUs and Men having Sex with Men; - Generate evidence for policy development for the private sector by conducting a private sector provider survey to assess private sector provision of HIV/AIDS services. This will provide data on the potential role of the private sector in meeting national goals, and on good practices, the regulatory environment as well as infrastructure and capacity limitations. This information can be used to guide private sector related policy decisions and promote a greater role for the private sector in service delivery in general.

3. Accountability and quality of service delivery - NSPs should be part of the monitoring and evaluation of the national response so that the extent and quality of NSP, including private sector role, in national HIV responses could be assessed. This will also contribute to improving accountability and transparency of their activities and to ascertain the cost- effectiveness of community-based interventions; - Develop and implement country specific accreditation systems and Codes of Good Practice based on the principles outlined in the Code of Good Practice for Nongovernmental Organisations responding to HIV/AIDS. This should be developed with the participation of the NSPs and other stakeholders.

2 4. Strengthening institutional capacity and technical skills of NSPs - In partnership with TS providers, develop a long term country-owned, overarching technical support strategic framework and workplan. This process should be based on needs assessment, and a mapping of the available resources (financial & TS providers) at country, regional levels to address the long-term capacity building needs all NSPs. - Harmonize and coordinate technical support at the regional and country levels through for example the development of an overall Technical Support Partnership strategy defining the provider roles and responsibilities, norms for TS provision & coordination, results- based framework for quality assurance - Advocate/support building in budgeted TS plans, based on needs assessment, into GF proposals. This should preferably be done with the participation of the proposed Principal Recipient and the identified sub-recipients to ensure TS particularly to improve program management and implementation capacity. Continuity in TA should be encouraged through inclusion in national programme budgets

5. Other areas for consideration - Explore/study experiences of other countries in private sector contribution to the social health insurance. There is a need to evaluate the best role(s) of the private sector in this respect and to define models of cooperation with the public system which could meet business interest.; - Explore/study experiences of other countries in forming partnerships with the private sector for cash transfer to benefit children affected by HIV and AIDS. This could provide insights into a possible role for the private sector.

3 Part 1: Introduction

Rationale and objectives Many governments in Asia and the Pacific rely on partnerships with non-state providers (NSPs) to deliver basic social services. These partnerships, traditionally referred to as Public-Private-Partnerships have been used to expand service coverage, improve efficiency, mobilize financial resources to supplement inadequate national budgets and to free up of public resources. PPPs have been engaged in delivering HIV/AIDS prevention and care services since the start of the epidemic.

The UNICEF Regional Offices in East Asia and the Pacific and South Asia will convene from 19-20 April 2010, a joint consultation with the Asian Development Bank (ADB) on the role of/and the challenges and opportunities for engaging non-state providers in the provision of basic services. It is expected that the outcome of this consultation will contribute towards the development of a policy framework for enabling and regulating Non-State Provision (NSP) of basic social services (health and nutrition, HIV/AIDS, education and WASH).

This background paper was commissioned by UNICEF to review the current status of the role of NSPs in meeting the prevention, treatment, care and support goals of HIV/AIDS programme priorities in Asia and what mechanisms exist to regulate and ensure that quality services are delivered by non-state actors. (Annex 1:TOR)

The development of this background paper will be in two phases. The first phase is the writing of a draft background paper is limited to drawing information only from secondary sources available from UN agencies and partners as well as on the public domain. This draft document presents an overview of the role played by NSPs, the challenges faced by NSPs and proposes ways forward. It looks specifically at how the policies of the Global Fund promote and strengthen the contribution of NSPs to the national HIV/AIDS response.

The second phase will involve a more in-depth study of public-private-partnerships in selected countries in the region through discussions with key stakeholders and case study documentation of selected projects. This draft background paper will be finalized based on comments from UNICEF country offices and ADB and will include up-to-date information gathered during the discussions in countries and the case studies.

Regional context of HIV/AIDS and its response1 Thailand is the only country in Asia, which has an adult HIV prevalence of more than 1%. Asia’s comparatively low HIV prevalence still translates into a substantial portion of the global HIV burden due to the region’s large population. South Asia has the highest number of people estimated to be living with HIV. India, with its huge population, accounts for 2.5 million of these people, or more than half of all people (4 million) infected.

Asia’s epidemic is diverse, with different transmission routes predominating in different parts of the region. The epidemic, which has long been concentrated in injecting drug users, sex workers and their clients, and men who have sex with men, now shows an increasing trend of infection spreading into lower-risk populations through transmission 1 All epi data taken from: 09 AIDS epidemic update. UNAIDS/WHO 2009

4 to the sexual partners of those most at risk. In both China and Indonesia, where the epidemic was previously driven by injecting drug use, heterosexual transmission has become the predominant mode of HIV transmission. Data also indicates that even though the regional epidemic appears to be stable overall, HIV prevalence is increasing in some parts of the region as in Bangladesh and Pakistan. Bangladesh has transitioned from a low-level epidemic to a concentrated epidemic, with especially elevated rates among injecting drug users (UNAIDS 2009).

Box 1: Overview of epidemic 2008 2001

Number of people living with HIV 4.7 million 4.5 million Number of new HIV infections 350 000 400 000 Number of children newly infected 21 000 33 000 Number of AIDS-related deaths 330 000 280 000

With the increase in transmission among the low-risk heterosexual population, the proportion of women living with HIV in the region rose from 19% in 2000 to 35% in 2008. In India, women accounted for an estimated 39% of prevalence in 2007. During this decade, women’s share of HIV cases in China doubled and consequently Mother-To- Child Transmission (MTCT) as a proportion of all modes of HIV transmission has been rising annually, resulting in increasing infant and pediatric infections2. But in general, mother-to-child transmission has been responsible for a relatively modest share of new HIV infections in the region. The number of new HIV infections among children (0–14 years) remains relatively stable in South and South-East Asia, although the rate of mother-to-child transmission is still increasing in East Asia.

In terms of response, the region is home to some excellent examples of effective programs. Thailand provides a vivid illustration of both the power of HIV prevention leadership and the importance of sustaining a robust response over time. Targeted interventions have brought down the HIV prevalence among 15–24-year-old women attending antenatal clinics by 54% between 2000 and 2007 in some of the most heavily affected states in India.

Several countries in the region have taken steps to expand access to evidence-informed strategies to prevent new infections among injecting drug users. Access to treatment represents a sevenfold increase in five years but the region is still below the global average (42%) for all low- and middle-income countries.

Punitive legal frameworks, stigma and discrimination in some countries continue to prevent access to services for those populations at risk such as MSM and IDUs. Low awareness of HIV within the general population is still a major problem in many countries in the region. All the more it is of concern that many national strategic plans fail to prioritize HIV prevention, though the region offers a tremendous opportunity presently to curtail the epidemic.

2 COARS 2009 – EAPRO HIV & AIDS

5 Part 2: Current status of the role of NSPs in the national HIV responses in Asia

1. Role of civil society in the national response

1.1 Advocacy and activism As in other regions, early civil society initiatives laid the foundation on which national responses were built in many countries in Asia. In southern India it was journalists, who challenged mandatory HIV testing and the detention of sex workers. Families in China demanded care services for people infected by transfusions of contaminated blood products3. In Thailand, NGOs have been a key force in pushing the government towards action.

Thanks to the tireless activism of organizations of People Living with AIDS, access to affordable ART and care has improved and been assured in a number of countries in the region. The AIDS ACCESS Foundation of Thailand, formed alliances, built networks, and drew together a range of expertise to increase the availability of an important HIV drug, ‘ddI’. 4

Civil society organizations led by Action Aid India, organized a public hearing in 2009 on the plight of children affected by HIV/AIDS in India and the slow Government response. They pointed out that it is ‘mainly non-governmental organizations and HIV-positive network groups that are working to reduce the effect of HIV/AIDS on children in India. They provide nutrition supplements, referrals to testing and treatment facilities, treatment for opportunistic infections, education support, and linkages with existing government child welfare schemes for children who need them’5.

Civil society engagement and activism has brought the voices and issues of marginalized communities and human rights, and social protection to the forefront of AIDS agenda. There are positive signs that decision makers are responding: the lifting of local laws against homosexuality by a court in New Delhi, India, is one very recent example; and Malaysia, China and Indonesia have all taken steps to support harm reduction for injecting drug users in spite of the apparent political difficulty of such actions6.

In the Philippines, the Lunduyan Foundation promotes and advocates for the protection of the Rights of Child. In partnership with UNICEF, the Foundation has conducted seminars to draw attention of the situation of children and was instrumental in the development of a national policy on children and represents the interest of children in Philippine National AIDS Council. 7. In Vietnam, despite restrictions, local NGOS, FBOs and groups of people living with HIV/AIDS have also demonstrated that, given the opportunity, they can contribute meaningfully to HIV control efforts, not only in implementing programs but in helping to guide and shape policies (see box 8).

3 REDEFINING AIDS IN ASIA:Crafting an Effective Response Report of the Commission on AIDS in Asia.2008. p. 153 4 5 Ghanashyam B. India failing children orphaned by AIDS. www.thelancet.com Vol 375 January 30, 2010 6 Asian Economies in Rapid Transition: HIV Now and Through 2031.UNAIDS.2009

7 Country Report Phillipines. East Asia and Pacific Regional Consultation on Children and HIV/AIDS Hanoi, Viet Nam 22 – 24 March 2006

8 HIV/AIDS Policy in Vietnam A Civil Society Perspective.Khuat Thi Hai Oanh. Public Health Watch report. 2007 by the Open Society Institute )

6 Box 2: Civil society participation in drafting of the National AIDS Strategy and the Law on the Prevention of and Fight against HIV/AIDS in Vietnam. The National Assembly of Vietnam held a series of consultations with local and international NGOs and people living with HIV/AIDS, inviting comments on the draft HIV/AIDS Law. The participation of nongovernmental actors in the drafting process contributed to the creation of strong language regarding stigma and discrimination and the rights of people living with HIV/AIDS. Joint efforts by policymakers, international organizations, and local activists to advocate for comprehensive harm reduction interventions resulted in the inclusion of substitution therapy in the HIV/AIDS Law. A local NGO worked closely with WHO and the Communist Party’s Central Commission for Ideology and Culture (CCIC), organized seminars on the topic with journalists, convened meetings with high-ranking officials. Before the final discussion of the HIV/AIDS Law, the CCIC and the Office of the National Assembly distributed a briefing paper focusing on substitution treatment to all National Assembly members. The entire advocacy process, which was supported by the POLICY Project, an international NGO, took more than two years, but ultimately resulted in the passage of a progressive law.

1.2 The status of NGOs, CBOs and their participation in national coordination mechanisms/councils and policy development The 2008 UNGASS report indicated that in 89%, of the 110 countries surveyed, the national AIDS coordinating bodies include at least 1 civil society representative. 73% of the countries confirmed that efforts to increase civil society participation are above average. In other words, the trend is positive, but there remains room for further improvement9.

In almost all countries in Asia, civil society is represented on the National AIDS Councils/Committees. In some of these countries there is genuine engagement of both the government and non-government in coordination and policy development of the national response as evidenced in Cambodia, India, the Philippines and Thailand.

Thailand's experience supports the widely held belief that policy development should be a joint effort of government officials and representatives of the NGOs with daily experience in AIDS prevention and care. 10. In Thailand, the representatives from both Thai NGO Coalition on AIDS (TNCA) and the Thai Network of People Living with HIV (TNP+), are members to the National AIDS Committee11.The National AIDS Committee has set up the NGO sub-committee with defined roles and responsibilities. The National Plan for Strategic and Integrated HIV and AIDS Prevention and Alleviation 2007-2011 states that „Based on the implementation of decentralization policies, the government should encourage the participation and self-support of people and communities on work related to HIV and AIDS. This should be done by systematically developing the capacity of communities“12.The Ministry of Public Health has established a budget within the Department of Diseases Control to support NGOs and affected people’s networks in HIV/AIDS.

9Peersman G. et al. Increasing Civil Society Participation in the National HIV Response: The Role of UNGASS Reporting. Acquired Immune Deficiency Syndrome Volume

52, Supplement 2, December 1, 2009

11 AIDS Thai.org: www. aidsthai.org 12 The National Plan for Strategic and Integrated HIV and AIDS Prevention and Alleviation 2007-201. Thailand.

