As funding from the Global Fund is phased out, Bulgaria struggles to find sustainable financing

4. NEWS
19 Sep 2017
Energy from civil society is missing

With Global Fund support coming to an end, the path towards sustainability of HIV and TB services for key affected populations (KAPs) in Bulgaria is not clear. The consensus among representatives of civil society organizations is that, unfortunately, Bulgaria still has not managed to ensure within its National Strategic Plan for HIV sustainable financing at the required level for the services provided by NGOs for prevention, treatment and reduction of HIV among KAPs. At the same time, NGO advocacy remains weak, and many activists see little recognition by government and local authorities of the NGO role in the response to HIV and TB.

“The lack of a vibrant and meaningful civil society is being felt very strongly right now,” Yuliya Georgieva, from NGO Center for Humane Policy, told Aidspan. “At a time when the Global Fund is finally ending its lengthy presence in the country, it has become clear that there is a complete lack of the civil society energy that is needed to advocate for the necessary funds and mechanisms for an effective continuation of the program.”

Bulgaria is a member of the European Union and is classified by the World Bank as an upper-middle-income country. Bulgaria has not been eligible for funding for HIV since 2015; it received no HIV funding for the current allocation period (2017-2019). The latest HIV grant, which was extended a number of times, ends this month.

Bulgaria’s current TB grant will come to an end in September 2018. Technically, the TB component should be eligible for a transition grant after that. However, earlier this year, the Global Fund Secretariat told Aidspan that the existing grant to the Ministry of Health (MOH) was developed and negotiated with the understanding that Bulgaria would not receive further funding from the Global Fund, and that the necessary measures for a successful transition to domestic funding would be adopted during implementation of the existing grant (see GFO article).

Epidemiological situation and the national response

Bulgaria remains one of the E.U. countries with the lowest HIV incidence: it registers 3.1 new cases per 100,000, or 200-220 new cases annually. According to research conducted by Optima involving modelling HIV epidemics for the next five years, two groups will account for most of the new HIV cases: people who inject drugs (PWIDs) and men who have sex with men (MSM). In the last six years, the proportion of new HIV cases attributed to injection drug use declined by two-thirds; however, it doubled for MSM, who have accounted for 50% of new cases in the last three years. A network of various services for reaching key populations with HIV prevention has been developed: 14 testing and counseling sites; mobile units; outreach work; and drop-in centers.

With respect to TB, the incidence rate more than halved from 48.8 per 100,000 population in 2001 to 21.3 in 2016. But the rate still remains among the highest in the E.U. Treatment success increased from 81% in 2007 to 86% in 2016, and few drug-resistant cases are present (unlike in most of Eastern Europe and Central Asia). NGOs provide TB services across the country among the following groups: inmates (13 prisons); Roma communities (23 sites); children at risk (nine sites); refugees and those seeking refugee status and other migrants (three services); and other groups, such as people who use drugs, and the homeless (11 sites).

Key national documents to ensure sustainable public funding for HIV and TB responses were approved of by the Cabinet of Ministers in March 2017, covering the period 2017-2020. The adoption of these important documents was delayed for several months, due to the rather low priority given to these diseases by the Bulgarian government, and also due to political instability and frequent government changes throughout 2016. The national programs described in these documents contain indicative budgets for the services implemented by NGOs, including for HIV prevention. There are specific budget lines for each key and vulnerable population group for each of 2017, 2018, 2019 and 2020 (see the table for the numbers for 2017 and 2018).

Table: National Program budget for HIV for 2017 and 2018 (BGN)

 
2017
2018
PWID
281,610 BGN
200,000 BGN
MSM
212,534 BGN
160,000 BGN
SW
156,895 BGN
170,000 BGN
Marginalized ethnic communities (Roma)
105,000 BGN
210,000 BGN
People in prisons
25,000 BGN
50,000 BGN
Refugees, migrants and mobile populations
50,000 BGN
100,000 BGN
Children and young people
55,000 BGN
110,000 BGN
Total for key populations
886,039 BGN
1,000,000 BGN
Total for HIV program
2,808,161 BGN
2,973,309 BGN

 

As a comparison, NGOs working with key population groups in 2015 effectively spent € 907,588 under the Global Fund grant. There are about two BGN to the euro. It is clear, therefore, that the money planned within the National Program for the most-at-risk groups is less than half of what was previously provided by the Global Fund This will likely have a major impact on the sustainability of the HIV services currently implemented by NGOs. Note, also, as shown in the table, that the sum of money for the PWID and MSM decreases in the second year (2018). The budget for these populations is maintained at this lower level for 2019 and 2020.

