According to UNAIDS[1], Eastern Europe and Central Asia (EECA) is one of only three regions where the HIV epidemic is growing. Since 2020, new HIV infections have increased by 72% and AIDS-related deaths by 24%. Key populations including people who use drugs, sex workers, men who have sex with men, prisoners etc, and their sexual partners are disproportionately impacted, accounting for 99% of the new HIV infections in 2019[2]. Finally, data suggests that antiretroviral treatment (ART) coverage in the region is low with just about half of people living with HIV (PLHIV) receiving antiretroviral therapy[3].
These worrying trends suggest that more action is needed to halt the spread of the epidemic as well as to address inequities in access to prevention, treatment and care services among PLHIV and key and marginalized populations.
Social contracting, defined as the process by which government resources are used to fund entities that are not part of government (e.g., NGOs), could provide a basis for efficiently delivering HIV and TB services. Regardless of the terminology used, social contracting mechanisms typically involve a legally binding contract, in which the government agrees to pay an NGO for services rendered and the NGO agrees to provide agreed deliverables in exchange.
According to our new Policy Brief, there are four conditions that are sine-qua non for effective social contracting mechanisms:
- existence of legal and administrative systems permitting and facilitating social contracting;
- strong national leadership and funding from national authorities;
- allocating budget resources for HIV-specific activities coupled with transparency, fairness and effectiveness in funding allocation;
- technical and managerial capacity of NGOs involved in the social contracting process;
Even though countries in the region have made significant progress, ongoing challenges prevent further development of the social contracting process. Some of these barriers revolve around the legal restrictions requiring that HIV services only be provided in healthcare facilities, which makes the process of outsourcing and provision of services in community settings difficult. Other issues are related to the capacity of the region’s NGOs to participate in the public procurement processes.
Significant returns on investment
Beyond the need for financial sustainability, the process of social contracting is associated with significant social returns. In order to study these social returns, our Policy Brief adapted and implemented the social return on investment (SROI) methodology to the context of HIV in the EECA region. Overall, the applied methodology takes into account not only the financial but also the wider societal value created by the process of social contracting. By doing so, the methodology also takes into account both, the direct and indirect benefits created through the process of social contracting as specified by the beneficiaries. The final result of the exercise is expressed in terms of ratio of benefits to costs.
Four case studies from three countries (Belarus (2 case studies), Bosnia and Herzegovina, and North Macedonia) were selected to pilot the SROI methodology in HIV-related activities. The case studies mostly revolve around providing two types of activities: counselling services to key populations as well as help to PLHIV.
There are a few broad conclusions that stem from this piloting of the SROI methodology in the context of HIV-related services. First, in all of the selected activities, there are significant social returns, which are realized as a result of their implementation. The SROI ratio ranges from 1.5:1 in the case of North Macedonia to 3.5:1 in the case of Bosnia and Herzegovina. This is mostly due to the type of activities that are implemented. The case of Bosnia and Herzegovina encompasses both, psycho-social support to PLHIV as well as counselling/prevention activities among key populations[4].
Second, the sensitivity analysis indicates that the results are robust to changes in assumptions such as modification of the drop-off or attribution rate. Finally, and given the similarity of the activities which are implemented (as well as similarities in assumptions), the SROIs across the different case studies are broadly comparable.
Against this background, the results from this (and future) SROI analysis can be used in lobbying and advocacy activities by NGOs to emphasize the benefits brought about by social contracting. Moreover, using the results of future SROI in the area of HIV could further reduce existing obstacles to social contracting in HIV. For example, results of SROI can be used to show that some activities, like harm reduction can be effectively and efficiently delivered by NGOs in a non-clinical setting. Finally, the easy quantification of the SROI results could also be used in bidding for funding, particularly when the funding is based on outputs or when there is performance-based funding.
Funds and financial allocations from various sources for health and HIV continue to be limited. That is why we are convinced that social contracting is a key element for sustainability of HIV and health services, NGO funding and overall social protection. The SROI methodology is proving to be a good contribution to the discussion and argumentation for increased investments in this innovative financing approach.
Zlatko Nikoloski, International Consultant, UNDP
John Macauley, Regional Programme Specialist, HIV, Health and Development, UNDP Istanbul Regional Hub
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