7 The vibrant and well established NGO community working in HIV/AIDS prevention and care is represented in the Philippine National AIDS Council and engages proactively in various national and local processes in the HIV response. They participated in the crafting of the 4th AIDS Medium Term Plan (2006-2010) and the subsequent two-year operational plan, the development of national monitoring and evaluation targets and indicators and the formation of Local AIDS Councils and actively follow implementation.

The process of facilitating civil society participation in the national AIDS response in India has not been without hurdles but much progress has been made during the last ten years. There is now involvement of NGOs at the policy making level through regular interaction and adequate representation at the National AIDS Council, chaired by the Prime Minister. National AIDS Control Organization (NACO) has a dedicated funding allocation for the involvement of NGOs in the National AIDS Control Plan and delegated responsibility to the State AIDS Cells (SAC) for the allocation, management and monitoring of funds to NGOs. 13

International NGOs have for some time had a strong presence in Cambodia and more recently the number of national NGOs has grown rapidly, particularly in the field of HIV/AIDS. By 2008, NCHADS had a total of some 85 NGO partners, most of them donor funded. The Cambodian Government has demonstrated willingness to engage with CBOs and NGOs as shown by the establishment of a National Multi-sectoral Orphans and Vulnerable Children Task Force comprising of key government and non-government organizations. But the daunting challenge faced by civil society in Cambodia is limited capacity and lack of coordination. Competition among NGOs and inadequate trust between NGOs and state agencies are problematic, complicating implementation and operation14.

The Chinese government has, in recent times, clearly recognized that civil society plays an essential role in HIV prevention and care and with Global Fund grants strengthened the sector. The principle of ‘whole society participation’ in responding to HIV/AIDS is articulated in China’s National Action Plan. The central government has increased its funding allocation for ‘social mobilization’, has set up mechanisms to strengthen communication and for the provision of technical support and developed NGO financial management tool.15 But in general, NGOs continue to remain marginalized and in many cases operate without legal registration. The current law on social organization registration in China, issued in the late 1990s continues to be a major constraint. There are reports that the government is reconsidering a revision of this law.

The civil society sector in Vietnam is dominated by “mass organizations” such as the Vietnam Women’s Union. International NGOs such as PACT, Family Health International also have a strong presence in Vietnam. Despite the restrictions related to registrations, community groups exist in rural areas providing services to vulnerable groups. Many self-help groups for people living with HIV/AIDS have emerged in recent years, these and the NGOs have formed national networks signifying the close cooperation amongst civil society. However, there is still a long way to go in Vietnam for a strategic

13 Guidelines on Financial & Procurement Systems for NGOs/CBOs. NACO. 2007 14 "Cambodia," Fighting a Rising Tide: The Response to AIDS in East Asia; (eds. Tadashi Yamamoto and Satoko Itoh). Tokyo: Japan Center for International Exchange, 2006, pp. 53-75

15 Proposal submitted for Rolling Continuation. www.thegobalfund.org

8 government approach with financial support to better coordinate and sustain the major contributions of self help groups and NGOS. In Indonesia, civil society organizations in Bali, East Java, Jakarta and Papua are involved in drafting provincial regulations that will determine budgeting for the AIDS response as well as presentingas experts in the parliamentary hearings16.

As the epidemic emerged in countries with little tradition of civil society as in Myanmar Mongolia, Timor Leste, support of international NGOs, FHI and the UN agencies has helped to facilitate the practice of community participation and changed attitudes toward vulnerable populations. For example in Mongolia, with initial support from the International HIV/AIDS Alliance (IHAA) and UNDP, the National AIDS Foundation (NAF) has become the leading national NGO on HIV and AIDS with a focus on prevention among MARPs17. In Timor-Leste, UNICEF continues to partner with the Government and NGOs to help mobilize the civil society into development efforts for children and to implement school-based programmes18.

Bangladesh has a wide range of NGOs contributing to the response to HIV but only a few are organized sufficiently to be able to influence policy and programs. Lack of policy frameworks on engagement of civil society organizations as well as weak institutional mechanism and low technical capacity remain a challenge in these countries. Work of both local and international NGOs in the area of HIV prevention in Sri Lanka has been limited. NGO work remains largely uncoordinated. Efforts are being undertaken to improve NGO collaboration and coordination with the government19.

1.3 Service delivery and community outreach Civil society remains at the forefront of HIV service provision, particularly among the most vulnerable and hard-to-reach populations such as sex workers, people who use drugs or men who have sex with men, and in places where behaviors that put people at high risk for HIV are criminalized. Civil society pioneered counseling and home-based care for the sick and have significantly augmented HIV services provided by the State20.

Several projects in Thailand demonstrate strong partnership between the public health sector and NGOs in service delivery. The ingredients for success in the pediatric treatment care and support project in Chiang Rai, for ensuring children survived HIV into adolescence and adulthood included the collaboration between the health sector and caregivers through the greater involvement of people living with AIDS. It resulted in a 95% treatment adherence and healthier children living with HIV21. The Positive Partnership Program, a micro-credit, community education and support network in Bangkok, Thailand, organized by the Population and Community Development Association (PDA), is one of few programs that have been successful in improving many different aspects of an HIV/AIDS affected individual’s life in Thailand’s villages through providing a pathway to financial security and through community mobilization 22.

16 The essential role of civil society. UNAIDS 2009 17 The HIV/AIDS Alliance case studies. www.theaidsallaince.org

18 COARS 2009 – EAPRO HIV & AIDS

19 HIV/AIDS in Sri Lanka. WB 2008

20 REDEFINING AIDS IN ASIA:Crafting an Effective Response Report of the Commission on AIDS in Asia.2008

21 Validated Good Practices and Lessons Learned (2009 EAPRO Regional Analysis Report: Children and HIV/AIDS 22 REDEFINING AIDS IN ASIA:Crafting an Effective Response Report of the Commission on AIDS in Asia.2008. p.57

9 UNICEF worked with partners in China to ensure that the national “Four Frees and One Care” AIDS policy was effectively implemented by a grassroots-level government/community structure through small grants, vocational/animal husbandry trainings, health trainings and other assistance to families with children and women living with HIV. A community-based care program supported by a network of women living with AIDS decreased loss to follow-up from more than 80% to less than 10% in the pilot areas. In addition, women’s groups providing referral services for testing and prevention of MTCT, drug adherence counseling and monitoring support raised the early antiretroviral (ARV) treatment rate from 30% to 60%, and drug adherence levels from 60% to 95% among women participating in the program.23 In Vietnam, a number of community-based interventions on prevention and response to the needs of child victims of trafficking and sexual exploitation, street children, abused children and children affected by HIV/AIDS were implemented at central and local levels together with mass organizations in partnership with UNICEF, Plan, Save the Children and Child Fund. 24. Through the implementation of the Continuum-of-Care (CoC) approach in 2003, Cambodia integrated the response into a decentralized public health care system with strong referral networks, and involving community-based organizations and people living with HIV (PLWH). Strong NGO/PLWH involvement provided psychosocial support, help reduce stigma and discrimination, and give valuable feedback to public health officials contributed to the effectiveness of this approach 25

Spiritia, a national support network in Indonesia formed in 1995, assists 65 groups of people living with HIV throughout the country by providing treatment education, basic fact sheets and training in advocacy. Members of the Spiritia team regularly visit most of Indonesia’s 35 provinces, documenting treatment, care and support and encouraging local government to improve services.

In Myanmar, UNDP, UNICEF and Save the Children support community outreach program focused on prevention among most at risk young people. Likewise in Bangladesh, Save the Children, in collaboration with the Government and other implementing partners, is targeting HIV prevention among those considered most at risk with an emphasis on vulnerable young people26. Action Aid works in collaboration with local NGOs, attempting to empower PLWHA and providing assistance to NGOs working with PLWHA in Sri Lanka27. The HIV/Alliance in India implements a Global Fund supported project together with several NGO partners and government to provide care and support to CABA living in four of the most affected states in India28.

2. Role of Faith Based Organisations Churches and other faith-based organizations, especially in developing countries, were among the first to deliver treatment, care and support to people living with HIV and dying of AIDS, and to address the needs of orphaned children. Worldwide, WHO estimates that one in five organizations engaged in AIDS programming is faith-based29.

23 COARS 2009 – EAPRO HIV & AIDS 24 Ibid

25 ibid

26 www.theglobalfund.org

27HIV / AIDS in Sri Lanka A Profile on Policy and Practice. Centre for Policy Initiatives. 2007

28 Chaha ProgrammeAnnual Report 2008 – 2009.The HIV/AIDSAlliance India.2009

29 09 Role of Civil Society . UNAIDS 2009

10 World Vision, a Christian relief and development organization dedicated to helping children and their communities worldwide is very active in the region. World Vision’s HIV and AIDS Hope Initiative is a child-focused response and emphasizes partnerships, particularly with churches and other faith communities and is being implemented in Cambodia, Laos and India. In Myanmar, World Vision has commenced a new three-year project to combat HIV/AIDS, funded by the 3 Disease Fund, which will benefit communities living mainly in border areas with Thailand and China. In Cambodia, WV implements a comprehensive HBC program and delivers packages of social protection and health benefits to adults living with HIV and vulnerable children, mostly children affected by AIDS. In Bangladesh, World Vision's six HIV and AIDS prevention projects in the country target MARPS 30.

Working in 18 countries in Asia, one of the project Caritas Internationalis supports is the Mai Tam Centre, based in Ho Chi Minh, City, Vietnam, which works to improve the quality of life of orphans and vulnerable children living with HIV/AIDS and promote independent living and community integration of families living with HIV/AIDS31.

In Papua New Guinea, HIV & AIDS is a priority issue for the Church Partnership Programme, which is collaboration between seven Christian denominations and AusAID. One of the Program’s key areas of action is to develop the Churches’ governance structures, quality of Church leadership, and ethical management in order to enable the Churches to engage with the government on issues of public policy and practice. The church-based organizations in 13 districts in Timor Leste have started implementing young people’s education and prevention program on HIV/AIDS including establishment of information and communication centers for adolescent. Christian churches, Muslim and Hindu leaders, in Myanmar, in collaboration with local and international NGOs, provide protection, care and support services to over 15,000 orphans and vulnerable children including children affected by HIV and AIDS and their families received and FBOs during 200732.

In Cambodia, top leaders of Buddhist, Islamic, and Christian communities were assisted by Religions for Peace to found the Cambodian Inter-Religious Council which works together in national committees at all levels to respond to HIV. Cambodia has adopted the National Policy on the Religious Response to HIV & AIDS, to ensure that the religious sector fulfils its role in the response to HIV & AIDS through community mobilization. A substantial number of monks, lay Buddhist leaders and nuns in the region have been sensitized to HIV & AIDS and trained and provide out reach service (see box 33)

30 changing facesTrends in HIV and AIDS in Asia and opportunities to reverse them.World Vision Asia-Pacifi c, 2007 31 Scaling Up Effective Partnerships: A guide to working with faith-based organizations in the response to HIV and AIDS. Church World Service, Ecumenical Advocacy Alliance, Norwegian Church Aid, UNAIDS and World Conference of Religions for Peace. 2006

32Background paper on FBO response in East Asia and the Pacific. UNICEF.EAPRO.2008 33 Regional ReviewBuddhist LeadershipInitiative UNICEF EAPRO.July 2009

11 Box 3: The Buddhist response to HIV/AIDS in the region The Sangha Metta Project is one of the earliest responses in the region which engages monks to provide HIV/AIDS education to young people, support for PLWAs and their families and CABA. The project, which also provides income generation opportunities, is now in other regions of Thailand, as well as in neighboring countries such as Laos, Myanmar, Cambodia, Southern China, Vietnam and even Mongolia and Bhutan. Based on lessons learnt from the Sangha Metta Project in Thailand, UNICEF in 1998 initiated the Buddhist Leadership Initiative, which is a regional strategy to build Buddhist involvement in the response to HIV. It currently operates in Cambodia, Lao PDR, Mongolia, Myanmar, Viet Nam and Yunnan province in China increasing access to care and improved community acceptance of PLWHA. The Buddhist Leadership Project has served as an example for Muslim and Christian communities. In China, for example the success of the BLI in Yunnan was documented and influenced the development of a Muslim AIDS initiative in Ningxia Province in northern China.