Further, as Dr. Georgi Vasilev, one of the authors of a recently published analytical report on contracting public healthcare and social services to CSOs in Bulgaria, told Aidspan: The problem is that these figures show the projected budget; the money actually made available is likely to be less.

Around 600,000 BGN is budgeted are planned annually for TB prevention in 2019 and 2020, the first years without the Global Fund support for the TB response. In comparison, the budget for the TB care and prevention module within the current Global Fund TB grant stands at € 1,504,841 for 2016 and € 1,288,286 for 2017.

Role of NGOs in HIV and TB response

Bulgarian NGOs have been significantly involved in the implementation of the program financed by the Global Fund for the prevention and control of HIV in Bulgaria ever since the program started in 2004. More than 50 NGOs were involved in providing HIV prevention services to KAPs, with 10 NGOs working with PWID; nine NGOs working with sex workers; five NGOs working with MSM; 10 NGOs working with Roma youth; and four NGOs providing support to PLHIV. In addition, 17 mobile units and a number of low threshold centers operating with different risk groups were established and run by different NGOs. 

With support from the Global Fund winding down, the key challenges faced by the NGOs and other community groups concern (a) funding; (b) their ability to continue delivering services at the same scale; and (c) how to utilize the capacity built up throughout past years. A few NGOs have already stopped providing HIV and TB services, though many NGOs have managed to survive funding interruptions because of their commitment to the issues.

The major problem with regard to ensuring the sustainability of NGO services to KAPs is the lack of a proper mechanism to allow NGOs to receive governmental funding. According to a recent analysis of this issue conducted by the Eurasian Harm Reduction Network, the existing mechanism for the implementation of NGO contracting was developed only for the purposes of the Global Fund grant. The State Procurement Agency has indicated that the mechanism adopted for the grant cannot be applied to state funding for NGOs. Instead, the Agency said, NGOs need to be contracted according to the provisions of the State Procurement Law. The MOH is still in the process of developing a new procedure for NGO contracting under the NSP. This will result in an interruption in funding for NGOs, and will affect the delivery of services to KAPs. As an interim measure, until the state procurement procedure for NGO contracting is operational, the MOH has instructed regional health inspectorates to hire outreach workers from NGOs previously delivering services, in order to maintain the outreach work into vulnerable communities.

Civil society advocacy

As it seems apparent that the national government has limited financial resources and thus might not fully replace the Global Fund’s support for HIV and TB services in the country, this could be the right time for sustainability- and transition-focused national level advocacy activities to take place in Bulgaria.

At the beginning of July 2017, a three-day civil society workshop took place in Sofia organized by the Eurasian Harm Reduction Network (EHRN) and the TB Europe Coalition (TBEC) with the support of the Global Fund Secretariat. The workshop brought together 23 local participants representing NGOs and affected communities, as well as governmental structures (such as the MOH), the CCM Secretariat and the National Municipalities Association. As a result of the workshop, the following key sustainability- and transition-related activities for this year were identified by the NGO participants:

  • initiate the revision of the national legislation which regulates the contracting procedure to ensure that NGOs are able to receive the governmental funding for HIV and TB prevention services among key affected populations in Bulgaria; 
  • support the national budget allocation processes for 2018 to ensure that the required amount of funds for HIV and TB treatment and prevention programs are included and approved in the national budget;
  • explore possibilities of national funding of services for key affected populations in other national programs, such as the National Strategy Against Drugs; and
  • create an informal coalition of community organizations and NGOs for the purpose of coordinating and implementing joint advocacy work.
 

According to the report of this workshop, in order to achieve the desired results, Bulgarian civil society has to gather support for their advocacy activities from both internal and external partners. This is particularly sensitive as most of E.U. member countries are normally not eligible for any donor support or development assistance other than that provided by the E.U. itself.

According to Sandra Irbe, Senior Fund Portfolio Manager for the Global Fund, civil society and community representatives could rely on the support of the Global Fund Secretariat for their sustainability-focused advocacy activities. For example, before the end of the current TB grant, NGOs could utilize the remaining support from the Global Fund – such as the CCM Secretariat funding of € 30,000 to finance advocacy meetings, consultations and oversight visits. The Global Fund’s political leverage with country stakeholders could also be exploited, Irbe said. “The Global Fund can also bring NGOs together with regional partners in other countries to learn and discuss transition and sustainability.”

Also, as the current grant for TB runs until September 2018, Irbe said that it is important to fully absorb the funding available with this grant. Some activities that are key for the national TB program might also provide entry points for KAPs to HIV-related services that are required, she added. Finally, she said, this grant could be also used for further modelling effective interventions for domestic financing, taking into account the results of the recent report of the AuTuMN project on the optimization of the strategic investments in TB in Bulgaria.


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