The UNICEF survey in 2003 in countries in South Asia indicated that, there have been few systematic, concerted efforts to engage faith-based organizations for prevention, care and support. Many FBOs, especially those of the Christian faith, have initiated programs or activities voluntarily, and primarily from a tradition of welfare and charitable services to the poor and needy. A number of them are taking actions to work concertedly with other Christian organizations as the need for a unified response to AIDS becomes more apparent with a more developmental approach rather than charity-based. The National Council of Churches of India is a good example, which has made the call for a joint response at the Ecumenical Church Leaders Conference on HIV/AIDS in 2003, and set up a coordinating desk called “National Christian Council for Combating HIV/AIDS” 34.

The exceptions are countries where state-sanctioned religions give faith-based organizations a natural place in their national response to HIV/AIDS. The Imam Training Academy, set up by the Islamic Foundation of Bangladesh, a constitutional body of the Ministry of Religious Affairs, for instance, has introduced reproductive health and HIV/AIDS-related topics in its training curriculum for Imams. In Bhutan, HIV/AIDS training and advocacy is now a part of the Bhutan government’s national Religion and Health Program, which began in 1989. The Supreme Council of Islamic Affairs in the Maldives also supports national HIV/AIDS programs undertaken by the Department of Public Health35.

In recent years, there has been progress made in mobilizing the commitment of religious leaders in South Asia. Regional Inter-Faith Conference in Kathmandu in 2007 and a consultation in Bangkok in 2008, both organized by UNICEF, saw religious groups confirming a commitment to a comprehensive response to HIV and AIDS36. At the Asian International Interfaith Conference on HIV/AIDS in August 2007, delegates called on the religious leaders to use their places of worship, and educational and health facilities to help in the fight against HIV and AIDS. The Asian Interfaith Network on AIDS, along with

34 Faith-Motivated Actions on HIV/AIDSPrevention And Care For Children And Young People In South Asia: A Regional Overview. UNICEF

ROSA.203 35 Ibid 36 Report.East Asia and Pacific RegionCHILDREN and HIV & AIDS. UNICEF EAPRO.2008

12 HIV/AIDS groups in faith communities committed to the development of "tools to train the leadership." At the first meeting of “Faith in Action: Hindu Leaders Caucus on HIV/AIDS”, in June 2008 over 70 prominent faith leaders from across India signed a joint declaration committing the religious leaders to working with UNAIDS and the National AIDS Control Program (NACP) to increase HIV awareness among young people and to end stigma and discrimination against people living with HIV. 37

During a Summit of High Level Religious Leaders on the Response to HIV in March, 2010 religious leaders from Baha’í, Buddhist, Christian, Hindu, Jewish, Muslim and Sikh faiths explored opportunities for religious leaders to promote universal access to HIV prevention, treatment, care and support in their communities and speak out against stigma and discrimination affecting people living with HIV and signed a pledge to commit themselves to strengthened efforts to respond to HIV38.

Many religious communities, however, have found HIV-related issues challenging, particularly HIV prevention, as it touches on sensitive areas such as morality and religious standards for ‘holy living’. In an evaluation of faith based interventions in South Asia, UNICEF found that religious leaders were often conservative, dogmatic and themselves sources that perpetuated stigma and discrimination39. There have also been polarized public debates over issues such as condom promotion, which have exacerbated tensions and prejudices.

FBOs like other community based organization and NGOs are also constrained by limited technical capacity & skills and access to sustained financial resources.

However, there is enough evidence shows that many FBOs run high-quality HIV programs and have increased community mobilization and access to HIV prevention and treatment, including prevention of mother-to-child transmission. They have contributed to improving the quality of life for people living with HIV; increase the level of support for women and orphans and other vulnerable children.40 Partnerships with FBOs, based on respect for their faith as being fundamental to their values and activities, will assist in integrating the activities of FBOs into national AIDS programs and strategies, thus strengthening the national AIDS response.

3. The role of the private sector There has been growing recognition by political leaders of the private sectors’ potential role in HIV/AIDS prevention and that HIV/AIDS is a key workplace issue. At the Asia Pacific Economic Commission (APEC) meeting in 2005, the participants noted that, ‘as the private sector was the largest employer in the region, it had the greatest potential to contribute to the well-being of the people living with HIV/AIDS by providing them with the opportunity to live with dignity as a productive working member of society’41. During the International Labour Conference in 2009, the Indian Labour Minister’s proposed to establish a SAARC Forum on HIV and AIDS and the World of Work. 42. 37 www.unaids.org 38 Ibid 39 Faith-Motivated Actions on HIV/AIDSPrevention And Care For Children And Young People In South Asia: A Regional Overview. UNICEF ROSA.203 40 Partnership with Faith-based Organizations UNAIDS Strategic Framework. UNAIDS. Dec.2009 41 www.apec.org./apec/ministerial_statement

42 www.ilo.org

13 The private sectors’ financial contribution has also been increasing during more recently. In 2003, the private sector contribution was barely one percent of overall support. In 2007, the Global Fund raised $80 million from the private sector which is 5% of overall support, which increased to 6.6 percent of all contributions in 2008. This includes the annual $100 million contribution from Gates Foundation. Six per cent of Global Fund financing is being already channeled to private sector recipients. Considering the financial potential of the private sector, efforts are underway to further increase their contribution.

3.1 Workplace interventions Workplace programmes are the most common private sector HIV projects. The Ok Tedi Mine Limited (OTML), in Papua New Guinea, a major producer of copper concentrate for the world smelting market, adopted its HIV and AIDS Charter in 2006 and implemented a comprehensive HIV and AIDS response. 43

Several companies in India have implemented HIV/AIDS programs for their workforce. As early as 1994 the Tata top leadership demonstrated commitment by establishing a Core Group on AIDS, adopted a practice of non- discrimination between HIV infected employees and other employees and implemented a comprehensive HIV/AIDS prevention, treatment and care programme for its employees and families. Educational support is offered to children affected by AIDS. Reliance Industries Limited, India’s largest private company, set up a well-equipped medical center near its industrial site in Hazira, Gujarat, where it provides both tuberculosis and AIDS treatment. Several others among them, the Transport Corporation of India (TCI, DCM Shriram Consolidated Limited (DSCL Hindustan Lever Limited (HLL) with millions of employees have implemented similar comprehensive programme not only for their employees but also for families and children affected by AIDS,44

International partners have also contributed towards establishing workplace programmes in some countries in East Asia. The US Academy for Education Development has supported the implementation of SMARTWork, a customized workplace HIV/AIDS intervention for each community in Vietnam. The HIV Smart Hotels campaign creates opportunities for leading hotels to show the industry and consumers that being a HIV Smart Hotel is good for business has been implemented in Thailand, PNG and in Cambodia45.

In Indonesia, FHI worked with NGO partners to assist 110 companies with 550,000 workers to establish HIV prevention programs. Colgate-Palmolive provided training and technical assistance to Colgate managers for establishment of HIV/AIDS workplace policy in its branches throughout Asia, including those in China, Thailand, India, and Nepal /AIDS prevention programs, the majority of which are supported by the companies themselves. Shell Philippines decided to implement an HIV/AIDS policy after an assessment was made of the costs related to prevention.

43 www.apbca.org 44 Corporate Responses to HIV/AIDS Case Studies from India. 2007. The International Bank for Reconstruction and Development/The World Bank 45 www.fhi.org

14 3.2 Service delivery through Private Sector Partnerships The commercial mass media provides an effective forum for the national policy dialogue necessary to reform societal norms to combat HIV as evidenced in Thailand in the early years of the epidemic. So too in many other countries in the region, as in Bangladesh, the private television channels played a role in mobilizing resources, co-investment, and developing effective strategies for the nationwide media campaigns, while private mobile phone companies provided information through text message quiz competitions and downloaded ring tones with HIV messages. The international media company McCann Healthcare and the local media companies contributed in-kind and financial resources to ensure a well integrated communication campaign to support the workplace program among the Geiju mining population in China. A company-funded drop-in centre run in partnership with a local nongovernmental organization provided resources on HIV, family planning, and drug dependence.46

A number of countries in the region have established partnerships focusing on supporting children affected by AIDS (CABA). In Nepal, the Universal Access for Children Affected by AIDS (UCAAN) launched in November 2007 by UNICEF, National Association of People Living with HIV/AIDS Nepal, FHI, and USAID Nepal, is a public private partnership with nine core partners, one of them being the private sector. In the meanwhile 16 private sector agencies have pledged cash and in-kind support47. In China, Coca-Cola China has in partnership with the Yunnan Provincial Women and Children Development Center initiated an AIDS Orphan Care program, which provides support and care to AIDS-impacted orphans from 75 villages across the region48 In the Asian region, UNICEF works closely with the Clinton Foundation in Cambodia, China, PNG and Vietnam to scale up pediatric AIDS treatment. In Papua New Guinea, UNICEF’s collaboration with WHO and Clinton Foundation has brought improvement in comprehensive HIV services for women and children, including ANC, HIV counseling and a child-friendly clinic in three provinces aiming at reaching over 10,000 pregnant women and 5,000 children each year.

The Global Fund, through its concept of co-investment, brought about partnerships between government, civil society and private sector. In the GF supported PMTCT program in India, the Confederation of Indian Industry worked with businesses to assist them in providing long-term ART, care and support services to communities in their area of operation. The businesses provided the space, infrastructure and human resources, whereas government health services provided training and ARV drugs.

3.3 Service delivery through partnership with pharmaceutical companies Pharmaceutical companies have not only provided support for laboratory strengthening in a number of countries in the region but have also partnered with the local government and/or with NGOs in service provision. Merck & Co., Inc. committed USD 30 million over five years in 2005, the largest public-private HIV/AIDS partnership in China, for a comprehensive program which included setting up testing and counseling centres and PMTCT facilities in collaboration with local governments. Likewise in 2005, Merck’s local subsidiary has joined forces with the Malaysian AIDS Council and the Malaysian

46 HIV-related Public-Private Partnershipsand Health Systems Strengthening. UNAIDS 2009

47 The Universal Access for Children Affected by AIDS (UCAAN). Presentation at 9th International Congress on AIDS in Asia and the Pacific

48 www.businessfightsaids.org

15 Society of HIV Medicine to spearhead the "It Begins With You" program to draw urgent attention to the pressing issue of HIV and AIDS among university students in Malaysia49.

The Abbott Fund, the philanthropic foundation of the global health care company Abbott, through it’s Partnership with the Indian NGO MAMTA and with the HIV/AIDS Alliance India, supported programs in HIV prevention among adolescents, community capacity development for PMTCT and for provision of care and support for CABA. Abbott and Abbott Fund have provided grants and products to support the work of the Angkor Hospital for Children, a pediatric teaching hospital providing free comprehensive care for more than 180,000 children in Siem Reap and neighboring provinces. In Papua New Guinea, a group of pharmaceutical companies set up the Collaboration for Health Papua (CHPNG) in 2003 to improve the quality and availability of HIV diagnosis, care and treatment within PNG's health system. The Life Skills Foundation, with support from Johnson & Johnson in 2006, provided life skills education, training and promotion for children and their families affected by HIV/AIDS in seven sub-districts of Upper Northern Thailand. In China, Johnson & Johnson, supports the Fuyang AIDS Orphan Salvation Association (AOS), which addresses the needs of more than 400 children affected by HIV/AIDS in An Hui Province in eastern China.

TREAT Asia, which is a cooperative network of clinics, hospitals, and research institutions working together with civil society, initiated among other projects, a mentoring program for community activists and advocates in the region with funding from GlaxoSmithKline's Positive Action. This three-year intensive program provided a training ground for building skills, broadening knowledge, and expanding capacity through increased interaction with medical professionals, government officials, and the international community. To help improve treatment for children in Asia, TREAT Asia has launched a new pediatrics initiative and have established a pediatric HIV observational database. 50.

3.4 Policies and accreditation for minimum standards for the private sector Several countries have developed corporate policies for HIV management based on the ILO Code of Practice on HIV/AIDS and the World of Work51. Thai Business Coalition on AIDS (TBCA) together with the Ministry of Labour developed a national quality certification tool for the private sector known as the AIDS-response Standard Organization (ASO), with minimum standards for HIV workplace programs called the AIDS Response Standard Organization. This tool which has been endorsed by Ministry of Public Health is based on the ILO Code of Practice and the Thai National Code of Practice. To date 4,111 companies have achieved ASO certification. ASO certification procedures require that companies give back to the community, in forms such as donations, visits to provide emotional support for people in AIDS hospices, support for orphanages, allowing staff time to provide education to the surrounding community, hiring of HIV positive employees, skills training for persons affected by AIDS, and in-kind donations of used or second hand products to raise funds for the community52.

49 Merck &Co.Inc. HIV/AIDS Program in Asia-Pacific. www.ifpma.org 50 www.amfar.org/world/treatasia 51 www.ilo.com 52

16 The Government of India stresses in its National AIDS Policy that the organized and unorganized industrial sector needs to be mobilized for taking care of the health of the productive sections of their workforce. Several companies in India have developed Corporate Group Policies and Company level Policies, based on the guidelines of the ILO Code of Practice on HIV/AIDS and the World of Work. 53

In China, in response to a call by the Chinese Vice Premier in 2006 to Chinese businesses to get involved in the fight against HIV/AIDS, Global Business Coalition on HIV/AIDS in China (GBC China) has designed and executed a company HIV/AIDS workplace policy 54. UNICEF, together with (GBC China), UNAIDS and the CNCCC, jointly launched a set of eight recommended responses for companies seeking to address the HIV/AIDS and children issue in China55.

In Indonesia, HIV prevention was, in 2004, integrated into existing national mandatory occupational health and safety programs. As a result, the Ministry of Manpower, working with the ILO, FHI, and local NGOs, trained labor inspectors to facilitate and monitor prevention programs in 9,000 companies, covering an estimated 4–5 million workers in five priority provinces.56

3.5 Role of Trade Unions and Chambers of Commerce in promoting private sector engagement Trade Unions, the representative organizations of employers and workers have been playing a role in some countries in the region. In India, the Central Trade Unions in 2007 launched a joint statement of commitment to join forces to enhance interventions on prevention and management of HIV at the workplace and to build up welfare schemes and income-generating activities across the board. This complements a similar statement made by the seven national employers' federations in 2005.

The Confederation of Indian Industry (CII), a non-government, not-for-profit, industry led and industry managed organization has developed a "Standardization of the CII HIV/AIDS workplace program." and established the Indian Business Trust for HIV/AIDS (IBT). Their HIV/AIDS Policy for Industry includes advocacy, design and development of workplace programs, capacity building and partnerships.

Twenty- two trade union representatives in Sri Lanka signed, in 2008, the Trade Union Joint Policy on HIV/AIDS at the Ministry of Labour. Developed within the framework of the National Policy on HIV/AIDS and based on the ILO Code of Practice on HIV/AIDS and the world of work, this policy aims to strengthen trade union interventions in HIV prevention and impact management. A Task Force monitors compliance of the implementation of this Policy.

53 A Compendium of HIV/AIDS Workplace Policies of Partner Enterprises & other Social Partners in India.ILO. Subregional Office for South Asia, New Delhi 54 China: Business & AIDS in China: strategic Planning exercise with GBC and Booz Allen Business, civil society and government participated. GBC support will continue and GBC will act as liason between gov and bus. Source: Booz Allen Hamilton.30 March 2006, Beijing, China

55 COARs 2009 56 "Indonesia," Fighting a Rising Tide: The Response to AIDS in East Asia; (eds. Tadashi Yamamoto and Satoko Itoh). Tokyo: Japan Center for International Exchange, 2006, pp. 96-118.

17 Under the leadership of the Vietnam Chamber of Commerce and Industry (VCCI), the business sector is a committed tripartite partner which maintains a cadre of 25 master trainers to provide HIV/AIDS focused management training to numerous partner enterprises. The Confederation of Trade Unions in Vietnam, a highly respected agency by both government and business whose primary role is to protect workers, has maintained a strong buy-in on the project, exerting influence on the government and employers to support the SMARTWork program and address HIV/AIDS in the workplace

4. Coordination, networking and technical support for NSPs A number of regional networks and coordinating structures exist in the region to provide support to national networks and organizations. Support to FBOS in the region is assured through the Asia Interfaith Network on HIV & AIDS (AINA) and through the Asian Muslim Action Network (AMAN) working across countries in the region and brings together FBOs from different faiths working on HIV & AIDS.

The Asia Pacific Network of People Living with HIV/AIDS (APN+), was established in response to the need for a collective voice for PLWHA in the region, to better link regional PLHIV with the Global Network of PLHIV (GNP+) and with positive networks throughout the world, and to support regional responses to widespread stigma and discrimination and better access to treatment and care. The APN+ and the Asia Pacific Council of AIDS Service Organizations (APCASO) which is a network of non- government and community-based organizations, together with five other regional networks have in turn joined forces to form the Coalition of Asia Pacific Regional Network on HIV/AIDS (the Seven Sisters). These networks contribute to strengthening the community based response to HIV/AIDS within the Asia-Pacific region, and to interact with a diverse range of organizations and share information on many issues. The Coalition of Asia-Pacific Regional HIV/AIDS Networks (The Seven Sisters) developed tools such as the toolkit for carrying out such an evaluation in relation to Universal Access processes, known as ‘The Minimum Standards of Participation of Civil Society in Universal Access’.57

In recognition of the need for institutional development and skills building, a number of mechanisms have been established at both international and regional levels. Technical Support Facilities (TSFs) have been set up by UNAIDS to improve country and regional access to timely, high quality, short term technical assistance for scaling up AIDS responses. There two TSFs located in the region providing support not only to governments but also to civil society. Focusing only on TS provision to Civil Society are the 7 Regional Technical Hubs set up by the international HIV/AIDS Alliance and the Civil Society Action Team (CSAT). CSAT brokers technical support to civil society organizations and coordinates advocacy for this support at local, national and regional levels and has decentralized by setting up six Civil Society Action Teams (CSAT) one in each region.

5. The role of coalitions and networks in promoting NSP engagement Global partnerships such as the Global Business Coalition on HIV/AIDS, Tuberculosis and Malaria (GBC) have become an essential part of the response. In 2008, a GBC led pledge was signed, committing 111 multinational businesses signatories to end HIV discrimination and stigma in the workplace. More recently, in March 2010, GBC met with

57 www.apcaso.org

18 UNAIDS to explore how the privates sector could contribute to achieve virtual elimination of mother-to-child transmission58. The Global Health Initiative of the World Economic Forum (WEF) provides tools and guidelines to help businesses in setting up their HIV/AIDS prevention and care programs.

Business coalitions have also been created at the regional and national levels, several of them with the assistance of the ILO or ILO constituents. The Asia Pacific Business Coalition on AIDS (APBCA) and the Asian Business Coalition on AIDS (ABCA) supports the establishment and coordination of country-level business coalitions throughout the Asia Pacific region and promotes coordinated and standardized HIV workplace programs, resources and services to active country business coalitions in the region and shares lessons learnt and innovations across the member network.59. They came together with UNAIDS in 2009 to discuss key issues around the activities and services offered by BCAs in the region, the challenges and opportunities they face as well as key partnerships and relationships developed with national and international stakeholders.

In most countries in Asia Pacific, Business Coalitions now exist but are in different stages of development. The Thai Business Coalition on AIDS (TBCA), established in 1993, is the first business coalition of its kind in the world. It has a membership of several hundred businesses and pursues a strategy that emphasizes HIV/AIDS as a management issue, to be managed just as any other business issue, without discrimination. In addition, TBCA brings in corporate resources, such as human capital, management skills and funds, to assist in HIV/AIDS prevention. The Indonesian Business Coalition (IBCA) approach is to bring employers, unions and government together to develop and implement comprehensive workplace HIV/AIDS programs at the level of enterprises, trade unions, national and provincial governments and employers. Working within the framework of the Sri Lankan government's National Strategic Plan for Prevention of HIV and AIDS, the Sri Lankan Business Coalition on AIDS (SLBCH) aims to engage fellow NGO's and partners to ensure member organizations have an HIV and AIDS Workplace Policy in place and provides on going tailored HIV and AIDS awareness training to members

6. Challenges faced by NSPs Participation in national bodies and processes Though, NSPs are now almost routinely included in national coordinating bodies and/or mechanisms, the 2008 UNGASS report data indicated that South and South East Asia scored consistently lower than the overall average in their representation in national planning processes. None of the countries in the region rated access to financial or technical resources as ‘‘good/very good’’60. Private sector participation in NACs and in CCMs is still limited. Even in countries where private sector is represented on NACs and CCMs, their active engagement is nominal. This means that their involvement in the national planning process is limited and hence little opportunity to influence policy development.

Restrictive policies and legal frameworks

58 www.unaids.org

59 www.apbca.com 60 Peersman G. et al. Increasing Civil Society Participation in the National HIV Response: The Role of UNGASS Reporting. Acquired Immune Deficiency Syndrome Volume 52, Supplement 2, December 1, 2009

19 An enabling environment through positive policy frameworks on engagement of civil society organizations remain a challenge. Policies and legal status in some countries restrict particularly small local NGOs and community-based organizations from functioning effectively: - The Cambodian government, expressing concerns about global terrorism, announced plans to pass a new law to govern its 2,200 NGOs and associations. National and international organizations have released a statement raising concerns about the lack of transparency and consultation in the process of drafting the law. - For groups to register in China, they must find a government agency sponsor before they can register with the Ministry of Civil Affairs, which is not always feasible. - In order to register in Vietnam, NGOs must meet a minimum standard for size of membership and must be government-approved or associated with one of the state- controlled mass organizations. In addition, the government has the power to dissolve NGOs in various circumstances. Since both drug use and sex work are considered “social evils”, organizations of sex workers and drug users are also illegal and organizations working with them can have problems. On the other hand, Laos has announced it will permit NGO registration for the first time in 2009.

Minimum standards for service provision Some multilateral institutions have made moves towards the concept of “minimum standards”. For example, a recommendation for the Asian Development Bank in their ADB-Government-NGO Cooperation: A Framework for Action (2003-5) was that participation by NGOs in ADB processes could be institutionalized and codified by formalizing guidelines, including minimum standards for participation ADB has developed policies on working with NGOs and a staff handbook for doing consultation and participation.

Currently few countries have established accreditation processes to ensure minimum standards for service delivery by NSPs and to ensure accountability to the communities they serve. The exception in the region appears to be the Thai Business Coalition on AIDS (TBCA), which together with the Ministry of Labour developed a national quality certification tool for the private sector known as the AIDS-Response Standard Organization (ASO), which has been endorsed by Ministry of Public Health. NACO in India, developed Guidelines on Financial & Procurement Systems for NGOs/CBOs but this only lays out the internal methods and procedures to be used by Grantees of State AIDS Control Society.

20 Technical support for institutional capacity and skills development In almost all countries, weak, limited organizational capacity in programmatic and financial management and low technical skills of community actors constrain community response and coordination at local level. The Global Fund Five Year evaluation found that in general, NGOs along with some non-health ministries are severely disadvantaged in accessing technical assistance (TA), both short term for skills building workshops, guidance for strategy development, development of M&E workplans and capacity building, etc as well as long term access to advisors for establishment of financial and management systems and capacity building. The NGOs reported that often they don’t have either the knowledge or the financial support to facilitate access to TA.61

Several recent reviews and analysis62 came to the conclusion that, though there are several channels and mechanisms for technical support at both regional and international levels, there is still no well-developed overall partnership strategy defining the roles and responsibilities of partners in identifying technical assistance needs and providing technical support. Current provision of technical support is mainly supply driven and short-term with little quality assurance. The major challenges in the provision and in the availability of TA were lack of coordination, insufficient planning, no adequate needs assessment and lack of oversight and quality management of short term TA provision. All this is compounded by the lack of ability of country players to call in technical assistance or even unwillingness to include TA in GFATM proposals with dedicated budgets.

Access to financial support Funding policies can constrain the flow of support to NSPs. Direct bilateral funding to civil society organizations get reduced when countries adopt SWaPs and/or pooled funding policies as is the case in Bangladesh where DfID, a funder of the CARE Bangladesh project, stopped funding non-governmental groups when it transferred its contribution to the national Government by means of a Sector-Wide Approach’ grant recommended by the World Bank. Till recently, USAID funding policies also limited access to funds for groups working with sex workers and IDUs.

61 Evaluation of the Global fund Partner Environment at Global and Country level, in relation to Grant Performance and Health Systems Effect, including 16 country studies. Final Report. June 25, 2008 62 Peter Godwin and Sujaya Misra. Lessons learned from four external assessments of the TSFs: a consolidation. Draft Report.UNAIDS. June 2008; Review of ongoing and recentlycompleted evaluations and studies of technical support to AIDS programme implementation. GIST. 2008

21 Although some countries have increased financing from public domestic source and have policies for funding civil society as in India and Thailand, NSPs in most other countries rely heavily on external sources such as the Global Fund, PEPFAR, and international NGOs. This raises the question of sustainability of important community-based service delivery particularly of treatment and care interventions and whether low-income countries can rely indefinitely on international aid to pay for treatment programs. One of the issues is multi-year planning, since many donors pledge only for a limited time-span (i.e. 2-3 years). This makes it very difficult to anticipate donor support beyond this timeframe for example in Cambodia very few donors have pledged funding beyond 201263.

Challenges faced by the private sector A UNAIDS analysis of partnership with the private sector64 indicated that the greatest number of projects can be found in the area of service delivery due to a business interest of improving the health of employees through more and better services.

The private sector at times lacks profound knowledge of the complex stakeholder landscape in the HIV response and health care provision. Particularly small businesses lack the resources and the know-how to access resources or form partnerships. Large private firms contemplating public/private partnerships with an expanded outreach could consider working with labor unions that cover both the public and private sectors

The Global Fund in an attempt to promote private sector participation in the countries held a number of regional meetings on the private involvement in GFATM structures and processes. The participants at the Global Fund South Asia meeting in 200765 highlighted some challenges related to effective public-private partnership. Most CCMs in the region do not have work plans to mobilize the private sector and the CCM representatives may lack capacity for sensitizing interested parties/organizations to participate in the CCM.

The Confederation of Indian Industries (CII) pointed out that India has a very large but unorganized private sector but that there is no plan of action to engage the private sector. The private sector is often not invited to meetings in which it should be participating. CII highlighted the need for a conducive policy environment for effective private sector engagement. Other issues raised during the meeting were related to reconciling the different working styles and pace of the private and public sectors and the limited access to accurate and timely information.

Participants also suggested a change in attitudes of governments and bilateral donors towards the private sector in order to build trust and ownership. The profit motive seems to interfere with trust building. Governments tend to think the private sector is always

63 Information taken from financial gap analysis in GF Rd 9 proposal 64 Regional Overview South and West Asia. Global Fund. 0ct.2008; South and West Asia Cluster Regional Meeting Private Sector Partnerships in the Fight against HIV/AIDS, Tuberculosis and Malaria. GF. 2008 The Role of the Private Sector in West and Central Africa. GF.2009 HIV-related Public-Private Partnerships and Health Systems Strengthening.

65 South and West Asia Cluster Regional Meeting Private Sector Partnerships in the Fight against HIV/AIDS, Tuberculosis and Malaria. GF. 2007

22 hunting profit but as the private sector pointed out those profits that allow companies to contribute.

Most private sector activities responding to HIV are isolated interventions which are monitored at company level without input in the national monitoring system. A partnership framework makes it easier to integrate monitoring according to national procedures. Regulation and oversight are at the heart of effective, high-quality private sector involvement in health care

To develop effective and sustainable partnerships, honest UCAAN: Strategies adopted for and wide ranging dialogue to inform and secure engaging the private sector: agreement in joint planning is essential from the very Engagement - One-to-one meetings with private sector partners earliest stages and participation in/links to national Incentive - Orientation of private sector coordination mechanisms would automatically facilitate partners on their benefits from UCAAN such a dialogue. National NGO and business coalitions partnership could be the brokers and promoters of this dialogue and Clarity - Clearly articulated support in the planning for the public-private partnership. plan Accurate, timely information flow is critical to ensure Partnership - Frequent meeting transparency but also to initiate support dialogue. An between partners for key decision effective information process would also contribute to making developing awareness in the private sector of its Transparency - Open and timely potential role. communication between partners

Part 3: Analysis of financial support to the Non-State Providers for HIV/AIDS prevention and treatment in the region

1. Global Fund’s contribution to promoting and supporting the participation of Non State Partners in HIV/AIDS national responses

1.1 Participation of NSP in Global Fund structures and processes The Global Fund to Fight AIDS, TB and Malaria, set up in 2002, as a global public- private partnership provides additional resources to prevent and treat HIV/AIDS, tuberculosis and malaria. The Fund, with its emphasis on public-private partnerships is the only financing mechanism which has made the participation of civil society criteria for awarding grants. At the country level, the Global Fund relies on the Country Coordinating Mechanisms, which are country-level multi-stakeholder partnerships to develop and submit grant proposals, based on country priority needs, select the Principal Recipient, oversee the grant implementation and process requests for continued funding. 66

The Five year Evaluation of the Global Fund (2007-2009) reported that the Country Coordinating Mechanism model ‘is perceived to be one of the most innovative and positive contributions of the Global Fund, which has provided an opening for participation that was previously non-existent in a number of countries67. The Global Fund's CCM model has already led to a substantial shift in the dynamics between civil

66 The Global Fund, Framework Document. www.theglobafund.org 67 TERG 5 Year Evaluation Study Area 2 Report, 2008

23 society and the government in many countries by increasing the participation of civil society and of PLWAs governance and in HIV/AIDS prevention and care programs.

An analysis of the composition of the CCMs in the EAP region show that on an average the CCMs in the region meet the recommended minimum of 40 % representation of the nongovernment sector, which includes also the private and the academic sector.

Gov: government; ML/BL:Multi/bilateral; NGO: Non-GovernmentOrganisation EDU: Education/academic;FBO: faith-based; Ps: Private Sector; KAP: Kep affected Populations

In the South Asia region, on an average the CCMs have 43 % representation of the non- government sector. Although this breakdown is sound in aggregate, it varies greatly between countries mores than in EAP. 68. In both regions, CCM leadership appears to remain largely in the hands of the government more specifically in the Ministry of Health with only 4 CCMs being chaired by non-government sector representatives and a fifth by a representative from the Private Sector.

68 CCM Information provided by CCM unit, The Global Fund

24 The GF requirements on transparent, participatory selection process have forced countries to establish transparent, participatory constituency processes69. For example CCM Cambodia has appointed a Constituency Coordinator for each of the constituency, who manages the process of nomination, selection and replacement of constituency members. In India, a Sub-committee developed guidelines for the selection of the NSP representatives. The election process was fully out sourced to the Centre for Sustainable Health and Development to minimize bias and was done through an elaborate web based online voting process. China went through a similar participatory election process for the CCM CSO representatives in 2007. 70

Several CCMs have, based on GF requirements, put in place participatory processes to ensure a wider participation of all stakeholders in the proposal development process such as advertisements in the daily newspaper for calls for proposals in Sri Lanka. Cambodia, in addition to newspaper advertisement, the NGO Networks were galvanized to reach out to their members and encourage them to participate in the process. The CCM, in Thailand, through its Technical Committees, issued calls for applications from potential implementing agencies through public channels such as the internet and newspaper advertisements. Participants at the CCS consultations pointed out that the proposal development process for Round 9 provided opportunities for the communities get together and build partnerships.

Challenges to true NSP participation in Global Fund structures and processes Representation does not in all cases equal true participation in the decision making process. The process of decision making has improved with time but both the 5 year evaluation and the CCM case studies report that many CCMs continue to function well below the ideal due to differing perceptions on participation and equality. Not all stakeholders have been exposed to dealing with national level committees and policy forums. The Non-Government participants, particularly Civil Society partners still feel that Government is a dominant constituency and exerts a higher degree of power of decision making. The need to protect working relationship with the government together with weak capacity, lack of a robust mechanism that would facilitate interaction with their constituency are the other barriers that many civil society representatives face71.

The case studies reveal that the country-driven participatory proposal development application process was not always adhered to by all CCMs. Power imbalance and bargaining advantage of governments and also that of INGOs at proposal development stages and resource allocation puts civil society at a disadvantage. Time constraints, limited access to knowledge around availability of funding and entry points, lack of capacity and inadequate funding for consultations with local interest groups are barriers that many civil society representatives face and which impose limitation on this inclusive process. Many community groups are not even aware that the CSS funding stream is available to them72. With the introduction of National Strategy Applications (NSAs) there is concern that the role of civil society will be diluted and possibly undermined73. National AIDS Commissions/Committees are the holders of NAP and these do not necessarily in all countries grant importance to civil society participation.

69 Guidelines on the Purpose, Structure and Composition of Country Coordinating Mechanisms and Requirements for Grant Eligibility.www.theglobalfund.org 70 CCM case studies. The Global Fund. 2009 71 Ibid 72 Community Systems Strengthening Global Consultation. 2009 Thailand. Global Fund, UNAIDS, IPN+

25 1.2 Participation of NSPs in Grant Implementation Since 2008, the GF has broadened the scope for greater civil society participation through the introduction of two major policies. The Community Systems Strengthening (CSS) Policy facilitates funds to reach the community level, provides the opportunity to focus on a broader response and on priority areas such as decriminalization and key populations. The Board’s decision to leverage community and private sector involvement in the GFATM processes prompted new developments for strengthening communities and defining indicators more suitable for CSS, which is work in progress.

The “Dual-Track’ financing” policy, implemented as of Round 8, encourages CCMs to nominate both a government entity and an NGO to be Principal Recipients for a grant. As a result of this policy, around 40 percent of Principal Recipients in Rounds 8 and 9 are from the nongovernment sector, compared to just 23 percent over the previous seven rounds (For more details see Annex: 2 Overview of Global Fund grants in the region )

The Fund has brought about increased partnership between not only non-government and government sectors but also with the academic institutions. In Bangladesh, the CCM ensured increased availability of technical capacity and high levels of transparency for strengthened program implementation through the selection of three PRs with different core competencies: Save the Children (USA) for prevention among MARPs and for expanding HIV prevention education in un-served areas through formal and non formal educational; the International Centre for Diarrheal Disease Research, Bangladesh (ICDDR), contributes to research and programme implementation and the Government PR is responsible for overall policy support, advocacy, linkages with MOH system. In India, the Rd 7 grant is being implemented by the Government, the Nursing Council and the Tata Institute of Social Sciences.

One of the HSS Strategic action objectives of the Global Fund Rolling Continuation Channel (RCC) grant (2008-2013) in Thailand is to formalize civil society organizations linkages to the Health System. It supports: the creation of platforms where civil society leaders can interact with government agencies and gatekeepers to influence government financing regulations and allocations; the delivery of a focused study that shows how civil society has been engaged in service delivery and how cost effective those programs have been; and the documentation of working models for co-service delivery and cost-sharing with government sponsorship to NGO service delivery.

The Global is providing more funds to areas which till recently has not been a focus of programming and funding attention. The approved Round 9 multi-country proposal by the NAZ Foundation will bring funds to the region for prevention among men having sex with men. The main focus of this program will be supporting and building the capacity of in-country community-based organizations engaged in service provision, policy development and advocacy, and research related to MSM and TG, and on creating stronger community systems to support and sustain this work.

The Global Fund has strengthened communities in the expansion of service coverage in populations with poor access to the health system. In Cambodia, a grant allowed the Khmer HIV/AIDS NGO Alliance (KHANA) to provide financial, technical and capacity-

73 Presenting National Strategic Plans on HIV/AIDS (NSP) to the Global Fund through the National Strategy Application (NSA) Modality. Country Experiences from the First Learning Wave (Flw).A Synthesis Report For UNAIDS. Peter Godwin. 2009

26 building support to local community organizations for providing home-based care to people living with HIV, as well as to orphans and other vulnerable children. This experience is being used to extend HIV outreach to men who have sex with men and people who inject drugs through a subsequent grant, including Cambodia’s first national network of men who have sex with men.

In Nepal, the Global Fund, in partnership with United Nations Development Program (UNDP), has supported the formation of community groups, many led and formed by HIV-positive women. In India, a civil society consortium led by Population Foundation of India, one of the PR provides support to smaller organizations, including INP+, to strengthen their financial and administrative management and in improving the effectiveness of program delivery74. The CCM in China focuses the Global Fund approved grants to increase and strengthen the participation of the civil society sector such as CBOs, and organizations representing PLWAs, for service delivery for  Out-of- school youth, support and care for  PLWHA and for Orphans and children affected by HIV/AIDS75.

The Fund has indirectly also increased the opportunities for technical support provision. The German Government’s Back-Up Initiative and the USAID Grant Management Solutions (GMS), provides demand-based technical support to CCMs and PRs in countries experiencing bottlenecks in their Global Fund grants. Civil society Action Team Asia Pacific was set up to provide TA to communities to strengthen their participation in GF structures and process and to benefit from grants.

Challenges to Participation of NSPs in Grant Implementation Though the Dual Track Financing policy is aimed at increasing the number of civil society and private sector as PRs, in many countries the large international organizations have benefitted more from this recommendation. The civil society scene is still dominated, in some countries, by larger international NGOs and these continue to benefit most from the GF Dual Track Financing Policy. Local NGOs have not been equally successful due to their limited programming and financial management capacity and experience. Community-based organizations at the grass roots level that can reach out to and provide care need support to facilitate their inclusion in proposals. This is an area where partners have an important role to play in supporting and developing the capacities of local NGOs.

Some of the key obstacles to greater participation by community groups identified by the Partnership Forum76 include: poor dissemination of normative tools and guidelines across health service levels particularly to district, health center and community levels, constrained financial resources, poor staff and institutional capacity, lack of/no access to sustained capacity building.

Capacities of communities need to strengthened in the development of good proposals and the management of funds and secondly in the development of capacities to reach more vulnerable groups, deliver services using innovative approaches, and building their own programmatic capacities. This cannot be addressed by short-termed supply driven

74 RegionalOverviewSOUTH ANDWEST ASIA. Global Fund.2008 75China Rd 6 Grant agreement. www,theglobalfund.org 76 A Summary of the Online Discussions Leading up to the 2008 Partnership Forum

27 technical assistance which is currently the case. There has to be a long term technical assistance strategy based on needs assessment

2. Overview of financial support globally to HIV/AIDS response International commitments to reach the Millennium Development Goals has resulted in increasing global resource flows for HIV/AIDS from US$1.4 billion in 2000 to an estimated US$15.6 billion from all sources (public and private) in 2008. A proportion (US$ 8.6 billion) of this was made available by G8, EC, and other donor governments like USA. This assistance is being channeled mainly through the Global Health Initiatives such as the Global Fund, PEPFAR, and the World Bank Multi-Country AIDS Program (MAP). As of 2007, the USG, which is the major funder of global HIV/AIDS programming, contributed at least 51% of international donor government assistance to HIV/AIDS and the majority of this funding is directed through PEPFAR's bilateral programs77.

Fig.: GF and total international Funds disbursed for HIV/AIDS 2002-200778

GF support to HIV/AIDS programmes By the end of 2009, with Rd 9 approval, approved HIV proposals have totaled close to US$ 10.8 billion covering 140 countries. This represents 61 % of GF’s total commitments and 25 % of all donor commitments for HIV/AIDS prevention and care programs in low and middle income countries. Overall, funding from international donors represented 70% of HIV spending in the 50 countries surveyed. 79

77 Financing the response to AIDS in low- and middle income countries: International assistance from theG8, European Commission and other donor Governments in 2008. UNAIDS/Kaiser Foundation. July 2009 78 Data on funding allocation and HIV programme support from:The Global Fund 2010 Innovation and Impact.March 2010. The Global Fund

28 The 2008 reporting cycle showed that 61 percent of the US$ 5.1 billion for 426 active grants, cumulative expenditures was allocated to HIV. Of this 61 %: • 30 percent was spent on prevention; • 27 percent on treatment; • 16 percent on health system strengthening (including community systems strengthening • 16 percent on activities aimed at creating an enabling environment (including policy development, civil society strengthening, stigma reduction efforts, and management); and • a smaller percentage on other activities, including care and support.

The Global Fund contributes to MDG 4, “Reduce child mortality”, in particular by increased access to pediatric HIV treatment and more comprehensive and geographically widespread care, support and treatment for infants and children exposed to and infected with HIV; and scale-up of PMTCT programs.

Table: Contribution to reduction of child mortality

The Global Fund supported PMTCT coverage increased from 35 percent globally at the end of 2007 to 45 percent at the end of 2008 but it still lags far behind needs and targets. The Global Fund, together with its technical partners (including UNAIDS, UNICEF and WHO), is intensifying the scale-up of PMTCT programs throughout 2010 and 2011. Basic care and support services provided to orphans and vulnerable children increased by 41% over the period from 2008 to 2009.

In terms of funding allocation by entity globally, thirty-five percent of the funds were disbursed to civil society organizations,37 percent to ministries of health, 14 percent to other ministries, and 8 percent to the United Nations Development Programme (UNDP) and 1 % to privates sector.

3. Overview of international financial support to service delivery for HIV/AIDS prevention, treatment and care in Asia The Global Fund for AIDS, TB and Malaria has become a significant donor to the AIDS response in the region. The total budget of Global Fund approved proposals, between 2002 and December 2009, in the 33 countries of the East Asia and Pacific and South

29 and West Asia regions amounted to US$ 4.5 billion and of this amount US$ 2.2 billion has been disbursed.

In some countries, in the region, the Global Fund finances nearly all HIV treatment services. In general, coverage remains low, however, with nearly 1 million additional people estimated to require ART. HIV prevention efforts undertaken in recent years have had a greater focus on the people most vulnerable to infection in the region: sex workers, men who have sex with men, and people who inject drugs. In China and the Philippines, among other countries, large numbers of men who have sex with men are being reached by prevention services financed by the Global Fund and this coverage will increase due to the approved Round 9 Multi-Country proposal on MSM80. Overall, however, the coverage of prevention services remains low.

Bilateral donors, who make significant contributions in the region include DFID (UK), JICA (Japan), SIDA (Sweden). For example, the Department for International Development (DfID) has committed an additional USD 45 million to Indonesia’s HIV response. DFID provides £102 million over five years to Indian National Aids Control Organisation to implement its third phase. AusAID funds progammes in several countries including the A$ 100million through the Australia-Indonesia Partnership for HIV 2008-2015 and A$40 million for 2008-2016 through the HIV Cooperation Program for Indonesia.

In December 2009, PEPFAR extended its support through the launch of a second 5-year strategy focusing on treatment in low-income countries in Asia while also working with governments and civil society to address barriers to services among marginalized populations. PEPFAR is operating in several countries throughout Southeast and East Asia funding initiatives by the government but mainly channels funds to support non- government sector initiatives through US NGOS. In some countries as in Cambodia, it is the largest external source of funding for HIV/AIDS and its main NGO partners are Care International, Family Health International, Population Services International, World Relief Corporation and the Khmer HIV/AIDS NGO Alliance. The Khmer HIV/AIDS NGO Alliance for example in turn supports service delivery initiatives of 29 local NGOs. PEPFAR reports that in general on an average, 86 % of its funding supports indigenous partners81. (Annex: Overview of PEPFAR funding support to countries in the region) The World Bank’s funding during these years has remained stable (around USD 100 million per year) with its main focus on South Asia82.

The Asian Development Board has provided small grants to CSOs working to combat corruption and to prevent the spread of the HIV/AIDS in the region. Through the project Fighting HIV/AIDS in Asia and the Pacific, ADB has contributed to building the capacity of civil society groups in more than 10 countries to support local responses to HIV/AIDS.

The ADB-assisted NGO Initiatives to Prevent HIV/AIDS project, the Constellation for AIDS Competence introduced an "AIDS Competence Process" in Cambodia, India, Indonesia, Papua New Guinea, Philippines, and Thailand. In early 2005, ADB and SIDA

80 Round 9 Multicountry MSM proposal for Asia. www.theglobalfund.org

81 www.pepfar.usgov.org 82 Redefining AIDS in Asia

30 established an HIV/AIDS Trust Fund with an initial commitment of $14.3 million to support ADB Developing Member Countries (DMCs) in designing comprehensive responses to the HIV/AIDS epidemic focusing on areas where partnership with ADB will be of strategic value. ADB recently approved an $8.6 million Regional Technical Assistance (RETA) grant, to be financed by the HIV/AIDS Trust Fund. The RETA comprises of 11 subprojects that will expand upon ADB's existing work on HIV/AIDS to identify effective and evidence-based responses to the AIDS epidemic, with priority given to areas and communities that are especially poor, vulnerable or affected by HIV/AIDS. The purpose of the ADB NGO Project is to contribute to the development and implementation of effective and evidence-based responses to the AIDS epidemic at country and regional levels.

Philanthropic foundations or organisations are playing an increasing role in contributing to national responses in the region. 17.9% of all global health funding from the Bill & Melinda Gates Foundation between 1998 and 2007 was allocated to HIV/AIDS and the category of organization that received the largest proportion of funding was nongovernmental or non-profit organizations83. The Gates Foundation is investing more than USD 200 million in India through the Avahan project.

In 2006, the Clinton Foundation secured large-scale funding from UNITAID84which committed more than $200 million to the purchase of pediatric AIDS drugs and tests through 2010, thereby making large volumes of these commodities immediately available to partner governments and dramatically leveraging the contributions of our original donors. CHAI helped to double the number of children on treatment across these 33 countries, to 135,000 in total. UNICEF works closely with the Clinton Foundation in Cambodia, China, PNG and Vietnam to scale up pediatric AIDS treatment.

Private sector support was mainly in-kind of which is more than 50% in most years, included donations of drugs. Some of the larger Faith Based Organisations such as World Vision, Caritas Internationalis, bring in resources having mobilized it from their international funders. INGOs such as the International HIV/AIDS Alliance contributes resources mobilized through bilateral mechanisms, the EC and foundations such as the Bill & Melinda Gates Foundation.85.

The leading UN agencies such as UNAIDS and its cosponsors, in particular UNFPA, UNICEF, UNDP, WHO provide resources and technical support to programming areas within their individual mandates. There is however, a shift in funding flow towards Global Initiatives and direct bilateral aid to countries and less to multilateral agencies.

This increase in external funding has not been accompanied by a parallel increase in domestic investment. In fact, the percentage of total HIV expenditure funded out of national budgets has decreased from 60 per cent in 1996 to 40 per cent in 2004 in the

83 Financing of global health: tracking development assistance for health from 1990 to 2007. Nirmala Ravishankar, Paul Gubbins, Rebecca J Cooley, Katherine Leach-Kemon, Catherine M Michaud, Dean T Jamison, Christopher J L Murray. Lancet 2009; 373: 2113–24

84 UNITAID: a multi-lateral donor and international drug purchasing facility supported by 27 governments including France, Norway, the UK, Brazil, and Chile. 85Ravishankar N. et al Financing of global health: tracking development assistance for health from 1990 to 2007 www.thelancet.com Vol 373 June 20, 2009

31 14 surveyed countries86 by the Commission on AIDS in Asia. The region as a whole is donor dependent to reach the universal access goals set by MDGs. Currently, the Global Fund is financing programs in ten countries in East Asia and 11 countries in the Western Pacific for the prevention, treatment and control of HIV/AIDS, TB and malaria.(Check on exact number for region)

4. Review of financial support to service delivery by NSPs in the countries in East Asia and the Pacific87 In Cambodia, the government’s contribution only represents three per cent of the total available resources for implementation of the national HIV and AIDS strategic plan for the period 2006-2010. National Budget contributions are primarily for salaries of government staff and basic operating expenses and for purchasing of drugs. The major bilateral donor agencies are DFID working through the Cambodian government and PEPFAR, channeling funds through US-based NGOs to local NGOS for primary prevention, PMTCT, care and support including for OVC. PEPFAR has been the single largest external source of funding for HIV/AIDS in Cambodia in recent years, having obligated $17.9 million alone in FY2008.

Cambodia has received seven Global Fund grants including approval for Round 9. All proposals included goals and service delivery areas for prevention among MARPS, for PMTCT and care and support for OVC. In Round 7, Phase 1, 45 % of the total funding of US $23,857,766 was allocated to 14 NGOs for the different service delivery areas and for community systems strengthening. The Cambodian CCM has, for the approved Round 9 grant to support the Continuum of Care programme, proposed two PRs - NCHAD and MEDICAM, which is a network of approximately 120 local and international NGOs nationwide. GFATM funding is seen as an important addition to the funding from USG, allowing NGOs to operate in additional areas and with more flexibility than might be possible with direct USG support.

Contributions from the INGOs Caritas, MDM and MSF are being reduced and MDM and MSF are in effect withdrawing from Cambodia. External sources of funding for HIV will decrease during the period from 2011-2015. Support from significant donors and partners such as ADB, DFID and the UNITAID donation administered through the Clinton Foundation will or have already ceased. Currently, HSSP2, a health SWAP in Cambodia, has not made HIV/AIDS funding a priority.

China has surpassed most other countries in the region in terms of increased domestic resource allocation to HIV prevention, treatment and care. China’s Medium and Long- Term Plan for HIV/AIDS Prevention and Control (1998-2010) explicitly requires that HIV/AIDS prevention and control follow the principle that ‘funds for HIV/AIDS prevention and control in China are mainly input by the governments at different levels from various sources.’ The regulations explicitly define the scope of HIV/AIDS prevention and control efforts that necessitate government funding, as well as the specific roles and responsibilities of the government at various levels in funding the responses to HIV/AIDS. China has been progressively increasing its funding input resulting in the

86 The 14-country review includes: Bangladesh, Cambodia, China, India, Indonesia, the Lao People’s Democratic Republic, Malaysia, Myanmar, Nepal, Pakistan, Philippines, Sri Lanka, Thailand, and Viet Nam

87 Budget allocation data and donor funding data are taken from section on financial gap analysis from the most t approved GF proposals . Information is not available for all countries

32 Central and provincial governments financing approximately two-thirds of the total HIV/AIDS program and international sources contributing the remainder.

DFID and PEPFAR are the main bilateral donors and AusAID focuses its interventions for IDU in China as part of its regional programme. The US Department of Labor (USDOL), the EU, the governments of Germany and Sweden and various other donors have also initiated HIV/AIDS programs with Chinese partners. All four bilateral donors and the RCC Global Fund grants have several NGOs & PLWA groups as implementers. Ninety two percent of the GF Rd 4 grants ‘Mobilizing Civil Society to Scale Up HIV/AIDS Control Efforts in China’ is allocated to NGOS, PLWAs and GONG for implementation. A total of 58% of the GF budget for R6 is allocated for implementation by NGOs and CBOs. The successful models of NGO or CBO-led technical support for CBOs, including mentorships, internships, and NGO-led training initiatives, is currently being brought to scale under the Community Systems Strengthening (CSS) in Rolling Continuation Channel funding till 2015 and for which at least 35% of the total budget is being allocated to prevention, outreach, and care and support services being delivered mainly by NGOs and CBOs, including PLHIV groups

In late 2007, Gates Foundation committed $50 million to work in partnership with the Chinese government and NGOs to expand HIV prevention efforts in China. The Clinton Foundation is providing pediatric ARV drugs in China through funding from UNITAID and is also supporting interventions with MARPs, particularly IDU. Numerous international charities, companies, foundations, and nonprofit organizations such as Marie Stopes International have projects that provide technical assistance to communities and funds directly to local implementing agencies. However, specific information on these external resource commitments is not available at this time.

UNAIDS supported the realignment of national and international resources to ensure that they are harmonized with national priorities and targets. Significant achievements have already been made in care for children affected by AIDS, prevention of mother-to- child transmission, and HIV prevention and treatment for migrant populations through UNICEF and UNFPA-supported projects under the framework of this UN Joint Program. The current Program comes to an end in 2010 but will be renewed.88

According to the National AIDS Spending Assessments, (NASA), the public sector in Thailand in 2008 shouldered up to 82.7% of the HIV/AIDS expenditure and international contributions accounted for only 17.3%89 and this is in a declining trend. Anti-retroviral treatment is mainly financed out of the Thai state budget, partly by the National Health Insurance Fund, partly through Global Fund grants. From 2008 onwards and continuing through to 2012, an increasing proportion of domestic resources to meet the national program’s financial needs will be mobilized from provincial budgets, local governments and the private sector.

Thailand’s main partners with regards to financial support are the Global Fund, UNFPA, CIDA and USAID, which contributed to programs for MARPs and migrant populations. The United Nations Children’s Fund (UNICEF) under the HIV/AIDS prevention and care children programs supports mainly PMTCT, while UNFPA remains the main supporting organization in the field of reproductive health services in the country.

88 Information on China NAP budget allocation and donor contributions taken from China CCM RCC proposal submitted 89 National AID Spending Assessment: Thai NASA 2007 presentation provided by Dr. Michael Hahn, UNAIDS

33 More than fifty percent of Global Fund grants in Thailand are being implemented by the Non- Government Sector: Round 1 RCC with its focus on expansion of access to treatment and PMTCT is being implemented by a number of community-based organization; in both Rounds 2 and 3, an NGO PR implemented the IDU prevention component and two NGO PRs and several NGO sub-recipients implements the Round 8 grant for Comprehensive HIV prevention among MARPs by Promoting Integrated Outreach and Networking.

In Myanmar, the current funding comes, to a large part, from the Three Diseases Fund established by the donor consortium together with some additional assistance to HIV programs through the EC and Australia and from funds raised directly by international NGOs. In addition, AusAID supports five NGO projects which cover the four priority areas of the UN Joint Plan of Action. The approved Round 9 proposal for HIV/AIDS with focus on prevention among MARPs and PMTC has proposed Save the Children, USA as one of the principal Recipients. The implementation plan in the proposal has pre- identified 8 INGO as sub-recipients with an allocation of approximately 75% of the total grant requested for implementation by these NGOs. The UN agencies provide substantial financial support through their core funds and additional resources raised.

The annual state budget for HIV in Vietnam has been increasing and it covers program implementation by 18 Ministries and Sectors in 63 provinces and cities. The resulting budget for individual programs is fairly limited. There has been a steady increase in external support to the national HIV response in Vietnam over the last 10 years receiving enough donor assistance to cover 90 percent of its 2006 AIDS spending90. HIV Prevention during the period 2006-2013 is mainly supported by bilateral donors and the Ford Foundation. PEPFAR, ESTHER, Clinton Foundation support HIV Care and Treatment. The Clinton Foundation HIV/AIDS Initative (CHAI), working closely with UNICEF, supports all the pediatric treatment in the country91. PMTCT receives funds from PEPFAR/LIFE-GAP, UNICEF, GF and Clinton HIV/AIDS Initiative (CHAI) All these donor funded initiatives contribute to supporting implementation by non state partners.

PEPFAR provides funds to the Ministry of Health but as in all other countries a large proportion of the funds is channeled through US NGOS to national institutions, NGOs & CBOs. Vietnam has to date received 3 Global Fund grants and Round 9 has been approved. Principal Recipients have for all Rounds been a government Ministry. Round 6 which is to support treatment and community based prevention and Round 8 targeting IDUs have non-government partners as implementers. The Rd approved 9 grant is for strengthening Government-Civil Society partnership in responding to HIV epidemic in Vietnam and will include support to the establishment of new CBOs for prevention among MARPs in 10 focus provinces.

The domestic contribution to the national program in Laos is at present low, but discussions are ongoing within the context of the Vientiane Declaration on aid effectiveness to ensure that the expected revenues of natural resources (i.e. big hydropower projects and mining) will be invested in social sectors including the national AIDS programme. Lao PDR has a limited bilateral donor base and some of the donors, use the resources from the Global Fund as an argument to reduce their support.

90 Asian Economies in Rapid Transition: HIV Now and Through 2031pg 70

91 UNICEF COAR, 2009

34 In Papua New Guinea, the GovPNG contribution in 2009 was only 11% of the total funding for HIV. PMTCT is 100% funded by the only Fund approved grant and by other partners. AusAID has been supporting community-based groups that provide peer support for people living with HIV and their carers and the establishment of seventeen community care centers for HIV positive people.

79% of the HIV/AIDS response in Mongolia 2004 was financed by USAID, JICA, UNAIDS, UNFPA, the German Development Bank etc. ADB is providing a grant of US$1 million over three years for prevention activities in conjunction with its infrastructure projects in the road, transport, and mining sectors. 57% of the total financing in 2004 went to non-state partners such as the community groups. The RCC grant in Mongolia with its focus on prevention among young people is being implemented by community based organizations. Thirty five percent of the Round 7 grant was allocated to NGOs for scaling up prevention among MARPs. The National AIDS Foundation has been proposed as PR and 8 NSP as sub-recipients for the approved 9th Round which plans to allocate 37 % in the first year and 15 % in the second year to capacity building of CBOs.

Indonesia is donor dependent with almost 75% coming from external donors such as PEPFAR through FHI, and AusAID in 200692. Indonesia has received 2 Global Fund grants for prevention service delivery for MARPs and for providing care and support for PLWAs and Rd 8 grant to strengthen Indonesia Response to HIV: Government and Civil Society Partnership in 12 Provinces’ with IPPA as one of the 3 Principal recipients with 55% of requested funds to be allocated to strengthening CS for prevention & supportive environment. The approved Rd 9 grant upscale the Government and Civil Society Partnership in the country has nominated the local NGO Nahdlatu Ulama as one of the 3 PRs. Fifteen per cent of the total grant goes to NGO PR for Community mobilization and care and 35% to the NAC for civil society strengthening and community mobilization & prevention outreach activities. The Clinton Foundation supported, in 2008, increasing access to HIV treatment and care for rural and remote communities in Papua and West Papua 2008-2009.

Review and analysis of financial support to NSPs for service delivery in the countries in South Asia Eight per cent of the total Global Fund is allocated to South Asia, of which 32% is to finance for HIV/AIDS/TB in the region. So far 19 HIV/AIDS grants have been approved for a combined value of more than US$ 720 million. 24 % of the Global Fund Grants are being implemented by NGO/CBOs/FBOs.

In Bangladesh, domestic resources for the National HIV/AIDS program account for less than 20%. Bangladesh has been granted two GF grants which were consolidated into the Rolling Continuation Channel with 80% for prevention among MARPs and the initiation of treatment care and VCT. Sixty two percent of Global Fund 2, 6 and of the RCC grants supported activities are being implemented by NSPs.

The Indian government has allocated 70% from the national health budget to finance the Eleventh Five Year Plan (2007-2012), NACP III was developed and designed for a total investment outlay of US$ 2.5 billion. In July 2009, the Gates foundation, which started its support in 2003, increased its total commitment to Avahan from $258 million

92 Asian Economies in Rapid Transition: HIV Now and Through 2031pg 70

35 to $338 million. Avahan works with the India National AIDS Control Organization and provides funding and technical support to a wide range of organizations. Fifty seven per cent of the funds are allocated to targeted interventions implemented mainly by NGOs and community groups. PEPFAR has committed $29.8 million to prevention, treatment and care activities for 2008 which is channeled through Indian and International Universities, State Aids Cells to numerous smaller local NGOs for implementation.

The Round 2 Global Fund grant focused on PMTCT and care and treatment for affected families. Round 4 was implemented through public- private partnership for HIV/AIDS prevention and treatment in six high prevalence states of India with the Population Foundation of India, a consortium as the PR with the actual implementation being carried out by more than 100 NGOs. The International HIV/AIDS, one of the 3 PR s for Rd 6 with its focus on scaling up of care and support services for CABA, implements the grant through eight NGOS who in turn work with a number of community-based groups for the service delivery. The Population Foundation the second PR works with IPN+ and Hindustan latex, and the Catholic Bishops Conference and all of whom in turn implement through community based organizations to upscale the care and support component in eight states. Round 7 with 2 Non State partners – the Tata Institute of Social Sciences and the India Nursing Council as PRs focus on strengthening institutional capacity for the national response. Sixty two percent of the Global Fund grants are now being managed and implemented by the NSPs but the management is still largely with the Government in India.

Nepal has received two GF grants and approval for the 9th Round. Save The Children, USA and the Family Planning Association, are the main implementers of Round 7, which was approved to upscale prevention among MARPs, Treatment and Care for PLWAs and strengthening civil society capacity, will manage almost 50 % of the total approved grant. In addition to the GF, there are 16 donors, among them, DFID, AusAID, USAID, World Bank, EU who are channeling funds through the Ministry of Health to both government and NSPs. The UN system is providing technical assistance for fund disbursement.

In Sri Lanka, more than 50% of the national response is financed from domestic resources in addition to a small contribution from UNFPA and UNAIDS. The IDA support ended in 2008. Sri Lanka so far had one grant in Round 6 for prevention including for school children and care and support and the Round 9 grant has been approved. The 2nd PR proposed for Round 9 is local NGO Lanka Jathika Sarvodaya Shramadana Sangamaya, who will in turn subcontract to 3 larger NGOS. Pakistan has only had one HIV/AIDS grant in Round 2 for prevention among school children and setting up of VCT centres among other service delivery areas. Though the PR was the MoH, 50% of the grant was allocated to NGOs as sub-recipients for implementation.

Part 4: Conclusion and the way forward

In analyzing the participation of the civil society in the national HIV/ AIDS response in the review of six countries in transition, the authors of the report “Asian Economies in Transition….’ came to the conclusion that ‘the opportunities for genuine community participation in HIV responses in Asia remain mixed. Occasionally, communities are able

36 to exert some influence on the response, but often their participation is nominal93 This means that there is much more needs to be undertaken to promote and strengthen the role of NSPs in the region and the following are some of the actions proposed in this direction.

4.1 Participation in national coordination, planning and policy development UNAIDS’ policy position states that participation by civil society will be necessary on National AIDS Coordinating Authority, in the ministry or department of health that is responsible for HIV/AIDS and in any broad-based national partnership forum. The Global Fund has made the participation of NSPs in CCMs criteria for funding.

NSP participation in national coordination would facilitate dialogue and joint planning towards harnessing core NSP competencies without unrealistic expectations. Community based organizations should be encouraged and be given the opportunity, through their participation in national mechanisms to share their input on policy and legal reform, and be encouraged to monitor implementation of programs relevant to their organizational mandates.

Representation on national bodies like National AIDS Commissions should involve a process in which communities nominate their representatives. Ad hoc representation by individuals selected by Governments from government friendly NGOs should be a thing of the past. The Global Fund has led the way by putting in place stringent requirements ensuring an open participatory selection/election for NGO and community representation to the CCMs and promoting genuine participation of all stakeholders.

One of the main barriers to civil society participation is a general lack of experience in engaging with the national level processes. Tailored training might be needed to achieve a better understanding of what such engagement entails and how to optimize involvement in formal governmental environments. Language and jargon may also pose barriers. It is important to set aside resources to translate essential documents into local languages and to develop summary documents in lay language, free of technical jargon.

The resources for civil society engagement for strengthening NSP capacity need to be built into national program budgets. Any legal obstacles to establishing, engaging and funding these organizations would need to be removed or eased.

The Commission on AIDS in Asia recommends institutionalization of community involvement, rather than to rely on good will alone. Institutionalizing community involvement means creating formal, salaried positions in relevant Government and other structures (National AIDS Commissions, HIV research bodies, decision-making or consultation bodies, etc.); such a step would greatly strengthen the relationship between Governments and communities.

It also proposes the creation of public–private partnership structures that would be responsible for the funding and oversight of community-run HIV projects and programs. Government and non-governmental entities would be equally represented in these structures, which should include strong representation from community groups. Funding would come from national AIDS budgets, as well as from bilateral donors. The same structure could serve as ‘principal recipient’ of Global Fund grants. Funds would then be

93 Asian Economies in Rapid Transition: HIV Now and Through 2031.UNAIDS 2009

37 disbursed to those projects or organizations that provide services to most-at-risk populations, people living with HIV and their families. 94

4.2 Policy and legal framework to facilitate true NSP engagement/participation ‘Money alone will not be enough. Politics and policy space matter as much, if not more than fiscal capacity’. The policy space in many countries is still restricted by prejudice and stigma, embedded in laws and policies. People living with HIV (PLHIV) face considerable stigma and discrimination. 95 Hence an enabling environment through policy frameworks on engagement of civil society organizations continues to remain a challenge but need to be overcome.

Strengthening civil society and building capacities for policy development and advocacy will therefore be critically important. There should also be an expansion of the policy space by those who can drive the transformation in the social and cultural environment by promoting greater openness and acceptance of groups and behaviors hitherto considered marginal

4.3 Establishing minimum standards and an accreditation process NSPs are increasingly taking on a large percentage of service delivery in some critical areas of prevention, treatment and care and therefore should be held to standards of accountability. Currently, most private sector activities responding to HIV are isolated interventions which are monitored at company level without input in the national monitoring system.

Meeting rigorous standards of quality, transparency and regulatory compliance will enhance the credibility and capacity of these actors and broaden the opportunities for a full and effective collaboration with governments. A partnership framework makes it easier to integrate monitoring according to national procedures. Governments, in turn, will need to strengthen their role as facilitators and regulators—a role that will include policy making, setting of service and quality standards, quality assurance and accreditation, and coordination.

An accreditation system should be designed to help deliver quality HIV programs that are supported by well-performing, sustainable and credible civil society organizations. The Thai Business Coalition on AIDS (TBCA), developed together with the Ministry of Labour the AIDS-response Standard Organization (ASO), a national quality certification tool for the private sector. The Code of Good Practice for Nongovernmental Organisations Responding to HIV/AIDS, developed in 2005, which identifies guiding, organizational, and programming principles that have been endorsed by over 160 international and nation organizations,96 is a good point of departure for civil society and non-governmental organizations. But there is no monitoring system in place to ensure that the signatories to this code are in fact basing their service delivery on the principles outlined in the Code.

Accreditation systems and/or country specific Codes of Good Practice with a monitoring plan drawn on the Code of Good Practice for Nongovernmental Organisations

94 95 Asian Economies in Rapid Transition: HIV Now and Through 2031.UNAIDS 2009 96 http://www.hivpolicy.org/Library/HPP001335.pdf

38 Responding to HIV/AIDS, should be developed and implemented through participation of the NSPs.

The International HIV/AIDS Alliance (IHAA) accreditation system97 provides a good basis for development of country specific Code of Good Practice including minimum standards for NSPs. The IHAA introduced the accreditation system in 2008 to assess their current members against a high set of institutional and programmatic standards with a view to improve members’ HIV responses and accountability to the communities they serve. The Alliance’s accreditation system comprising of a 3 step sequence: - Puts into practice the Code of Good Practice for NGOs Responding to HIV/AIDS - Identifies where an NGO needs support to meet good practice standards - Builds donor confidence in Alliance members’ ability to deliver quality HIV programs - Provides a set of standards applicable across the Alliance, building on a shared mission and vision - Ensures that the meaningful involvement of people with HIV and other marginalized groups, and gender equality are central to the work of all Alliance members - Provides an opportunity for Alliance members to learn from each other

4.4 Quality assurance and accountability through M&E NSPs should be part of the monitoring and evaluation of the national response so that the extent and quality of civil society participation and community engagement in national HIV responses could be assessed. This will also contribute to improving accountability and transparency of their activities as well as to ensure cost-effectiveness of community-based interventions.

The GFATM 5 year evaluation study also drew attention to the fact that implementation of Global Fund-financed activities is now mainly in the hands of the sub-recipients and even sub-sub-recipients, who mainly NGOS and CBOs. The evaluation found that an effective operating model of reporting, monitoring, measurement of outputs and outcomes and instruments for accountability, does not function systematically or even at all in countries. It highlighted the need for a much more systematic performance monitoring and fiscal oversight requirements to minimize the potential for funds misuse and to maximize the potential for achieving strong grant performance.

The Coalition of Asia-Pacific Regional HIV/AIDS Networks (The Seven Sisters) has produced a toolkit for carrying out such an evaluation in relation to Universal Access processes, known as ‘The Minimum Standards of Participation of Civil Society in Universal Access’98. Use of this toolkit together with skills training and resources would help to facilitate NSP participation in M&E.

Most national M&E systems continue to be weak despite the increased support, in recent years, by donor and funding agencies for monitoring and evaluation99. Both the Global Fund and the UNAIDS evaluations recommend the strengthening of country capacity and skills of national stakeholders in surveillance and monitoring and evaluation 97 Ensuring quality and accountability. A New Accreditation System for Effective Community Responses to HIV. The HIV/AIDS Alliance. 2008. www.aidsalliance.org

98 The Seven Sisters: The Coalition of Asia-Pacific Regional Networks on HIV/AIDS

(2007), Minimum Standards for Civil Society Participation in the Universal Access Initiative available at: http://www.hivpolicy.org/Library/HPP001335.pdf. 99 The Second Independent Evaluation of UNAIDS. 2002-2008. HLSP/ITAD. 2009

39 4.5 Generating Empirical Evidence related to role of the private sector in HIV/AIDS response As the global response evolves from emergency relief to sustainable programs, it is important to understand current and potential NSP’s role in mitigating HIV/AIDS. There is still limited evidence about the role of the private sector in financing and delivering HIV/AIDS services beyond workplace programs.

It might be useful to conduct a private provider survey to assess private sector provision of HIV/AIDS services as was done in Ethiopia100. The survey in Ethiopia provided data towards increasing government recognition of the potential role of the private health sector in meeting national goals, such as universal access to HIV prevention and treatment and in documenting current practices and future potential could guide policy decisions. This survey revealed that barrier to greater participation in delivering HIV/AIDS services and products stem from the current legal and regulatory environment; lack of training opportunities; and infrastructure limitations. Similar surveys in this region could also provide the data to develop an evidence based, impact-oriented and sustainable, long term plan for strengthened private sector role.

4.6 Strengthening Institutional capacity and building technical skills The Global Fund has opened up opportunities for greater civil society participation by channeling funds to NSP recipients. But insufficient absorptive capacity hampers them from effectively using the funds available.

In almost all countries, weak institutional mechanism, limited organizational capacity in programmatic and financial management and low technical capacity of community actors constrain community response and coordination at local level. Though there are more opportunities to access technical support, current provision of technical support has been supply driven and short-term.

There is consensus among both providers and users of technical support about the need for a more strategic, coordinated approach at country level for: - the development of a long term, country-owned, overarching TS strategic framework and work plan for each country in partnership with all technical support providers. This process should be based on needs assessment, and a mapping of the available resources (financial & TS providers) at country, regional levels to address the long-term capacity building needs all NSPs; - The harmonization and coordination of technical support at the regional and country levels through the development of an overall Technical Support Partnership strategy defining the provider roles and responsibilities, norms for TS provision & coordination, with results- based framework for quality assurance; - Advocacy and support for including in budgeted TS plans, based on needs assessment, into GFATM proposals. Continuity in TA should be encouraged through inclusion in national programme budgets; - Through a broader approach to cooperation with the private sector, . devise strategies for exploiting the potential of the private sector for strengthening leadership, management and governance of NSPs and the public sector

100 Generating Empirical Evidence: What Do We Know About the Role of the Private Sector in HIV/AIDS Services? Sara Sulzbach, Abt Associates, Inc

40 - establish forums for sharing the experience of work done and lessons learnt.

Study tours to visit company operations will be useful for all partners to learn more about how to play a more effective role in mobilizing private enterprises to join public/private partnerships. In -country guidelines on how to identify, promote and support public/private partnerships at the country level and describe the basic modalities and potential contributions of public/private partnerships and the roles of partners, with a list of all available resources partners would also be useful.

The NSPs currently working in HIV/AIDS should be provided with skills and information to advocate for a broader partnership, going beyond the AIDS activists and those who are working on AIDS, to address social development challenges such as gender inequality and human rights in which AIDS problems are embedded.

4.6 Explore the role of private sector in health insurance The lack of any form of social protection in most poor countries makes a bad situation much worse. Women may be disproportionately impacted by such costs: just under 80 percent of the women in a number of countries in Asia said that they did not have sufficient financial resources to access ART services. The increasing privatization of health care is aggravating overall health inequities. 101 The global financial downturn emphasized the catastrophic cost of medical care for people without insurance in many countries.

There is an urgent need for high level support of subsidized health insurance programmes Insurance schemes are vital for financial sustainability of HIV and health projects. It would be useful to explore/study experiences of other countries in private sector contribution to social health insurance. There is a need to evaluate the best role(s) of the private sector in this respect and to define models of cooperation with the public system which could meet business interest. It would also be worth exploring the experiences of the Namibia PharmAccess Foundation and the Nigerian Health Insurance Fund both a subsidized health insurance scheme for low-income worker groups102.

4.7 Role of private sector and civil society in cash transfers Although many community initiatives and NGOs are attempting to respond to the growing needs of families affected by HIV and AIDS, they are simply not meeting the needs of millions of children. Cash transfers hold the potential to make a considerable difference to the lives of children affected by HIV and AIDS. However, like any other intervention intending to benefit children, transfers need to be long-term, regular and predictable and linked with other services. Civil society participation is critical to ensure transparency and efficiency. UNICEF has supported the government in Papua New Guinea in the implementation of cash transfer programme. It would be useful to draw lessons from this experience as well as to study experiences of other countries to use as a basis to explore the feasibility of forming partnerships with the private sector for cash transfer to benefit children affected by HIV and AIDS. In Malawi, the Government cash transfer is being funded by GF grant. Currently the Global Fund itself is already in a state

101 102 HIV-related Public-Private Partnerships and Health Systems Strengthening. (UNAIDS) 2009.

41 of fiscal crisis, it would be useful to explore other potential sources one of them being the private sector.